It’s been said that junior doctors are paper-pushers, secretaries to the real doctors (no slur on medical secretaries as that is hard work in its own right – my mum is one!), a bit clueless, and the cannon-fodder for the ward while the real doctors get on with the work of curing, treating and healing. This always makes me smile! Partly because it has some semblence of truth at times and partly because at times, well, it couldnt be further from the truth! Often though it sits somewhere in the middle. Maybe as my own means of coping, I see us, as junior doctors, as the apprentices – we are there to do the grunt work yes, grab the experience in treating patients for ourselves, and learning from the seasonsed experienced doctors and nurses that we work with. What this means, ladies and gents, is that no day – is ever the same. In fact, when I think about one particular day last week….no minute was ever the same!
Thursday 12th 2014…
Having survived actually waking up, negotiating the obstacles littered on my bedroom floor (very unlike me, and an indicator of my week thus far), managing to work the shower with only half of one eye open, and then making it into work, having not fallen asleep on the train, I step onto the ward at 7.15am. As I collapse into a chair on the ward, drowning out the sounds of alarms and chatter, I realise with some desperation that I am, once again, on my own on the ward – no other doctor but me. I tell you, how, on that day would I have wished I had someone else to share the work-load with. I contemplated bribing another doctor to come and join me…but felt the General Medical Council (GMC) who regulate doctors may not approve of this.
Right, with the scene set and the characters in play, let the day begin.
The first task is over very quickly – the lady I had planned to discharge back to her nursing home has not had her loading dose of warfarin, a blood thinning tablet, given and so I decide that it’s not safe to discharge her not properly anticoagulated (the risk of another stroke is too high). I have to let the Ward Sister know (she’s the real boss) – and the patient. Not good. Then a gentleman in one of the side rooms starts to deteriorate clinically – he is tachycardic, hypotensive with a tachypnoea and increasing oxygen requirement. All that means he is that he is very unwell with his heart and breathing systems under increasing stress. I assess him – airway, breathing, circulation, and so on, make a plan and then inform the family. In the case of this patient he is sadly for palliation only. This means our focus is on comfort, and supportive measures. The family are accepting of the situation and I encourage them to come in as he is likely to have less than 24 hours left. It is never easy speaking to families on these matters not matter the level of experience. If it is easy – you have become desensitised…and that is dangerous.
I draw some breath – that’s the on-call bleep going off – but – it is only 10am?! I still have to do my entire day job of looking after my regular patients on my ward before I can safely ad reliably do on-call duties – after all there are NO other doctors to look after them. I answer the bleep and it’s the on-call medical registrar asking when I think i’ll be free. By 3pm I said, closing my eyes and shaking my head as I said it….there’s no way I’d be free by then! Why did I say 3pm. Nick – you idiot.
Now the clock is truly ticking…I have some real work to do!
As I put down the phone, I am informed by the nursing staff that the Nepalese translator for a scheduled family meeting is here. I still have only seen 3 patients on the ward round. This is not good. In fact, let’s be honest – it’s very bad. But still, I knew my Plan A for this day was never going to come true to form – so I made the decision to just role with the punches today and attempt to come out unscathed. Once you make that decision and stop forcing control on a situation it is amazing how much more peaceful you become – or at least I do. The Nepalese family meeting lasts 45 minutes in a tiny, swelting room to the side of the ward. It’s fascinating to learn about a new culture – and having been to Nepal back during my PhD, I am particularly fond of the Nepalese culture and people. Incredibly warm and giving. The benefit of the meeting too is that I get to have a cup of tea and some food during the meeting. Win Win.
Walking back onto the ward, with my mind wandering to the beauty of Everest Base Camp all those years ago, reality snatches me back. “Mrs Smith [not her real name] has no intravenous access and she is for surgery tomorrow so needs it”. This, ladies and gentlemen, is a true heart sink moment – Mrs Smith is IMPOSSIBLE to get a cannula (a small tube in a vein to take bloods and give medicines directly into the blood stream) into. I have tried before and know this is a non-starter. So where do you go in a situation like this….that’s easy – my old friends from my last rotation in intensive care. I stroll down and grab the ITU registrar who is luckily free. It’s a nice breather to be off the ward and have a catch up on the gossip from ITU – I miss it so much. Sadly, after twenty minutes of trying the ITU reg and I make eye contact above the patient’s own eyeline – it says all that needs to be said – this truly IS impossible. I have never had a vein-less patient like this before! And with that, the surgery is delayed until next week until I can get intravenous access requiring radiological guidance. And that doesnt happen at the drop of a hat….
