Ward cover

Today was my first evening of ward cover. It's exactly the same as weekend ward cover - being asked to make decisions about patients you don't know and constantly being asked to review patients for no good reason. Here is what I spent my evening doing:

1. Bleeped to go and review a patient with severe abdo pain. Didn't bother trying to get any other details on the phone since the nurse could barely speak english. Arrived to find that the patient had metastatic bowel cancer, she had had the same pain since admission and had been seen by palliative care who had advised PRN tramadol. Looked at the PRN section of the drug chart only to find that no analgesia apart from paracetamol had been give for two days despite the fact that tramadol, diclofenac and morphine had all been prescribed. When I asked the nurse why she hadn't given any of the painkillers that had been prescribed she just looked at me blankly. Wrote tramadol up regularly since the patient just won't get it otherwise. Poor woman.

2. Asked to review a post-op patient with a swollen calf (alarm bells ringing at this point). Arrive to find the patient had knocked her leg on something and has a bit of a bruise on the side of her leg but no swelling, no tenderness, not hot etc. Not in any pain. No action needed. What's more the (lovely) registrar had already seen her a few hours ago and told her that it was just a bruise.

3. Asked to review a patient's regular medication because the doses had been prescribed wrong. Looked for the patient's notes to try to find out the correct doses only to discover they had gone home two days ago.

4. Asked to consider changing several patient's antibiotics from IV to oral despite never having met them and not having a clue why they were even on antibiotics.

5. Asked to prescribe vaccinations for a patient who had a splenectomy and needed them sometime before going home next week.

5. Asked to write TTOs for a patient who might be going home on monday.

6. Asked to rewrite 2 drug charts.

The surprising thing is that this is all within a couple of hours of the normal teams leaving. I'm sure the nurses wait until 5 before looking to see if any fluids need prescribing, drug charts need rewriting etc. I wrote "No - this is a job for the normal team" on a couple of the notes left for me. I was very very close to writing "Fuck off"

Miserable Bastard Registrars

There is a huge difference in the way different registrars treat F1s. There are some absolutely brilliant regs who are patient with us when we don't know all of the answers and even take the time to teach us about what we could have done differently when they come to review our patients. This usually earns them the prefix "lovely" before their names when we discuss them between ourselves.

There are also some absolute bastards of regs. I had to deal with one of them today when I wanted to make a referral to another team. I've started a new specialty today so I don't really know the patients but the SHO asked me to refer one of them to respiratory. I spent about 20mins reading the patient's notes, looking up the results of their investigations and checking their obs chart etc so I would know what to say when I called. The patient had pneumonia, they had been started on IV antibiotics and had started to improve.

Thinking I had a reasonable handle on the case I bleeped the respiratory reg and asked if I could make a referral to him. His reply was "well to start with, no you can't make a referral to me, you can only ask my advice and I'll decide whether to see the patient or not" - ok, I thought that was pretty much the same thing but never mind. I then asked very politely whether in that case I could ask his advice about a patient. He then asked where my registrar was and why they weren't calling him. I explained that there are no registrars in this specialty, only me and an SHO who was busy. After a lot of sighing and tutting he agreed to listen to the case.

I actually summarised the case pretty well since I'd prepared myself and could answer all of his questions quickly but as soon as I had finished he started going on and on about how this person didn't need to be referred to respiratory and could be managed by my own consultant. He was annoyed that I had called him when I was only an F1 and seemed to be under the impression that the referral had been entirely my idea (when does that EVER happen?).

It's so annoying because I don't know how the hell medicine works. This is my first day. I can only assume that if one of my seniors asks me to make a referral then this is the right thing to do. I don't know that arsey respiratory regs will only accept referrals from other regs or that not all people with pneumonia are referred to respiratory. When I explained that it was my first day and I was just doing what I had been asked to, his response was "That's not good enough. You're wasting my time". Thanks for the understanding.

Anyway... what a pompous wanker. There is absolutely no need to be so rude. I bet he's either short or ugly. Probably both.

I want to go back to surgery :(

Annual leave

I get 5 weeks of annual leave this year.

I work one weekend in every four and don't get any time off during the week to make up for it.

I worked out today that this means I work an extra 26 days per year outside a normal 5 day week and get 25 days off.

Therefore my annual leave allowance is minus one day per year.

Great.

Playing truant

Naughty naughty me. I didn't go to teaching today. Again. I've missed four teaching sessions now and am sure to get a big slap on the wrist in the very near future.

