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Diary of an FY1 – Futures

May 17, 2015

I’ve been thinking about the future a lot recently.

This is due in part to ARCP. The Annual Review of Competence Progression is a committee from St Elsewhere’s and the deanery to decide if I am suitable to be a FY2 doctor. They evaluate me in the form of ePortfolio, a mandatory repository of my exploits as a junior doctor. They should just read this column instead. In preparation for ARCP, I have been running around the hospital, gathering all the evidence that I can that I am at least competent. Filling in DOPS and logbooks as a medical student prepared me well for this.

In a few months’ time, I will be an FY2 doctor. Lord, that has a funny ring to it. A fully qualified doctor, with a few more training wheels taken off. It is entirely possible that I will have an FY1 side-kick, wide-eyed and naïve. I wonder what they, in their own Diary of an FY1, will write of their SHO. Will he be authoritarian, driven by guidelines? Cool, hip and often found napping in the doctors’ mess? Odd, but probably a good doctor? One can hope.

As I ponder who I want to be for my future FY1, I subconsciously scan the hospital for role-models. There’s an otherwise lovely SHO who seems to attract all the massive infarctions, perforations and crash calls. As a result, he is permanently on edge, waiting for the next crisis that Lady Luck will deal him. I’d rather not be the Jonah of the hospital but I don’t think I get much choice in the matter. Then there are consultants who are better at treating the patient in their head than the patient on the bed. It’s easier, I admit, but since when has medicine been about doing what’s easy? In contrast, I watched one of my consultants explore DNAR and end-of-life decisions with tender and simple language – a paragon of “That’s how you do it.” Then there’s the medical registrar who when he’s on-take, the whole hospital breathes a sigh of relief. He bats away inappropriate referrals like [insert credible baseball simile here] and deftly manages all the patients he clerks. Even my haematology registrar, cynical of general medics after so many woeful referrals, is impressed by him. It wouldn’t be a bad thing if I grew up to be a bit like him.

And then. What next? What training scheme do I channel myself down? I’ve always envied those medical students and doctors who have always known what they want to do and devote every fibre into achieving that aim. Bastards. Instead, I have been slowly whittling down my options. Surgery has always been out due to my two left hands. While I liked the generalism and cups of tea in general practice, hospital medicine gives me a much-needed run around (albeit often Kafkaesque). If I haven’t been run off my feet, I tend to get cranky. Haematology has taught me that I have a love of learning above all – I need a specialty where I am always learning.

And y’know what? Microbiology has been growing on me all year. Dealing with quirky UTIs in urology, then the lurgies of patients with bronchiectasis and now neutropenic sepsis in haematology, microbiology has featured throughout this FY1 year. I’ve grown to think of Pseudomonas as a personal nemesis. And all this time, the microbiologists have been at the end of a phone, like the hospital’s Wizard of Oz, dispensing wisdom and permitting my use of ciprofloxacin. The way they conjure up solutions in the theatre of bugs, drugs and rock n’ roll – I’ve got to admit, its sexy.

But in haematology the future will be terrifying. As I’ve said before, patients come to us with some kind of acute leukaemia and we craft a bespoke cocktail of poison to treat it. That’s not terrifying – that’s just business as usual. The problems start after the chemotherapy. The drugs target the most-rapidly dividing cells, which is fine for anarchic myeloblasts but also hits the gastrointestinal mucosa, hair follicles and the bone marrow as collateral damage. These are problems that we can do something about. You would be surprised at the difference that a regular mouthwash regime can make. Ailing numbers of erythrocytes and thrombocytes can be boosted, buffered and buoyed by red cell and platelet transfusions.

For hair loss, we do have a wig specialist in our multidisciplinary team. However Big Pharma have yet to patent a pill or injection that can ameliorate the crisis of identity and self that can come with losing locks. But we do what we can and most patients I’ve seen so far have taken it quite well.

The infections are another matter. The patient will spike a fever, we’ll draw blood cultures and start antibiotics, Tazocin and gentamicin being our favourite opening gambit. Then, a few days later, another fever. We take more blood cultures and up our anti-microbial game. At this point, we might see a positive change – fevers disappear, CRP begins its descent, the patient feels better.

But equally, I have gone into work to be greeted by news that things aren’t getting better. The patient is still spiking fevers and feels awful; the antifungals have knackered their liver; the tag-team bruisers, gentamicin and vancomycin, have stuffed the kidneys. At this point, the microbiologists roll up their sleeves and I perform a ritual dance on the hospital roof for neutrophils to bless our barren bone marrows.

And even then, we can’t catch a break. I’ve seen a patient spike fevers while on six different antibiotics. We’ve pulled PICC lines, motorways of IV access, for fears of biofilms and endocarditis. In the face of these infections, I’ve seen microbiologists left speechless and shrug – the only weapon left is time.

So far, these scenarios – a microbiological Kobayashi Maru – have only affected a few of our patients. Of those who develop these infections, most will respond to Tazocin or maybe meropenem. The fevers break, they get better, I breathe. But as the arms race between man and microbe runs on into the 21st century, the bacteria will continue to evolve as they have always done. Our antibiotics will lose their edge, and we’ll have to give them in larger, more toxic doses, or novel combinations. But more and more, we run out of drugs to give and what then?

I’ve seen the future and it scares me.

One Comment leave one →
  1. May 17, 2015 2:37 pm

    Like it!

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