Only 7 patients seen, 11 to go. It’s already 11.45am.
Walking to my next patient I am met by a very distressed relative. And I mean very distressed. The ward corridor is no place to help a patient or their family so I guide her into an empty side room. This takes a further 25 minutes to calm her down, go through their relatives case and put their mind at ease. I am so so mentally tired at this point. I just want to curl up in a ball.
I think about lunch momentarily will staring at my list of jobs I need to do with a tunnel-visioned gaze..until the bleep shatters the silence. It’s a cardiac arrest. Now as part of the on-call team that day I am supposed to attend these. This one, in the opposite end of the hospital, means I leave the ward and run (well, walk as quickly as I can like those odd Power Walkers) to the ward. When I arrive chest compressions are ongoing, the anaestist is dealing with the patient’s airway and there is a flurry of activity. It was a clear case of too many cooks and after checking with the medical registrar running the arrest call that he didnt need me, I returned to the ward (via the caffeteria for a coffee and lunch!) to continue seeinng my patients.
The next couple of hours as an uncontrolled whirl of seeing patients, re-writing drug charts, dealing with odd jobs, being shouted at my the clinical imaging department (it was their fault not mine by the way), and answering the telephone. I discharge a young lady who, to be honest, didnt belong on a stroke ward anyway (she was far too young and it was clearly not a stroke!), and was happy to see her go. This however was not an easy process – I have to coordinate her medications with pharmacy and the discharge team. As an aside, the biggest show-stopper of my day is an impromptu discharge like this. You see, there you are, running around, trying to see the patients, and you are suddenly tasked with sitting down and writing a detailed discharge summary (containing clinical history, past medical history, invesitagtions performed, plan for follow up and so on) and prescribe the drugs to take away – this can take time to do. It’s like being shown a red traffic light every 100m when you are in a hurry to get somewhere!
It’s 4pm. The on-call bleep goes off. I sit down at the ward desk, having been beckoned to accident and emergency to start seeing new medical patients on ‘The Take’ (that’s doctor speak for the new patients that are admitted during your on-call shift i.e. you take them in), and contemplate the state of the ward. On the balance of things, it is under control. Not perfect, but under control. I chat to the nurses and therapy team on the ward so they know what is going on and where I will be. It’s also a chance to check that there are no burning issues bothering them that I can help with. And with a few odd jobs completed, I plan to off to A&E to start my on-call. It’s 4.20pm. I have 5 hours of on-call to do. My stomach grumbles – I wish I had had some more weetabix that morning! Just as I do though one of the staff nurses brings me a can of coke. She said to me that she could see it’s been a tough day – and that maybe I could do with this. It was such a nice gesture and I was so so grateful for it – not just for the drink and quick hit of sugar but for the reminder that I have a great team on the ward – they all work so so hard and I hope I help them as much as they help me. TEAM: Together Everyone Achieves More.
Ok, I am sure you are getting bored of reading this lengthy blog entry so I will be quick. The on-call serves up 5 hours of unrelenting chaos – but fun chaos all the same! I see urosepsis (that’s a urine infection that has spread to the blood and made the patient very unwell) in a Nepalese patient who didnt speak any English; An acute heart attack in a 50 year old Italian man with the set of risk factors were classical (smoker, over weight, poor exercise, high stress, poor diet, high blood pressure, strong family history of heart attacks); A young lady with gastroparesis (your gut stops moving food along and you get symptoms of vomiting etc); and a old chap with an untreated chest infection. I even manage to grab 5 minutes outside in the mid-evening sunshine with the on-call senior house officer – a friend of mine – to catch up on the gossip and chat about anything but medicine for a few minutes.
Finally after the 12 hours plus of running about, thinking far beyong my poor brains capacity, and thinking about food, at 9.30pm we hand over any jobs to the night team who will look after the hospital until 8am, grab a train at 10pm, and crash into bed at 11pm.
As my eyes slowly close in the dark and solace of my bedroom, the whites of my eyes suddenly pierce the black as I realise….
“Bugger – It’s Friday 13th tomorrow….”
I’m too tired to care. Time to dream.