Births, Deaths and Miscarriages
Wow. What a weekend. In fact, its just a Friday night. There’s the rest of it is still to come.
So, it started about 4pm. I was sleeping, having just done the second of my four night shifts in A+E. My phone rang. I didn’t hear it. I was asleep. It rang again. And then again. I wearily checked my answerphone. It was the surgical rota coordinator. Oh, this isn’t going to be good. I’m an A+E doctor. And the surgical rota coordinator needs to speak to me urgently. Better give her a ring back...
Sheila: Oh Hi DrWho! Thanks for getting back to me. I need to ask you a favour. I’ve checked with Chris [Head of A+E department. He’s a big important Consultant. My boss] and Ross [my rota coordinator] and they have agreed to it. I’m sorry but we’re really desperate. We need you to hold the surgical SHO bleep this weekend. You’ll just need to cover the surgical wards. And they might need you to assist in theatre. We can’t get anyone to cover it. And [reiterating] Chris and Ross say that’s its all fine and its all been agreed, is that ok?
Me: Um. Right. Err. Ok yes I guess.
Sheila: Great! The day SHO will bring it to A+E at the start of your shift, thanks, bye!
Er. Right OK. So I am supposed to hold the bleep whilst doing my job as the (only) night SHO in A+E too? Ok Ok I’m pulling at your heart strings here a bit. There are two registrars in A+E overnight too, but usually its pretty busy. There’s probably about 30-50 patients to be seen between the three of us on a typical night. So, that put me in a bit of a bad mood. I hope they’re going to pay me two bloody salaries for these night shifts.
So, a little bit grumpy (for me, I am usually probably the smiliest person in our department) I head to work.
The day SHO is waiting for me. She explains the job. I am to cover the two surgical wards, the psychiatric unit, the elderly care wards, orthopaedics and maternity. Oh great. And there’s about 15 jobs to hand over. Lovely. I explain this odd new arrangement to my registrar. She says don’t worry, come back when I can.
And so, off I go.
Just about to leave the department when.. “DrWho! Wait! You’ve forgotten the bleep!”. Huh? No I haven’t, its right here in my hand where I just put it. I turn around. There is Anna. Oh shit. Ah yes. Another bleep. I remember this now. This hospital also has two ‘Private Wards’ for ‘Private Patients’. And there is a formal arrangement that the night A+E SHO takes this bleep too. Forgot about that one. I attach it to my increasingly heavy scrubs. “Oh they want you to go up there straight away. There’s a new admission”. I’ll add it to the list, thankyou.
Off I tootle to the surgical wards. A few drug charts to re-write, a couple of patients to review, some analgesia to prescribe. The usual stuff. I’m quite enjoying myself. A little variation from my 6 month stint in A+E.
I head back to A+E. There is a girl with a dislocated jaw and shoulder, but she’s going to need some sedation. So, I call in a man with a sore foot (maybe gout) through into a cubicle, whilst the nurse sets everything up for the sedation.
Then the pager goes off. Its vibrating too. In rather an awkward place. Rather than being on my left hip, where I placed it a couple of hours ago, it has worked its way around my elastic waistband, to the front of my trousers, and is trying to wheedle its way right inside. I fumble around with one hand in my groin, and the other holding the door open for the patient to hobble into the room. ‘What are you doing?’ he asks, quite sensibly. I retrieve my pager to illustrate I am not receiving any personal gratification from the current situation.
“Attend immediately. Death Imminent. Ward 6S”
Oh dear. Is this some kind of pre-crash call? Not much to go on there.
“I’m sorry sir, I’ll have to go. It’s an emergency. I’ll be back as soon as I can’. He doesn’t look very happy about it. He’s already been waiting two hours. Never mind, no time for that now.
I run upstairs.
No hurry required. In fact, the death has already occurred. A palliative patient. Well, he wasn’t officially palliative. Helpfully, the day team had deferred that decision to the most appropriate person: me, the locum night SHO. Earlier in the day they had just started him on some more antibiotics and increased his IV fluids. And then I’d reviewed him earlier in the evening. Thankfully his family were very understanding, and we’d come to the decision he was going to be palliative. A few hours later he had passed away.
No hurry then. I, only half jokingly, tell off the nurses about scaring me with page requests like that.
I certify him, give his wife some sympathy and a cup of tea, and head back downstairs.