We have teaching for 3 hours every two weeks. It's compulsory and is billed as an important part of the foundation programme. It's all about making us better doctors and helping us achieve our competencies and all of that crap apparently. The glossy and expensive looking 'handbook' they gave us tells me that I am supposed to get "up to three hours per week of protected, bleep-free time set aside for a timetabled learning programme."

Sounds great.

But how exactly is this time protected? The answer, unfortunately, is not at all.

The reason I missed teaching is not that I went home early or did anything fun. The reason I couldn't go was because I had sick patients to look after on the ward and there was nobody else to cover for me. This happens every week. It's actually completely impossible to leave the ward for a whole 3 hours because who will do all of the things I usually do? We are supposed to go to teaching and not bring our bleeps but who the hell are the nurses supposed to call if a patient gets sick? Perhaps the idea is that nobody is allowed to get sick on tuesday afternoons but nobody seems to have told my patients that. It is very inconsiderate of them. Don't they know tuesday afternoons are 'protected time' and they should wait until 5 before having their MI/getting septic/going into heart failure?

We do have an SHO who could in theory cover the ward but in true NHS right-hand-doesn't-know-what-the-left-hand-is-doing style, medical staffing have allocated her to only work a half day every tuesday so she leaves at lunchtime.

We did start off going to teaching but we took our bleeps with us in case there were any problems on the ward. Inevitably there were, and we were bleeped out of teaching repeatedly. This resulted in a lot of tutting and dirty looks from the people teaching us (do they actually think we like being bleeped? Don't they realise we would absolutely love not to have to be at the mercy of our bleeps for 3 hours?) and and in the end we gave up and just went back to the ward. On days when we went to teaching we ended up having to go back to the ward afterwards and working at least 2 hours late in order to get all of the jobs done. There isn't anyone else to do all of the venflons and look up blood results so the work has just piled up by the time we get back.

I'm not sure what is actually supposed to happen. Who is supposed to do the work? Has it even crossed anyone's mind that the work won't go away just because we have teaching?

I'm almost looking forward to the inevitable email asking why I have missed teaching. I intend to tell them exactly why I was unable to go. I genuinely want to ask them in what way they consider this time to be protected. What measures have they actually taken to allow us to attend teaching? Unfortunately I think I know the answer already but I'd be interested to see them try to explain themselves.

This is just yet another example of something that is good in theory but f***ing abysmal in implementation. I would expect nothing less from the NHS.

No uniform + stethoscope usually = doctor

Today two patients called me "nurse". I would have thought that doctors and nurses were easy to tell apart (except for nurse practitioners of course but I will be blogging about that in due course) but obviously this is not the case. Apparently the fact that I am female overrules the fact that I am not wearing a nurse's uniform. I have also been mistaken for a receptionist on several occasions when sitting behind the desk on the ward (despite the stethoscope).



People don't seem to mind coming up to me and asking me if I can get them a cup from the kitchen, or find them a vase, or come and help their relative sit up in bed or go to the toilet. I'm not sure if this is because they don't understand that I'm a doctor or because they think that doctors do that kind of thing.

I'm not sure if people would have done this sort of thing in the past but I'm inclined to think that they probably wouldn't. I think doctors are seen as a lot more approachable now than they were in the past and I'm not sure whether this is entirely a good thing (of course it's mostly good - I don't think people should be afraid of us or anything). It also made me wonder if they would ask a male doctor to do those things. I bet they wouldn't.

The Weekend from Hell

Last weekend I was on call. It was so horrendous that I've only just recovered enough to write about it. I was doing my week of surgical take and on top of that was expected to provide ward cover for all of the surgical wards in the hospital (in my hospital you are either on take with just a reg or with an SHO and a reg. If you are on your own with a reg, another F1 also works the weekend and does the ward cover stuff but if you have an SHO you are expected to do ward cover as well. I'm not sure about the reasoning behind this because the SHO generally just goes to theatre all day and doesn't actually help with any of the ward stuff)

I was working from 8am until 8.30pm on both days and basically didn't stop working for the whole 12.5 hours. I didn't have lunch on either day (missing lunch is pretty much a given when you're on call) and didn't even have time to have a drink during my shift. As a result I was utterly useless by the end of the day. My ability to put in venflons was somewhat undermined by my hands shaking contantly due to hunger and I couldn't even remember which patient was which when the SHO asked me about the new admissions when he got out of theatre. People always tell you to make sure you take a break but it really is impossible when you're being constantly bleeped and harrassed by the nurses.

