Gas Man

Colin Black

• Publisher: HarperCollinsIreland
• Year: 2021
• Print ISBN: 9780008541156
• eBook ISBN: 9780008470159
• Topic: Medicine
• Subtopic: Medicine Biographies

Part 1

How to Become an Anaesthetist

Medicine

I didn’t always want to be a doctor. It’s not the family business; there are no doctors in my family. I surprised myself and my parents with my Leaving Certificate points haul, beating my parents’ predictions by 80 and 85 points respectively.1 ‘How did you get those points, Colin?’ asked my form teacher. I literally have no idea. So, I headed into University College Dublin (UCD) as a physiotherapy student, determined to become part of the set-up at a Premier League football club. Picking up Dennis Bergkamp from the pitch, dinner parties with Patrick Vieira, charades with Tony Adams, playing golf with Thierry Henry. That was the job I wanted. Unbeknownst to me, the role of a physiotherapist consists of a lot more than picking up overpaid prima donnas from a football pitch.

It was during one practical session in which we learned how to vigorously expel sputum from the murky depths of a patient’s lungs, or perhaps another on how to help to stabilise the pelvic floor during pregnancy, that I decided that this career wasn’t for me. I barely passed the first practical exam at Christmas. But what I had discovered was the subject of physiology: how the body works. The only way for me to pursue this further was by studying medicine. After one year of life as an unenthusiastic physiotherapy student, I made the switch, scraping my way into medicine. I was yet again entirely naïve as to what sort of life I was embarking on.

Our system for entry into university is not a good one. In the minority of cases, a teenager has a burning desire to be a doctor/police officer/trapeze artist, and always has done. The fact is, though, that the majority of teenagers haven’t the faintest idea what they want to do. How can you when you’ve spent most of the last five years trying to become a professional footballer or an Instagram influencer? Medicine is a very interpersonal and communication-heavy vocation. Social skills and emotional intelligence are almost half the job. There are some doctors I know who would be best placed in a back office, well away from any human interaction, for the sake of both parties.2 There are many doctors who found their way into the profession by simply retaining and regurgitating facts on one sunny day in June better than the other candidates.

Studying medicine is hard. It’s not that the concepts are exceedingly difficult or abstract at undergraduate level, it’s the immense size of the syllabus. You literally learn everything about the human body. We learned the syllabus in blocks, from the ground up. First, anatomy, physiology and biochemistry – the basic sciences of medicine.

For example, the renal system. Renal anatomy: what are the anatomical relations of the kidney in the abdomen, label the anatomical features of the kidney, what is the blood supply, what is the nervous supply, what is the histological appearance of the kidney? Exam question: Describe the anatomical features of the urinary system with emphasis on blood and nervous supply. Next, renal physiology: what are the functions of the kidney, how does it perform these duties, where are some of the therapeutic drug targets within the kidney? Explain the role of the renal system in arterial blood pressure regulation. Then, renal biochemistry: what cellular mechanisms are involved in these processes, how does it affect your electrolyte homeostasis and fluid balance? Draw and label the structure of the nephron and emphasise mechanisms used to control sodium resorption.

Next we move on to when things go wrong. We learn how to diagnose and how to treat various ailments: pathology and pharmacology. Staying with the kidneys, renal pathology: cancer, vasculitides, glomerulonephritides, drug injuries, auto-immune disease, congenital abnormalities.3 Compare and contrast nephrotic and nephritic syndromes. Then, renal pharmacology: what drugs affect the function of the kidney, what biochemical receptors do they target, how do they work, what are the desired effects, what are the side effects? Classify diuretic medication with emphasis on the mechanism of action within the nephron. This process is repeated for every single organ system in the body. Breathe, but don’t rest; you’re only half-way through. That’s just the ‘pre-clinical’ years.

