Monday
You are a Foundation Year Two Doctor.
It’s eight o’clock (in the evening) and you’re fairly well
rested from a relaxing day in which you told yourself you would try to sleep
but you ended up in the kitchen concocting something. You reluctantly don your
scrub top, hug your spouse goodbye and return three times for various things
you’ve missed; a stethoscope, your key-card, your car keys. This is looking
promising already.
As you drive to the hospital you realise you are nervous.
You’re nervous because you’re working in a team tonight that must be cohesive –
and you’ve never met the people you will be working with before. You imagine
the worst-case scenario; a lazy Foundation Year One (FY1) doctor leaving it all
up to you, and a terrifying, sarcastic Medical Registrar (Reg) who will wonder
why you’re not smarter/better/faster. You muse on whether it would be worse
with a sarcastic FY1 and a lazy Registrar but you settle on the first scenario.
This is going to be awful.
You arrive early on your first night because, as a
conscientious individual, you are concerned with how it might sit with the
colleagues you are working with for the next four nights if their first
impression of you is of a tardy, disruptive, disorganised whirlwind. You walk
through an ominously full waiting room to be greeted by an empty handover room,
which is disappointing even if this was your objective. Your disappointment
doesn’t last long though as through the door one minute later comes the FY1.
Apparently you aren’t the only one who’s paranoid about making a good first
impression!
The FY1 has done nights before so she spends time talking to
you about how the system works and why the number of patients waiting – 10 –
means it’s going to be a difficult night. The day team walk in looking completely
deflated, adding to the air of gloom and doom. There have been staffing issues
which mean they have been under a heavy load all day. You try and smile, hoping
that people will realise you’re part of the night team from your fresh face.
You succeed in looking hopelessly naïve as you take handover of the ‘bleep’.
During handover you zone out a bit – most of it isn’t for
you – and stare intently at the Reg. You decide he has a kind face and you’re
pleased that he speaks softly. Maybe he won’t be the tyrant you imagined. The
FY1, meanwhile, is busily taking note of her list of jobs – diligent and
thorough notes. Things really are looking better than expected. You discuss
which roles the three of you will take if a “crash call” should come.
When handover finishes you spend thirty minutes just working
out the computer system – a different one to the one you use in your day-job.
You realise your password for an essential component doesn’t work. You’re going
to have to work around it and rely on the nurses.
You pick your first patient from the top of the growing –
now 13 – list of patients needing to be clerked. You decide to concentrate on
those patients on the Acute Medical Unit (AMU) as that’s what you’ve been told
to do.
You manage to get through the first few patients quickly –
they have simple problems you can resolve and send them home once you confirm
with the Reg. It’s a good job they are straight forward because when you go
back to the list there are five to replace the two you took off it – 16
waiting.
It continues like that for the next four hours, two steps
forward, five steps back. But, on a positive note, no crash calls. In that time
you see patients presenting with a range of weird and wonderful symptoms:
generally unwell, headache, chest pain, jaundice. Your personal target is to
‘sort out’ a patient in 40 minutes – which includes taking a history,
performing an examination, checking blood results, chasing x-rays, taking
bloods for additional tests, coming up with a management plan, making phone
calls to other specialities, prescribing medications and of course ensuring you
meticulously document all of the above. Somewhere along the way you realise
it’s….
Tuesday
You suddenly realise you haven’t seen the Reg or FY1 for a
long time. They’re seeing the patients waiting in A&E so you decide to
crack on with seeing more patients in AMU.
It’s 3am and you find yourself staring at a computer screen
for two minutes not actually achieving anything. You can feel your body warning
you that it’s time for a break, but you’d feel so guilty taking one while
patients are waiting and your colleagues are still working so you, instead,
grab a jaffa cake and your water bottle so you at least stay hydrated and just
take gulps in between documenting blood results.
The list is now so long of patients waiting to be seen that
your Reg has asked if the doctors from A&E can clerk patients on the acute
medical proforma – it’s 9 pages long and as you see a patient in A&E you
can hear the staff aren’t particularly happy but you’re too tired to care and
there are still 12 waiting.
You see a few more people
- overdose, seizures, shortness of breath….
Mostly, you just try desperately to get things right for
your patients and to write and follow a
coherent plan that will not make your consultant’s head blow up with rage.
Around 6am the air in the hospital shifts and you notice a
difference – maybe it’s the fact that it’s not pitch black outside anymore
(though you can’t remember seeing any windows) or maybe it’s the gradually
escalating activity and volume of the corridors and departments.
