Wednesday, June 1st, 2011
It’s 4.22am at Middlemore Hospital; my second set of nights this year. At a few tertiary hospitals around the country if your first run is general medicine you will start nights after three months. My first set of nights was back in March. I quite enjoy doing nights. The chaos of the days is replaced with a quiet calm and you have the chance to be an “independent practitioner” (which is both freeing and challenging).
The idea of doing nights can be scary. Now having done them, I think what scares us more than anything else is the idea of being on our own. During my elective I met a young doctor who spent a year in rural Ethiopia with Doctors Without Borders. From the experiences he shared with me it was obvious that for days at a time he was literally the only doctor at his ‘hospital.’ But New Zealand is not rural Ethiopia. If you take a moment to think about it you’d realise we are never alone. There is always help we can ask for. The part that scares us as new doctors is, how do we know WHEN to ask for help? It’s a fine line between being safe verses being unfiltered in our asking for help to the point of incompetence.
It’s hard to articulate, but there is a gauge inside each of us, a gauge in the metaphorical pit of our stomach that screams, “This is out of my depth!!” This gauge will grow with time, confidence, and clinical knowledge, but the actual feeling remains the same. Let me present you with the following three situations in which my gauge was put to the test recently.
The sick patient who looked well
Around half past midnight I got called from a nurse about a patient complaining of chest pain. Vitals? Tachy but stable, they replied. ECG? Doing now. Oxygen, GTN, morphine, I’m on my way, I replied. [Lesson 1: Never leave a chest pain unvetted.]
Upon entering the room the patient had a negative “end of the bed” test (meaning, she looked completely well from the end of the bed). Furthermore, the first thing the patient told me was that the chest pain had occurred over an hour ago and had since completely self resolved. No more pain.
No more pain? I repeated, quietly reassured.
At that moment the nurse walked in with ECG in hand and told me that they thought we should make a ‘888’ Medical Emergency call-out. To put it in context, at my hospital if a triple-8 call is made the full cavalry of medical registrar and house surgeon, ICU registrar and specialist nurses, would arrive within a few minutes. Nervous about making my first call, I hesitated. Was this nothing? The pain didn’t sound beautifully cardiac, there was no radiation, and it had self-resolved. The patient was completely non-distressed. Was this just reflux in the middle of the night? Was I disturbing busy registrars, all for nothing?
Do I? Or don’t I? Do I or don’t I? A rare moment when both Google and Wikipedia can offer you no solace.
All these thoughts raced through my mind in a flash. The nurse showed me the ECG, which was tachycardic, but before I had time to process anything else they said to me, “I’m going to call it.” [Lesson 2: Vital signs are vital. Never dismiss an acute change and/or continuing deterioration in one of the vital signs.] Okay, I replied, as I started to look more closely at the ECG in my hand.
Fast a-fib. In a patient whose systolic blood pressure was normally never higher than ninety.
Whoa.
Within minutes the cavalry arrived, an organised chaos followed, and a long discussion about where to go from here in light of the patient’s background. Ultimately the decision was made to start the patient on an amiodarone infusion under the watchful eye of HDU.
I waved goodbye to the patient as they were wheeled out of the ward an hour later and thought to myself, “If in doubt, Anna, call it out.” I don’t know what would have happened had the nurse not decided to call it when they did: would I have made the call myself, or spoken urgently to a med reg for advice? If the latter, would I have done harm to the patient by taking that path instead of making a triple 8 call? Was taking her to HDU the best option for her? Would she have deteriorated if we hadn’t?
I am reassured by the fact that even the medical and ICU registrars were uncertain of what the best course of management was for this patient, that in the end it required a multi-specialty discussion to come to a decision. The meeting of great minds. It WAS beyond me.
Never leave a chest pain unvetted. Vital signs are vital (and they are your best friends in triage on a busy on-call night!). And most importantly, if in doubt, call it out. The worst thing that can happen by making the call then realising on retrospect that you probably didn’t need to, is you may feel silly for overreacting. The worst thing that can happen if you DON’T make the call and the patient truly is deteriorating is, they could die.
Which would you rather have on your conscious as you walk out the hospital doors on your way home?