Next, the ‘clinical’ years, covering rotations in medicine, surgery, obstetrics, paediatrics and psychiatry begin. Hundreds of medical students are released into the hospital system to spend the next two and a half years trying to make sense of it all. Heads bursting with new words, speaking in tongues. Pneumothorax, Wegener’s granulomatosis, Virchow’s triad, carbamazepine, schistosomiasis. White coats bleached and pressed by proud mothers. Some cheeky bastards even put on a stethoscope, but it’s far too soon for that.4 Those who prematurely bear the weight of the stethoscope across their shoulders will shrink in confidence after a dressing-down or two from a real doctor, and quickly stuff the offending guess-o-scopes back into their pockets. We nervously escort each other around the wards, the blind leading the blind, a bunch of lemmings plunging over a cliff into the frosty sea, squealing inappropriate diagnoses and irrelevant investigations. ‘What investigation would you like to perform for migraine?’ Em, a brain biopsy?

At this point we begin to learn the core elements of being a doctor: the skill of history-taking – asking the patient all the relevant questions about why they have come to see you – and clinical examination, examining the patient for evidence of the disease process you suspect to be the problem, based on the questions you asked. We disperse and roam the wards. We are initially quiet as mice, not wanting to get in anyone’s way. But closer to exams, we are more like bleating goats, head-butting our way onto crowded wards.

On escaping from our cages, we start by relentlessly pestering the nurses. ‘Are there are any patients we could talk to or examine?’ The nurses pull out the patient list and point us in the direction of beds 6 and 9.5 Medical students are very discerning in whom they choose to interview on the wards. Hhhhmmmm. We can be seen coyly screwing our heads inside the wards, ogling the suggested patients. It is imperative you have a good gawk before committing. You shouldn’t judge a book by its cover, but by God we judged all those books. Bed 6 appears to be asleep but wakens to start chatting animatedly to the fruit hamper left in by Annie from next door. Bed 9 just doesn’t look like a good patient; you can’t put your finger on it. This won’t do. Medical students are picky. We go back to the source and ask for another recommendation. Interrupting the nurse twice is not acceptable: it’s 3.10 p.m. and she has eight more patients to get to in the 2 p.m. medication round. We get the message to move on to another ward.

We saunter down to the adjacent ward and meet a classmate in the corridor:

‘Any good histories? Any signs?’

This is a frequent question. A ‘sign’ is a positive finding on clinical examination such as a heart murmur or a lump in the abdomen or a hamster in the rectum. God help you if you are ever in a hospital as a patient with a ‘good sign’. Be warned, it is not a good sign for you, as you will have a queue of medical students out the door asking you to expose your abdomen/boobs/genitalia. If you seem particularly comfortable with the students you’ll almost certainly be asked to take part in the medical examinations as a live subject.

When a diligent medical student has been brave enough to take a full history and examine a patient, they will seek out a real doctor and ask if they can ‘present’ the case. Presenting a case is also a core skill, as you use this technique to talk to superiors and peers for the rest of your career. The idea is to summarise the reason a patient is in hospital and their relevant medical history, present the findings of your clinical examination and come up with a differential diagnosis (what might be wrong with the patient). You follow this with a list of tests you might request to confirm your suspicions, and offer some potential treatment plans. The key is to present only what is relevant. Novices at presenting a history will insist on telling the listener what size shoe Frank bought from TK Maxx last week as if it were a clue as to why he has been having explosive diarrhoea.

Presenting a case to a new intern is not daunting as they will be helpful and offer pointers on how to keep it succinct. Presenting a case to a registrar is scarier, as they will point out all your omissions and your shortcomings as a human being, then sigh as they realise that the break they had been looking forward to will now be spent straightening out medical students. But if you are presenting to a consultant, you better hope you put on a second pair of underpants that morning. They can be scathing and intimidating, but crucially they are training you to be accurate and precise, as this is what is necessary when you call a superior at 3 a.m. asking for advice.

I owe my medical degree to a professor of obstetrics and gynaecology. He scared the living daylights out of everyone. He detested tardiness and untidiness. He could see through a bullshitter with a passing glance. He remembered everyone. On our first day, 40 of us sat in the lecture theatre as he called the roll. With each response, he glared and imprinted each face into his vast mental catalogue of medical students. He forgot no one’s name. Ever.

