Monday, 5 March 2012

A 'royal' visit

Motivation is something that you soon loose after your first couple of 100 hour weeks. Don’t get me wrong, you don’t mean to loose this motivation and it isn’t because of you not caring, it is simply because you are too tired to even stand up. This doesn’t matter though, you have to keep going. It doesn’t help with your motivation when you have a ‘difficult patient’. I’m the first to admit that I can be moody when I’m not well and I am very happy to allow for this when people are admitted. Hospitals aren’t nice places at the best of times, if you then add in being scared or in pain then I think you have a good enough reason to forget to say please and thank you. Every now and then however, you come up against someone who you just can’t seem to get it right for.

It was on my thirteenth day working out of a fourteen day stretch that this happened to me for the first time. Mrs Jackson was a 58 year old lady with a history of asthma, eczema and coeliacs as well as a long list of allergies ranging from penicillin to wool. She was morbidly obese and spent most of her time either sitting in a hospital bed or sitting on a sofa at home. She had spent more time in hospital over the past few years than the average NHS employee and she felt she deserved special treatment due to this. It started the moment she was wheeled onto the ward.

As the porter manoeuvred the bed into the bay Mrs Jackson was to be placed in the problems started. She let out a shriek that made me jump to attention, instantly assuming that someone had collapsed or maybe died. I made my way to the source of the noise only to see a very red faced Mrs Jackson bombarding the porter with abuse vaguely wrapped in a veil of polite language. From what I could make out, she was refusing to go into the bay as it was not the one she had stayed in last time. She was a superstitious person apparently and she informed us all that if she was not placed in the same place as last time then it might mean she was going to die. This bay was the worst possible option as on her previous visit there had been a crash call to this part of the ward and she took great delight in retelling the gruesome tale of someone’s demise in her hushed, dramatic tones.
“So you see, I absolutely cannot stay in a bed that someone else may have died in! What kind of an effect will that have on my recovery?”
I thought it was probably best not to tell Mrs Jackson that most of these beds had probably had someone die in over the years so I let that one slide.

All this time, her focus had been firmly on the porter and one of the staff nurses who had been in the wrong place at the wrong time but then she saw me – fresh meat for her complaints.
“Doctor!” She called out as she her hand shot towards me as if grasping for my intervention. “Please, doctor, don’t let them put me there. I need to be in Bay C, that’s where I went last time and everything went so well. I can’t go here, what if I caught what killed the last lady in that bed?”
I desperately wanted to tell her she was being ridiculous and she was much more likely to catch something from the lady with the hospital acquired infection in Bay C than the disinfected bed that someone died in several months ago, and in reality, the beds had probably all been moved around since then anyway. Instead, I found myself reassuring the hyperventilating lady in front of me that we didn’t mean to upset her but also explaining it wasn’t up to me where patients were placed. In the end, Mrs Jackson agreed to sit in the wheelchair in the day room while we discussed the problem amongst ourselves.

The office was engulfed in a cloud of swear words as the ward staff vented their feelings about Mrs Jackson’s readmission to our ward. Apparently she had made a student nurse flee the ward in tears last time she was here and had managed to fill one of the nurses’ night shift with a constant stream of complaints. The sound of her bedside buzzer was enough to drive the sanest member of staff running and screaming for the exit. A debate over where Mrs Jackson should be placed was held with such intensity that you would think we were trying to place a member of the royal family. In the end it was the voice of reason, our ward sister, who decided she should go in the bed that was originally intended for her. It would be wrong to ask someone else to move for her as that would show preference of one patient over another and anyway, the bay she wanted to go in was on the verge of being quarantined anyway due to an outbreak of hospital acquired pneumonia.

The news did not go down well and Mrs Jackson had clearly decided that we should all suffer. The window wouldn’t close properly and so it was too cold. The sun was bright in through the windows and it was giving her a headache. There were not enough blankets. The pillow was too hard. The nebuliser being used by the patient next to her was too loud. The lady in the bed opposite was confused and kept talking to her… the buzzer didn’t stop and it wasn’t just the nurses having to deal with it while at the same time see to the twenty other sick patients. No, I did not escape her sharp tongue either. She had come in on a day when there was no senior ward round and so I was making my way from one end of the ward to the other seeing the patients myself to make sure everything was ticking over alright until the consultant came around the next day. I made the mistake of starting in the bay that Mrs Jackson had been placed in.
“Young man, what time will your consultant be seeing me?”
“There’s no consultant round today Mrs Jackson so you’ll be seeing me. The consultant comes around tomorrow morning.”
“Is this a joke? What kind of hospital allows a patient to be admitted and then wait a whole day to be seen by a consultant?”
I tried to explain that seeing as she had been admitted via MAU, she had been reviewed by their consultant just a few hours ago so technically speaking she had been seen by a senior that day and my ward round was simply to check that any tests or investigations requested by that consultant had been carried out. She wasn’t listening to anything I had to say.
“Who do I speak to about the food?”
“I’m sorry?”
“The food! Or should I say the rubbish your chef serves and calls food! I had supper here last night and I can tell you, it was far from palatable!”
“I’m sorry to hear that but unfortunately the food choice is limited. If there is a specific allergy you could talk to one of the nurses…”
“Allergies! You know about my allergies I take it because I have a list written down in my bag if you need it.”
“We have a list from MAU that…”
“I do have a lot of food intolerances so I want to make sure that you are aware of them all.”
“I’ll make sure everyone is informed Mrs Jackson and then…”
“Now about my X Ray. I was told they wanted me to have a chest X Ray, I want to have it in the morning because I’m tired and need to get some rest.”
What are you supposed to say to a request like that? How best to remain professional?
“I’m sorry Mrs Jackson but as I’m sure you appreciate, the X Ray department has to work around any potential emergencies coming in through A&E, so while I can assure you that you’re scan won’t be done in the middle of the night, I can’t book a specific time for it to be done.”
Well done, I thought to myself, that could have been read from a textbook.
“Clearly you are not nearly high enough up on the ladder for me to be talking to!” She barked back at me. “If you can’t do a simple job like arrange me a civilised time for me to visit the X Ray department then you clearly aren’t capable of doing your job. Fetch me the consultant!”