Mr Sore-Foot is still waiting, but, much more exciting, the nurses are now ready to help the registrar and I relocate the shoulder and jaw of that unfortunate lady who has been in a fight. We start the propofol. 30mg. Nothing. Another 20mg. Nothing. A further 20mg. She starts getting a bit drowsy. We start wrestling her jaw. Seem to have got that in. Now her shoulder. She’s fighting us off. Two nurses are holding her down whilst us two doctors pull at her arm in various directions. Hmmm. No satisfying clunk. We try several times. Eventually it seems to be in a slightly better position than it was before. She starts waking up. Her jaw pops out again. Oh great. Then, a commotion. A paramedic rushes in to say a girl is delivering her baby in the car park!
We run outside. The car park is on a slope. Unfortunately this lady seems be lying her with head down the slope. There’s allsorts of blood and juice and slime everywhere and its trickling down the slope and getting this poor lady, and her hair very wet. The registrar takes the bottom end. I’m at the top. There are a couple of nurses and the paramedics too. The porters go to stand guard at the end of the car park so nobody will run us over.
The baby is out in just a minute or two. Pushing it out up hill! And then the placenta. The whole thing probably only take 15 minutes. The husband jokes about how they were packing their bags for ages at home before they managed to get here. “No one will ever believe this!” the mum says. Oh yes they will! I take some photos for them on Dad’s phone. We clean them all up, and then quickly onto a trolley and inside and upstairs to maternity.
Talk about the circle of life! Only just before that I was certifying a death. Now look! Big happy smiling faces all round. And great story for the rest of that child’s life. And I was there!
We go back inside and try again to pull on this poor lady’s joints. Again we get them back in. Sort of. For a few minutes. Then we try again. And again. They just won’t stay in the right place. There’s no orthopedics on call here. She’ll have to be transferred. Right, that’s her, sort of sorted out. At least from our perspective.
Finally, Mr. Sore-Foot. His son has been getting pretty angry. He has waited about another 2 hours because of all that commotion. Unless I can turn him around in the next 7 minutes he’ll miss his four-hour target. Can’t worry about that now. Seems like he’s got gout. I send off the bloods, but he’ll have to wait another hour for those. At least his son has calmed down a little. I’m just writing the blood forms, when the pager goes off again. I call the number.
“Hello its DrWho. Did you bleep me?”
“Yes Doctor. We have a septic patient here. He was diagnosed at 7pm and he hasn’t had his antibiotics. They haven’t been prescribed properly”
“How is the patient?”
“He is tachycardiac at 110, and his blood pressure is 81/40”
“Is he on fluids”
“Put the rest of that bag through stat and I’ll come now. Where are you?”
“Elderly care rehab ward”
“What’s that? Do I cover that? Where is it?” Ah actually no time to ask those questions. I hang up and head into the main corridor. I study the hospital map, and head off in roughly the right direction. Takes me a little while to find it. His BP is 71/37 when I get there. He’s a bit unresponsive, but looks like he might crinkle and crack at any moment due to dehydration. I read through the notes. The Med Reg saw him, but left the FY1 to decide on the fluids and IV antibiotics and neither seem to have been prescribed properly. He’s got fluids going and the nurses are sorting out the antibiotics. There isn’t much else I can do at the moment, but I can’t really leave him. I call the Med Reg, and he comes too. We spend about an hour with this chap. Get a second IV line. Give him the antibiotics. We spend a long time discussing getting him transferred to another ward on the phone with the bed manager*, but its difficult as there aren’t any beds. We end up calling the ICU reg down with a view to taking him to HDU, although he isn’t really sick enough.
The nurses on this ward really aren’t used to seeing sick patients. They can’t cope with 2 IV pumps. They’re getting quite worked up. They want to put out a crash call. His BP has recovered a bit to 80/40 again and his HR is down to 80. We’re getting there. And the ICU registrar is coming down anyway. I try to persuade them we don’t need the crash team, but they’re really not comfortable managing this man. They put out the crash call. I feel a little embarrassed. Apart from a transfer, we can’t really do anything else. I turn most of the crash team away at the door, but at least it has got the ICU reg here a little more quickly. There are some loud discussions about the bed management situation, and some slightly frayed, although still very polite, tempers. Eventually, the ICU reg agrees to take them, but only on the bases of ‘there isn’t a medical bed’ and not on the basis of ‘they are sick enough for HDU’.
A couple more bleeps to answer. A cannula and a catheter on maternity. They do realize that I’ve done about three catheters in my entire life? If they can’t get it in, I don’t think I’ve got much hope…
I struggle through. After a long time fiddling around, I eventually seem to have it in the right place. I start filling up the balloon. Then a big slop sound happens and the fully inflated balloon flies out of the vagina. Oh great. This is sooo much fun at 4am on a Saturday morning.
