The coffee is hot, my brain alert, my body slowly recovering, and the sun is rising. Not a bad Sunday morning by all accounts. It feels a particularly jubilant Sunday – not just because most of us, including myself, will have another gifted and treasured day off tomorrow before waltzing energetically into a slightly contracted 4 day week – but because my 12 day stint at work is over.
Now way back when on my surgerical rotation I had a 19 day stint – which, very nearly made me another statistic it was so bad. However, that involved surgical on-calls which, yes, are challenging, but in comparison to my first medical on-call weekend just gone, it was David and – this, Goliath.
If you’ve never had to work a weekend before let me shine a quick spot-light on the psychology of it. First of all, let me assure you – you are aware of this impending weekend ‘on-call’ shift weeks, if not months in advance, as it too in all likelihood will coincide with some cherished family event that you will no doubt (like many of the others) be unable to attend. The week before the weekend on-call is filled with dread as every exhausting day you do in that week is punctuated by the thought that there is NO weekend respite for you – just continuous exhaustion. The Friday is the most tragic as you awake, not with that “Friday feeling” but more a “Shit – I’m not even half way though the 12 days!” often accompanied by a groan that is only ever heard in times of extreme anguish. Ok, maybe that is over-kill a little. The weekend itself, we will talk about in a minute – as that is the main dish of this blog today. The week after the weekend on-call is a bit like a roller-coaster that is loaded with highs and lows. The low is definitely the monday afterwards as you awake (well in my case at least) in a flash, acutely unaware of what day it is and if you should or should not be going into work. And when you realise you do have to, it is as heart-breaking as seeing the horse in The Never Ending Story get stuck and sucked into the mud. As the week after on-call progresses you start to recover a little – you get a bit more sleep, don’t have to deal with so much on-call chaos, and the weekend of rest is slowly but surely emerging from the un-ending tunnel of exhaustion and you feel the desire to push towards it. The Friday is euphoria! You have survived! It a very strange twist you become super-charged and I found myself taking on more jobs that day, doing everything double-time, all in an effort to complete the 12 days with the ward in order and satisfaction soaking my mind.
And let me just say, the sleep after a 12 day stint, is just sublime. It makes me smile just thinking about it.
What makes me smile a little less is thinking about the weekend on-call. So in the effort to remain transparent, let’s talk about it.
During the weekend on-call, as a junior doctor, I am essentially the human sponge that gets to absorb all of the crap that happens during the acute admissions over the Saturday and Sunday. Let me explain how it works: when a person gets sick, they come to accident and emergency (A&E). The A&E staff then start treatment and triage the patient as either a surgical patient, a medical patient, or a patient who can be sent home straight from A&E. If it is a medical patient, they call the medical on-call team which consists of a junior doctor (me), a senior house officer, a medical registrar (God, basically), and the consultant. One of the team will then go and assess the patient and decide if they need to have a spell as an inpatient for treatment i.e. they are too unwell to go home. This patient is then transferred from an A&E bed, or chair, or cleaners cupboard (basically wherever there is space to put them) to the acute medical unit (AMU) where their treatment continues. As a junior doctor my jobs during on-call can include all manner of things from assessing and starting treatment, performing proceedures (bloods, urinary catheters etc), requesting investigations (urgent CT scans for spinal inujuries, for example) and being general dogs-body.
Oh, and you would realistically need a week to complete all the tasks you are asked to do….But you usually have about 20 minutes….followed by a look of disappointed on your seniors face when you inform them you have sadly not been able to bend time (just yet) and the allocated task is not finished. Now I know how the untrained pup feels when he does he pees over the floor and the owner tells me off.
So apart from not having anything to eat of drink from when I got up to have breakfast (0530) to when I got home at 10.30pm each night over the weekend (and probably only just avoiding developing acute kideny injury), let me share with you some of the highlights. As there are just SO many I have chosen the best (no, it’s not when “I finished the weekend”) and the worst.
The best was definitely putting in a chest drain and draining 1.2 litres of fluid out of this guy’s chest cavity while he sat on bed! To explain the guy who was in the UK from overseas while travelling had presented to A&E with increasing shortness of breath. An X-ray of his chest had shown that he had a massive left sided collection of fluid inside the cavity where his left lung sat. This is known as a pleural effusion and it meant that his lung had no space to expand when he took a breath in – as there was all this fluid in the way. As a result he was short of breath. Now the cause of the pleural effusion was a bit of a mystery – but given the specific demographics of this young man, his travel history, and the less than common presentation of a massive unilateral pleural effusion – exposure to some tropical infective process or tuberculosis, was at the top of the differential list. We worked up the patient with more blood tests and examination but knew that the best clues would lie in getting our hands on some of that pleural fluid. Plus, of course, in the process giving him some symptommatic relief for his shortness of breath! So, up comes my moment to do my first chest drain (well, a ‘thoracentisis’ more specifically as the drain wasnt left in place for long).
Let me explain what a thoracentis actually is. I sat the patient on the edge of the bed (like in the picture below) and then identified the ‘safe triangle’ of this guy’s chest. The safe triangle is a zone identified by various anatomical structures ( above the horizontal line of the nipple, lateral to the lateral wall of the pectoralis major, and medial to the anterior axillay line) – that is just so that you don’t hit something important like lung (causing it collapse [a pneumothorax]), or a puncture a major blood vessel. That would be very very bad. I then check this space with a portable ultrasound machine which helps me to identify the fluid and importantly any flappy bits of lung that sometimes get in the way. So once I had done all this, I inject some local anaesthetic, get my equipment ready, and then basically insert a rather large needle in between his ribs until fluid starts dripping out – that pleural effusion fluid that stopping his lung from expanding. Hey presto!
Now, in the case of my thoracentisis, it all very nearly went quite badly wrong. You see this guy starts complaining of worsening shortness of breath. “Hmmm…this is not good” was my first thought as I glanced to my medical registrar who was watching me – hoping in the process to get a reassuring nod of “it’s ok” but instead got a look of “ut-oh, looks like you’ve won yourself a pneumothorax!”. Had I just punctured and collapsed this guy’s lung (i.e. a pneumothorax)? Time went rather slowly and I kept asking this guy if his breathing was getting better – every time he said no. So, being stubborn, I just kept asking the same question – until he said Yes – his breathing was feeling easier. See – persistance pays. And the reason for this symptom relief – well I had just drained 1.2 litres of fluid that had been squashing his left lung! And below is the actual photograph of my equipment and what I drained (see the full bowls and syringes…):
It was epic! So much fun. Oh and the good news was after we had done another chest X-ray – no pneumothorax. Win. Win.
You know what I have rambled on so much about this experience, I am sure you all have better things to do with your day. So with that in mind we will leave my worst moment of on-call (a patient I had to literaly walk away from as I was about to loose my cool) and let’s just have a positive, cup is half full, day. The sun is out and I am sure we will all have a great week ahead.
Look out for one another. See you next week.