There aren’t many sounds that can haunt me. In fact there is only one really. That, ladies and gentleman is the sound of the pager that I have to carry when on-call. Just to bring you up to speed, an ‘on-call’ is typically outside of the normal working hours when all the regular doctors that manage their respective ward patients have gone home – so after 7pm until 8am or, at the entire weekend. It is then the responsibility of the on-call team to respond to any medical issues in the hospital.
A medical on-call team consists a Foundation Year One Doctor (F1), a Senior House Officer (SHO), that’s me), and a registrar (with of course a consultant available if needed). Between the three of us, we manage the entire cohort of medical inpatients – which in my hospital is a rather heart-sapping 300 plus patients.
So the weekend just gone, I was the medical on-call SHO. Saturday morning I clipped on the pager into my scrub trousers at 8am, took the final resignatory sip of my coffee, demolished a banana in one, and enjoyed the feel of comfy chair for a minute, knowing full well that I may not get to experience any of these simple pleasures for the next 12 hours.
And then it began.
The first call was a patient acutely unwell, with oxygen levels dropping below a safe level to oxygenate organs like the heart and brain. I told them I’d be right there. However, as Sepp Blatter knows all too well, life doesn’t always work out the way we want. “BLEEP BLEEP” – a second bleep echoes from my scrub pocket as I’m walking towards the rapidly oxygen-starved patient. The voice at the end of the mobile when I call the page number tells me they have a patient who has just spiked a temperature, has a heart rate of 140 (and they’re only lying in bed not running a marathon, remember) and a blood pressure low enough to be in their boots. Still walking towards the first patient I was bleeped about, I tell the anonymous nurses voice I’ll be there as soon as I can, to push some fluids through the patient’s drip, and put up some paracetamol through a drip. They tell me they need me there right now. Sorry, I have a higher priority patient. Brutal but true.
“BLEEP BLEEP”, “BLEEP BLEEP”…two more bleeps come through as I arrive at the first patient. The nurses on the end of the phone I speak to (as I am mouthing and pointing to the other nurse at our first oxygen starved patient to put the high flow non-rebreathe oxygen mask on and crank up the oxygen in a fashion that explains why I was never any good at charades) deliver me two more blows – a patient has fallen out of bed and has a deep laceration to the forehead and is more drowsy, and another patient on the coronary care unit has central crushing chest pain.
Those four patients were a snapshot of my first 25 minutes on-call last Saturday. My coffee was probably still warm, and my comfy chair still with my bum impression on it. How things can change so quickly!
Plus, I had 11 hours and 35 minutes left of the shift.
Now many of you may be expecting me to be writing this from some padded cell, drowsy from sedative, with one arm of out the straight jacket, having completely lost my mind at such a weekend. However, I am pleased to say I am not. In fact, I am sat in my living room enjoying the buzz of Londoners as they comes to life for another busy day in the Big Smoke. I have, you see, experienced many weekends like this now. The first few, I must confess, I did not cope, became stressed beyond my own expectations, and returned home feeling like I had not only let down my patients but let down the perception of who I thought I was as well. I am not sure which one was worse. It left me with many sleepless nights.
But experience is a tricky beast. You see you have to give yourself enough experience to really grow and adapt. The second and third on-call weekends were still too early in on in my experience journey to truly get to grips with how I was adapting, learning and growing.
Then I started to get better. I started to see my clearly what patients were critical requiring IMMEDIATE response, what patients were URGENT but not critical, what were patients were IMPORTANT but not time-sensitive, and what patients reviews were NOT ESSENTIAL (if time were to run out). Now I can fully appreciate that to many this can seem callous. The truth is that you quite simply have to see patients in the order that they are most likely to die.
So, my patient with low oxygen was at greatest risk, then the low blood pressure patient, then the chest pain (possible heart attack), and then the head injury. What I haven’t mentioned is that as an on-call doctor you begin to work out what you can do remotely over the phone. So, while I am seeing the low oxygen patient, I can ask the nursing staff if they can give the low blood pressure patient some fluids through a drip, put them on a heart monitor, have 5 minute cycled blood pressure measurements, and ask them to page me again if it falls below a certain number (e.g. Systolic Blood pressure of 80). For the chest pain I can ask for an ECG (a heart tracing), heart rate and blood pressure, and give them some medicine to relieve the pain. For the head injury I can ask the nurses to get the patient into bed, put a pressure dressing on the laceration and do half hourly neuro-observations to make sure he isn’t having signs of a bleed within the brain. The reality is, I may not get to some of these patients for well over 90 minutes.
So I suppose the bottom line is that life as a weekend on-call as a doctor has taught me some lessons that we can apply to all walks of our lives:
- We can’t bend time
- We can only be in one place at a time
- Stressing about what is beyond our control is a waste of time
- The more stressful and heavier the workload becomes, the calmer you need to become
- Indecision is worse than the wrong decision
- A sense of humour goes a long way
I am definitely still a work in progress (I know this as I still have the most vivid, real dreams of patients I have seen the nights after an on-call) but I sit back this morning with a smile on face, feet up on the sofa and a coffee in my hand, knowing that I am stepping in the right direction.
Have a great week.