Friday, 14 November 2008

Anatomy of a night shift

The tagline under the title of my blog says “Diary of a junior doctor.” I feel that, currently this is a bit of a misnomer because since I started, this blog at no point have I written a “diary” of what I actually get up to. I’m going to attempt to rectify this situation with four posts that detail what I, an anaesthetist in training, actually do with myself all day (and it’s a bit more than sitting reading the paper).


Anatomy of a night shift

19:45

It’s dark and it’s raining. I’m in my car driving towards the hospital to do another night shift. I’m actually feeling pretty good. Hands-free mobile technology has allowed me to spend much of my journey chatting to my girlfriend. I pull into the hospital car park and have enough time to grab a coffee, and get changed into my scrubs before the shift starts at 8. As the anaesthetic SHO on-call, my most important duty is to keep the Emergency Surgery (CEPOD) Theatre going so all the patients who need operating on that day have their operations. Sometimes, there’s an operation going on as I start my shift, sometimes there isn’t. I wonder what’s happening in theatre at the moment

20:00

There is indeed an operation going on. I walk into the operating theatre and say hello to Melanie, the anaesthetic SHO on-call for days. We exchange pleasantries about how her shift has been (frustratingly slow) and she tells me about the patient. Surgery has just started on a fit, healthy 4 year-old girl who had split her lip open and the Maxillo-Facial surgeons were just going to sew it up again. There were a couple of other people on the list for surgery tonight, one 12 year-old for an appendicectomy and one 71 year-old with a broken leg that needed fixing. I get a handover from Mel about the child on the table, take hold of the breathing circuit and Mel goes home.

The Max-Fax surgeons were true to their word, the operation doesn’t take long at all. When they finish, I turn of the anaesthetic vapours, turn up the oxygen and wake the little girl up.

20:20

I’m in the recovery area and I’m satisfied that the girl is awake, comfortable and breathing for herself. One of the theatre nurses comes up to me and asks, “Can we go and get the next patient now?”

“No,” I reply. “I haven’t seen this boy yet.”
“Can’t you just see him in the anaesthetic room?”
“No. I’ll see him on the ward.”

Personally, I think that people should be given the opportunity to speak to the anaesthetist before they come down to theatre. Also, my seeing the boy on the ward gives me to pick up any problems that the surgeons may have missed/ignored and potentially do something about them before the operation.

I trek across to the children’s ward and meet young Joe who is lying in bed with his mother beside him. Joe is actually quite sick. He’s had belly pain for two days now and he has a fever of 39.1˚C, his heart is racing and he’s very still and quiet, the way children get when they feel really rough. I do my pre-op assessment and then I tell Joe and his Mum what to expect when they come down to theatre. Joe has lots of questions about exactly how I’m going to keep him asleep and I spend a bit more time explaining how anaesthesia works and reassuring him a bit.

I let the paediatric nurse looking after Joe that someone will be up to collect him quite soon and then head back to theatres via the Intensive Care Unit. I find the anaesthetic specialist registrar (SpR) – my immediate senior. It’s VJ tonight. He already knows there’s a child booked for theatre. He asks me if I’m happy to carry on with the case alone. I tell him that I am and head off back to theatre.

21:10

Joe and his mother arrive in the anaesthetic room. I’ve got everything prepared and I set about getting Joe anaesthetised. He’s been sick earlier, so I plan to do a “crash induction” and intubate him. Crash inductions (or Rapid-Sequence Inductions) can be quite fraught with danger, especially in unwell patients and especially in youngsters. I’m aware that I’m all alone so I make doubly sure that everything is ready and everything I may need is to hand. It’s not a problem though. I safely get Joe anaesthetised and intubated and the nurse takes his Mum away to have a coffee.

The operation takes a while because the surgical reg is teaching the surgical SHO. About half an hour into surgery, my pager goes off.