Thankfully we only had about 8 new admissions over the weekend (which is pretty quiet) but even so it takes me at least an hour to see each new patient if you take into account all of the mundane crap like writing up drug charts/fluids, filling in all of the blood forms and bottles, filling in the x-ray forms, calling radiology to book the x-rays, scouring the entire hospital to locate a pod to sent the bloods etc etc. It's really frustrating that however efficient your clerking is you just can't seem to cut down on the overall time it takes to admit a patient.

Most of my time was taken up by ward work. I think I must have put a new venflon in every single surgical patient in the entire hospital. Several patients had two new venflons and one lucky man actually had three new ones in one day (they apparently kept 'falling out'). I must have written up enough IV fluids to fill a swimming pool and prescribed enough warfarin to kill a hell of a lot of rats. I rewrote at least 10 drug charts despite the fact they could easily have been done during the week if the nurses had had the forsight to ask the patients' normal teams to do it (they had filled in the shaded boxes at the ends for the last two days and only called me when they physically ran out of space to sign off the drugs).

You get called about the most stupid things at weekends. I'm not sure whether nurses understand that you are looking after ALL of the surgical patients, not just the ones on their ward, and should really only be called about things that need to be sorted out immediately and can't wait until monday. I was called three times about a patient who had a hoarse voice, twice about a patient whose eye was a bit red and was asked to see multiple patients who had been noticed to have a rash (and no it wasn't a drug reaction or something that I could actually do anything about). I was called several times about a patient who had a blood pressure of about 170/100 (longstanding hypertension in a 90 year old with chronic renal failure who was already on a beta blocker) and the nurses were incredulous when I was unwilling to prescribe another antihypertensive. I had to write a whole essay in the notes about why I was not prepared to start any more medication since 1) I am an F1 in surgery and am not an expert in controlling blood pressure in people with renal failure and 2) I have never met this patient before and this is something that can be managed by her normal team.

When you're on call the most frustrating thing is not being able to do anything without being constantly interrupted by your bleep going off. You can't get through a 20 minute clerking without having to excuse yourself to answer your bleep at least two or three times. It just makes everything take so much longer than it should and when the calls turn out be about something that you really shouldn't be being bleeped about anyway it's enough to make you scream. I narrowly escaped losing my rag on several occasions when I was bleeped for the second or third time about patients with some minor ailment or something like cold hands (no honestly, that was a real one, which I miraculously cured by putting the patient's hands under the blanket) even though I had already promised that I would come to see them as soon as I had a chance.

Amazingly although I was a little short tempered at times I managed not to shout at anyone. I think perhaps that's the best you can hope for from a weekend on call. You just have to get through it. If nobody dies and the nurses are still speaking to you at the end of the weekend then you've done ok.

Dangerous Incompetence

When I first started working I asked the nurses for advice about a lot of things and trusted their judgement about whether a patient was sick and needed to be seen etc. I figured they had been doing the job for years and had seen lots of junior doctors come and go and probably were pretty clued up about most of the day to day patient care. A few things have happened recently that have made me seriously question that assumption.

Yesterday was a good example of this. A patient had come back from ITU on IV amiodarone which had been started to treat a (life-threatening) cardiac arrhythmia. The nurses left a note on the drug chart asking us to change the amiodarone to oral because they couldn't give it IV. I was a bit concerned about this so phoned the ITU doctors to ask their advice. They told me in no uncertain terms that the amiodarone must be continued IV (the patient had just had bowel surgery and was unlikely to be absorbing oral medication) and informed me that the nurses always claimed they weren't allowed to give it but in fact they were. Giving it IV means they have to do frequent obs on the patient and creates more work so they say they are not allowed to give it on the ward. The ITU doctors suggested I speak to the nurse in charge and explain that it had to be given.

I found the nurse in charge and explained the reasons that the medication had to be given IV very clearly. She conceded that it could be given but told me that she would have to ask the other nurses "really nicely" to get them to give it. I thought that had sorted the situation out but two days later on the ward round we looked at the drug chart and noticed that the medication hadn't been given at all since the patient had come back from ITU. The nurses had taken it upon themselves to stop giving it without telling anyone.



Luckily no harm came to the patient. We did an ECG and thankfully he was in sinus rhythm. It could easily have turned out differently though. I was really scared by the fact that nurses can go ahead and make stupid decisions like that and nobody really knows about it. Unless something goes wrong of course. They didn't go to medical school. They really don't understand what arrhythmias are or what amiodarone does, yet they are in a position where they can decide whether the patient is treated or not.

I wonder what would have happened if the patient had suffered another arrhythmia and died. Would anyone have admitted that the nurses were at fault or is everything the responsibility of the doctor? Do I really have to go around and look at the drug charts of every patient on the ward to make sure the nurses are actually giving the medication I have prescribed?

Scary.