This was going to be a long day.

Friday, 17 February 2012

A Time to Die

Nights were finally coming to an end and I had almost survived, that was the important thing to remember. I hadn’t made any stupid mistakes (as far as I knew) and no one had died because of me (as far as I knew). You see that was the big thing about becoming a doctor, at some point in your career someone was more than likely going to die because of you. They may have died anyway but they might die a few hours sooner because you gave them too much IV fluid or maybe you didn’t write them up for the medication they needed in time. People die on hospital wards and that is just the way it goes but until you get use to that, you always worry that they died because of you.

Part of a junior doctor’s role is to confirm death in patients on the ward who have recently passed away. Not everyone expires in a flurry of activity with crash alarms going off and people jumping up and down on chests, this is in fact more of an unusual way to pop your clogs while in hospital, some may argue anyway. Being resuscitated is an undignified, messy and violent way to die and if it can be avoided at all, it should be. Why would you want to have the ribs of your elderly granny fractured into pieces and tubes rammed down her throat if it was unlikely to help her in the long run anyway? Depending on which article or study you read, only 10-15% of crash calls are successful. That is why when a lot of elderly patients, or maybe those at the end of a long terminal illness, are admitted the have a piece of paperwork signed by a senior doctor stating that they are “Not for Resus”. This is a decision made between the medics and nurses as well as taking into account the wishes of the patient and their family. We are not being ageist or discriminating, I feel we are being kind by sparing them a terrible ending that would probably have little effect on the outcome anyway. If I was at that stage of life, I would happily sign the form.

It was on my final night shift that confusion struck me. It was around 5.30am and it had been a terrible night. The bleep had never stopped going off and every ward had been hit by one admission after another of very poorly people. We were all exhausted and were praying for the end of the shift. I had finally found a moment to sit down and get something to eat for the first time since the shift began the night before. I hid myself away in an empty office at the end of the deserted admin corridor hoping that I could have half an hour undisturbed break where I could recharge my batteries before the final burst of energy that would get me to the finish line. I was halfway through my second chunky kitkat when my bleep went off. Now I’m the first to admit that when tired, my brain does not function correctly. What should be incredibly simple suddenly becomes a terribly complicated task and no matter how hard I try, I just can’t seem to get my head around it. This was the perfect example of one of those times for both myself and the harassed nurse on the other end of the phone line.
“Doctor, you’ve got to come immediately! Mrs Jennings has stopped breathing!”
“Why are you calling me? Put out a crash call!”
“No, she’s not for resus.”
“So she’s dead?”
“No, she’s just stopped breathing and I can’t get a pulse. You’ve got to come, we need help.”
“But she’s dead?”
“You need to do something, it’s urgent.”
“I’m really sorry, I’m very tired and very confused but if she has stopped breathing and she’s not for resus, then she is dead.”
This was met with silence on the line and I could almost feel the embarrassment seep down the phone to me. I knew from past experience when I had done similar things that the poor nurse just wanted to hang up and pretend the conversation had never happened. Many time as a medical student I had dug myself into holes deep enough to bury a small horse in through my lack of engaging my brain, either through exhaustion or stupidity. I had been sent from theatre on numerous occasions with my head hung in shame and my cheeks burning red. On this occasion however, the nurse couldn’t hang up as despite the patient being dead, we still had a job to do.
“Yes,” her voice broke the silence, “that’s right. She’s dead. So it’s not urgent.”
She sounded absolutely exhausted, probably just like I did, and I’m sure she was waiting for some arsey retort over what had just happened. I simply told her I would finish my coffee and head over shortly to confirm death.

This was going to be the first time I had confirmed someone as newly dead. I had seen dead bodies before, I had even cut one up in our anatomy classes at Medical School however they had been dead for some time and held little resemblance to a live human being. The only other time I had seen a recently deceased person was when I went to see my grandfather after he had passed away in hospital when I was a small child. This was clearly different. I had never met Mrs Jennings while she was alive, I knew nothing about her, I didn’t even know if she had family as I walked on to the darkened ward. I made my way towards the nurses’ station which was the sole source of light in the pitch black ward entrance. A health care assistant sat behind the desk filling in paper work. She looked up and smiled at me warmly. Her grey hair reflected the light and cast what looked to me in my delirious state, like a halo around her head.
“You’ve come to see Mrs Jennings.” She said more as a statement than a question.
“Yeah, just to confirm the death.”
“Laura, the staff nurse, is on the phone to the family asking them to come in.”
“Oh, okay. Do I need to talk to them when they get here?” I asked warily.
“No, not unless you want to. We can deal with everything tonight and if they have any questions we can point them in the direction of our own team when they get in at nine.”
“That’s great.” I said with a sigh of both relief and appreciation.
“Busy night?” She asked as she moved around to my side of the desk.
“Very.” I said humourlessly. “At least it’s my last one. Feel like I could sleep for a week.”
“You got much time to recover?”
“Two days, then I’m back doing long days.”
“You must love it here.” She said with a wink.
“Must do.” I said as I rolled my eyes. “Either that or I really have started to loose it!”

She led me down the black corridor towards a side room that had the bedside light switched on and pointing down towards the floor giving the room a softer glow than the usual burning overhead strip lights.
“She’s in there love. I’ll leave you to it, let me know if you need anything.” She said as she turned and made her way back to the paperwork.
“Thanks.” I said, wishing that she would come in with me.
I entered the room and was instantly struck by how peaceful it all seemed. Mrs Jennings was laid out in the bed and the pillows and sheets had been arranged neatly around her. All around her there was evidence of life, Photos of relatives stood on the bedside table filled with smiling faces looking down on the departed elderly lady. Next to these stood various ‘Get Well Soon’ cards and a big bunch of flowers. Her book and glasses had been placed neatly next to her wash bag, all lined up and in order. For some reason it was the book the captured my attention. I just kept thinking that she would never find out how the story ended. I moved closer to the bed and reached out to feel for a pulse. The skin was still warm but there was no steady rhythm of the pulse to be found. I reached over to check the other wrist – still nothing. I looked up to the face which displayed no hint of emotion, no pain or distress was evident. I gently moved the eyelids up and shone my pen torch into her eyes. Fixed and dilated. Finally I placed my stethoscope against her chest and listened for any evidence of breathing. This was the hardest part because the body is far from silent in death. The gurgling of escaping gases and the creaking of relaxing muscles filled my ears but no air swept into her lungs. They had been switched off for the final time. This lady was dead. I should have felt something as I stood over the lifeless body but all I could think was how nice it was to be in a quiet room for a few moments in the middle of such a hectic shift. I suppose that is what makes us good doctors, not getting over involved. I was going to see many dead bodies over my career and I would see many of my patients die and if I were to become emotionally involved with each one of them, I wouldn’t last long in the job.

