stories from the wards

And That Was Wednesday

I woke up this morning, got dressed, got on the bus to work, and sat down in what I am almost positive was urine.

That was 8.15am.

Thankfully, I work in a job where no one is going to think it’s all that inappropriate if I go about my day dressed in blue pyjamas. So en route I went into the theatre changing rooms and borrowed a pair of scrubs.

And then got in the lift to go up to my ward and stepped in the puddle of vomit that was on the floor of the lift.

I found a packet of the big alcohol wipes and wiped off my shoe.

And finally started my ward round and made a theatrical gesture and sent a patient’s full glass of Irn Bru flying.

There are days when you just have to call it good and try again tomorrow.

giphy

Sitting in ill-advised places. I’m blaming it on the Bossa Nova.

New Fangled Terminology

Beth: It’s for a patient with a background of Yadda Yadda who has come in with Symptoms, and has a new acute kidney injury. So, I’ve spoken to renal and…

Person To Whom I Am Handing Over: [interrupts] Oh, my God, what happened to their kidney? Did they fall on it?

For the non-medically minded, sometime about five years ago it was decided by the universal powers that be that we couldn’t call acute renal failure “acute renal failure” anymore. The only other time I’ve ever encountered confusion is from the Registrar of Births, Deaths, and Marriages, who panics and starts asking questions if you don’t point out on the death certificate that “injury” =/= “trauma”.

Secret Dogs

Once upon a time, a young doctor was going about her daily business on the ward when she became aware of a noise of an unusual nature coming from one of the side rooms. In that room was a person of whom it was thought unlikely that they would ever again leave the hospital, or see the friends they had left in the outside world. The doctor carried on with her business, but over the next little while she began to hear whispers of a rumour about these unusual sounds.

Eventually, her curiosity took her to the charge nurse.

“O Great Charge Nurse,” said the doctor doubtfully (for the rumour was ludicrous one). “Is it true there’s a dog in Room C?”

“Sssssssh,” she replied. “It’s a secret dog.” And: “It’s wearing a coat and hat.”

For the ward staff had sneaked in the dog, that it and its human might have one last chance to see each other.

And when some time later the doctor found herself having a conversation about therapy animals, she told this story to her new colleagues.

And her consultant said: “Do you know, Beth, I think that if ever I’d heard a story about a secret dog in a hospital dressed in a hat and coat anyway, I wouldn’t actually be surprised to hear that you were somehow involved.”

Overheard in Medical Assessment

Occasionally a doctor answers a ward phone.

This is almost always a bad idea. The person on the other end is almost never looking for a doctor, and I never know how many beds we’ve got or whether patient transport has been booked or if that person is ready to go down to CT or what linen we need or what Mrs Smith had for breakfast this morning. And yet sometimes we do anyway, whether because there’s a touch of Russian roulette inherent in answering the phone just after you’ve paged someone from it or because some of us worked in offices and call centres in our previous lives and will evermore be constitutionally incapable of ignoring a ringing phone.

As a doctor becomes more senior, they are less likely to know the answers to any of those questions and they are more likely to have learned well the lesson that answering the phone leads only to trouble.

So it was that all of us who were engaged upon our own business near one of the nurses’ stations this morning witnessed this:

“Hello, Medical Assessment Unit … Um … Okay, if you just hold on, I’m sure I can find that out for you … (hasty consultation with nearby nurse) … Yes, Mr Jones, your brother had a settled night and is doing very well this morning … Er, well, no, I’m not actually the telephonist, sir, I’m the Professor of Medicine, but I can certainly take a message.”

 

My Job Is Amazing

This weekend, I have…

  • Sat down for half an hour with a patient, their partner, and a pharmacist to come up with a robust, flexible management plan upon which we were all agreed.
  • Done my medical detective schtick.
  • Talked more than either of us would have liked to oncology on call.
  • Taught three medical students. Given one of them a logistically impossible task of the FY1 bureaucratic nightmare variety, and got to see him accomplish it and then grin so much I thought his face might fall off. Because teaching that impossible is relative is still teaching.
  • Been thanked.
  • “I have to ask you some daft questions. Do you know what year it is?” “2014.” “Who’s the Prime Minister?” “That bastard.”
  • Via well-timed phone calls and much help from other people, found alternative diagnoses that made more sense, were truer to Occam’s Razor, and led to changing treatment for the better.
  • Had important conversations.
  • Been called Madam Doctor. Lots. In bad French, once. Madam Doctor, comprendes oui?
  • Genuinely saved someone’s life, which is a thing that I get to say less often than you might think.
  • Had fits of giggles when I walked through an A&E waiting room that contained maybe fifteen patients who were all intently watching Casualty.
  • Drunk not enough.
  • Got home on time not at all.
  • Got better at being a doctor than I was on Friday morning.