Eventually, I get the job done, and finally get back to my actual real job in A+E. Mr Sore-foot’s blood results are back. Gout. I give him the treatment and send him on his way. 6 hours he’s had to wait. Someone will get told off for that. But they can hardly blame me. Its 5am now. Time for a sandwich. Thank goodness. Maybe I might be able to sit down too. But, wait. Oh no. “DrWho! Will you see this baby with a temp of 40, and he’s a bit lethargic?”
Yes of course. I can’t really say no can I? I stop and think for a moment. Try to compose myself. If my child were sick, I really wouldn’t want them seen by a 25 year old SHO who had 4 hours of sleep yesterday, and hasn’t eaten for twelve hours, and who really needs a poo. But I can’t let them know that.
A very anxious mother brings in her toddler. He’s OK. A little bit grumpy. But otherwise well. Still a bit febrile. He’ll live. Long enough for me to eat, anyway. I leave mum with a sample pot to get some wee, whilst I finally go and get my sandwich.
Ahh. A sit down. A glorious relaxing sit down. I open my lunchbox. Take the first delicious bit of my old, stale, warm ham sandwich. Mmmmmm…… !!?Beeeeeeeeeep?!!!** !!?Beeeeeeeeeep?!!!**
Oh FFS. Please just leave me alone for a few minutes. Am I ever going to be able to poo?! A patient is febrile and tachycardic on one of the wards. I give some feeble instructions over the phone and mumble about going there shortly.
I sit there for a couple of minutes before I realize I’m just staring into space and not actually doing anything. Then, off we go, sandwich in hand, to see Mr. Febrile.
I just do the basic stuff. Sepsis Six. I’m good at that. It doesn’t require much thinking. Day team can review in a couple of hours.
Back to the emergency department. Child is better. Send child home. Brain unable to do sentences properly anymore. Just a couple of hours to go now.
See a woman with a big broken wrist. I can see it’s broken from the other end of the waiting room and she feebly dangles her arm by her side. Her hand doesn’t really appear to be attached to the correct part of her wrist. Its not bleeding or anything. Just her hand is definitely in the wrong place. She’s been out drinking and fallen over. She’s feeling a bit worse for wear. “Can I have a jug of water doctor?” Yes. Yes of course you can. I’m not evil. That hangover is probably kicking in now. I fetch her a jug of water and give her lots of oral analgesia.
Call radiographer in from home. Accidently request wrist x-ray on the computer for that febrile child whom I have sent home. Luckily radiographer spots mistake when child not present in waiting room, but woman with obviously useless massively broken arm is present in waiting room.
10 minutes later. Oh look. It’s broken on the x-ray. We’ll need to reduce it. How do we do that? Oh yes. We need to sedate her. Oh no. We can’t sedate her because I’ve just given her a jug full of water, and she needs to be fasted. What a numpty. And there’s no orthopaedics here. I call orthopaedics at the nearby hospital. Oh yes. Its broken. She’ll need surgery. Can you reduce it and send her over? Yes of course, Ill send her over right away. But I cant reduce it. “Why not?” Because I’ve just given her a jug of water. “Oh”. No need for any more words. The orthopaedics registrar is very understanding. Maybe he could sense it in my tone of voice that now is not a good time.
We give her some morphine, plaster it up as best we can, and arrange for her to be transferred. An hour to go. Next please!
A woman with PV bleeding. Ahhhgg. I hate PV bleeding. I hate vaginas. Not socially, you understand. Just professionally. This is my third encounter with a vagina in one night. I think there is something quite disturbing about any man who wants to be a gynaecologist. Just some things should remain mysterious. And that should be one of them.
She’s pregnant. It’s her first child. And now she’s bleeding. A lot. With clots and stuff. Oh dear. Now I have to be all empathetic and supporting and counsel her on the potential outcomes. I think I do ok. Tissues and a cup of tea and let her do most of the talking. I request the necessary tests and then we just have to wait.
Almost time to handover and go home. But not quite yet. 16 year old with overdose. I haul myself over the impenetrable psychological barrier and put on my most understanding empathy face. She’s crying. Her parents aren’t here but they’re coming in. She’s full of regret. I feel something inside me. Ah yes, actual real sympathy. I am still human.
Eat. Sleep. Repeat.
*Ironically, when typing ‘bed manager’ it keeps auto-correcting to ‘bad manager’.