I made my way back down the darkened corridor to the light at the end. Someone had already laid out the notes for me to make my entry;

Asked to see patient to confirm death. Noted by N/S to be non responsive at 05.15am.
Pupils fixed and dilated.
No breath sounds present and no pulse palpable.
Patient confirmed as deceased.
Rest in peace.

As I signed my name it felt like I was ending this person’s story. No one would write after this entry, the large volume of notes had come to and end. I looked around to see if the nurses were around but everywhere was quiet. I thought she was probable avoiding me after our awkward conversation on the phone.

The final ward round of my weeks of nights was just as bad as the shift had been. It was getting closer and closer to 11am and there was no sign of an ending just yet. We were seeing a patient who had been admitted after a first seizure. Due to the busy nature of the night shift, this lady’s bloods hadn’t been written in the notes before the round so I had been sent to the computer to download them from the results server. It may sound very high tech being able to ‘download’ results – it wasn’t. The connection was terrible and the sever would reset at least five times before you could even log on and then, if feeling temperamental, the computer may decide that it didn’t like your password, even though it was right, and send you back to the beginning again. It would have been quicker to just phone the lab but we couldn’t do that. Since the results server was set up the staff in the lab had been banned from giving the results out over the phone and so we all had to curse and shout at computers for half the working day. It was half way through this process I must have fallen asleep. One moment I was waiting for my password to be accepted, the next I was being shaken awake by the ward sister. I jumped out of fright at waking up so suddenly when I had been unaware of being asleep and managed to slam my knee into the underside of the desk with such a thump that I almost screamed. The ward sister was trying her hardest not to laugh.
“He’s waiting for the results and getting more pissed off than usual so you better hurry.” She said with a chuckle. “I’ll tell him the computer crashed but get a move on and then you might be able to get home!”
I limped back to the round with the print out in hand. The Med Reg had a look of confusion on her face as she noted my limp.
“What did you do?” She whispered. “Was that crashing sound you?”
“Yeah,” I mumbled quietly, “I had a fight with a desk.”

Saturday, 11 February 2012

Difficult Decisions

Nightshifts are hell. There is no other way to describe the way they completely wreck your internal body clock, deprive you of natural light and take away all social contact from your life.

When I started this job we still did seven night shifts in a row each lasting twelve hours, however in reality you were often there for thirteen or even fourteen hours as you couldn’t leave until the Post Take Ward Round was over. In my hospital, this round starts at 8am run by the consultant on call and reviews all the patients that were admitted the night before, which on a weekend night could be over fifteen people. The one good thing about leaving work a bit later was the sunlight. If you do these shifts in the winter, it is completely possible to never see the sun. It hasn’t risen by the time you get home and go to bed and it has set by the time you wake up. Let me tell you, this is beyond depressing. Leaving at 11am at least meant that I could walk home with the sun on my face, not that it was exactly strong in the north of England in November time.

Despite my complaining, by night three you do start to slip into a routine. You get home around 11.30am and get straight into bed feeling too tired to even think of having something to eat. The alarm then goes off at around 7.30pm. I would force myself out of bed, shower and eat whatever was in my fridge that didn’t require much preparation. At 8.30pm it was time to set off for work again, on the way I’d stop at the corner shop and stock up on cheese and onion crisps, chunky kitkats and Pepsi to keep me going through the shift and then handover started at 9pm. There was no time for friends, fun or any type of life during this week and seven days like this can really drag.

The best part of nights for me was getting to know the nurses on the different wards I covered. They were always the first ones to make the coffee when I looked about ready to drop, the ones with a funny story when my mood lowered and the only other person to ever offer to answer my never ending bleep for me when I had my hands full. It was this week of nights that made me realise that the nurses weren’t to be feared like we were led to believe at medical school. As long as you weren’t an arrogant idiot (which unfortunately couldn’t be said of all my colleagues) and were able to take a joke, the nurses could be one of your closest allies as a junior doctor. God help those arrogant idiots however! I think they forgot who had access to their bleep and if you were going to be rude, then that bleep wasn’t going to stop all night. I always thought it was amazing how stupid these people could be, they never seemed able to put the two things together. They would just assume it was the same for all of us. I never corrected their assumption.

