12 all out

An hour ago I handed over my on-call bleep to a (disgruntled) SHO about to start her night shift. This act signalled the end of a 12 day stretch of shifts. I should be pleased (indeed I am), but right now I don't have the energy to celebrate too much.

The Monday before last, I came into work with a smile on my face, full of enthusiasm. We were one SHO down on our team as she was working nights but we would manage just fine. The consultant ward round that day went smoothly and the jobs were done by 6pm - a good finishing time.

The next day we were without a registrar, but we coped. I even had some excitement, correctly diagnosing a benzodiazepine overdose and reversing it with flumazenil, impressing the nurses and medical students in the process.

As the week wore on however, we started to flag. The work load was increasing, patients seemed to stop responding to our treatments and our finish times were becoming later. By Friday I was well in need of a rest. The "Friday feeling" was very much evident on the ward that day - everyone looking forward to the weekend. Everyone, that is, apart from my team, as we had a weekend on call approaching with alarming speed.

So the weekend was spent on EAU, clerking the new medical admissions. I love this, it's medicine at its best. Be the first doctor to see a patient, stabilise them, do some initial investigations and start some basic treatment. Any problems and you have EAU consultants and 2 registrars to give you advice. Saturday was chest pain day. Lots of ECGs and troponins were done, but I made no diagnoses of ACS. We had 19 patients on the post-take list. Sunday was less busy with 16 patients clerked, but we had some proper sickies. I went off to see a ?NSTEMI on our cardiac care unit, only to find that it was actually a STEMI and needed thrombolysis. Very exciting stuff.

The weekend itself was alright but I was well and truly shattered on Sunday night. Unfortunately I had to do it again on the following Tuesday, on call with another team for the day - my 3rd 13 hour day in 4. This was also my birthday and so I was hardly pleased to spend the majority of it in EAU.

Our list wasn't getting any smaller and our next take was getting ever closer. Thursday I was on the ward alone whilst my SHO and registrar went back to EAU to clerk some more patients. They even stole my med students, who (unsurprisingly) found the prospect of clerking new admissions more exciting than ordering scans and bloods for me on the ward.

Miracle of miracles, we managed to get rid of all our patients that we took yesterday (short stay cases stay under the EAU consultant) and our list remained at 25 patients. And so roll on Friday - day 12 of 12. Registrar-led ward round, we finished by 1pm, but we had a LOT of jobs to do. This afternoon was utter chaos. I've removed 3 chest drains, pleurodesed another drain, done 3 cannulas, taken 7 sets of bloods, discharged 3 patients, done 3 TTAs for the weekend discharges, checked 6 chest x-rays and made 2 referrals.

And, just to finish off the stretch, I had another 13 hour day today. Ward work finished, I headed off to switchboard to pick up the ward cover bleep, being the first point of contact for 9 medical wards from 5-10. Luckily it was a quiet night. My biggest concern was a hyperkalaemic patient with poor IV access but we sorted it eventually and he got his calcium gluconate and insulin before he had chance to develop any funny cardiac arrhythmias. Come 10pm I practically threw my bleep at the poor night SHO.

So yeah, right now I'm drained. I literally have no more to give. I love this hospital and the town it's in, but I need to run far away to recharge my batteries. So at 6am tomorrow morning I shall be on the first train back to Manchester where I can go and think about something other than medicine.

Appreciated

Mr Richardson has cancer. He came to us with a history of weight loss and these funny-looking growths under the skin. You don’t need to be a doctor to figure out this diagnosis. We haven’t really done all that much for him other than confirm our suspicions and break the terrible news. He’s been with us for a couple of weeks now, not because he is acutely unwell but because he’s too weak to be safely discharged to his home. The physios are working with him to try and help him build up his strength so that he can walk again, and the occupational therapists are sorting out a whole host of gadgets for his home to help him cope, but in reality they’re probably fighting a losing battle as he grows weaker by the day.

As we approach his bed on our daily ward round, he greets us with a welcoming smile. “Hello Mr Richardson, how are you today?” asks our registrar? “I’m fine doc, thanks for asking,” he replies warmly. A quick glance at the obs chart and review of the nursing notes is all we need to see, and I am happy to record in the notes “patient well, obs stable, plan: discharge planning, medically fit”. He shows us a picture that sits on his bedside cabinet of two smiling children in school uniform. “These are my grandchildren, doc, Lucy is 8 and Tom is 15. They’ll be coming to visit this afternoon and I would love for you to meet them so that I can show them the people who are looking after me so fantastically whilst I’m here”. We all blush, not sure what to say, and the registrar mumbles a word of thanks for his kind words. As we turn to leave his bedside and pull back the curtains, he speaks again. “I mean it you know. You’ve all been so kind to me and I can’t thank you enough for everything that you’re doing.” Tears well up in his eyes and he turns away, not wanting us to see him cry. We oblige, smile, mutter some more and quickly move on. However his kind words have had an effect on us all. We don’t deserve to be thanked, we haven’t really done anything. But it is nice nonetheless to be appreciated and I think that we all have him in our thoughts as we continue to fight through the remainder of the ward round.