The sick patient who looked sick
A few hours later that same night I got called about another chest pain. The patient was someone I knew very well as they were my regular team’s longstayer. Initially admitted to ICU with multi-organ failure, they had made a good recover over the past month and a half and was now on the yellow brick road to the bountiful land of Older People’s Rehab.
As I entered the room my own heart quickened. Over the course of the night their systolic blood pressure had slowly been declining, and they had a positive “end of the bed” test. They were in pain and they were distressed. What’s more, they had the same look on their face as an elderly not-for-resuscitation patient I had watched literally die from a myocardial infarct earlier that week.
I froze. Everything started moving in slow motion. It took me what felt like a lifetime to tell the nurse to give some IV morphine, LIKE, NOW. And as my brain was processing what was going on around me, that inexplicable gauge in the metaphorical pit of my stomach screamed, “THIS IS OUT OF YOUR DEPTH!!!” I knew this patient could potentially be on the precipice of death, and I wasn’t ready to deal with this on my own.
Call it, I told the nurse. And I had no regrets.
In the end it wasn’t a myocardial infarct but septic shock. Yet much like OSCE exams, getting the final diagnosis right is only one mark out of twenty. The rest is your process.
Never leave a chest pain unvetted, vital signs are vital, and if in doubt call it out.
The first year doctor who failed an arterial blood gas FIVE TIMES
Yes, I am that first year doctor. And yes, I failed an ABG five times… on the same patient… at four in the morning.
The job was handed over to me by the evening on-call who wanted to rule out pulmonary embolism (PE) as a cause of the patient’s acute drop in oxygen saturation. The patient was otherwise well, all their other vitals were normal, and clinically their risk of PE was very low.
A frail elderly patient, tortuous superficial veins coursed over their bounding radial pulse. To make matter worse the patient was a squirmer, unable to sit still as I slowly navigated the needle down their wrist. After three unsuccessful attempts at midnight, I paused and asked myself, “How necessary is this ABG?” I wasn’t all that convinced they were at high risk of PE, their saturation had improved (though still not ideal), and I was reassured by their Wells score of 1. So I explained all this to the patient and made a deal with them: if their vitals remained normal overnight I would hold off on further attempts of this blood test.
At four in the morning I received a call from the patient’s nurse telling me their saturation had dropped again as well as their blood pressure. Still not convinced it was a PE but unable to justify holding off on this blood test any longer, I took a deep breath in and grabbed hold of my lady balls. What was it that Beyonce said? “If at first you don’t succeed, pick yourself up and try again, pick yourself up and try again.”
Apologetic but adamant, I conveyed to the patient the importance of this blood test in the context of what was going on. They reluctantly agreed.
Gloves soaking with sweat. Two more failed attempts. Wow. A new low. What a horribly mean, mean doctor I was. And then that gauge in the pit of my stomach started to whisper, “I think you are now out of your depth.”
What to do, what to do… One upside of doing general medicine as your first run is that you get to know the medical registrars. And, luckily for me, I knew one of the registrars working that night. I called them up and explained the situation I was in, sheepishly, with my tail between my legs. But they were so lovely; they were up on the ward within a few minutes, talked me through technique, and then they did the ABG on the patient oh-so slickly.
RESPECT.
An hour and a half later, as I was counting down the minutes until the end of my shift, I got a call from my surgical registrar.
“Hey Anna, can you do me a favour for a medical patient I’ve just reviewed who I think is obstructed?”
“Sure thing. As long as it’s not an ABG,” I replied, half jokingly.
Pause
“It’s an ABG,” the registrar stated. “The medical house officer’s just done one but it’s totally venous.”
“You’re serious?” I asked.
Pause
“Okay, yup, I’m on the way,” I resigned.
Did I have a choice? I shook off my five failed attempts, took on board the advice that the medical registrar had given me earlier, and went into that room like I freakin’ owned ABGs. Fake it till you make it, right? And you know what? Perfect arterial sample, first pop.
Medicine is both a science and an art. And sometimes to do no harm will mean recognizing when you are out of your depth and need to ask for help. That’s how we learn, that’s how we grow, that’s how we become confident. Never forget the oath you took to — above all else — do no harm.
And on that note I want to finish this entry by acknowledging all the medical registrars at Middlemore Hospital. They are, both as individuals and as a group, the most amazing, gracious and smart people I have had the privilege of working with. Middlemore is blessed to have them. And I am blessed to have worked with them. Thank you.
