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!