“Could you attend A&E resus IMMEDIATELY please. Airway problem.
Could you attend A&E resus IMMEDIATELY please. Airway problem.
Could you attend A&E resus IMMEDIATELY please. Airway problem.”

There’s no way I’m leaving this anaesthetised, intubated, ventilated child to go to A&E resus so I ask one of the theatre assistants to phone switchboard and get them to page VJ, the night anaesthetic SpR on-call, as I am unable to attend.

22:45

The operation is all over. Joe had a nasty, perforated appendix but now it’s been removed he should start to get better. I waken him in recovery and he’s comfortable, if a little tired.

Emily, the ODP on nights asks me what I’m going to do about the last patient on the list – the man with the broken leg. I tell her that I’m going to check what’s going on in A&E and speak to VJ, and then I’ll get back to her.

22:50

A&E resus is empty. I figure that if it was an airway problem, then the patient may well be in the CT scanner so I walk round to radiology. I’m proven right. There’s a clutch of people in the observation room of the CT scanner. VJ has intubated and sedated the patient and a quick glance at the screen tells me that whoever the patient is, they have a significant amount of bleeding inside their skull. Bad news.

On the return journey to A&E resus, VJ fills me in with the story of what happened. Basically, the patient is a 25-year-old man found semi-conscious by his housemate when she got home from work. VJ had done a great job in stabilising the patient regarding blood pressure, sedation, monitoring, carbon-dioxide levels, oxygenation and ventilation etc… etc… There’s more to do though, and I give him a hand as the A&E doctors get on the phone to the neurosurgeons at TheBigTeachingHospitalDownTheMotorway.

The brain surgeons listen to the history, review the CT scan results and agree that this man needs emergency brain surgery tonight.

“I’m going on a journey, aren’t I?” I ask VJ
“Looks like it,” he replies. “Have you done inter-hospital transfers before?”
“No.”
“OK, well there’s a few things that you’ll need to be careful of…” says VJ, and then proceeds to give me a five-minute crash course on how I should transfer this patient.

I’m not actually all that concerned. The patient, Jimmy his name is, is pretty stable from a cardio-respiratory point of view. I just make sure that my monitors are working, I have the drugs I may need in my pocket and that all my equipment is present and in working order. I also make sure I take my coat, some money, my mobile phone and my sandwiches.

00:15

The ambulance crew are here and we load Jimmy into the back of the ambulance. Emily, the ODP, and I squeeze into the back and the two ambulance crew hop into the front, turn on the blue lights and off we go.

The journey itself is pretty uneventful. I have to play with Jimmy’s arterial line a few times to get it to keep working. I also notice that when we’re on a bumpy part of the road, the ECG monitor does a good impression of VF, which was initially quite disconcerting.

During the journey, I start to feel tired. I wish I’d had a coffee before we left, but Emily and I share my sandwiches and this helps keep us going.

When we arrive at TheBigTeachingHospitalDownTheMotorway, we go into A&E resus. Straight away, TheBigTeachingHospitalDownTheMotorway’s nursing and medical staff are surrounding us asking questions and organising various things. I give two handovers, initially to the A&E SpR and then to the consultant anaesthetist who has come to take the patient to theatre. I have to say, having so many people who I don’t know doing stuff all at the same time is really distracting. I have to really concentrate on ensuring that in the midst of the milieu, we are still breathing for Jimmy and looking after him. He goes to theatres pretty quickly though and Emily and I hop back into the back of the ambulance for the journey home.

02:40

We arrive back at my hospital. I really am feeling quite shattered at this point, so I go and get myself a coffee. I really do believe that after midnight, the NHS runs on caffeine. I go and find VJ and get my pager off him.

He’s on the High Dependency Unit (HDU) and we have a quick debrief about my journey to TheBigTeachingHospitalDownTheMotorway. Our chatter is cut short by the sound of his pager going off. It’s the medical registrar with a referral for us from A&E.