As The Romans Did

Last year, in the middle of the Preparation for Practice rotation I had in what would become my hospital, I had a couple of weeks with a consultant who likes to teach on ward rounds.

I like consultants who teach on ward rounds. I had just switched over from vascular surgery, mind, and I’d therefore become unused to having my presence acknowledged on ward rounds, let alone taught anything on them. And I do genuinely like that specific consultant, even if most of our interaction these days is based on him kindly doing medical reviews of my surgical patients and then me calling to ask if he would mind terribly translating his handwriting as I’ve been squinting at it for a half hour and cannot make head nor tail.

On a particular day, I was taken into a room and pointed at a pleasant gentleman in the corner and asked for a spot diagnosis.

Er…

I had an answer in my head, but the problem with spot diagnoses is that getting it wrong means inadvertently insulting someone’s appearance. Honestly, ask anyone who thought they had a perfectly normal neck until four medical students panicked and told them that they had a goitre. My dithering went on for a beat longer.

“BRING BACK COMPULSORY LATIN!” he bellowed.

I studied Latin for four years. This threw me completely and I dithered a bit more.

“If you have too much of something…” came the prompt from my SHO.

I gave up and took a punt on my original answer. “Oh, OK,” I said. “He has polycythaemia rubra vera?”

Yes. Indeed.

“So,” I said to the SHO as we went back out to the notes trolley. “Hypothetically, how badly do you think he would take it if I told him that ‘polycythaemia’ is Greek?”

 

Hi, I Have A Ludicrous Referral For You

I’m settling into my new job as the surgical F1.

The way I can tell that I’m working with surgeons, who are turning out to be unexpectedly lovely, is that sometime between medical school finals and FRCS, some of them, no matter how lovely, have clearly given themselves a common sense-ectomy. To wit, the instructions I was given on Monday on the ward round vis a vis one of the very well elective patients who was almost ready for discharge.

“Beth, this man had a heart rate of 90 when he was assessed in pre-op and he had a heart rate of 90 during theatre and he had a heart rate of 90 when he returned to the ward post-operatively and now he still has a heart rate of 90.”

Okay.

“His ECG has been normal.”

Okay.

“His other obs are all fine.”

Okay.

“So, I got the F1 who was on the ward last week to check TFTs. If those are normal, can you refer him to medics for cardiology assessment, please?”

… Wait. What?

The Care and Feeding of Your On-Call Junior Doctor

1. Thou shalt have a basic grasp of mathematics.

You are looking after between seven and twenty patients. Your FY1 is looking after a minimum of 96 patients. She is entirely within her rights to growl when you try to tell her that you are “very busy”.

2. Thou shalt learn how to read a EWS chart.

The score for BP is for systolic BP, not diastolic BP — a diastolic BP of 8o does not trigger an urgent clinical review, no matter how many times you try to tell me that it does. The nausea score is not part of the EWS — you cannot decide that a patient whose obs are all normal is scoring EWS 3 because they were sick three times. And if a patient has had their parameters adjusted, you need to observe the new parameters —  your FY1 is unlikely to be impressed with your long-standing COPD patient’s SpO2 of 91%.

3. Thou shalt put non-urgent jobs on the non-urgent jobs list.

You do not need to page your FY1 to rewrite a Kardex.

4. Thou shalt not put urgent clinical reviews on the non-urgent jobs list.

A review of a patient with a new tachycardia does not belong on the non-urgent jobs list. A review of a patient who has dropped her systolic BP by 40 in the last hour does not belong on the non-urgent jobs list. A review of an unconscious patient with a blown pupil does not belong on the non-urgent jobs list.

5. Thou shalt not harrass.

It is a waste of your time and your FY1’s time when you page her “just to check whether you’re coming back to the ward” or “just because we haven’t seen you yet today”. She has not forgotten that she is covering your ward and she has not gone for coffee. If you have not seen your FY1 for a while, it is because the brown stuff is hitting the fan somewhere else. The only way your FY1 knows that you are paging her with a stupid question rather than a properly sick person is if she stops what she is doing and calls you back, and if you are the third person to pull your FY1 away from a properly sick person just to tell her that it’s been a few hours since she looked at her non-urgent jobs list, she will be rude to you and she will not apologise later.

6. Thou shalt learn how to use a telephone.

Do not page your FY1 and then walk away from the phone. Do not page your FY1 and then pick up the phone to make another phone call. Do not page your FY1 to the paging system.

7. Thou shalt not expect on a Saturday that which can (and should) wait until Monday.

You may be right in thinking that your patient’s high blood sugars, which have been high for a fortnight and which they are asymptomatic of, are steroid induced, but your on-call FY1 is not going to make a unilateral decision at the weekend to stop steroids that they were started on by a neurosurgeon for their brain tumour.