When the nurses hand over at 7am you start to get really
excited. Just two more hours and you will be doing the same! The…. Minutes…
are…. Now… excruciatingly… long…
You’re not sure when your consultant will arrive to
‘Post-take’ the patients who are in A&E and on ‘outlying’ wards. You put
your name down to see a patient and the consultant arrives halfway through you
seeing them; he scrutinises your patient-plan and you feel really stupid for
even suggesting the management you came up with for the individual in front of
you. It doesn’t matter that you had no time.
At handover the FY1 expresses how difficult that night was –
which reassures you as that means tomorrow has got to be better, right? You
hand over quickly and race to your car to get home. You can’t believe it’s
Tuesday already and you are working again tonight. You get home, you shut your
bedroom door, pull on your sleeping mask and try and sleep the most unnatural
sleep you’ve ever had – you’re tired but your body clock is just all wrong.
You wake up at about 6pm and set about making dinner –
determined to make it work for both you and your partner you make ‘Brinner’ (Breakfast-dinner)
which includes eggs and sausages. You need your strength!
At 8:15pm you leave the house, making it to handover just
ten minutes early this time. The waiting room isn’t rammed full of people as
you walk through – which you’re taking to be a good sign – but when you look at
the list of patients waiting there are still 7. That’s two and a third each to
see even before you start – though you decide that ethically it’s probably not
appropriate to split the last patient three ways just for ease of labour
division. *Sigh*
You are handed one job to do during the meeting – to go to
one of the wards and check if a patient there has been clerked as the nurses
can’t find the documentation. Dutifully, you go to the ward and pick up the
patient’s notes. There is a full clerking there – it’s just not on the right
paper. You roll your eyes and go back to look at the list. There are now 11
waiting.
You see two patients both with very pleasant manners and
families. They are concerned but polite and ask questions that you provide them
with answers to. One of them needs a blood test and though the nurses could do
it, they are so busy that when you mention it to them they ask if you wouldn’t
mind. You know there are 10 patients on the list but you take the blood test –
it will be the difference between whether the patient can go home or not, and
you’re also aware that putting pressure on already busy nurses is not the way
to make friends and influence people. You decide on balance that you can spare
ten minutes to take the blood. You manage the patients appropriately and start
feeling quite positively about how the night is going – this is the part of
your job that you love.
You’re just writing up notes from the second patient when
you hear an ominous bleep – you strain to hear the message, “ADULT EMERGENCY;
WARD 34”. One of the nurses overhears the message, “you’d better run!” she
remarks. You do, meeting the FY1 on the way. She has longer legs than you so
you jog while she walks – you know that if you get to the arrest out of breath
you are good to no-one, but you still need to get there ASAP. You arrive and
find the patient is a frail elderly man. Looking through the notes you realise
he has a terminal cancer but as no ceiling of care has been decided by his ward
team if his heart has stopped you need to commence CPR until it is determined
to be futile. Someone hands you a syringe full of blood and you spend the next
ten minutes sending some of the bloods off and trying to use the machine to get
a blood gas reading. But you’re fairly sure what the outcome will be.
Wednesday (though
you haven’t realised it)
When you next check the list, there are 18 patients waiting.
The whole clerking team was at the crash call so patients are building up –
some are waiting for more than 5 hours to see a medical doctor but fortunately
most of these have been seen and stabilised in A&E.
You see more patients – stroke, sepsis, overdose. You
receive a bleep from the nurse about your gentleman who was waiting for the
blood test result – you had checked ten minutes ago and it wasn’t back but looking
at it now it is normal and the patient can go home. He is very grateful. You
advise him to come back if he has any more problems. You quickly write the
discharge letter and go back to see another two patients; diarrhoea and
vomiting, shortness of breath.
You are tired and hungry. You feel guilty but when you feel
like you can no longer concentrate you go to the handover room and shovel down
as much of the rice as you can, congratulating yourself on having the foresight
to pack something so easy to eat. You guzzle down 500mls of water and even
allow yourself a bathroom break.
Refreshed, you get back on to the list. It’s now around 6am
and the flow of patients has had a temporary lull. Oh yeah, it’s Wednesday! You
wonder how many patients’ notes have the wrong date on them because you forgot
to start writing the next number. You probably wrote 2015 on most of them too.
You see a patient in A&E who has come in for shortness
of breath who is tired and bored. You indulge her boredom by listening for a
few minutes. She tells you about her family, that you have nice eyes and about
her dreams for the future. You make your apologies, genuinely regretting that
you can’t talk for longer, and go to see a patient on AMU who has sepsis.
