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?!”