Primary Anaesthetics Exams next year in August. And this is how I feel right now! Now, unlike Linus, I am studying but the more I read, the more I realise how little I know...

For those of you who know me, I'm not the slimmest chap on the block. I'm in the process of sorting that out... Poorly, but I'm aware it's a problem. However, there seems to be a subset of fat people who have no insight into their problem of being horizontally challenged.

I just came out of the staff carpark and this fat woman was parked on level 2 as well. Whilst I chose to take the stairs, she chose to take the lift. Now, she might be taking the lift so that her knees that are sore from carrying all that extra weight can be saved from tackling the one flight of stairs to the ground floor. More likely this was a sign of the laziness that led to her obesity in the first place.

To all the fatsos out there. If you're going to take a lift, park up at the top level so physically active people can get a spot that's closer.

A topic of discussion has hit the SRMOs this week in view of the job offers for training next year. Predominantly, the talk has been about who should have missed out and who we wished didn't miss out. Let's be honest...not every doctor is created equal and in the end, we are all humans so everyone has their own idiosyncrasies. The SRMOs as a group this year is a really good bunch and if possible, I would prefer everyone to get on the training program but four of us didn't; a whopping 30% mostly due to interview issues as far as we can tell.

I have reservations about  certain SRMO who did get a job next year. He's a bit of a loose cannon and has some issues with being power hungry, so to me, he is the ugly duckling. In my opinion, I don't think he is suited for a career in anaesthetics and I can imagine that the only thing that will take his arrogance down a notch would be a catastrophic patient event. And two other SRMOs I have talked to have agreed about this. Of course, we all smile when working with him but a recent conflict at work between him and another SRMO has highlighted to me exactly how difficult it may be to keep a cordial relationship. Despite objections from the medical registrar and the other SRMO, he gave a patient in active CCF and having a NSTEMI 5mg of IV metoprolol for hypertension (clearly GTN would have been a better choice). What would I do if I saw him doing something that would be unsafe for the patient? The bigger issue is after the matter, he tried to downplay the mistake to the bosses by saying "it was a slow push"; clearly lack of insight is an issue here.

So what do we do with this ugly duckling? Can we wait for him to turn into a swan? WILL he turn into a swan? None of us are excited about studying with him and certainly this will affect us next year but at the moment, it's all just questions in the air. For now, let's just help the remaining four SRMOs get jobs for next year.

Just got notified of jobs for next year. Apparently Monash feel I'm going to make a good anaesthetic trainee. However, the same cannot be said for some of my colleagues and there was the awkward moment in the Whatsapp chat group where people announced they got a job followed by those that said they missed out.

What are you supposed to say under these circumstances? "Sorry to hear you missed out on the job"? Or should you remain silent and let the awkward moment dissipate? Or maybe you should change the topic to something else.

So far, three out of twelve people have said they don't have a job for next year. That's a fail rate of 25%...higher than expected for the SRMOs who pretty much spend the whole year doing anaesthetics. I suppose there must be people who miss out for each job position but the feeling is terrible when it's someone you've worked with for the whole year.

Different specialities often have different perspectives when looking at a patient, sometimes to the exclusion of other details. On Friday, I was looking after a patient who had a prolonged procedure for an elective parotidectomy, it went until 7pm and beyond. The mass was the size of a tennis ball so I can understand why it took so long to excise it without damaging the facial nerve.

When talking about this case with Yeu Sheng, her first question was "What type of malignancy was it?" It was only then that I realised that I actually didn't know. I shrugged and said, "I presumed it was malignant, they had to do frozen sections to make sure it didn't spread to the scm. The only thing I care is whether it affects my airway really.... The diagnosis doesn't make a difference to me."

Interesting to see what our blinds spots are if we don't pay attention to all the details :)

Ever look at yourself after a busy night shift? Or after a shift where things just don't work out for you? Our job typically is so soul draining that vital exhaustion sets in, often many hours before you finish. I have seen this in my eyes when I get home sometimes, the look of vacancy and fatigue that's more ingrained than just the bags under the eyes or the wrinkles at the edges.

Just walked past one of the night doctors leaving Clayton, don't know her but she had dead eyes. Her gaze was so vacant, I could have sworn she was sleep walking.

How does one avoid this? Not sure really... There isn't any effective way that I'm aware of. Some turn to alcohol, some exercise, some binge eat. Who knows?

Interesting comment in orientation today. Being an anaesthetist is like being a superhero. Physicians and surgeons are like normal cops, they can deal with the normal sick patient. ICU and ED are like the SWAT team, when your patient is deteriorating, they come in and try to control the situation. But when you have an arrested patient or difficult airway and everyone else is shitting their pants, the anaesthetist comes in, fixes the ABCs and saves the patient, then leaves and let's everyone else sort out the rest saying, "bye, I've got other patients to save. Call me if you need me!"