Nights always gave you access to the crazy side of the patients as well. I don’t mean true psychiatric illness by this, I wouldn’t be so simplistic as to label this ‘crazy’. No I mean the type of elderly patient who by day is lying in bed with a smile on his face offering Toffees to the staff, patients and visitors and then by night turn into a weapon wielding maniac. On night four I was bleeped to go and help a ward deal with one of these situations. A 79 year old man being treated for a chest infection had woken up at 2am and become confused as he did not recognise where he was, this confusion melted into fear which led him to feeling the need to defend himself. He had jumped out of bed, grabbed the drip stand at the side of him and started to swing it around like a sword, in the process he had pulled out the other end of the drip that was attached to his hand and sprayed blood over the wall and floor. As I arrived on the ward Mr Thompson was standing by the nurses’ station, holding the drip stand in an attack position. There were two nurses on each side of him trying to calm him down in a gentle voice and behind them they had a security guard each. Security stood there looking suitably gruff and angry, as you would expect from 6ft of security guard. Every time someone got too close to Mr Thompson he would swing the stand towards the perceived threat using all the energy left in his frail body. I have to say, I was impressed with the energy and power behind the swing. I wasn’t surprised to learn later that he had been in the army for much of his working life.
“Mr Thompson?” I asked. “My name is Dr Randal and I’m the on call doctor tonight, can we have a chat?”
“Fuck off!” He barked back at me.
“Do you want us to disarm him?” Mr Security Guard asked with a glint of excitement in his eye.
“No! He’s not a professional gunman! He’ll get hurt.” I said, a little shocked at their gung-ho attitude.
“Mr Thompson, have a look at my ID badge, I’m a doctor and you’re in hospital.”
“I can’t see that!” He said as I passed him my badge, just ducking in time to avoid the stand as it rushed over my head. “I want to go home!”
“You’ve not been well sir, you need to get back into bed and let us look after you.”
“I want to call my wife.”
“It’s 2am.” One of the nurses pointed out calmly. “You don’t want to wake her up and worry her at this time do you?”
“Rubbish, you’re just saying that!”
I edged around him, all the while fearful that I was going to have to explain to my SHO that I was going to have to go down to A&E after receiving a head injury from an elderly patient with a drip stand, and switched on the TV at the side of the nurses’ desk, turning the channel over to the all night news feed that had a clock at the side of the screen. Mr Thompson watched me and came over to see what I was doing. He stared at the screen.
“Terrible,” He said as he placed the drip stand on the floor. “no fluids on a flight. I like to bring a drop of scotch with me to Spain each year, but now…”
It took me a moment to realise he was commenting on the story being shown on the news. He turned to look at me and smiled; “Any chance of a cup of tea?”

Difficult decisions have to be made on nights. Not long after I had left Mr Thompson, my bleep went off. A ward at the far end of the hospital had a middle-aged gentleman, admitted the previous day with chest pain, who had just started vomiting large amounts of fresh blood. His pulse and blood pressure had started to fall and he was still vomiting. At the same time, a ward at the opposite end of the hospital informed me that a 28 year old woman, admitted due to poorly controlled asthma, had started having an asthma attack fifteen minutes ago and there was no sign of it easing. She was fighting to breathe and her oxygen levels were falling. What should I do in that situation? Once again, I found myself dealing with something that Medical School had never taught me, how to choose between two life threatening situations in two separate parts of the hospital. Everyone will have an opinion on what to do but when this happens at 3am on your fourth night shift, you can’t always think through every option and you just have to do what you think is right. Both of these people needed a doctor with them, straight away, and I could only go to one of them. The best way of getting a doctor there fast at this time of night was to put out a crash call. I asked the nurse who I was speaking to at the time to hang up and call for the crash team as I was already on my way to a patient in need. What else could you do?

As I ran down the corridor towards the vomiting patient my bleep went off informing me of the crash on the ward that I had just spoken to, so I knew they had done what I asked. I ignored it and kept running towards the patient vomiting blood.

When I got there, I saw that the ward nurse hadn’t been exaggerating. Fresh blood covered the sheets and pooled in vomit bowels scattered around the cubicle. The patient looked as pale is ice and was fighting to catch his breath. Every few seconds he would heave as if he was about to vomit again but nothing came out. I slipped into auto pilot and did what my training told me to do. I got a line in, took out blood at the same time, cross matched his blood to prepare for a transfusion and set up fluid to keep his blood pressure and pulse up while we waited for the blood. All the time I was praying that this wouldn’t turn into an arrest situation as well as I knew the crash team were already busy and it would leave me totally on my own here to deal with it if it did.

There is no clear line between who belongs to medicine and who belongs to surgery. If you have ever worked in an emergency department you will have seen the debate over who the patient belonged to on many occasions. The surgeons insist it is not their problem and so refuse to admit the patient to one of their beds, have you tried the medics? The medics insist it is not their problem and so refuse to admit the patient to one of their beds, have you tried the surgeons? In our hospital, vomiting blood most definitely counted as a surgical problem. I bleeped their team and asked for immediate assistance and I got no argument back, in fact they were more help than my own team. Maybe my opinion on surgery was completely wrong! They were so helpful. I was starting to think that all my views on the hospital teams were wrong.

By the time the surgical team arrived on the ward we had stabilised him. His vital signs were no longer falling and the lab was getting suitable blood ready to replace what he had lost. (My urgent bloods had shown a massive drop in haemoglobin since they had been checked earlier in the day.) The surgical registrar even said “well done” to me, which took me by surprise. They wheeled that patient off to theatre to find the cause of the sudden bleed and I made my way back towards Medical Admission to explain what had happened to the Med Reg. It felt good to have managed a situation like that, the patient was stable and another team were now going to investigate. I had done all this without having to get help or advice, maybe I was learning. As I entered MAU and saw the anger on the face of the Med Reg, that all came crashing down.

“Where the hell have you been?!”

Saturday, 4 February 2012

The Night Shift Ghost

Fear. Cold hearted, steel gripping fear. That’s what I felt as I crossed the road towards work on my way to my first ever night shift. I was now a month and a half into my first job and I was starting to get the hang of it. I was basically a glorified secretary spending my time filling out paperwork and making appointments. I was given an order by a senior doctor and I carried out the task. Simple, it didn’t take a medical degree to do most of what I had to do. The few times I got to give my brain a work out were my weekly long day shifts. On these days, after 5pm I would cover all the medical wards until 9pm dealing with any urgent problems that came up and couldn’t wait. It was here that I was given the chance to practice medicine, interpreting blood results and examination findings, talking to patients and relatives and working with the nursing staff to keep things running smoothly. For some reason, going home at 9pm meant that those shifts didn’t seem so bad. It was only four hours and even I could hold things together for four hours. Nights were another story. It suddenly went from holding things together for four hours to doing it for twelve hours while the rest of the city slept. That was a daunting challenge. I knew what I felt like if ever I had to be awake in the early hours of the morning and it wasn’t a pretty sight. I was terrified that this would be when everyone would see me for the impostor I really was. I wasn’t good enough to be a doctor, by some miracle I had completed my course and got the degree but I couldn’t cope with twelve hours of making life and death decisions, I was much better with the paper work.

I had already heard the horror stories from my friends of the constant bleeps, numerous new admissions and lack of senior support that made up a night shift and these stories just added to my anxieties. So, the facts? I was to cover ten wards, all with approximately twenty five beds and the Medical Admissions Unit of twenty beds. If any of the wards had any problems, new admissions or emergencies, I would be the first point of contact for them and on top of that, I was also a part of the dreaded crash team. How hard could it be? How many things can go wrong in just twelve hours, and shouldn’t everyone be asleep anyway?