‘Mr Black, you’re on nights in the labour ward this week.’

What the …? Nights? I’m a student, I go drinking at night. I sleep for 11 hours a day.

‘Yes, professor.’

We heard that he hovered around the halls at night wearing a black cape. But, if you managed to overcome your terror in his forbidding presence – and if you knew your stuff, he would pat you on the back and say well done. I have never studied so hard in my life. I wanted that pat on my back. I learned everything there is to know about pregnancy, the female menstrual cycle and where to find the clitoris. This was all to avoid his wrath. I didn’t intend to do well, it was all an avoidance exercise, but I achieved first-class honours in my final obstetric exam. It might have been a first achieved through the modus of fear, but it showed me what I was capable of and what level of dedication was required to make it.

The last of the clinical years is the formative year. You follow the doctors around more, you rotate through different specialties, you go to the operating theatre for a close-up view of real surgery. You get a sense of what the job is really about, you start to think like a doctor and, hopefully, you get a feeling for what specialty interests you. All the exams from this point are largely clinical – meaning they are with a real patient. Although it’s supposed to be where you can demonstrate your knowledge, it can be a frightful experience.

The crux of the clinical exam is the ‘long case’. On exam day, an invigilator meets you at the entrance to the ward and, with a curt smile, gently guides you to a room on the ward. A curtain is drawn and you meet the gaze of the expectant patient in front of you. Suddenly, you are thrown in to the bedside with the briefest of introductions and 20 minutes later, on the button, the examiners all arrive. The examiners, all being consultants, naturally cut you off mid-sentence. You present the case, offering a differential diagnosis and how you might treat the patient. The ideal scenario is to have a medical patient when one of the examiners happens to be a surgeon, or vice-versa, a surgical patient when one of the examiners happens to be a physician. At least in this case, you can assume the surgeon isn’t completely up to speed with the latest high-tech immunomodulating drugs used to treat chronic rheumatological problems, and thus won’t be quizzing you on them. Not that you know anything about them either. The worst scenario is seeing the professor of medicine, with her head bursting with the latest research developments across the entire medical spectrum, walk in and you’ve been extracting information piecemeal from a suitably demented medical patient and thus have no clear information for your performance. After your limp presentation, there follows a barrage of questions. You attempt to duck and weave your way through the entry-level questions for a pass. You sweat and flounder your way through the honours questions. An almost deathly silence descends as you attempt to describe the histological appearance of Langerhans Cell Histiocytosis to a consultant haematologist for first-class honours. Your body starts to incinerate itself from the inside before, mercifully, they let your burning carcass rest inside that once-pristine white coat. Off to the pub to dissect the exam. Am I a doctor yet?

To a medical student used to spending almost an hour talking with a patient on the wards, 20 minutes to chat to a patient in an exam scenario is not much time at all. Often, these extended pre-exam practice chats are the result of being too polite to redirect an elderly pensioner back from his tales of life as a young whippersnapper climbing trees in Mullingar to the salient question of why he is in the hospital in the first place. Come exam time, politeness goes out the window. You have 20 minutes to extract all the information out of a poor patient who is being asked the same questions for the fourth time today.

‘So, Mary, what brought you to the hospital?’

‘I had a turn.’

‘Ok, what do you mean by a turn?’

‘I felt a funny thing.’

Suddenly it feels hot in the room.

‘Can you be more specific, Mary?’

‘Well, it’s like when you know something is not quite right, you know?’

‘Did you have pain?’

‘Not really.’

A bead of sweat forms on your brow.

‘Did you have trouble breathing?’

‘No. Are you from Dublin or do you just go to college here?’

‘I’m from Dublin, Mary. Did you vomit? Did you faint? Were you short of breath?’

‘I went to UCD years ago. It used to be all fields around here you know.’

JesusfuckingChrist, Mary, answer the bloody question! The examiners will be here in 11 minutes and I haven’t a fucking clue what’s wrong with you!

