I was in Mexico last week, and whilst wandering around the streets of Ensenada I was startled by the amout of pharmacies – to the extent that often every second shop would be a drug store of some description. I was fairly surprised, and didn’t really get why there would be so many pharmacies in one place.  I asked my boyfriend (who is from the US) about it, and apparently there are a LOT of medications that are available in Mexico either without a prescription, or substantially cheaper than they are in the US. Amongst the drugs advertised were:

• Pretty much every kind of antibiotic: penicillin, amoxycillin, erythromycin, ciprofloxacin, doxycycline, metronidazole, and oral antifungal medication
• Viagra
• Ritalin
• Disulfiram
• Premarin
• Paroxetine
• Valium
• Citalopram
• Tramadol
• Vicodin
• Oxycodone
• “Atridol” – a dangerous drug manufactured in Mexico. It is a combination of indomethacin, methocarbamol and bethamethasone and is not authorized for use in the US or elsewhere.
• Prozac
• Zoloft
• Phentermine (an anorectic drug for weight loss that has many drug interactions)
• Tretinoin
• Isotretinoin

Wowser. I’m pretty disturbed by this list – considering how restricted these drugs are where I am from. Many of these drugs are very dangerous and can cause death or serious side effects. Many of these drugs I am hestitate to prescribe, even with a medical degree! And isotretinoin I am not even allowed to prescribe, as I am not a dermatologist. I’m not going to go through the list and say why it’s frightening that these drugs are available, because I could write paragraphs on each of them – needless to say, I have never, in my sheltered existence, come across a place where medication was not regulated! I did not even fathom that such a place could exist.

However, the situation at a hospital is markedly different. And in particular when it comes to socialising or being on good terms with nursing staff.

I learnt very early on in my intern year – actually, when I think about it I learnt very early on in medical school  – that it is imperative to be on good terms with the nursing staff, or they can make your life very, very difficult. I admire and respect what nursing staff do immensely, especially because I do not think it is something that I would be able to do – it is a lot of work, and is often work that is devoid of praise or glory for the most part. Nurses are the ones who keep the wheels of the hospital turning, and make sure that the things that need to get done do in fact get done. They tie up the loose ends that we doctors sometimes over look, and save us from our mistakes before they have a chance to have an adverse affect on a patient – or on our lives or careers!.  It makes life a lot easier if you can be on good terms with those who have so much effect on your working life. I had a nurse tell me once that if the nursing staff do not like a particular intern then they will go out of their way to call them back to the ward to perform unneccessary tasks, and effectively think up extra work for them to do; if they like you then you have a few extra people watching your back, which is always nice when it is peoples well being, and sometimes their lives, at stake.

All of this said, the truth is that it is very difficult to be true friends with a nurse if you are a doctor. It’s something that I have found has bothered me quite a bit this year, and more than I thought it would. I am on great terms with many nurses on the wards I worked at; when I was working nights I would go and hang out in the nurses station and eat chocolate with them if I was not busy, and gossip about what was going on in the hospital. The fact is though, that depsite all of this cameraderie, I am still the one who they have to call to make decisions for a patient, to sign things, to authorise things. Naturally there are times when I make a decision that they do not agree with in regards to a patient, however because I am the doctor they have to action it, because I have the final say.  As nicely as you can put it, and as casually you can say it, it does still make a difference when you have people asking you for your advice, opinion, and when you are essentially telling them what to do. For this reason there is always this power imbalance between the nursing staff and the doctors, that does not always come from one thinking they are better than they other, but regardless is there and is keenly felt.

Nursing staff have a great deal of camaraderie amongst themselves as a group also, and much of this comes from the feeling they have that they are a unit against the evils of the hospital, the patients, and the egotistical attitudes of the doctors. It is a sense of camaraderie that it is difficult to have with fellow doctors, for the simple fact that we are often one of only 2 or 3 doctors on a ward at a particular time – there is no denying that when I get together with my medical friends there is that sense of belonging, but it is one thing to experience that on occasion in a casual setting, and another to have that sort of team attitude and togetherness on a daily basis. In addition doctors are by nature exceptionally competitive, and it is a rare occasion when I am working side by side with another doctor without some kind of competition coming in to it – who made the better decision, who knew the most about the patient, the treatment, the diagnosis. Sometimes I look at the nursing staff and long for that kind of ‘family’ ethos.

All of that said, I don’t think I am about to turn my stethoscope in, not just yet. I’m kinda enjoying being a doctor, despite all of the above!

“We all love nurses, because they do the jobs we hate, and look out for us when we are just learning. They also gave the correct dose of drugs when you accidentally wrote milligrams instead of micrograms on your first day. We need them. But…

…there are a few points of etiquette that are unwritten, unspoken, but you just wish every nurse read, understood and inwardly digested:

1. Bleeping/paging is not a spinal reflex. Please take a few seconds to breathe, think and organise your thoughts, and stop flapping about. Half the time you may realise you didn’t even need to pick up the phone.

2. Mention what ward you are on. I don’t have the whole hospital directory of numbers memorised. If you hang up before telling me, chances are I won’t come along. This is called the ‘bingo-bleep’.

3. If you bleep/page someone, please wait by the phone. How can there be no-one picking up the phone at your end when I ring back?! This is called the ‘bleep-and-run’ and is exceptionally irritating.

4. Have the notes, obs chart and drug chart in front of you. Chances are I need to know what the obs were without waiting for you to run over to the bed and look, then run back over to the trolley to get the notes when I ask the next question. This is called the ‘relay-bleep’ and is probably not fun for you.