02:45

VJ and I arrive in A&E and get the full story from the med reg about his patient, Mr Singh. Basically it’s a middle aged man with very severe, community acquired pneumonia. We go and review the patient along with the results of the investigations the medics have done. VJ ummms and aaaahs for a bit about whether or not to accept the patient onto the HDU. Eventually he decides to accept him and he explains his rationale to me.

“Basically, Michael, this man is on the borderline. As he is right now, he would probably be alright on a normal ward – just. My concern about him is his oxygenation. His pO2 is only 15 despite breathing high flow oxygen via a rebreathe mask. If he gets any worse than he is at the moment, then we’d probably have to intubate and ventilate him and it’d take forever to get him off the ventilator. If we accept him now, give him some CPAP and lots of chest physiotherapy, we may help him turn the corner and avoid intubation.”

We discuss things with the med reg, add a few things to his management plan, call in the physiotherapists and ask the nurses to transfer him to HDU as soon as they can.

03:40

Mr Singh arrives onto HDU. The nurses do their admission and the physiotherapist does some chest physio with him with moderate success.

VJ finishes writing up the admission notes and then turns to me and says, “I might go and try and get my head down for a bit, are you alright to put in an arterial line by yourself?” I tell him that I am and he leaves the unit.

The nurses had kindly put together an arterial line, “A-line,” trolley for me and I go to Mr Singh’s bedside and explain what I’m about to do. The last three A-lines that I have done have all gone in like love’s lost dream, so I’m pretty confident I’ll be able to site one into Mr Singh. The one I did last week went in so easily that the attractive-married-but-still-very-flirty A&E nurse remarked, “Wow! Well done! You are really good at those!”

Unfortunately, my confidence is misplaced in this case. Maybe it’s because of his tachycardia, maybe it’s because it’s the middle of the night and I’m tired, but I find it a real struggle. I try once and get a flashback but the catheter refuses to advance. I try again and manage to kink the tube. I always use large amounts of local anaesthetic when doing these, so Mr Singh is not at all bothered by me poking around his radial artery with a big needle. I don’t seem to be able to feel a radial artery pulse at all on the other side so I try a third time on the same side. “One last try,” I tell myself but it’s no good. I get a flashback again but once again, I can’t get the catheter to advance. I’m getting really frustrated as I’ve been trying to get this sodding line in for nearly an hour now. I consider trying a different site- perhaps the brachial artery or the dorsalis pedis, but, on balance I decide to keep my promise and I give up.

I tidy away the A-line trolley, go to the phone and bleep VJ to come back and help me out. He comes back to the unit and uses the ultrasound machine (why didn’t I think of that?) to gently coax the A-line into Mr Singh’s radial artery. VJ is a great reg to be on with and he gives me a quick 101 in how to use the ultrasound machine and the best tricks for locating the ulnar, median and radial nerves in the forearm using ultrasound.

05:30

Our little teaching session is interrupted by one of the ICU nurses asking us to come and have a look at her patient because she’s rather concerned about him. The patient is question had had a long maxillo-facial operation and reconstruction for cancer. We were using a drug (metaraminol) to keep his blood pressure up, but, the same drug was causing his heart to beat worryingly slowly. Said nurse had turned off the metaraminol pump and asked us to come and review.
VJ had had a handover of all the patients in Intensive Care at the start of his shift and was pretty au fait with this gentleman’s problems. He turned the drug back on again and gave the nurse explicit advice about which drugs to give if his heart rate fell below 40 beats per minute. As we leave his bedside, it occurs to me that this big man with scars and staples across his face looks not too dissimilar to Frankenstein.

05:45

We go back to HDU to see how Mr Singh is doing. He’s tolerating the CPAP well and he tells us that he’s feeling slightly better and is breathing slightly easier. His blood gas shows and improvement too. Satisfied, we leave him to get some rest.