Doctor

For me, choosing my medical subspecialty was a process of elimination. As I never knew I wanted to study medicine, I certainly had never given any thought to what type of doctor I wanted to be. My wife is a senior surgical trainee in urology. Her father is a surgeon. For as long as she can remember, she always wanted to be a surgeon. Many of my friends are general practitioners (GPs) and they have always wanted to follow that path to follow their parents. I started narrowing down a mental list in my final year of medicine based on what I felt to be valid reasoning. Surgery – too long to train, what if I’m just shit at it? Obstetrics – too high risk, don’t want to be sued. GP – too much talking. Pathology – not enough talking. Radiology – too lonely, would spend too much money on coffee. Psychiatry – my beard is not strong enough. Internal medicine – too many endless ward rounds and overbooked clinics. My goal appeared to be a specialty with a moderate length of training, in which I wouldn’t spend all my money on legal advice or coffee, or have to talk to patients either too much or too little, with instant gratification and no ward rounds. I had my intern year to ponder this conundrum.

The hospital hierarchy from the most junior position up is as follows: intern (also known as house officer, or your foundation year in the UK), senior house officer (SHO), registrar, specialist registrar (SpR), fellow (only in some hospitals), then, finally, consultant.6 As an intern, although you are a bona fide doctor, you really have the role of administrative officer for your assigned team. It feels more like being a medical student with a folder and a list of patients rather than real clinical doctoring, certainly during daylight hours. The day job consisted of begging other specialties for consults, begging radiology for CT and MRI scans and begging the nurses to cut us some slack. Please just do it! My consultant wants a CT scan, I don’t know why. PLEASE. We were sweaty beggars roaming the hospital with enough paper under our arms to start a decent forest fire. By the end of the day, we were expected to have followed up on results of various investigations and have all the information to hand for when your registrar or consultant embarked on a ward round. It is flat out, but mostly clerical work.

As an intern, you are ‘on call’ at night on the wards and thus have a bit more legitimate medical facetime with patients. However, there are several more senior doctors to call immediately if any patient is looking a little ropey. The majority of your calls from the nursing staff at night are still for mundane tasks such as charting pain relief or siting a new intravenous (IV) cannula. The IV cannula – the gateway to drug administration, the bane of the life of an intern. Why is something so simple and inane more troubling than singlehandedly cracking the human genome for the fresh-faced intern? The perhaps shocking truth is that medical graduates do not have the faintest idea how to perform many of the elementary tasks one associates with being in the hospital (IV cannulas, urinary catheters, suturing of wounds). You learn and practise on real subjects, as an intern.

Let me give you an example. An arterial blood gas (ABG) is a sample of blood taken from an artery, usually performed if someone is looking fairly peaky, as it gives you heaps of very valuable information. It can tell you in mere minutes the pH of the blood, the blood oxygen and carbon dioxide levels, the haemoglobin, several important serum electrolytes (e.g. sodium, potassium) and the lactate level (a measure of anaerobic metabolism – not what you want). These are all fairly non-specific measures in that they tell you what is wrong, not why. You still need to use your brain somewhat. But if any of the measures are grossly abnormal, you’ll need to take action soon to prevent further deterioration. Having an ABG sample taken hurts, but a registrar could take a sample with their eyes closed with one little poke in a second or two. Even after months as an intern, one former colleague of mine had such trouble with it, he would advise patients that the procedure would involve ‘five or six little pokes in the wrist, and take about 15 minutes’. If he managed to successfully obtain the blood sample in only three or four attempts in half the time, the patient would be delighted. Medicine is all about managing expectations, I learned.

Interns wade through a lot of shite at night and over the weekends. Some patients decide that 3 a.m. is an appropriate time to...

Table of contents

• Title Page
• Copyright
• Note to Readers
• About the Author
• Dedication
• Contents
• Author’s Note
• OBSERVATION: An Introduction
• PART 1: How to Become an Anaesthetist
• PART 2: Observations of an Anaesthetist
• Epilogue
• Notes
• Acknowledgements
• Glossary
• About the Publisher