5. Please mention the name, age, and working diagnosis of the patient. The following is not acceptable: “Hello doctor, please see patient in 4, 6, she has chest pain”. That is ‘bleep-spam’

6. All patients with chest pain need an ECG. Don’t bleep/page me until one is being done or there in front of you.

7. If I’m in theatre (surgery), leave a clear message. The following is not acceptable: “Can you come to the ward afterwards, there are a few things to do”. This also counts as ‘bleep-spam’

8. Once in a while I will not respond to my bleep/pager. This is because I am jumping on top of someone’s chest trying to save their life. I am NOT ‘on break’. Doctors don’t have these.

9. Please check with the other nurses that you aren’t asking the same question as them. I really hate being bleeped/paged from the same ward from two phones and two nurses for same patient. This is called the ‘déjà-bleep’ and is distinctly un-fun

10. You spend twenty times as much time with each patient than we do. We appreciate your opinion and pertinent information. The following is not acceptable: “Well you’re the doctor, you should know”. Well actually I’m on call and have never met this patient who has spent 5 weeks with you.

11. Please be cheery on the phone and perhaps even flirt a little. I’ve just spent 12 hours running around the hospital doing mundane tasks, talking to angry relatives, putting my finger up bums, taking blood and ordering xrays. You will get your way far easier by making me smile.

12. When I answer the bleep/page please don’t say ‘Oops, sorry I had a question but not any more”. This is called the ‘fart-bleep’ and gets on my nerves (See also point 1).

13. Please don’t ask me to see virtually every patient on your ward when I’m on call. That’s called a ward round.

14. If you do cannulae on the ward regularly you will be my favourite nurse and I will do anything you say.

15. If I answer my bleep/pager and the line is engaged because you are bleeping/paging me from that phone again, I may well explode. This is called the ‘torpedo-bleep’ because of its incessant battle with my morale. Three hits and the boat may sink.

16. If a patient has died, he/she no longer cares how long it takes me to get to the ward. That’s a medical fact. Chances are I can do a few other jobs on my way there. If you bleep me again for this patient it better be because they have miraculously come back to life. This is called the ‘Lazarus-bleep’

17. The ‘MEWS / EWS / EWSS / PARS / MET’ score is a trigger for you to call me and is useless after that. I don’t give a crap what the score is. Tell me WHY the patient has scored it (e.g. respiratory rate? BP? heart rate?).

18. Please don’t start a sentence “Just to let you know…” or “Just so you know…” I hear this 50 times per shift. This is called the ‘zombie-bleep’ and you have just inadvertently disengaged my brain.

19. Please don’t bleep/page me and then instantly walk over to the other side of the ward to continue washing a patient behind a curtain. That makes the person who picks up the phone have to search for you miles away from the phone. This is called the ‘bleep-and-hide’ (See also point 3).

20. Don’t have someone else (e.g. a student) bleep/page for you. It’s cruel to them, and they are not your secretary. This is called the ‘kamikaze-bleep’ (see also points 4, 5 and 19)

21. Dosing a patient’s warfarin (whom you have never met and don’t know their history) at 4am is horrible, tedious, legally dubious and just plain bad for the patient. Please slap the day team round their faces when they arrive the next morning and don’t let it happen again.

22. Sit down! You may be surprised with how much this helps points 1, 2, 3, 4, 5, 9, 11, and 19

23a. If you happen to have a spare moment, eavesdrop when a doctor bleeps/pages another doctor. The majority of the time you will see how it should be done.

23b. Sometimes point 23a doesn’t work because the doctor is a week old and still learning the ‘etiquette’. He/she will learn very quickly as their senior on the other end shouts them down!

24. When a patient is in an ACUTE confusional state, please do not repeatedly ask me for, or demand sedation. This is not the year 1912. I might give sedation AFTER ruling out an infection, over-medication, drug withdrawal, metabolic cause, trauma, neurological, hypoxic, endocrine, and vascular causes, and AFTER using every other method of calming down the patient.

25. Read the latest entry/entries in the medical notes. Your question may be answered already (see also points 1, 4, 12, 13)

26. Please don’t bleep me half way through a ward round to ask whether we will be seeing a patient on the ward round. The answer is yes, and I’ve just missed what my Consultant said because I had to answer the phone to tell you that.

27. If I’ve told you I’m on my way to your ward, please don’t bleep again. Chances are that you have actually STOPPED me getting there while I went to the nearest phone. This is called the ‘road-block-bleep’

But it is not. The sad but stark fact is that we do treat patients who are seriously ill and so young differently to those who are seriously ill and past the prime of their life. Medicine should be objective, and everyone, regardless of age, should be entitled to the same treatment. But the fact is that if I miss something when I am reviewing my patient who is 87 and he dies, we will all be sad and briefly mourn his loss, but it will not reverberate through our lives for long – he was old, he was sick, it was his time. Whether or not it could have been prevented we will fall back on his age and not blame ourselves too much – for a he lived a good, reasonably long life. But 27 year olds are not supposed to die – 27 has too much wasted potential. If I miss something it will not be ok. Which is why I took my notes, all of his ECG/EKGs, and all of his test results and discussed it with my superiors to ensure that there was nothing at all that I could have overlooked.
When someone is young you don’t take chances. It makes you realise that medicine is not just a science; you cannot be a doctor and at the same time also not be a human being. The only thing that made me so much more thorough on this occasion was not a certain alarming symptom or sign that was different in this case, it was that the tragedy of the loss of this life would be too great to take a chance with.
All of this makes me sad, I guess. It’s not that I am negligent when I am assessing and treating the elderly amongst my patients, it’s that I do not always take the extra, extra steps to make sure that there is absolutely nothing that I could have missed. I hope that meeting this young man tonight has opened my eyes to how differently we treat our patients based on their age, and that maybe next time I am called to see an old man with the same history and the same problems as his younger counterpart, I will think twice about what else I can do to make sure that nothing is left to chance – for who am I to judge, even subconsciously, the merit of his remaining years?