06:00

There’s nothing really pressing for me to do now and I’m feeling really exhausted. I’m wary that I’ll have to drive home at the end of my shift so I head off to try and get a little sleep. Doctor’s working patterns have changed from “on call” to full shifts. This means that we are meant to be working all the time we are present in the hospital. Hospital management have therefore taken the “on-call rooms” away from junior doctors. This means that when your night shift does get quiet, there are no beds to sleep in. Junior doctors do still have the Doctor’s Mess thought and this is where we all go to try and grab a little shut eye.

I enter the mess and all the lights are off. The large sofa is occupied by the Obs & Gynae house officer who is snuggled up with someone I’ve not met before. Judging by his snores, I doubt there is any hanky-panky going on. The surgical SHO is sprawled out on one of the small sofas. The surgeons always seem to be in the mess during the night – this is mainly because we anaesthetists keep telling them that they’re not allowed to operate through the night unless it’s life or limb saving surgery. Fortunately for me, the other small sofa is free and I curl up and quickly nod off to sleep.

07:05

I’m awoken about an hour later by a pager going off. I come out of my daze and realise that it’s not my pager, but that of the Obs & Gynae house officer. She gets up, gives whoever she was sharing the sofa with a quick kiss and leaves the mess.
I decide that I’d better get up anyway and wander back to the Intensive Care Unit. VJ is there reviewing all the patients ahead of the morning handover to the day team. I have a look at Mr Singh. He’s sleeping. His latest arterial blood gas shows that he is continuing to improve. I very much doubt that he’ll need a ventilator now and I hope that he’ll be well enough to go to a normal ward within the next 24-48 hours.

Coffee in hand, I go up to the anaesthetic office and fill in my form for some annual leave over the Christmas period and leave a note for the anaesthetic secretary regarding a query I have over the rota.

08:15

My shift is over. I meet Mel, who has just arrived for another day shift. I tell her briefly how my night was and then she goes to work seeing the patients booked on the morning’s Emergency Surgery list. I leave the hospital main entrance and head towards the car park. As I walk I smile because I know that soon, I’ll be fast asleep in my own bed.

12 comments:

angus said...

Really great post, being non medical I had no idea of what went on at night in a hospital.

Your behind the scenes diary has caught my imagination.

Would you make it a regular feature?

Angus

madsadgirl said...

Excellent post. Thanks so much for the insight into your working life. I'm looking forward to the other posts in the series.

Elaine said...

Great post. You gave a really illuminating, and eye-opening, insight of what goes on for an anaesthetist at night.

Oliver Smith said...

Very interesting. As I pass Anytown Royal Infirmary (which is a big teaching hospital) at 11pm on my way home from work I often wonder what's going on inside that massive building...your post has given me some insight into what you do and I'm looking forward to the rest of them.

steph said...

Wow! Fantastic stuff!

I'm very impressed by your insistence on seeing the lad with the perforated appendicitis before he came to theatre.

A very sad case occurred in Ireland earlier this year where a young child had a wrong kidney removed and the subsequent enquiry found that one of the contributory factors had been that the child hadn't been reviewed by the surgical team on the ward before going to theatre.

Hats off to you for sticking to your guidelines despite the pressures you were under.

You tell it so well!

The Manchester Medic said...

That was a really fascinating post. I look forward to future installments.

Jo said...

Thank you very much for a great post - it was really fascinating (again, as a non-medical person) to find out what goes on during the small hours - I'd love for you to do more of these!

Tazocin said...

Michael, you never fail to make life as an Anaesthetic SHO sound infinitely more varied, exciting and enjoyable than slogging on the wards as a medic!

Dr Nicholas Kelly said...

Really interesting post. Working in Genito-urinary medicine I often forget what happens in the hospital at night

The Underappreciated Medical Student said...

Really really interesting! I always wondered what happened away from the Medics on nights. Look forward to reading another!

Internal Optimist said...

fantastic read. Thanks! I look forward to such experiences of my own :)

shift change management said...

Wow what an amazing look into your shift, thanks for sharing.