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…

The doctor will see you now...

Welcome & thanks for stopping by. When I started work several years ago as a junior doctor, I thought my life would change for ever, and I was right – it did, just not in the way I thought it would. I always pictured myself running down corridors with my white coat billowing in the wind just like they did in Holby City. In the picture I had in my head, patients would thank me and colleagues would support me. I couldn’t have been more wrong. From that first day I stepped onto the wards and to this day, the rollercoaster never really stopped. There is nothing quite like the ice cold grip of fear the first time you hear the crash bleep screech out at you at 4am, or being confronted by a sword wielding, intoxicated drug dealer in A&E three hours after your shift ended, or the palpitations brought on by the constant fear of getting something wrong and maybe, just maybe, someone drying because of something you didn’t do – or worse, did do! I rotated through the hospital departments seeing everything from birth to death before settling for psychiatry as my career path. From there it went from the bizarre to the ridiculous. On my way, I saw bullying worse than anything you might see in a school yard and politics more complex than Westminster. At times, I found myself in very dark places because of the things I saw and the pain I went through. It took a lot to drag me out of this hole. I did however drag myself out because of the fun, love and support I would find in surprising places. I always joked that I could write a book about the things I’ve seen and that led to this blog. No offence is intended and no names or places are real but everything I write really did happen and it might have happened in a hospital near you.