Why working with doctors can induce hypertension.

Whenever my Manager at work asks me to go to the ward to set up a patient with overnight ventilation treatment, I internally groan. This reluctance is the direct result of a combination of three things:

1. The patient is too ill to comprehend, hear or understand what I'm saying. In a role where communication is key, having difficulty channelling information seriously sets me back, normally on time (and sometimes on patience). I don't have anything against ill patients, most of them are lovely people, but when you've already been rushing around all morning and stressed all afternoon; facing challenging patients is the last thing you want.
2. The doctor is annoying. This has been the case usually. I have worked with only a small range of doctors, but in each one I found something to get annoyed at. If it wasn't egotism, or mismanagement, or even ignorance, then it was definitely the doctor's negligence towards the patient's mere presence, if not mine. I remember one actually talked about how I was going to do my job without even introducing me to the patient or the patient's translator. Actually there was one that I found tolerable, and that was because he didn't say much but actually asked questions as opposed to acting like he knew it all. 
3. The patient has run away smoking and no one in the entire hospital can track him down, even after several hours of absence. 

My ward work this week had to spread over 3 days. The first day I was told by my Manager that a patient at a different hospital needed an emergency sleep study done. Normally we don't do such things as the studys need to be booked in advance as the sleep centre only have a limited number of ambulatory recording devices used to study the patient while asleep. However the patient was moved to our hospital and I was sent to wire him up. A consultant had demanded it be done, so it was done, and done it was. So I went, and did it, but I felt sorry for the patient because he had to be wired up 6 hours before he actually went to sleep. The patient, thankfully, did not complain.

The next morning I removed the wires and immediately analysed the data. What I saw was one of the most severest forms of obstrucive sleep apnoea I had ever found, it was right up there in the top 3 most severe OSA cases I had ever analysed (Oxygen saturation level would drop into the 50% range occasionally). Poor man, I couldn't even imagine how he lived! I talked it over with the consultant a few hours later during which he spoke to the registrar on the ward, five minutes later a request form was placed into my hands to set the patient up on treatment. I told the doctor in the same instant that I would be at the ward before four pm. This was at 14.30.

I get to the ward in a rush because I had so little time and so much to do, but I reached the ward at 3.35. I went to the patient' bed to find... a bed. No patient either ontop, beside or under it. I searched the room thoroughly.

I ask the doctor 'Where is the patient?'
She replies, very nonchalantly 'Oh he's at the eye clinic' and proceeds to call the eye clinic immediately. 'How long can you stay?'
'5 minutes.' I say, not being annoyed yet as I'm thinking of getting home in time for my driving lesson (which got cancelled due to drained petrol stations).
'The patient's on his way up.' said the doctor when she finished talking to whoever was on the line.

So I wait for the patient, 5 minutes later and I remember that I told the very same doctor that I would be down before four... so why did she send him away???? 10 minutes into the waiting game and I tell another doctor (the registrar) that I am  leaving and that I had warned the doctor previously of when I would be arriving. I don't normally like the registrar (he explained a patient was dying to me right in hearing range of the same patient) but he was sympathetic and asked if there was anything he could do.. maybe he could set up the patient on a ward CPAP? I declined politely as I honestly did appreciate his sentiment; saying the patient wasn't going to die without one night of treatment.

Guess what the registrar did?

The next day I called the ward in the morning, saying to God knows whoever I was talking to, that I wouldn't be able to come in the morning as I working two people's shifts (understaffed should sooo be the NHS middle name), I would be there in the afternoon.

I manage to get there in the afternoon. I knock on the patient's room door, to get no reply, I knock a little louder calling out a subtle 'Hello?'. Getting nothing, I walk in warily to find the patient snoring, fast asleep; a clear sign of symptomatic OSA. When I woke him up, the first this I hear is a complaint about the ward CPAP, how it was uncomfortable and how it was at such a high pressure he felt like he was choking. I restrain myself from shaking my head. There is no point saying 'No' to a doctor.

I set the patient up on long term CPAP and I quickly understand the patient has not been given any details about his sleep study results. So I give him a brief overview; warning him that he might not want to hear the figures. But bless, he was as excited as a golden retriever and even fetched a pen and paper; enabling him to write down what I said. I spent nearly an hour with him, he told me of what appeared to be the doctors emotionally blackmailing him into using CPAP and about how he was at risk of stroke... bla bla bla.

You must understand that the main complaint of this patient was severe headaches... Considering that a sign of OSA is headaches, even when the O2 saturation level only drops by 7%, that a pretty bad headache might appear when the sats drop by 20% for most of the night and 40% for the rest. But no, further investigations were carried out during the course of the day and the patient had to have three (possibly unneccessary) lumbar punctures to analyse CSF. Oh how I felt for this poor man.

He was to be moved back to the former hospital by the neurologist's command for extra tests. Maybe I'm being too blase, maybe this man has an intracranial tumour, I don't know and neither do the doctors. But shouldn't a painless investigation be considered and done before more invasive ones like lumbar punctures If the evidence suggest so? I don't mean to sound arrogant, but I'm pretty certain his severe OSA is what is causing his headaches, so shouldn't the patient be left to try out the treatment in peace????

Arrrgh... the pain... the wasted money... the politics of it all. So silly.

Compassion: Innate or taught?

I feel terrible, I know I re-opened this blog on a positive note, but what happenned to me today has widned my eyes to how truly selfish I can be.

A woman on the train today collapsed from what looked like epilepsy, it could have been cataplexy but I doubt she was experiencing a strong enough emotion to have experienced it at the time. Anyway, her muscles froze (more technically, her muscle tone dropped) and her eyes were wide open, I don't think I'll ever forget her eyes, wide as though in shock and unmoving as though dead...

It was really quite horrific.

The gentleman around her tried to help her and then she fell to the floor, they then tried carrying her off the train... This is where my selfishness came in. I was directly behind the group of men and sick woman and the train had come to a stop at my destination and as you can imagine they were rather slow... so slow that I was woried the train doors would close before I could get off. So vast was my anxiety for myself that I deliberately brushed past the group.

When my feet were on unmoving ground I was thoroughly mortified in shame... did I have no human compassion? No instinct to help those in immediate danger? No recognition of an emergency? I was so calm throughout the whole thing that it unnerved me. In fact, I was shaking after the whole thing had happenned because I was so shocked at myself. I didn't offer to help and didn't hang around to see if she was okay like the hero men who did. I just carried on walking to the next platform. I did go to a staff member and tell him the situation. But I was still very upset at myself.

This got me thinking all the way home of how I should be more compassionate in the future should another situation arise. But... how can you learn compassion? Is it even a taught material? What makes a person compassionate and caring? Is it because their parents taught them how, or was it something that was genetically installed? Or something else entirely?

In the end.. I feel rather cold hearted, the good bit I suppose is that I don't like being cold hearted at all. 

Quick Midnight Rant

CPG = Central Pattern generators, responsible for rhythmic locomotion like walking or swimming. No need for sensory stimulus or commands from cortex/descending tracts of the Spinal Cord.

CPGs were firstly identified in invertebrates such as the tadpole and Lamprey (what the hell is a lamprey?)

Glycinergic = inhinbitory (maintains Left-Right alternation)

Glutamatergic = excitatory (maintains Left-Right synchrony)

Blocking GABA receptors affects rythm, hence, anatgonising them will cause higher frequency of motor output.

GABA important in patterning locomotion in early embryonic life.

GABA later replaced by glycinergic inhibitory systems, and glutamatergic excitatory systems.

I'm supposed to know much more than this.