8. Thou shalt use SBAR.

The on-call FY1 has never met your patients before. If you ask your FY1 to review a patient, she will expect you to know why you want them to be reviewed, what their current obs were, what their obs were before that, and whether a plan has been made by their day team. If you ask your FY1 to review a patient urgently, she will expect you not to have gone on your break in the three minutes it takes her to walk up the stairs.

9. Thou shalt read.

If you ask your FY1 to prescribe analgesia/anti-emetics/fluids for your patient who is, quote, not written up for any, your FY1 will assume that you have actually checked and will be unamused when she comes to the other end of the hospital and opens up the Kardex to discover that you had not checked and that those things had been there all along.

9. Thou shalt realise that it is in your best interests that your FY1 does not keel over in the middle of the ward.

If your FY1 says at 6pm that she is leaving the ward to buy lunch and will be back in five minutes, do not block her path and ask her to “just…” unless your patient is actively trying to die. It is at this point more important for her to treat her own hypoglycaemia and acute renal failure than it is for her to treat your patient’s nicotine withdrawal.

Down The Rabbit Hole

Today, every foundation doctor in the country changes jobs.

It isn’t like Black Wednesday — we’ve all been here for eight months, at least, and are slightly less terrified than we were on the first day of our first jobs, back in August, and mostly know at least where the toilets are by now, and it’ll be another four months before the next set of newly minted doctors start work. It’s still weird, though, because no two wards ever keep blood forms or radiology requests in the same place and you keep writing down your old pager number and the consultants are all different and you don’t actually remember the first thing about gastroenterology.

It’s a curse and a blessing at the same time that, in my job, I’m almost always on the move to somewhere new. It keeps things interesting. It means that I get a lot of experience in a lot of different kinds of medicine. But just as I’ve learned all of the nurses’ names and started to sound as if I might vaguely know what I’m talking about, I’m gone.

I loved my first job.

And then not only did I change jobs but I changed from a ward-based specialty to four solid months in medical receiving, which is absolutely crazy and like no other job in the hospital. I spent the first fortnight of my new job wandering around and muttering oh-my-god-I-want-to-go-home.

A few weeks ago, I talked about feeling as if I was getting burned out on receiving. It’s a fast pace and a high turnover and a constant string of long days punctuated by the occasional day off, and unless, I suppose, you’re an acute physician by temperament, which I’m not, it’s difficult to keep that level of energy up for four months all in a row. I would like, just occasionally, to finish work before bedtime. I would far rather have done a second general medical job and had both of them punctuated by receiving weeks and receiving weekends, which is the way my SHOs and the F1s in a lot of other hospitals do.  Anyway, a lot of it is because this isn’t the job that I want to do — among the best parts of medicine for me are having my ward and having my patients and getting to the end of the story, and that’s not what this has been about.

So, yes, I did get burned out on it.

But that isn’t the whole story.

Because once I conquered the oh-my-god-I-want-to-go-home feeling of once again not having a clue what I was doing, I learned a lot and I worked with some cracking people and I had fun. I learned how to make a management plan for real and how to take responsibility, and, oh, so much about the kind of doctor I want to be and also the kind of doctor I don’t want to be. I’ve been right and I’ve been wrong, and the times I was right were important but I’ve learned more from the times I was wrong. The most crucial thing I’ve learned, I think, is that there are ways to make a difference to people even in an environment like that, and that an environment like that is maybe one of the places where it’s most important to do it.

I’ve been on nights this week and I worked last night, the very last night of this rotation. Thus, why I’m at home writing about my old job instead of at work doing my new one, but it meant that I hadn’t left yet when the F1s who are about to start there came crowding into the office for their induction, all two-thirds of the way through their F1 year, just like me, and every one of them looking like Sputnik had crashed down on their heads. The best way to deal with that is to just jump into the chaos and not think too closely about the way nothing really makes any sense and trust that it will, eventually, come to make its own kind of sense, somehow.

It’s just how this year goes.

Looking like Sputnik has crashed down on my head is after all precisely the way I looked in August and again in December and precisely the way I’ll look again on Friday when I realise that I have to work with surgeons now.

Camouflage, Doctor Style

The scene is the medical receiving unit, at the nurses’ station, shortly after lunchtime. I have apologised and tripped and generally made a nuisance of myself to squash past three nurses and into the corner, and I am now crouched on the floor, foraging in the bereavement drawer for paperwork.

I get nudged in the back. I ignore it. There are a lot of people crammed into a small space, feet and elbows and knees everywhere. Besides, I’m preoccupied with wondering where all the crem forms have gone.

I am poked again, harder.

And then there is a voice from far above my head…

Nurse 1: What are you doing?

Nurse 2: I’m moving this chair out of the way.

Nurse 1: Eh?

I suddenly become aware that the thing that I’m being poked with feels a lot like a shoe and I look up.

Nurse 1: That isn’t a chair! Did you try to sit on Beth?!