Concrete Boots

I was once a barman. I liked being a barman for numerous reasons, one of which was the fact that you weren't expected to know everything about being a barman from the moment you walked in. There was a nice little intro to the ins and outs of it all: how the till works, how to change a barrel, how to pour the spirits. If somebody asks for a lager top (and there really is no excuse for doing so I must say!) and you give them a pint of lemonade with a splash of Foster's then who gives a fuck! Your concoction goes down the drain, somebody explains how you make it properly and, best of all, nobody's going to get killed over it.

Medicine, alas, is the polar opposite. With medicine you go in at the deep end. As a junior, every six months you will swap jobs. Just when you've finally got to grips with the nuts and bolts of your job, it's time to up sticks and fuck off to a whole new speciality that you know nothing about. Except, this time, there is no nice introduction, no explanation and no instructions. This time, from the moment you walk through the door, you're expected to know it all. It all.

And that's why today I nearly killed somebody.

As you all know I was recently elevated to the exhalted status of an SHO in neurofuckedology. Today a fat young girl rolled up (quite literally some might say) with 'terrible headaches and suspicious eyes'. The latter were suspicious not because they were warily eyeing up anyone who might potentially steal her pork pie, but because the optician had noticed that the nerves at the back that allow us to see were both very swollen. She had papilloedema and see needed an urgent MRI and a needle shoved in her back to see what was going on in her spinal fluid. Problem was she wasn't the only one that needed stuff doing. There was that bird whose spinal cord is rotting away and can barely breathe, the chap who can't walk properly anymore, and this lass who now needs detailed instructions to do what she's always done without a second thought previously. They all needed needles shoved in their back, and before 4pm when the neuropathologist goes home. Then there's that woman who's bleeding from her bowel and needs a telescope test. Plus all the daily crap for the more-stable others. Shit. Where to start? What to do?

No great surprise then that I found myself rushing at 3:30pm to do the lumbar puncture on the fat chick with the weird eyes. "You get the lumbar puncture quick and I'll go see the patient downstairs.", said my reg. In my rush to beat the clock, I completely forgot why I was doing the test in the first place. I forgot her fucked-up eyes suggested raised pressure in her skull. I forgot that if you stick a needle in somebody's back who has raised pressure in their head then the resulting gradient means their brains are sucked down and forced through the hole at the base of the skull. Crushing your brain through the bottom of you skull is known as coning and is, alas, not generally compatible with life. Indeed I forgot all of this as I pierced her leptomeninges and saw with a smile the crystal-clear spinal fluid that I so desired. I remembered all of this in a blood-curdling flash as the fluid shot up the pressure guage and overflowed the top of it. Fuck, high pressure! Oh fuck, the MRI! The M-R-fucking-I! I'd forgotten to check if there were any big masses in her head on the MRI - if there were then she's going to cone for sure. I finished the procedure in a sickly sweat. I must have asked her about 20 times in the few minutes t lasted if she still felt OK. Nobody had told me to check the MRI but I knew that was no excuse. In fact, nobody told me anything about lumbar punctures at all - I was just expected to do them. Yet, if she died, I would be to blame. The law agrees too. It is an established precedent that, from the minute you start any new job, you are expected to know everything about that job. The fact that you are some naif neophyte is no excuse in the cold eyes of the law. According to the Bolam test, the standard of care expected of professionals is judged by comparing with those skilled in the particular speciality in question. However, the experience of individual health professionals may differ significantly: a newly-appointed SHO in a speciality may have no prior experience of that area. Should he then be judged against the highest standard expected of that post or his own qualifications and experience? The law is clear: just as the learner driver has the same level of responsibility as the qualified driver so the newly-appointed SHO has the same level of responsibilty as his more experienced seniors. Now there's the concrete boots in it all for when you fall off the side of the bridge. If you're drowning because nobody bothered to tell you the fence was missing, don't expect the law to pull you out..

The girl did not cone and die, thank the Lord. There were no masses - she probably just has benign intercranial hypertension - but that doesn't make it any less scary. Every day doctors do things that they don't know how to properly because that's just what you do in medicine. It's the same as any other job, once you've made a few mistakes, you quickly learn what and what not to do. Except that it's not the same as any other job. Unlike the bastardised lager top, a mistake in medicine might just end up getting somebody killed, and yourself thrown in jail to boot.