Later on that day, at visiting time, I make sure that I take a couple of minutes to visit Mr Richardson and his family. It’s the least I can do for him. I just wish we could offer him more.

(needless to say, all patient details in this post have been amended to a point where everything is completely anonymous)

My problem

As I walk onto the ward this morning, our ward clerk calls me over. "Just wanted to let you know that Dr X (the consultant) has an elective admission this afternoon for a ultrasound-guided liver biopsy. He's booked for 2pm and will be here by 1pm." I thank her for the tip and make a note of the patient details on my list, mentally running through what it expected of me when he arrived.

The morning is uneventful and by lunchtime me and my F2 have pretty much seen every patient under our team. Plans have been created and we have a lengthy list of jobs, as well as a mental note of the sickest patients who may require an extra review prior to us going home.

As I return to our own ward having seen the outliers, the ward clerk informs me that our elective patient has arrived. I check the clock, 1.15pm. That's plenty of time to get him sorted out and down to radiology for his procedure at 2pm. The nurses do their stuff first. He puts his gown and wrist band on and all the nursing assessments are completed. Then it's my turn. I have a look over his last clinic letter, head over, introduce myself, take a brief history and perform an even briefer examination. I check the obs - everything is nice and stable. He tells me that he had a blood test at his GPs surgery last week as requested to check the clotting of the blood. A cannula is inserted so that we can give him fluids/drugs/blood should anything untoward happen. I take a drug history and fill out a drug chart and VTE risk assessment. Next is the consent. I run through the procedure, benefits, risks, and what to expect when he goes down to radiology. Does he have any further questions? Nope, he's happy to sign the consent form, and I place it at the front of the notes,ready for the radiologist to sign the consent confirmation. It''s 1.45 by the time I sign my entry in the notes, wish him well and leave his bedside. Oh, one last thing. I should probably scribble his blood tests in the notes and check that he's not likely to bleed out during the procedure.

It is then that I realise that we have a problem. The patient wasn't wrong, he did have a blood test last week. On the computer system I find the results of his full blood count, urea and electrolytes, C reactive protein and liver function tests. Unfortunately none of these tests tell me what I want to know, what is his INR (international normalised ratio - the tendency of the blood to clot). Crap. There is no way that the radiologist is going to do the procedure without the result of this test. There is only one thing for it. First of all I grab a needle and green blood bottle and rush to the patient. Luckily he is easy to bleed and I have my sample in a matter of seconds. Next I ring the radiologist. I apologise and explain the problem. He isn't happy but agrees to wait. INRs can be done very quickly by the labs and we can have a result in 15 minutes or so. Next I give haematology a call. They agree to do the blood test as a matter of urgency and I send the sample their way via the pod system. 20 minutes or so pass and there is still no INR on the system. Getting anxious, I call the laboratory to enquire about the delay. They claim that they have no record of the sample even arriving in the lab. I explain that I personally saw the sample disappear up the plastic tube on its way to the lab and urge them to have another luck. They promise to do so and I leave them to it. By this time the porter who had come to collect the patient had got bored of waiting and returned to his department. Then I get a bleep. It is the radiologist. He is angry and tells me that he is cancelling the procedure as he can't afford to wait any longer. I beg and plead with him, and explain that the lab have the sample and are currently trying to find it. Begrudgingly he gives me another 15 minutes after a lot of grovelling on my part.

I ring the lab back to find out how they are getting on in their hunt. There's no luck so far. Then, just as I'm giving up hope, success! The sample was found. It was processed 20 minutes ago however had been logged on the system under the wrong hospital number, and so it wasn't appearing as belonging to our patient. The INR was 1.1, perfectly satisfactory for an ultrasound-guided liver biopsy. Great! We now have 10 minutes to get our patient down to radiology. First priority is the porter. I interrupt his coffee break to get him back to the ward, then give my new best friend Mr Radiologist a call to tell him that the patient is on his way with an INR of 1.1. We eventually get him down for his procedure with barely a second to spare, everything goes well and he returns to the ward an hour or so later with a smile on his face.

The reason I write this post is not to moan about grumpy radiologists/GPs not knowing what blood tests to do/laboratory mixups. Firstly I think it gives a good example of the day-to-day job expectations of a junior doctor working in the NHS. However also to make a point. One of the worst things about being an F1 is that shit rolls downhill. Whenever someone has a problem, it tends to become YOUR problem and you're left to deal with it. I was desperate for my patient to get his procedure, not just because my consultant would have shouted if he hadn't (he probably wouldn't have done) but because the patient is a really nice guy and I want him to leave the ward thinking how professional we all were and that he had no complaints about his care. Being an F1 involves dealing with a lot of problems such as this, and whilst it's stressful, it is ultimately rewarding when things go well and a patient gets the treatment they need because of your perseverance, determination and ability to grovel to busy consultant radiologists!