The well thumbed hashtag on Twitter will give you its own advice about treating your pharmacists and physios and senior nurses as the pillars of wisdom they are, doing a warfarin and fluid and insulin prescribing round before you go home for the night, remembering #hellomynameis, not leaving ePortfolio until the last minute, not putting yourself into acute kidney injury (no, really), and a great deal more.
I have one piece of advice – a #tipfornewdocs, but, perhaps more importantly, a #tipfornewshos – and a few short stories to go with it.
The highest compliment I was paid in FY1 was being told, while asking a consultant surgeon to come and review my medical patient, yes, I know it’s half past three on Friday afternoon, that I was quite bolshy for an FY1. I am almost certain that it wasn’t meant as a compliment. It also disguises the truth that I am as prone as anyone to prefacing any question I ask my seniors with, look, I think this is probably a stupid question… But developing the ability to get help and get it quickly requires getting over that apologist instinct we all have to presume we’re being a bit silly.
“The reason we might seem a bit on edge is that you are describing to me something that is relatively uncommon and that could be extremely serious,” I say, sometimes. “I could easily be wrong, but indulge my paranoia until we’ve got these investigations done, okay, because there are worse things than being worried and wrong and I wouldn’t be doing my job properly if I weren’t.”
“I’d rather you were paranoid, too, Doc,” they say, sometimes.
And sometimes I’m right, but often I’m wrong and we can all breathe a little easier.
I’m okay with that. (I don’t want to be proven right about the parts of my differential that are 1) Awful Thing, 2) Awful Thing, 3) Really Awful Thing.) The broad strokes of acute medicine are in the sometimes diagnosis but more often elimination of the things that are statistically improbable but acutely life-threatening. The trouble with any kind of medicine is that it isn’t a science, which means that nothing looks like it does in the textbooks and anything that does isn’t what the textbook says it ought to be.
And speaking as the person who has very often this past year been the first in line to be paged by a worried FY1, it is never wrong to ask for help.
I’m certain that most of us have had at least one nightshift when nobody seemed able to maintain their blood pressure. My new wee FY1 colleagues, I promise that you will have this experience in your storybox before long.
Sometimes, this is because there is a local policy that routine four hourly obs should include overnight obs. Do you know who gets hypotensive at 2am? Everyone. Or, on one particular occasion when I was the only doctor actually in the building, nine people, all at once. The skill lies in working out which of those nine people dropped their blood pressure because it’s two o’clock in the morning and they’re trying to sleep, and which of them has dropped it as a precursor to falling off the proverbial cliff. It is a triage skill and it is not one that anyone learns overnight, and I am still learning it. But if a good nurse tells you that two fluid challenges haven’t done anything and the systolic BP is now in the sixties, that’s a hint and you should take it. It might be that the only way to get help is to point out that if nobody comes when you ask for it you will sooner rather than later be summoning it from the arrest team. I’m not saying that that ought to be your opening gambit. I am saying that if things are actually getting to that point, it at least has the merit of being true.
For my newly minted SHO friends, you should know that the help you think you ought to be asking for does not always come. It doesn’t happen often and I wish that it were not so, but it does happen and it is so and you should know that. And the reason you should know that is so that I can tell you this: get help from someone else. One of my newly minted SHO friends will remember the time when they were my FY1 and found me crying in the sluice because I had not been able to convince help to come. This was after I had quoted a remarkable array of very terrible numbers and deployed the phrase “this is incompatible with life” and explained my inability to fix the situation. The help I thought should be coming never did, and I got the med reg and muddled through and kept the patient alive until morning. A few days later, on a morning when my educational supervisor had asked me if I was always able to access senior support, I blurted out the whole story. He looked at me in moderate horror. “If that ever happens again, ignore them and ring the consultant instead,” he said. It had never occurred to me that I could do that.
Incidentally, and this is just as important for FY1s, the med reg is always in the building and will always come (unless someone else is dying), even if it isn’t a medical patient.
Remember this, too: If a patient is unwell, the question is never what you think you should be able to do but only what you can do. On that day when you vowed to make the care of the patient your first concern and became professionally bound to act within the limits of your own competence, you were agreeing to let go of your own ego.
A few weeks ago, I phoned my registrar who then phoned a consultant because I had convinced myself, largely based on a chest X-ray, that one of the patients I was looking after had a pneumothorax and I have never put in a chest drain. Very quickly, the nicest consultant in the world arrived from home and looked at it and then found me. “Ah, Beth. It was you who ordered that X-ray? Come, show me where you think this pneumothorax is.” I brought up the film and showed him the line between the lung and the chest wall. “And where does that line go?” he asked. I followed it down. “It goes… er, well, it sort of bends,” I said. This was a teaching moment for him, and he asked me: “And which anatomical structure might you expect to find there?”
The blood drained from my face. “Oh, no, God, the scapula,” I said.
And spent the next ten minutes apologising.
“It’s all right,” said the nicest consultant in the world. “You have to learn these things. Anyway, I’d rather you were paranoid and got help and were wrong than the alternative.”