The day doctor looked on the verge of tears. He handed over five new admissions waiting to be seen, two sets of bloods awaiting review and an elderly man who hadn’t passed urine in the last two days, had a bladder the size of a football and would require a catheter to drain this. He also warned me of an outbreak of vomiting on one of the elderly wards and advised that if at all possible, I should avoid that ward and try to put off any problems until their own staff arrived at 9am. Just the way you wanted to start a Friday night? No, not me, you have the wrong man, I wanted to be down the pub, on my third pint with a pizza or maybe a kebab waiting for me at the end of the night. With my heart sinking into my shoes, I set off towards the nearest ward that needed my help. It was then that it started - the bleeping. The constant, high pitched, incessant bleeping noise that would invade my dreams and turn each sleep for the next week into a nightmare. Anyone who has been a junior doctor will know just how painful the constant sound is and what it can do to your sanity. Friday night had turned the wards into chaos and suddenly, everyone needed me at once but I couldn’t go anywhere or do anything because I was stuck at the desk in the doctors’ mess attached to a phone, answering my never silent bleep. The list of jobs grew by the second and all I could do was try and reassure the nurse at the other end that I would be there as soon as possible and yes, that noise was my bleep going off again so I better go.

My list now included;

1. A 33 year old man with chest pain wanting to self discharge as we wouldn’t allow him out to the pub for an hour
2. A 79 year old delirious woman who had tried to get into the wrong bed, realised there was someone already in the bed and thrown herself to the floor in fright and now couldn’t move her left leg
3. A 55 year old man who had started vomiting on a ward without the vomiting outbreak
4. An IV drug user who appeared to be now withdrawing from alcohol as well as heroin and needed detoxing

The list went on and on and on…

I don’t know how many of you have been to a hospital in the middle of the night but my view is that a hospital at night is very different to one during the day. The corridor lights were set to dim and the wards themselves were cast in darkness with just a glow being emitted from the nursing station. The thing that I hated the most at first was the silence. It was unnatural, these rooms and halls should never be so quiet but as you race to an emergency at 3am, all you hear is your own heart beating. By the end of the first nightshift however I had grown to love the silence and found it a welcome break as I walked from one job to the next.

The old part of the hospital I worked in was rumoured to be haunted and these storied hardly surprised me. I have already mentioned the gothic architecture of the ward I’m based on, well the entire wing of the hospital looks the same. The main entrance hall of the wing is dominated by a sweeping stone staircase overlooked by a stern statue of the hospital’s founder. Great arched windows flank each side of the stair case casting the corners of the room in shadows and creating shapes out of nothingness. Many of the wards have high ceiling which cause an echo as you walk down them at night that would not be out of place on a sound effect CD for a horror film. I had been rewriting several drug charts on one of these wards and as a thank you, one of the nurses had made me a cup of coffee. I sat at the ward desk with the two night nurses drinking my coffee, hoping it would give me the motivation to walk to the far side of the hospital to see an old lady with recent onset diarrhoea. The nurses decided that this was the perfect time to fill me, the ‘new recruit’, in on the ghostly goings on that they had witnessed in their time on the wards at night. They spoke about hearing a crying baby in a room a new mother took her own life in, about feeling a hand on their shoulder whenever taking vital signs from a patient who is about to die, even of a patient being admitted who vanished into thin air once they got into bed! They told me the stories with such conviction I was completely drawn in to them. How was I to know they were having a laugh with me?!

Later that night, as I was walking down one of these old corridors, my mind started to go into over drive. The main lights were all switched off leaving just the occasional side light to illuminate my path and they left large parts of my route in complete darkness. The pipes above my head had started to rattle and the vacuum tubes that were used to transport bloods to the lab started to grown, normal noises in an old hospital but with my head filled with ghosts and ghouls, I could feel my heart rate increasing and let me tell you, as the clock reaches 4.30am and you’ve had only 10 minutes to yourself since you started at 9pm the night before, there is no logic left in your head! I felt myself walking quicker, pushed on by the tricks my exhausted brain had started playing on me. It was at that point I started to hear footsteps behind me. Now I realise looking back on this I was acting like I was some kind of extra in a bad horror film but this was not what I was thinking at the time. I decided to break out in a light jog, aiming for the far end of the corridor which would open out into the nice new state of the art, modern wing of the hospital. It was then that my bleep decided to go off. The noise was so sudden and so piercing as it echoed through the darkness that I jumped about a foot in the air, landed in a pile of clean bed linen sending it all crashing to the floor and shouted out “Fuck!” This was met with a roar of laughter as the source of the footsteps behind me ran over to check if I was alright. It was the nurse who had fed my head with ghost storied earlier that night. She was on her way back from the canteen with several rounds of toast and was not in fact a serial killer preying on junior doctors lost in the darkness of the old hospital. She found the sight of me sitting in a heap of bed sheets so funny that she dropped her toast. After helping me to my feet she finally stopped laughing and asked me if her horror stories had made me paranoid. She clearly decided that my denial was a lie and promised to make it up to me the next night be ordering a pizza and letting me share it. She told me it was a Saturday night ritual for her if ever she was on nights and told me that I was always welcome to join in. Feeling more embarrassed than I ever thought possible, I thanked her, told her I loved the sound of pizza and then ran off to answer my bleep.

“Doctor, I’m sorry to bother you but you have to come straight away. That patient you saw who was withdrawing from alcohol, well he’s picked up one of the nurses and he won’t put her down…”

I made my way over to the ward that had called me. The whole way there all I could think was how stupid it was that medical school had never prepared me for a patient refusing to put down a member of staff. What the hell was I going to do about it? Surely it would have made more sense for the ward to call security? When I got there I was confronted by the withdrawing patient not only holding the poor Filipino nurse over his shoulder but also standing on a rather insecure looking chair and occasionally letting out a small scream. The healthcare assistant came over to me with a look of sheer panic on her face. She informed me that the patient woke up screaming about spiders and when the nurse went over to check on him, he had grabbed her and made his way to higher ground. The nurse did not look happy. Fair enough, the patient hadn’t taken a bath in weeks and the smell of the street living mixed in with stale alcohol was enough to make me feel nauseous at a comfortable distance so I could only imagine what it was like for her being so up close and personal with him.

