I worked last Saturday and a Sunday two weeks previously (see post of 11/9/06) on ward cover*. While one normally works the whole weekend, it just so happened that my 'buddy'** needed to swap a day in his weekend, so it split up both our weekends. Which was a very good thing and I am considering splitting up my other weekends, as I was just beginning to recover from the trauma of my Sunday on the wards, when I had to do my Saturday.
My day started off reasonably well - I did a ward round of the post-admissions ward with the medical registrar, which lasted til 1100, then headed off to the ward I usually work on. After agreeing with the nurses, for them to do the easier bloods while I did the harder ones (as there was no clinical support this weekend either), I sorted out all the little jobs that needed attending to and went to the respiratory ward. Unlike my ward, there were no obliging nurses, but a very rude nursing assistant, to whom I had to explain: Yes I am the doctor. Yes I can take bloods. But I also have to review 4 sick patients on this ward, as well as 3 on another ward. And bloods are something that I can delegate. In the end one of the nurses said she might be able to fit in some bloods. I didn't bother - I just did the lot. Otherwise they'd bleep me at 2045 saying they hadn't been able to take blood sucessfully/that they were busy/some other excuse. I reviewed the patients that needed seeing and then went for lunch. No sooner had I a cup of coffee and my rather squashed sandwich in hand, I got bleeped to see some patients. But they were all fine - just speaking to the nurse, it seemed like they were getting worried over one low blood pressure reading (and when I did go to the ward much later in the day, all the patients with low BPs now had normal BPs). But I as I was finishing my lunch I got bleeped by my ward to see one of my regular patients - Mr H - the nurse was worried he wasnt feeling too well.
I'd treated Mr H the previous day for a high potassium, which was attributed a blood pressure tablet that can cause elevated potassium levels and him starting a diuretic which has a potassium sparing effect. Both the medications were stopped and he seemed all right. When I reviewed him on Saturday he seemed much the same, but to be on the safe side, I did a blood gas test - which gives instant results and among other things gives a pretty accurate estimation of potassium. And it was high again. So I treated him for it, but as I was baffled as to what the cause of it was, I called the SHO to see whether he could spot anything that I was failing to do. While on the phone, the nurse told me Mr H had had a massive bleed from his rectum. The penny dropped. That explained the funny smell when I was examining and internal bleeding is one of the causes for a high potassium. I rushed to his bedside, and got intravenous access, and started pushing fluid into him, all the while talking to him so I was aware of his consiousness. The nurse attempted to take his blood pressure with the machine - it wasnt recordable. I attempted it with a manual sphygmanometer - it was still unrecordable. I got one of the nursing assistants (NA) to get hold of the SHO, while I squeezed on the bags of fluid (one was going into each arm). He came - and in good time too. Mr H stopped responding to my threats that I would make him sing (his family had previously told me that he was a well known singer in the village). A crash call was put out. CPR began. But after eight minutes it was stopped and Mr H pronounced dead.
As I left his bedside (I'd been doing compressions), the tears started coming. I suppose its cos he is a father and a husband and I empathised with the family. Or maybe cos he is a fellow human being. Its not cos I felt I had failed him. There was no way this could have been predicted and he had no risk factors for a gastrointestinal bleed. But I felt ashamed for the tears. I spent 5mins gathering myself and then plodded back to the ward to finish off the paperwork.
I then went back to the respiratory ward - there was more to be done there. While there I was bleeped by another ward. The nurse on the phone said she had tried bleeping me earlier in the afternoon, but as I hadnt answered (I was trying to save Mr H's life at the time) she had reported my 'erratic behaviour' to the site sister, who was not happy with me. And she went on abusing me, not understanding the reason behind my inability to answer her bleep. And for the second time that day I was embarressed by the tears that forced their way. Thankfully it was after I'd hung up, telling her I would come to put in a cannula (something that does not require a doctor) after reviewing more serious patients.
I was trying - I really was. But for some reason its just not enough. I needed a break, but there wasnt the time. So with a tissue in one hand and a pen in the other, I carried on with my jobs, occaisionally swapping the pen for a stethescope or a syringe.
The rest of the day passed off relatively trauma-free. But the only breaks I had during the entire twelve hour shift was ten minutes for lunch and two minutes after Mr H died. And if I were one of the patients, I would have been worried about my kidney function as all I had was a cup of coffee and I did not urinate once during the entire shift. This is very common among all doctors on the training ladder.
This is in comparison to nurses. Doctors, like nurses, are paid to take a 20min (or is it 30min?) break every four hours. However unlike nurses, who timetable breaks into their day and will take their break no matter what is happening, doctors only take a break if they have the time. Which for most of my weekdays is about 10mins to swallow a sandwich.
Does not taking a break affect patient care? It certainly does: a low blood sugar and a lack of sleep certainly aren't conducive to thinking.
During our induction it was stressed that we should take our breaks - we were being paid to do so, but its something that's easier said than done. I would not be able to enjoy a cup of coffee knowing that Mrs X needed her x-ray reviewing/pain relief prescribing/or something else. But this doesn't mean that when I'm working it is with a light head and shaking hands. I usually stop when my head feels fuzzy and head for a chocolate fix.
*ward cover - medical on-call duties for PRHOs are either covering the wards (reviewing patients/medications, re-writing drug charts etc that one does normally, except one has to cover 6 of the 8 medical wards - the other two are considered to be beyond the capabilities of the on-call PRHO) or being on the medical admissions unit (seeing new admissions). Weekends on the admission unit are 1000 to 1800, while the more stressful ward cover is 0900 to 2100.
**all PRHO's are buddied up with another who works on the same/nearby ward, who cover for each other during periods of annual leave/sickness.
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