Courtesy of the anaesthetist doing our orientation today :-)

Yesterday I was in short stay. There was a patient who speaks Croatian. Also has mild dementia. After a very difficult history with a phone interpretor, we decided he needed repeat bloods and a surg review. So I organised that, end up needing Gen med review and then home. I called his wife to come pick him up and gave a discharge letter to him and told the nurses to remove his IV. Three hours later, the nurse in charge comes to tell me, "Did you say to the nurses to put Mr X in the waiting room? He was put there by the afternoon nurses and the family is here to pick him up but he's gone." Well of course I wouldn't say that... I want someone in the bed so I don't get another patient but I think my exact words were, "If the nurse in charge is happy, he can stay in bed for family to pick him up."

Then comes the craziness of trying to find the patient. Eventually we hear from the family that a stranger found the patient in Mt Waverley and took him home because he still had an ID band on. Ended up coming back to hospital and admitted for mild rhabdo... Walking out in the sun for three hours. Thank god for stranger love :-|

Just saw a kid who looks like he's barely 18, coughing and coughing and then pulls out a pack of cigarettes. See you soon when you have your first admission to ED with COPD or when I tube you for your lung cancer lobectomy B-)

I've found something worse than acopic rehab nurses; it is acopic ED nurses.

Yep, you wouldn't believe it but they do exist. Tonight in ED, it was a particularly bad night, even by MMC standards. At the end of the night shift there were 30 patients waiting to be seen, some hitting 4 hours already. At one point in the night, I counted 15 patients arriving in one hour; terrific.

This shift was made worse by this one nurse I had to work with. Now, to be fair, he is in the less acute area of ED which is probably not as well staffed as the rest of the department but when there are so many patients waiting, you just put patients wherever you can find a bed right? I saw a lady with end stage metastatic non-small cell lung cancer. She had come in with APO because someone thought it was a smart idea to stop all her regular medications in preparation for end of life care but did not put a plan in place for when she would inevitably go into rapid AF and APO. Whatever. The true problem is when I saw her, she did not look well. Imagine peri-arrest. Gurgling in the upper airways, breathing at 40 per minute, heart rate of 190 and BP 200/140. Saturating well on 10L at least but that was her only saving grace.

When I walked in, the first thing this acopic nurse asked was: "Can you document her NFR? Because she's palliative, we don't want to do CPR on her if she arrests here." My first reaction, "Hang on. She might be end stage cancer but surely we won't let her just die from hypoxia and respiratory distress right? I'll talk to the family and patient and get it documented but I want to see her first OK?" It took all my effort to stop rolling my eyes as he walked out of the cubicle. I ended up putting in a cannula, taking bloods and writing up some frusemide, antibiotics and IV magnesium. When I went out to find the nurse, I was met with the same request, "Can you document her NFR?" Now, I wanted to lose my temper at this...there's a sick patient in your cubicle who needs some treatment and all you can think about is what NOT to do if she deteriorates? Who the hell are you???

I gave my orders and walked away to talk to the consultant about CPAP for my patient. After I came back, guess what? None of the medications given, not even the frusemide. Partially because the patient wanted to go to the toilet so he had gotten a pan for her but surely somewhere along the line he could have had the medications drawn up. I went in and asked him to give the medications and get some morphine for her respiratory distress. You know the reply? "I can't do it" and he walked out of the cubicle. Excuse me? What do you mean you can't do it? If you can't then who can? Luckily my patient was transferred to resus soon after to get her CPAP so I didn't have to strangle this nurse personally.

Later on in the night, I was walking past another one of his patients who was half sliding out of bed. I managed to stop the patient from falling and got her back into bed, saying I will go find her nurse to get a pan for her. Once again, he was standing at the desk (sort of around handover time I think) and I said, "Hey, I just stopped your patient in A6 from falling out of bed. Want to get her a pan or something?" and he replies, "Yeah, she's too big so I can't get her onto the pan. I'm looking for someone to help." I had no sympathy so I told him, "Well, do it now before she starts climbing out and has a fall. I've already saved her once, not going to do it again." He looked sort of not impressed and simply said to me, "Well, she shouldn't have been put in the cubicle anyway, she's too unwell for that cubicle." Now, A6 is supposed to be a psych cubicle but putting medical patients in there is a frequent occurrence. Either way, I didn't care much for the excuse that this lazy fat-ass was giving me so I just said to him, "Sorry, I don't care. If you have a problem, take it up with the nurse in charge who put her in there. Otherwise, get it sorted before she falls."

Unbelievable. Never thought there was such a thing as acopic ED nurses but apparently they do exist. I haven't met this nurse before; hopefully he's agency/bank and I'll never see him again.