human behavior

The 3 month-old doctor

Posted in Health & Medicine by humanb on April 22, 2011

When most patients see a doctor in hospital, they assume she’s been practicing for years. No one thinks the doctor might only be 3 months old.

And when some nurses with decades of experience see a new doctor, they assume the doctor knows more than he really does and more than they do – despite knowing the doctor just graduated from medical school.

The only people who consistently recognize how little we junior doctors know are the senior doctors.

It’s a pity then, that they’re so often absent when things get hairy.

Half the time in hospital the nurses won’t even address me by name. They just say “Excuse me doctor!” with an unsettling air of deference to someone 10+ years their junior.

You have to learn quickly to recognize your new name.

And when nurses become anxious about a patient whose blood pressure has plummeted, they calm themselves when they see you leaving the patient’s room: “It’s fine” one says to the other. “The doctor has seen him.”

You have to learn quickly to recognize your burden of responsibility.

Learn quickly.

Imagine reader, that YOU – assuming you’re not a doctor – wake up one morning to find yourself on a surgical ward. A senior nurse comes to you and says:

Doctor! Mary Simmonds has just been transferred to the ward from ICU. Should we clamp the NG? Should we flush the drains? When do the clips come out? Shouldn’t she be on her usual anti-arrythmic? And could you chart some more fluids?

There’s not another doctor in sight.

Just you.

How do you feel?

That’s how I feel. I’ve never heard of Mrs. Simmonds. I have no idea what operation she had, when she had it, or how long she’s been in ICU or why. It follows, that I have no idea where her clips are, what her drain is draining, and what her usual medications are. Does she need more fluids? Does she need her anti-arrhythmic? Why was it stopped?

I haven’t a clue.

I need to learn quickly.

But first I have to say the 7 words that I’ll be repeating on an hourly basis every day.

I don’t know. But I’ll find out.

First stop: the patient’s medical record: a collection of two-hole punched sheets of paper in danger of falling out as the holes have ripped, covered in the unintelligible scribbles of 30-odd people: interns, residents, specialists, overtime and evening doctors, nurses, physiotherapists, and dietitians. I can recognize every 3rd word of every 4th entry.

Maybe the blood results and image reports will shed more light on Mrs. Simmonds, so I head to the computer.

BEEP BEEP BEEP

That would be my pager.

I’d love to ignore it, but it won’t stop beeping until I answer it. I call the extension that flashes up:

Hello this is humanb. I was paged?

Yes doctor! John Reynolds has dropped his blood sugar on ward 3B and his respiratory rate is in the yellow zone. We need a clinical review.

Um okay. I’ll be right down.

So I’m off to ward 3B. On the way, another nurse sees me…

Oh doctor! Lionel Wiggins needs his medications recharted.

Okay, but that will have to wait.

But he’s due for his insulin before lunch!

BEEP BEEP BEEP

That would be my pager again.

Hello this is humanb. I was paged?

Yes doctor! Tom Black is being discharged this morning. Transport is booked for 20 minutes from now. Have you written his discharge summary? We need it before he goes.

I have no idea who Tom Black is.

BEEP BEEP BEEP

Hello this is humanb. I was paged?

Yes this is pharmacy. You charted Rita Lightheart for metaclopramide 4-6 mg TDS. Didn’t you mean 10mg TDS?

Uh…

And she’s also charted for tiotropium and iotropium. They’re the same class of drug – one long-acting and one short-acting. Do you really want the patient on both?

Um, I don’t know. But I’ll find out.

I hang up.

So what was I doing?

Another nurse:

Ah! Doctor! Mike Borne’s cannula has tissued. His urine output is only 10 mls per hour and the night doctor charted 2 litres over 12 hours but I need a new intravenous line and he’s got really crappy veins. The medical student tried, but no luck. The patient will only let us try one more time and then he says he’s done!

BEEP BEEP BEEP

That would be my pager. I go to answer it, but headed my way is a Consultant, i.e. an Attending Doctor, i.e., a senior doctor under whose name some of my patients have been admitted, i.e., one of my Bosses.

Shall we do a round?

He wants me to walk with him as he sees his one patient who is stable. I have to scour the ward looking for the medical record and medication chart fast enough so I can hear everything he’s saying at the bedside and then diligently record his findings and plans going forward. Only there are no more blank pages in the record, so I have to dash back to the nurse’s station to get paper. I miss what he’s said at the bedside, but he doesn’t notice. I record his plan and he’s off. He won’t be back on the ward again for two days.

Meanwhile, John Reynolds on 3B still needs a clinical review…

BEEP BEEP BEEP

Hello this is humanb. I was paged?

Yes this is Lesley at Pre-Admissions Clinic. You’ve got 4 patients here who need to be seen. They’re all booked for surgeries later this week. Two of them have been waiting for 30 minutes now.

Um, okay. I’ll be down as soon as I can. 

I’m starting to feel weak, and then I realize that I haven’t had anything to eat or drink today. Also, my bladder is starting to feel paralyzed from being full for the past 2 hours.

There are so many things I’m supposed to do and so few things I know how to do.

Well I know how to pee. I’ll go do that.

On the way from the toilet, I see the patient tea trolley, so I grab a packet of cookies.

Now what? My mind goes blank. I’m not sure where to go.

Oh yeah, John Reynolds on 3B.

But a patient catches my eye and calls me over.

Nurse! I need a bottle, I have to go!

He’s not my patient.

Sir, let’s press your call button and a nurse will be over. 

I reach for the button but he grabs my arm.

Nurse! I need a bottle now!

I see that he actually has a urinary catheter in, so he doesn’t need to pee in a bottle; but he’s delirious and doesn’t know this.

BEEP BEEP BEEP

Deep breath.

I silence my pager.

I close the patient’s curtain and check to make sure his catheter isn’t blocked, but actually draining urine. I smile at him and explain that he doesn’t need a bottle and show him his catheter. He settles down. I squeeze his hand and smile good-bye.

On leaving his bedside I think about what’s left to do. I start prioritizing things in my head.

#1 Keep your cool.

#2 Stay kind.

#3 Remember the point.

John Reynolds on 3B isn’t well. He needs a doctor.

So off I go.

It turns out that John Reynolds has lung disease and an anxiety disorder and often has a respiratory rate in the yellow zone when he’s distressed. His blood sugar has dropped but it’s barely below the lower limit of normal, and it goes up nicely with a simple glass of orange juice.

Orange juice.

Next time…

I’ll tell my Boss, “I’m sorry sir, but there’s a few more urgent matters that I need to handle first.”

Next time…

I’ll ask for help from other junior doctors and suggest to nurses that they seek another doctor’s help if it’s urgently required and I’m busy.

Next time…

I’ll get more information from nurses about the patients who need clinical reviews so I appreciate the level of urgency. I’ll also make simple suggestions over the phone – like giving the patient some orange juice and re-checking the blood sugar in 15 minutes.

Next time…

I’ll pee when I have to and eat when I should.

You learn quickly when you’re a new doctor.

But never quickly enough.

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