“Hello sir, I’m the on call doctor tonight, I need to ask you to come down off the chair and let go of our nurse.”
“Can’t do that.”
“Why can’t you do that?”
“The spiders will get us, can’t you see them? They’re all over the floor, they might be dangerous.”
“I can’t see any spiders sir. I think you’re not feeling very well because of not having a drink today. If you come down, we can get you some medication to help with that.”

It took ten minutes and a visit from security to talk him down. He let go of the nurse and was given enough sedatives to drop a charging rhino. I went over to ask the nurse if she was okay and offer my assistance in anything that she needed but within minutes my bleep was going off again summoning me to the far side of the hospital.

“Doctor one of our ladies is having trouble going to the toilet, she’s in quite a lot of pain.”
“I’ll be there as soon as I can.”

Monday, 30 January 2012

I'm Switzerland!

 The ward I was based on was like a war zone. This was not because of how busy it was or due to the volume of workload, and let me tell you it certainly was busy, no it was because of the constant battle going on between the consultant and pretty much everyone else. I worked on a medical ward with twenty five beds and five side rooms as well as a massive MDT room where we could find refuge for five minutes from the chaos that seemed to be going on all around us. The ward was in the old part of the hospital and was in dire need of renovation. The decor was straight out of the 1970s but the architecture itself would have been more at home in a gothic cathedral. The large, stained glass windows cast an eerie glow throughout the ward which was divided up by large stone archways. Someone had decided to try and split the ward up a few years before, as the old Nightingale Wards fell out of fashion, and had done this by sticking some cheap plywood boards to these stone archways to try and create a thin wall to separate the male and female ends of the ward. This had not been a good idea. The wood was as thin as paper and so by now was covered in holes, the paint had peeled away in several areas leaving the woodchip exposed and able to give you a nasty splinter if you weren't careful and it had been known for a porter to send the whole 'wall' crashing to the floor if his aim was a bit off when trying to get a trolley through the door. As well as this attempt at a redesign, someone had also decided to fit 'modern' lights in place of whatever had been there previously. The main issue here was the fact that the ceiling was so high and the cable the light was attached to was so short. They clearly were not meant to be hung from such a height. If a light went, changing the bulb was no easy task. Scaffolding was required! This meant the ward had to be cast in near darkness before anyone would come and do anything about it. Julie, one of the nurses, told me that on several occasions she had be tasked with holding a torch over the junior doctor's shoulder as he put in a cannula.

As for the war going on around me, I tried to remain Switzerland in the middle of it all. Now might be a good time for me to you to the family.

Dr O’Henessey was the consultant. She was widely known throughout the hospital as the Ice Queen and not for her love of frozen margaritas. Not only did she have no emotion whatsoever apart from anger, she also looked as hard as ice. Her skin was as white as a sheet which was contrasted by the jet black hair she had flowing down over her shoulders to the waist. She was thin as a stick and her eyes could turn you to stone with one glance. She never raised her voice, instead when angry she would whisper so quietly that if there wasn’t absolute silence, you hadn’t a hope in hell of hearing her. The one blessing was the fact that she was rarely on the ward. In fact, the only time we did see her was for her ward rounds that happened twice a week and from my point of view, that was quite enough. Even on those days she would turn up hours late but still expect us all to be sitting in the MDT room waiting for her with fresh coffee brewed, medical notes at the ready and X rays on display. The notes had to be laid out in a very particular order otherwise she would refuse to start the meeting. We started with the most recent admission and would work our way through the others in reverse chronological order, unless one of her 'regular' patients came in, these were people she had seen for years in the Outpatient Department and for some reason, she had decided they required special treatment and so they were always placed at the top of the pile. It was months later that I found out that these patients had been seen by her privately as an outpatient, not as an NHS patient, and only came to us when admission was required. This explained why they would frequently ask me if they could book an X Ray at a more convenient time, or if they could make a special request of chef. When going through the notes during the meeting, if she found one set out of place, she would stop talking in mid sentence and stare at them until someone quickly removed them from her sight and filed the offending article in a more appropriate place.

The only way we knew she was on her way was thanks to her much abused secretary. Kate’s office was at the end of the corridor and the Ice Queen had to pass the office door on her way to the ward. Kate would then phone Carol, the ward clerk, with a warning giving us under a minute to stop whatever we were doing and get into place. It was like a military inspection. We got it right most of the time, when we didn’t the atmosphere would drop to minus twenty and the rest of the ward round would be like slamming our heads against a brick wall but slightly less pleasurable.

Once we had presented the patients to her, discussed any issues and come up with a plan of action, she would wiz around the ward at break neck speed showing her face to the patients under her care. It was my job to push the notes trolley and write, ‘word for word’ in the medical notes what was said on those rounds. This was an impossible task. On average she spent sixty seconds with a patient and then took under ten seconds to move on to the next. It was this amount of time I had to find the notes of the relevant patient, get to the correct place in said notes, write what I could remember of what was being said, put the notes back in the correct place and move on to the next. As this was all going on, I also had to try to remember the long list of jobs that were being barked out by the Ice Queen for each individual patient as I did not have enough time to write them down as well as write in the notes. Once the round was done, the team would gather and try to make sure I remembered everything that had been asked of me and I would compile a long 'To Do' list which would then by attached to my brand new clip board which never left my side. I would spend the rest of the day going through this list ticking things off with great satisfaction.

In a moment of kindness one day she told me to tell her if I was struggling to keep up and she would slow down. I took this opportunity to ask her if she would mind just giving me a moment to get myself sorted between patients. She smiled at me and said ‘of course’. I was shocked, had she actually realised the impossibility of my task? On the ward round that day she gave me fifteen seconds between patients, not ten.