The consultant arrives and because there is not a lot of
time they let you off the hook – they will go and see the patients by themselves
so you can make it to hand over at 9am. You describe the patients and your
management to him – what you can remember of it, anyway. There’s one on your
list whose face just hasn’t stuck so you can only go on what you’ve written
down.
That night was worse than the first, you reflect. You
handover and go home. Sleep feels a little more natural today – you are
exhausted and feel nauseous.
You wake at around 5pm with your sleeping mask off. You can’t
find it so go back to sleep for an hour. You wake up at 6pm and realise it has
slipped down and is around your neck. You laugh at your 5pm self for not being
able to find it. It is the exhausted doctor equivalent of not being able to find
your specs which are balanced on your head.
You stick a pizza in the oven feeling much less inspired
tonight. Any food will do. You see your spouse for an hour, then kiss them
goodbye and leave for work.
Walking through the waiting room you are again pleasantly
surprised to find it isn’t too full and are shocked when you look at the list.
There are 13 waiting already.
The FY1 walks into the handover room and tells you that the
reason for this busy-ness is that a local hospital had an infection control
risk identified and can’t take as many patients there – all the ambulances are
diverting to our A&E. You can only hope this crisis is sorted soon because
it looks like you’re in for a monstrous night. The day team let you know there
has been another problem – the computer system was down in A&E and AMU
during the day for three hours, which slowed everything down as the team were
using paper request forms for everything. They look exhausted but are able to
see the funny side to what they are handing over. You don’t see it as much at
this point – maybe you’ll get there at 9am tomorrow.
You are handed over three things to review at some point
during the night. You write them on your list and decide you’ll get to them as
soon as you can.
You see a young breathless woman and start treatment for a
chest infection. You see a woman with a history of alcoholism who came in with
a bleed. You rule out the most worrying things and admit for observation. You
see two more patients with chest infections – it’s the time of year.
Thursday
A&E is busy tonight and the nurses are rushing around
fairly panicked. They ask whether you would be able to clerk patients before
they have seen them. You tell them it’s up to your Reg to make that decision –
if he wants you to do that, you will. You never hear back on that. Since you
arrived in A&E four hours ago it is actually getting a lot better already –
in fact, it’s looking quite…. But you would never use the “Q” word (…quiet) for
fear of retribution from karma and subsequently your colleagues. Things are
okay though.
You start seeing the next patient and as you’re writing in
her notes, a nurse in charge of managing flow through the hospital approaches
you – you want to tell her how very busy you are but you swallow that down to
listen. She says there are two patients on A&E who they can get to the
wards if you can see them quickly. You want to scream but instead ask politely
which two. When she tells you, you feel a sense of relief and reply (trying
your hardest not to sound smug) that you have, in fact, already seen one and
the other is the patient whose notes you are writing at this very moment. She
is pleasantly surprised and you feel very smug indeed.
That sense of smugness dissipates as you see the next
patient – he is really very poorly and you go to find your Reg next door to ask
him to come and take a look. He agrees the patient is very unwell and asks
Intensive Care to come and see whether he would be a candidate but you both
know he is not. Though nothing is diagnosed you suspect from his slight physique
that something has been wrong for a long time.
Your Reg asks you if you wouldn’t mind taking a blood sample
from a patient they have seen who was really unwell to see how they’re doing.
You take the sample and run it through the machine… it doesn’t look promising
and you report the results to the Reg who thanks you for your efficiency.
It’s now about 5am. You decide you have to eat and you check
blood results as you shovel down more rice (if it was a good idea last night,
why buck the trend?).
You see two patients – confusion and shortness of breath.
The second has a high heart rate which you miss; this is pointed out by the
nurses who take him to resus so he can be monitored. You see a patient who
A&E forgot to inform you was already going home. You’re irritated by the
waste of time. You see your chap with the high heart rate and prescribe
something to slow it down.
You squeeze in seeing one last patient – a man with an
abnormal blood test result – before your consultant arrives at 7am.
She is annoyed due to being disturbed in the night by a call
from the nurses in charge of flow through the hospital. They told her that
A&E was so busy she needed to come in and clerk on A&E. This went down
like a lead balloon, and she was wondering what on earth was going on. This
morning, things seem fine and she is confused.
It doesn’t help that as you start to see patients with her,
an ominous bleep sounds. “ADULT EMERGENCY: WARD 36.” You look at the Reg and,
apologising to the consultant, run down the long corridor to the ward.
