That is what the nurses on my ward have taken to calling me.
Welcome back everyone, I know it has been a while, but new job, new country, 2 episodes of homelessness in 2 weeks, and landing in “employee accommodation” that would make a cell in ancient Sparta look like a 5 star hotel, without internet, has really reduced my writing time. But has given me lots of stories.
For those of you who do not normally hang out on my Facebook, because you are not my friend, I have landed a spot in a trauma surgery department. I am actually really unsure what my job actually is. Some days I assist in theatre (the part of the job I really love), some days I hang out in the emergency room, doing the ATLS (aka Trauma for dummies) primary assessment in the resuscitation bays (another one of my favored tasks). Some days I just wander aimlessly around the trauma ward wondering why on Earth I was hired (which does not endear me to the job).
You see, trauma here is run by surgeons, who notoriously do not understand medicine, particularly pain medicine. As such, it seems for many years they have been using over-the counter medications and dosing regiments for their trauma and post-operative patients. In fact, most of the patients are getting the actual doses printed on the box, with occasionally the addition of sub-therapeutic doses of patient controlled opioid pumps, or some cough medicine( they call it oramorph) with morphine in it.
I imagine it would be perfectly fine if you had a tension headache or twisted your ankle playing rugby. But after having a major surgery like having your pelvis and/or ribs fixated, or multiple long bone fractures repaired, it does leave a bit to be desired. One patient even told me on 1-10 his pain was a 6, and he expected that would be the new normal. I asked him what his pain was because as I was passing by, he looked visibly distressed. I don’t find that acceptable at all, especially in a hospital, that has hospital level medications.
But as of my first day on the job, I was making waves. My first act was to laugh at the consultant’s order for 4 grams of paracetamol (Tylenol for the NorthAM folks) a day for a post-surgical patient and ask “why bother at all” to ordering a 5mg bolus of morphine on the same, before one of the nurses informed me they could not do that and word around the campfire was that I was a menace about to kill patients by overdose at any moment. In the same day I twice advocated for 2-4mg of midazolam, for various patients and I was promptly told “that is way too extreme.”
I was then told any patient not responsive to the Tylenol and cough medicine should be referred to the pain team for evaluation. So I thought, maybe I will just go down to anesthesia, introduce myself, speak the language of those in anesthesia and intensive care, and get their blessing for my “Yankee dodge” of actually providing pain relief to surgical patients by virtue of my long-standing history and knowledge about critical care.
With that, I marched down to the anesthesia offices. After talking to the on call anesthesia consultant, he informed me that anesthesia didn’t actually have anything to do with it (something I was quite surprised at), and that I would have to consult with the “pain team.” So in my team-building, interpersonal relationships, and general ENFJ ways, I marched over to the pain team offices, where I met 2 very kind and helpful nurses. They were very surprised to find a “surgeon” at their door at all, and certainly not one who wanted to talk about weight based opioid dosing, chemical cocktails, and acute vs. chronic pain control. They eagerly and kindly explained to me that even on the pain team they were bound by protocol, but, I, as a “real doctor”, could prescribe anything I wanted. They warned me that I would have to push it myself and accept responsibility for any outcomes. I couldn’t help but laugh and explain that as a former paramedic, and doctor from a country where nurses routinely did not push opioids or benzos, that I would have it no other way. They were even kind enough to tell me the secret code on the pain pumps to bolus right from the machine, overriding the lockout.
After returning to the ward, I started doing the unthinkable. I ditched the Tylenol, which aside from treating negligible pain, only really inhibits IL1 (the inflammatory molecule that causes fever and breaks down bone) with 2400-3200mg/day ibuprofen, shown to be better for ortho pain than even morphine, and is actually a hospital level dose of anti-inflammatory medication that reduces bradykinin’s ability to lower pain thresholds.
At first many of the junior doctors were afraid I was going to cause gastric bleeding. They had been taught in their medical schools and reinforced in their internship that using NSAIDs would result in the rapid and irreversible death of patients by gastric bleeding. The nursing staff was quick to point out that while I knew the secret code to bolus the machine based morphine, they did not feel comfortable that I shared it with them. They are still not comfortable with my requests that somebody bring me a syringe and a vial of morphine, there is no fentanyl or hydromorphone or I would call for that. Besides, fent is way too short acting for ward patients.
So every morning I go through and make plans and prescribe treatments, and a few hours later, a consultant or senior registrar comes along and cancels out everything I have done, making my job and my work pretty much superfluous. When I asked one of my bosses (I have many) what my actual role was, he told me “to take care of patients.” When I pointed out he was not letting me do that, he just shrugged and said “it will be ok.”
One of my bosses, openly questioned why I had written the orders I did, and when I pointed out I actually have a PhD in intensive medicine and explained to him how various neurotransmitters and various drugs affect them, he handed me back the chart and said “from now on, you handle pain control, and let me know if there are any problems.”
I was again offered multiple positions in anesthesia. That happens to me a lot for some reason?
Another of my superiors was not so accepting. Without knowing anything about me or my background, he took the attitude of “mid-level doctor”, you cannot possibly know as much as I do, and I read a single clinical study, designed to prove the negligible level of pain management we are providing, was in fact adequate. I so much love doctors who are amateur scientists. They actually believe that clinical studies designed to prove what they are doing is effective are in any way valid, and that they should actually be given any credibility. Sad news my friends, those studies are as worthless as the ones that were done that show cranial vault volume is proportional to intelligence. They may convince administrators, and doctors who don’t know their ass from a hole in the ground, but they are not worth shit to anyone who actually understands medicine and/or science. (This is also why nobody outside of nursing reads or cites nursing studies, because this pseudoscience is exactly what they do to prove the efficacy of nursing treatments.)
I was particularly impressed when he changed my plan with his admonishment “I disagree with your position on our paracetamol dosing regimen.” I didn’t even want to explain it to him. I just chalked him up as “too stupid to explain to or argue with.”
So, I am going about my days, effectively trying to provide pain control to patients before somebody more senior comes along and undoes all of my efforts. I still have no idea what my job actually is. But I am really enjoying 2/3rds of it. Maybe by the end of my 6 month probationary period somebody will discover I am not totally inept or a menace to patient safety.
In the meanwhile, I may have to come to terms that I am going to simply give up on my surgical career and go into anesthesia, for no other reason than surgeons don’t seem to want or even understand medicine. I am finding a strange satisfaction in reminding everyone my title is “Dr.” and not “Mr.” though. Even if by some miracle, I manage to make a go out of surgery, I think I will list myself as “Mr. Doctor” or just “doctor” instead of “mister” as they do here, to distinguish myself as being quite capable at medicine as well.
Let the good fight continue