Dr Neal was the SpR, the next in line in terms of seniority in the medical hierarchy. He was the complete opposite to the Ice Queen. He was kind, caring and always knew how to make you smile on a really bad day. He would offer support whenever needed and was keen to teach me skills that I had never had the opportunity to learn as a student. He seemed to take a real interest in people and would make the effort to get to know each member of the team and spend time with each new admission on the ward. Due to our absent leader, it was him making the hard decisions on the ward and it was him making sure that the day to day jobs got done by Simon, the SHO, and me. As a new doctor, there were many things I struggled with at the start but I never felt stupid going to him for advice. One month into the job he didn’t turn up to the ward round as expected. The ward sister came in to inform us that he had been signed off work due to sickness. Rumour spread that he was depressed and this spread across the department faster than any vomiting virus. I didn’t see him again for the rest of that year.

This left Simon, the SHO in the position as my main senior contact on the ward. Luckily he seemed to slip into the role without argument and soon tried to give me a good balance between responsibility and guidance. Between him and Katie, the ward sister, I soon found my feet and started to get into my daily routine without too many things going wrong. Katie was like the ward mother and was the only person strong enough to stand up to the Ice Queen when the demands she made got past a reasonable level.

It soon became crystal clear just how low down in the overall scheme of things a first year qualified doctor is. As a Foundation doctor, I was as far down on the food chain as you can get, in fact, the security dog was probably several levels above me. I had no problems with this, as I had said before, I felt very unprepared for my job as a doctor, so to be told on many occasions that we are there to do as we are told and to ensure the mundane ward jobs were done, was fine by me. The main role of a junior doctor appears to be paperwork. I spent a majority of my time filling out request cards, writing referral letters to other teams, or filling out discharge summaries, known as TTOs on the ward, not that I know what that stands for, even now. My other role was to be told off. I was constantly being bleeped by one person or another, telling me that the treatment my team's patient was receiving was not right for them for one reason or another. If it wasn't Microbiology telling me they were on the wrong antibiotic, why didn't I wait for the cultures to be reported (several day later), it was Pharmacy telling me that the dose of the patient's medication was wrong, why hadn't I spoke to the GP (which normally I had attempted to, but have you tried getting past their reception team?!). As well as being told off over the phone there was the ritual humiliation of being torn apart by the Radiology team every time I went down to request a scan. They would quiz me on the exact reasons the specific test had been chosen, which half the time I just didn't know. The Ice Queen was not someone you questioned after all, it was my job just to carry out the sometime bizarre and often illogical whims of the consultant. So by the end of my first month, I was getting quite good at apologising and I was a master of the paperwork. To be honest, it all became routine quite fast. There were few life or death emergencies, the only blood I saw was that I was taking in small bottles, and very few people were dropping dead on me. I started to relax and realise that maybe I was over reacting, I was able to do this medical thing. It was when my first set of night shifts could be glimpsed on the horizon that I started to think that just maybe, I had come to the conclusion a little too quickly.

Thursday, 26 January 2012

Running like a mad man

When a crash bleep goes off on your first day you know there is only one explanation. You’ve been cursed. That’s it, must be the only option. A crash bleep goes off to inform the on call team that a patient somewhere in the hospital has died or is about to die and it is the crash team’s responsibility to get to that patient as soon as possible and attempt to bring them back. Nothing too complicated then. For me, that happened shortly after the ritual humiliation of my first ward round.

The consultant had spent two hours quizzing me on why patients hadn’t had tests ordered and why medication hadn’t been started. He seemed to be completely oblivious to the fact that it hadn’t been me that admitted the patient and in fact I wasn’t the same person that had been on his ward round the morning before and no, my name wasn’t Dr Sharma. He wore a sharp pin striped suite, white shirt, bright red tie and matching pocket square. His glasses were perched on the end of his beak like nose in a way I always thought only teachers could perfect. Also along for the ride was The Medical Registrar, or Med Reg as he was called by the team. He was the second in command and some might say the most important doctor in the hospital. Our Med Reg looked thoroughly fed up with this role. His bleep must have gone off at least once a minute during the round and each time he came back looking more and more aggravated and when he wasn’t on the phone he was correcting the various mistakes made by the junior staff and apologising to patients for the major flaws in the Consultant’s communication skills. The worst of these flaws came when the boss told a lady who had taken an overdose after having a miscarriage that she should remember to be ‘thankful for her health’ in situations like these. That will surely be enough to stop her wanting to harm herself. Then there was the SHO, the doctor directly above me, and the ward sister. It was the two of them that steered me in the right direction as the morning went on and let me know what I needed to do next to escape the wrath of the Consultant when he returned for the evening round.

After the morning round had finished I was sent to the X Ray department with a handful of request cards. I had been given the instructions by my SHO that I mustn’t just leave them in the request tray, I had to speak to one of the staff there and stress the importance of these requests. The SHO had fed me phrases like, ‘to get them home’ and ‘we’re out of beds’ and suggested I try to use them as much as possible to try and encourage our X Ray colleagues to give into my demands. It was as I walked through the department doors that a screeching noise came from the brick like bleep attached to my belt followed by a voice shouting ‘Cardiac Arrest, Ward 34’ again and again at me. For a split second I felt like I was the one having a cardiac arrest and then the adrenaline kicked in for the second time that day. I threw the request cards down on the reception desk and raced back down the corridor in the direction I hoped Ward 34 would be found.

Racing down a hospital corridor is not glamorous. Within 30 seconds I had hit myself in the face with the stethoscope around my neck at least three times, one of them hard enough to leave a bright red mark on my nose, my list of jobs had flung itself from my pocket in a bid to escape and my bleep had crashed to the floor spilling its batteries in the process. I did not look like a professional at all as I tried to scoop up my dropped possessions. As I ran around a corner I collided full on with the SHO coming in the opposite direction with a smack that echoed all the way back to the main entrance. Both our bleeps went flying, our stethoscopes became tangled and his knee landed firmly in my crotch.
“Where are you going?” he barked at me, breathlessly.
“Ward 34.” I whimpered back at him.
“Shit, I thought it was this way.” He said pointing in the direction I had just come from.
“You’ll know better than me.”
“Don’t bet on it, this is my first day in this hospital too!”
It was at that moment a porter came into sight. He both ran at him shouting “Ward 34?!”
“Keep going that way,” he pointed in the direction I had been running, “and it’s on your left.”
I may not have a clue what to do when I get there but at least I was running in the right direction. Result!