The patient has no access so all the members of the resus
team are crowding round trying to find a vein so his low blood sugar and low
blood pressure can be treated. You try and take bloods but fail – the blood
pressure is the problem. The Reg sends the FY1 away to continue doing the
post-take with the consultant – who seems set to leave a devastating path of
jobs in her wake. You stay to try and stabilise the patient but it doesn’t seem
to be working. When more help arrives your Reg tells you to make your way back
to the post-take.
You catch up with the consultant who complains about the bad
night’s sleep they got due to the phone call from the nurses. You try to
sympathise…
At handover you find out from the Reg that the patient you
were called to see stabilised in the end. You are glad but leave celebrations
to the less tired. You try and go quickly after handover but don’t get far
before you realise you don’t have your phone – you were using it to look at the
drug formulary and must have left it somewhere. Fortunately you bump into a
nurse who knows where it is – an answer to prayer!
You get home and do some last minute studying for a test you
have later that day. It’s at 4pm, about 40 minutes away. Yes, it’s crazy that
you booked it for then but there were no slots left anywhere else and you have
to sit this test for your applications to training.
You sleep for three hours and then wake up, get dressed and
go to sit your test.
You arrive home at about 7pm and eat a quick meal with your
spouse and prepare to go out to work.
It seems normal now to arrive when there are ten waiting and
tonight is no exception. You are pleased to see the day team who look relieved
that their last shift of the week is coming to an end. They tell you the day
hasn’t been so bad.
You try and start seeing patients on A&E but they’re
sending them all through to AMU so within the space of ten minutes three new
patients arrive on the unit. You decide to help there first as otherwise the
nurses won’t know what the plan is for each of the patients.
You clerk four patients – all ladies. Sepsis, falls, chest
pain and overdose. The second patient needs to be seen by a different
speciality so you make several phone calls and eventually get the right person.
They give you two minutes of advice and tell you they aren’t coming to see the
patient as there is nothing different they will do. You spend some time with
one of the families and are awed and amazed by the way they communicate with
their disabled relative. Moments like this give you a real sense of the faith
you can place in the goodness of people – they are wonderful. You follow their
lead on communicating with their relative and they seem content.
You grab a quick drink and head round to A&E where they
tell you they are discharging one of the patients so you don’t need to see
them. You take them off the list.
You glance at some notes trying to find your next set and
realise someone you know personally is in A&E and that a friend of yours is
clerking them. Your knee-jerk reaction is to tell your colleague you know the
person they are seeing, but you are restrained. You know if you mentioned it
your colleague might feel like you want some information and as you aren’t
going to see the patient you have no right to confidential details – so you don’t
tell your friend you know the patient they are seeing. That way they don’t
accidentally tell you something they shouldn’t.
A man collapses in a cubicle and you go to see if you can
help.
Friday
You see a young woman who came in after taking an overdose.
She is crying and tells you everything is awful. You take the time to reassure
her that help is available. You use the word “hope” along with telling her
there is help and you deeply wish for her that what you’re saying becomes
reality.
It’s 2am but tonight you don’t feel tired. Adrenaline is
carrying you through. You stop caring about how many there are on the list.
You see some more patients; alcohol withdrawal, urine
infection, foot infection and shortness of breath. While in the middle of
seeing the last one (at about 6am) you hear an ominous bleeping noise. “ADULT
EMERGENCY; WARD 202.” You have no idea where 202 is but you bump into your Reg
in the corridor and follow him. Of course, it’s on the other side of the
hospital – in a different building. A patient has collapsed. You manage to give
her some glucogel and she begins to come round.
You get back to A&E and see a patient who has had a fall.
You think he can probably go home. You wonder if you can squeeze in seeing one
last patient before the consultant arrives and you go to find your FY1
colleague on AMU. You see this last patient together – you examine and he looks
up the results. It’s quick and efficient and you manage to complete the
clerking before the consultant arrives.
You start seeing the five post-take patients with the
consultant – most of them are yours as the FY1 saw the AMU patients last night.
The consultant asks who saw the fourth patient and when it is, again, you he
pauses to compliment you. He asks how many patients you saw and when you
respond he takes time to appreciate your hard work and even asks you to come
and see him at some time next week so that he can fill a form for you on your
portfolio.
You are so buoyed up by this recognition that you decide you
will stay for half an hour after handover so you don’t have to ask the next
doctor to take on the few jobs you have left to do – you will do them yourself.
You leave the hospital around 10am on Friday morning. You
are free! The morning air has never been so refreshing. Most of all, you are
grateful to the kind consultant who allowed you to finish your nights on a sweet
note.
Disclaimer: genders, locations and details in this blog do not necessarily reflect the reality of people and places discussed. Efforts have been made to ensure confidentiality of patients and their relatives are preserved.
