My first ever referral

'Mr D is bleeding tears. Can you come and have a look?' the nurse said with some panic in her voice. Me eyes went wide opened, and my first thought: Exorcist!

Nah... it didn't look like that at all. We had a look and the nurses pressured the SHO to get him seen by an ophthalmologist. It was a very busy day and I was asked to make the referral. I foolishly agreed.

Firstly I needed to know who to call as my hospital has no ophthalmology service. We have an eye team from a DGH 10 miles away who runs an outpatient clinic here, but then just last week I heard another doctor arguing on the phone as they would not accept in-patient referral from our hospital. At the back of my mind, I remembered when I have had my placement at the eye hospital (the tertiary eye referral centre in Manchester) I was repeatedly told by a keen registrar about an interesting case from my hospital. I wonder if they would that a referral from us? So I googled and found their phone number. I just tried my luck and asked if they cover in-patient referral from my hospital, and they do! The nurse passed on the phone to the on-call registrar.

That was when my palpitations began. You might think, what is so difficult about making a phone call? Well, doctor to doctor conversation follows a specific format and I have seen many miscommunication happened over the phone. You'll be surprise if I tell you how many times I've seen people getting really pissed off and having a fit on the phone. I'm just terrified to be reminded of that. I think my SHO assumed that I know how to do it and pretty much just said to me 'Can you do the ophthalmology referral to Mr D?' and left. So before I called, I read Mr D's notes and checked the eye complaint several times. Then, I remembered a registrar who grumbled 'these SHOs are referral patients to us without even seeing the patients themselves first'. So I thought I ought to quickly take a history and examine Mr D's eyes before I proceed.

The on call registrar was not too bad actually. He said hello, and then just let me present the patient for 2 minutes without interruption. Then he gave his ophthalmology opinion and recommendations. He said he's very busy but will try to come over and see the patient. I thanked him and hang up. Relief! Apart from my stress induced slurred speech (had to say chloromphenicol for three times before I get it right) it was not as bad as I expected. The only thing I got told off was that I didn't check his visual acuity (I did, just not using a snellen chart!). I documented almost every word that was exchanged - probably not a usual practice but I just want to be extra extra careful.

As always whenever I'm involved in patient care, I learn by leaps and bounds. For a start, I am twice as alert. I double check, no actually, I triple check everything. What for? Well, to make sure that I don't look too stupid, but more importantly people supervising me will often trust my words and judgement, and plan their management from what I have told them. If I've made up something in the history for example, the diagnosis and management will be based on those false information. They say we shouldn't bring patient issues home, but I always go home with nagging questions in my head. Have I done everything right? Or more importantly have I done anything wrong that could have harmed the patient? And to follow on, what would I do differently next time? Every single involvement with patient care is indeed a huge learning curve for me.

So for today, in hindsight, I could have done much better. Especially because I've just done an ophthalmology placement, I should have been able to get a better history, do a more thorough examination of the eye and come up with a more accurate diagnosis. I just forgot to take a moment to gather these thoughts. And I forgot that the receiving specialty doctors always want to know 'what do you think it is?'. The registrar must have thought that this is such a crappy referral. Today's experience also further reiterates to me that surviving as a junior doctor is all about communication, resourcefulness and being a little thick-skinned. It was a valuable learning experience for me. Definitely will be better next time.

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Free thoughts

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Occasionally when I walk pass student flats and smell food that I know and I like, I would crave for it uncontrollably. Such happened about a month ago. It was the chicken dish that women in confinement eat. I love confinement food. They taste spicy and appetizing. So I asked mummy for the recipe. Apparently it requires wine, so for the first time in my life, I bought a (small) bottle of wine from the supermarket. I cooked the chicken dish - not great, and I am not keen to try again soon. What should I do with the rest of the wine left? Two days ago, I poured a quarter of a glass to drink with my dinner. I felt awful after that! Terrible headache, felt sleepy, and absolutely couldn't concentrate on my reading (of some journal articles, not surprising!). I think I even have a little hangover on the day after. Why? I fear this may well be a psychological response, since (based on my knowledge of medicine) to make me feel that awful from 30mL of wine is physiologically impossible. I am very pressed for time this week, so not going anywhere near it.

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I wonder if one of my friends has got bipolar disorder. I have not really seen the manic side of her yet, but occasionally she does dresses very fancy. And yesterday she wore really really colourful make ups. And I know she has suffered from severe depression before. I will be looking out for some more manic features.

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I dislike being dragged along into management meetings, or even just hearing senior doctors talking about management. I feel like a child in a room full of adults discussing and arguing over adult matters and I really shouldn't be in here.

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I had a great dream last night.

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This week is extremely busy. I have just realised that as late minute person I am in a lifelong race against time and I have always won so far.

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I feel like curling myself under the duvet. for the past few days. want to avoid the world as much as possible. not good.

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Patients

I was out with some friends yesterday and they asked if I've ever thought about not wanting to do medicine. I said no, not since I've started anyway. And they were surprised, and asked why. 'The patients.' I answered. Will tell you about this two patients I've seen this week.

A elderly patient in the stroke ward. Very sweet, seen shuffling up and down the ward with his zimmer frame. Reminded me of my grandfather (a gong - father side). Had that face of him. His hands... thin, covered with tight but inelastic skin, protruding veins. Was trying so hard to convince us that he can manage to be discharged back to home, almost made me laugh... A gong would never had been so articulate. He had always been a very soft spoken person ever since I'd known him. He passed away a few years ago. Seeing this old man talk, I had tears at the corner of my eyes.

A consultant doctor admitted with a big bleeding stroke needing surgical evacuation. Although personally I never ever do it, there is always a risk of being patronised and treated like an institutionalized person when you are in hospital. Now he can't move the right side of his body, have trouble swallowing and is only allowed puree food, and have short term memory loss. I could just imagine that a month ago he could have been resuscitating patients, teaching junior doctors, being asked 'consultant opinion' about patients ; and now he needs people to wipe his bum and get out of bed using a hoist... If I'm lucky enough, I'd probably have the privillage to enjoy a fast and painless death. But I know that most of us would possibly end up like this one day. I know this ever since I started working as an auxillary nurse. Just had never really thought of it in this context before. People that I really respect and look up to, almost infalliable in my eyes, can actually be bedridden and lose all the dignity we spend all our lives building.


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Pushing the boundary - Part 2

I saw Mr G in the ward round last week. He was sitting out on a chair. Eyes wide opened, alert. ABCDE was perfect. Could even whisper a full sentence 'when do you think I can get back to normal'! He's now all ready for rehabilitation. So happy for him!!!!!

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