We got there a few seconds later and I can say that there was no comedy about that scene. It was horrendous and it does not need to be spoken about here. After that day, crash calls became second nature but the first one I ever attended, the first time it was my responsibility to bounce up and down on a person’s heart will never leave me. He didn’t survive.

There was no time for a chat, no time for a coffee, no one asked if everyone was okay. It was straight back to work. As I walked back on to the Admissions Unit I picked up the notes belonging to the next patient needing to be seen. I stepped through the curtain to be greeted by a smiling elderly lady and a nurse who turned to me before announcing to the frail patient that “The doctor is here now…” I turned to look over my shoulder to see if my SHO was following me in and then realised she was talking about me.

It was on the evening round later that day that I remembered the X Ray request cards dumped on the department reception desk.

“Now, let us have a look at Mr Oaks’ Chest X Ray.”


Wednesday, 25 January 2012

The First Day

‘The week to stay out of hospital.’ ‘Death week.’ ‘Don’t get sick today!’

The newspapers just love to turn this day into a circus, they do it every year. It might be because, as we reach the first Wednesday in August, there isn’t normally much else going on to report about and so the slightest chance for those reporters to whip up panic can’t be passed by. I mean, there are only so many times you want to report on the lack of summer sun reaching record levels if you don’t want to be held responsible for a mass suicide. It was those kind of headlines I saw as I made my way past the shop by the front entrance to the hospital on that first Wednesday in August. That was the day that hospitals up and down the country were to be hit by something much more dangerous than any government reform, more lethal than any super bug. What could it be? I hear you scream as you clutch your chest, panic stricken. This is the day every year that the leash is finally taken off and hundreds of newly qualified doctors are unleashed onto the wards for the first time. Five years at medical school did nothing to prepare us for that first day.

Luck was never on my side. That first day also just happened to be the first time I was ‘on call’. This meant that there would be no nice cushy induction for me with my new team, no coffee and a welcome chat with my new consultant, no I was plunged into the chaos that is a Medical Admissions Unit in a busy inner city hospital. This was not enough of a trauma however, as well as being lost in an alien environment of this busy department, I would also be stuck here for at least the next twelve hours. No leaving at 5pm for me, I was going to see the day through, one way or the other! Maybe the papers were right, this is the day to stay out of hospital.

As I took the bleep off the exhausted looking night doctor, I realised he was me one year from now. The handing over of the on call bleep marked the end of his first year working and from the look in his eyes, it could not have come quicker. The clothes were crumpled, the hair was dishevelled and the bags under his eyes looked like you could take a nap in them. He put his hand on my shoulder, like a fallen captain passing on the baton to his lieutenant, he wished me luck without quite finding the energy to smile and turned around and left before I could even say thanks. It was at that moment that I realised how unprepared I really was for this.

Medical School had been hard work. Don’t get me wrong, there had been a lot of fun but the parts that stick in my mind, when I wake in a cold sweat at 4am, consist of hard work. Getting up at 4.30am to travel over two hours on various buses to get to the hospital I had been sent to on time for the Midwife handover just to be told they were too busy for me to join them that day. Standing in theatre as an eye was being removed trying desperately to look interested while at the same time fighting off waves of nausea and the sudden urge my body had to collapse right there on the floor in front of everyone. The exams; spot tests where you had to point out anatomical markings on a cadaver, slide shows were vague images were flashed over computer screens for you to comment on and diagnoses, or worst of all, the clinical exams, where you had to show off as much of your knowledge as possible in front of an examiner with an actor as a patient, all of these done while the clock was ticking.

I had survived all of that, could tell you the meaning of ADME, which blood vessel supplies the Latissimus Dorsi and the name of the cells to be found in the kidney, yet I still felt I hadn’t a clue how to be a real doctor. Three weeks before the newbies start work we get to ‘shadow’ the person doing the job we will be starting with. All these three weeks did however was to work me up into even more of a panic. I was ready to learn the best way of getting blood from an obese patient and how to react to a medical emergency on my ward, what I wasn’t ready for was the politics of being a house officer. If I wanted a CT scan I had to prey for a certain radiographer to be on duty as she might say yes, if she wasn’t there I had to go down and offer to sell my left testicle to get the scan done and I had to do it before the hordes of other house officers from every ward in the hospital arrived to do the same. If my consultant asked for a CTPA, Chest X Ray or even MRI, it was not my job to ask why it was needed, no matter how unclear his reasoning was, it was however my job to know why when filling in the request card as – ‘consultant said so’ apparently isn’t a valid reason. Then there was phlebotomy, the blood takers, they would do a round every day but would get there at 7am, two hours before I started work, so I had to remember to get the blood cards in before I left the night before otherwise three hours of my day would be spent bleeding the twenty patients I had on the ward. These were simple compared to the incredibly complex etiquette involved in communication with the nurses and ward clerk. Some examples of this;

  1. Nurses are boss and junior doctors were to remember that. The consultant liked to think he was boss, he was wrong.
  2. Never get cocky or rude with a nurse, they can easily ruin your life if spoken to in the wrong tone.
  3. Never sit in the ward clerk’s chair, that is her chair, it is not and never will be your chair.
  4. Don’t ask a nurse to make you a coffee but always offer to make them a coffee and comment on how busy they look.
  5. Always remember please and thank you, never shout and never, ever play the doctor card with them.
Yes, I had spent time on wards before, I had spoken to patients, taken blood and put in cannula but before as soon as the going got tough, all I had to say was – ‘I’ll just get the doctor for you.’ I couldn’t do that anymore though, now I was the doctor. What if I make a mistake? What if I can’t get blood out of the patient? What if I can’t think of the dose to prescribe? What if someone dies? The thoughts started racing through my head at such a rate I thought I was going to have a full on panic attack. The adrenaline started to surge and my body got ready to respond – fight or flight? The age old question, but right now it wasn’t a Woolly Mammoth attack I was braced for, it was much worse, this was a post take ward round with a team of people who had no idea how incompetent I really felt. Into the valley of death…