Izzy Lomax-Sawyers - Vital Signs: Heartbreaking, Sometimes Hilarious Stories from A Junior Doctors First Year

YOURE CARRYING A patient file, a ring binder packed full of clinical notepaper, ECGs, nursing care plans and discharge planning forms that threaten to fall out as you scribble your note. Between the synthetic scrubs and the N95 mask youre sweating like a pig. The boss is talking faster than you can write, your protective goggles are fogging up, youve needed to pee since five patients ago and it will be another hour until you can.

Youre a first-year doctor at Middlemore Hospital in South Auckland, one of the busiest hospitals in New Zealand, and youre partway through a very long list of new patients to see on your morning ward round. Your phone rings for the fifth time in ten minutes. You hand the notes to the registrar to keep writing, and step outside the curtain to answer it. Kauri House Officer, Izzy speaking.

Mark, a nurse from the Medical Assessment Unit in ED, wants to know if he can take a patient off cardiac monitoring. Its a new patient youve never met, and whom you know next to nothing about. Sorry, we havent seen her yet. Can I let you know after?

You slip back into the bedspace, where the boss is saying that this patient needs a CT scan. You quickly grab a laptop on a trolley to fire through an electronic order, then brace yourself to speak to the radiologist. You dial the operator, who accidentally puts you through to the CT bookings coordinator. You apologise, and dial again. This time, you get through.

Hi, its Izzy, one of the medical house officers. Im calling to discuss a CT KUB request for Mr Andrews, you say.

Sure, let me read through the request.

You wait nervously. Radiologists are the guardians of the hospitals limited available scanning slots, and they decide whether the benefit of the scan you requested is worth the radiation dose to the patient. This radiologist is renowned for being particular about request forms, and you did this form in about 30 seconds between patients. Your work phone starts to ring, but you decline the call. It rings again. Hi, can you ring back in five minutes? you say to the nurse on the other end, and hang up, apologising to the radiologist.

Have you done a urine? the radiologist asks. You havent, and youre desperate to, but she means the patients urine. You should have put that information on the request form. Yes, sorry. You read out the urinalysis result.

Now, why do you want a CT KUB and not an ultrasound? the radiologist asks. You have no idea. You offer to check with the team and call back. The boss says an ultrasound would be fine, so you call the radiologist to let her know. She changes the scan request to an ultrasound from her end, and you thank her.

The rest of the team is already with the next patient, Mrs Beauchamp. You join them, pulling the curtain behind you and waving at the patient. Shes about your mums age, and you admitted her the night before with a suspected TIA or mini-stroke. When she came in she had an irregular pulse, and her ECG showed an irregular heart rhythm called atrial fibrillation (AF), which can cause a stroke. Her heart is back in a normal rhythm now, but you suspect that it may have been flicking in and out of AF for a while. Shell need some investigations, including an ultrasound of the heart called an echocardiogram or echo. Shell also need to be started on blood thinners to prevent a stroke, and will probably take them for the rest of her life.

Shes terrified, and tearful. Shes young in the grand scheme of things, healthy until now, other than a single medication for blood pressure, works a professional job and has children in their teens and early twenties. Shed expected that it would be years before she had to confront her mortality. The boss squeezes her hand and makes comforting noises. You nudge a box of tissues her way. Your phone rings. You give the notes to the reg and step outside.

Kauri House Officer, Izzy speaking.

Its the nurse who tried to call before. Hi, its May from Ward 33 east. Im just letting you know Im sending Mr Chua to the discharge lounge.

You thank her and hang up. The rest of the team are still comforting Mrs Beauchamp, and it is an awkward time to rejoin them. You find the file for the next patient on the list, Mr Donald, and start preparing the ward-round note as you wait outside the curtain. You read through what the admitting doctor has written overnight, and click through a few things on the computer. Then you grab a fresh piece of clinical notepaper and lay down the bones of a note.

CWR McNeill (Kauri)

45M

1) UGIB

2) EtOH excess

S:

O/E: EWS=0 Hb 105

Imp:

Plan:

1. CIWA

2. NBM for OGD

3. Pabrinex

4. Cont omeprazole

5. Call if melaena, haematemesis, HR>110, SBP<100 or concerns

6. Advise EtOH reduction

During your first clinical placements in medical school, these notes with their acronyms and jargon might as well have been in another language, but you now write like this without even thinking. CWR McNeill is the consultant on this ward round. The patient is a 45-year-old man whose problems are an upper gastrointestinal bleed, and alcohol (EtOH) intake in excess of recommended limits. As a junior doctor working in medicine (not psychiatry), its not your place to label him with a diagnosis, but that it exceeds recommended limits is an objective fact. He has been drinking twelve beers every night for years, and more on weekends.

Youve been on this rotation for a month, and already you know the patterns for how to treat the handful of problems responsible for most hospital admissions. Anyone who drinks as much as this man needs to be observed closely to make sure he isnt going into life-threatening alcohol withdrawal; the withdrawal scale used at this hospital is called CIWA, and you have never cared to learn what that stood for. He also needs Pabrinex, an intravenous multivitamin that replaces all the nutrients hes missed out on when drinking twelve beers a night hasnt left him with much appetite for food. People who drink this much for this long are at risk of irreversible brain damage, not so much from the alcohol directly, but from vitamin B1 or thiamine deficiency.

Its also your teams responsibility to give him what is called brief advice that it would be a good idea for his health if he cut back on drinking.

He will need a camera down his throat to find and treat the cause of bleeding, and he will need intravenous antacid medication to speed up the healing of whatever has bled, and protect it from the powerful acid we all have in our stomachs. Bleeding in the upper gastrointestinal tract can be incredibly dangerous. You know doctors who have watched people bleed to death from it, vomiting blood faster than it could be replaced, and faster than they could get to the source of the bleeding to stop it.

You finish the note with your name and medical council number via a stamp that you wear on your lanyard, and you scribble your phone extension so the nurses can contact you. The boss has just finished with Mrs Beauchamp, and joins you and the registrar outside Mr Donalds room.

Who do we have here? asks the boss, and you quickly rattle off what youve read in the admission note.

Mr Donald is a 45-year-old man admitted following an episode of haematemesis yesterday afternoon. Sounds like he did also have an episode of melaena. No regular meds. He drinks twelve beers a night, no other medical history, no red flag symptoms. Works as a builder. Hb 105, haemodynamically stable. He has two IV lines and is consented and starved for OGD this afternoon. Hes getting IV omeprazole and has Pabrinex charted.