Anatomy of a day shift

A mere six months after the first post in this series, I’m going to continue my Anatomy of… series and tell you about a normal working day.

 Anatomy of a Day Shift

 08:05

 I pull up into the hospital car park, grab my bag and make my way towards the main entrance. When I was working as a junior physician, we started work at 9am. Anaesthetists start work an hour earlier, which gives us time to pre-assess our patients before the operating theatre lists start at 9. I’m well used to the earlier start now and one of the good things about it is that there’s always plenty of space to park in the hospital car park and I don’t have to drive around it for five minutes every day trying to find a vacant spot.

 08:10

 I’ve decided to come to work “casual” today, so I change into some scrubs before I go and see the patients. At our hospital, there is a distinct shortage of “medium” and “large” scrubs, but plenty in the “XXL” and “gigantic” sizes, but today I’m lucky. I quickly change into the scrubs and head out to find a copy of the anaesthetic rota so I can find out where I’m working.

 08:11

 

Chair Dental

Dr McAndrew

Dr Anderson

 Fair enough. I actually really quite enjoy chair dental lists. When children need teeth extracting under general anaesthesia, they can come to one of the chair dental lists. What’s meant to happen is this: The child enters the room with their parent, sits in the dentist’s chair. The anaesthetist gives a quick gas-induced general anaesthetic, the dentist whips out the offending teeth, the child wakes up and then goes home. It’s very quick, it’s very simple and I really enjoy meeting kids, so I find these mornings really good fun.

 It takes ages for the nurses to get all the children checked in and prepared so the chair dental theatre list never starts on time. The children have all been seen in the pre-assessment clinic so there’s little point in me going down there and waiting, I just get in the way. I make my way to the doctor’s mess to have some toast and a cup of tea.

 08:50

 I wander into the theatre and say hello to the theatre team. Catherine is the dentist today, and she’s in a particularly joyous mood. Soon after I arrive Dr McAndrew, the consultant anaesthetist, walks in. I like this man. He’s coming up to retirement and is pretty much the embodiment of the phrase “old school.”

 “Look, Michael,” he says to me. “You’ve done this list before with me haven’t you?”

I nod the affirmative.

“So you know that it’s basically fucking boring. If there’s anything else you want to do, or any other list that you want to join that you feel will be more interesting, please feel free to go off and do it.”

“Actually Dr McAndrew, I would quite like to stay and do this. I need to do more paediatric stuff, and perhaps we can do some of my Workplace Assessments this morning as well?”

“Fine, it’s your choice. Tell you what, you can do everything this morning and I’ll just hover in the background and make the occasional sarcastic comment. Show me your paperwork – let’s have a look at some of these forms you want me to fill in.”

The nurse tells us that she’s going to get the first child round and I prepare to give the first gas induction. 

The morning passes by pretty uneventfully. The children are well behaved and there were no major dramas. Actually, that’s not true. There were a couple of dramas – one of the children had particularly a particularly stubborn molar tooth. Catherine, the dentist pulled and pulled and huffed and puffed and then the tooth broke and she had to take it out in pieces. She had to stop a few times so I could give the kid some oxygen, but the tooth came out eventually. The last child of the morning was also the oldest (10), so I assumed she’d give me the fewest problems. I was wrong. She got to the stage where she was partially anaesthetised and then her heart slowed down dramatically to the point where it was dangerously slow (down to 32bpm at one point). Dr McAndrew lay the chair flat and I quickly put a cannula into her hand and gave her some glycopyrrolate and this sorted out the problem.

Interestingly, when these things were happening, at no point did I feel out of control, nor did I feel that the children were going to come to harm. These things now seem to me to be run-of-the-mill hurdles that the job as anaesthetist necessarily entails. I guess I’m become more experienced and I know exactly what to do in these situations, hence why these things worry me much less than they used to.

11:30

 The other good thing about this list is that it frequently finishes early. This gives me a chance to pester Dr McAndrew into going through a case-based discussion form with me. I have to say, that I’m finding these flipping pieces of paper more and more tedious. Apparently, the forms allow the deanery (who are in overall charge of my training) to tell which are the good doctors and which are the bad ones. I don’t believe this for a second, all they are tedious exercises in form filling. Dr McAndrew tries to make it a bit more interesting and we have a bit of a chat about various neuro-muscular blocking drugs, but really, I just want the piece of paper signed.

 12:00

 I head back to the Department of Anaesthesia, there’s a lunchtime meeting today, so the consultants, staff grades and trainees gradually filter into the meeting room. Most of the chat is about the pandemic ‘flu and the (lack of) training or advice that we’ve all received. It seems to me that the way my hospital is preparing boils down to “let’s all hope it doesn’t get serious, if we ignore it enough, maybe it’ll all go away.”

 12:30

The meeting begins, one of the other ST2 anaesthetists presents a recent piece of anaesthetic research and we have a discussion about it afterwards. Sometimes these discussions just end up with consultants ranting on about their own particular hobby-horse, but today’s was actually quite interesting.

 13:00

I pick up my copy of the afternoon list and I’m going to be flying solo this afternoon. I’m doing gynaecology day-case with no direct supervision this afternoon, the patients are all young, healthy women, so I’m not expecting any problems. I go through all the routine pre-op stuff with each of them and then head back to the operating theatres to prepare my drugs and equipment.

 13:45

Janet is the ODP working with me this afternoon. After briefing her about the patients and my plan for them, we manage to kick the afternoon theatre list off (just about) on time.

 14:15

Mr Jeffries, the consultant gynaecologist, has a SHO and a couple of medical students with him today, so there’s a lot of chatter going on down at the “surgical end” of the patient. Mr Jeffries’ style of teaching is to ask loads of questions at the students in rapid succession and then wait for some sort of response. At first, this seems to bamboozle the students and I smirk to myself as I see their worried faces – I remember being in their position only too well. The medical students are quite bright though, and they soon figure out that by picking just one of the questions that Mr Jeffries fires at them and answering that one, Mr Jeffries would forget he asked the others and then answer them all himself.

 16:30

The students have gone now, leaving Mr Jeffries and his SHO to finish the last case. The afternoon has passed calmly and uneventfully, just how I wished. I’ve had chats with Janet, Mr Jeffries and the rest of the theatre team and feel I know them all a little bit better now.

 17:10

This is my favourite part of the day. I go back to the ward where my patients are recovering after their operations. They’re all reasonably comfortable and they all thank me for what I did. I wish them a speedy recovery and then go and get changed. As I’m leaving work, Big Ed texts me to see if I’m up for tonight’s pub quiz. I’d forgotten that it was quiz night and was planning on going running this evening. I weigh the options up for a moment then decide that a pint and banter is probably more fun. I text back:

 Absolutely! See you at half 7

 And then get into my car and drive home.

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.