Remembering those First Moments as a Junior #Doctor #hcsm

by Dr Nick

It’s a long time ago but in many respects that first shift is still fresh in my memory and it all came flooding back when I read this great piece by Deepak Chopra: My First Job: My Dark Night As A Real Doctor

He recounts his first night on call having arrived in to work in a 400 bed community hospital in New Jersey in the 1970’s and his first patient – “an expiration”
I cast my mind back to Friday 1st August 1986 and my first day – the Friday was significant as I discovered, marking the beginning of a weekend on call that commenced on Friday at 9am and finished at 5pm on Monday 4th August – yes that 80 hours! I don’t think I quite understood what that meant but I sure did by the end.
I was partnered with my medical school friend and colleague Niamh Anson part of my graduating class from the Royal Free Hospital School of Medicine. We were set to spend the next 6 months joined at the hip spending more time with each other than some married couples spend together. We would be each others support, backup, confidant and friend. I was lucky – she was the perfect balance to my brash youth and over confidence. She was a steady hand guiding through what were some very rough seas and although I did not know it at the time I was really lucky to be her partner offering me the chance to get to know her.
We worked for two consultants – Dr Woodgate and Dr Willoughby a cardiologist and a gastroenterologist and were joined by a dynamic registrar John Lee. Between us we took care of the cardiology patients, coronary care ward, coronary care monitoring unit and the gastroenterology patients day to day.  But come Friday afternoon took on medical responsibility for all medial patients, medical admissions through the Accident and Emergency Department (A&E aka as the ED) and the Intensive Care Unit. On top of that we (Niamh, John and I) were the code team – with the anesthetist (aka Gasman or Anesthesiologist) as the 4th member. I don’t remember how many patients this covered but it was a lot.
Our first day was filled with taking on responsibility for the day to day activities finding out how to get things done, where things were kept and most importantly getting to know the nurses who were the key to surviving the ordeal since they knew everything, had worked there for far longer than you (and many others) and had more relevant experience that you needed to learn from. I was reminded of the “Doctor in the House” film with Sir Lancelot Spratt from years back:

To be a successful surgeon you need the eye of a hawk, heart of a lion and the hands of a lady

And while I don’t remember all the nurses by name I remember all their kindness, support and actions that helped me survive the grueling assault course of medicine.

At 5pm we knew the patient load had changed as our “beepers” (aka pagers) started sounding like a cardiac monitor going off so frequently. There were missing orders for pain medication, tissued drips (a drip that was no longer working and needing to be re-done), admissions in the emergency department, patents with abnormal rhythms on the coronary care intensive unit, blood gases needing taken in ICU…..
Division of labor and unofficial coordination became the order of the day as Niamh and I split the work taking on admissions and ward coverage. I remember during that period working out my rate of pay based on the number of hours I did per week (typically 136 hours per week) and thinking that while I understood that I was inexperienced I felt worth a little more than the £1.36 per hour (roughly $2.20 per hour) given that I recall all the critical clinical decisions we made, the CPR we performed, the relatives we had to speak to give them the sad news that their spouse had died.
By Saturday afternoon we had been on call for 36 hours and there seemed no let up in activity. The nights were sometimes quieter but that was rarity. As a means of coping we split the night with either Niamh or I taking all the calls after midnight (except in the case of a code when it was all hands on deck necessary to cope with the high work load in these events). In one memorable night I remember 23 admissions coming through the emergency department – if I saw my bed it was never for more than a few minutes. The nurses were all familiar with the work load adn they knew when they paged us that even if we answered and said we were coming they would oftentimes have to page us a second and third time as we would answer but then fall immediately back to sleep. As for our performance and efficiency – I hesitate to imagine how poor we were at tasks and what our decision making would look like if it were assessed. The good news was that there were many experienced nurses involved who did not work the same hours so were not suffering the same chronic sleep deprivation and were checking up on our orders and activities, prompting and intervening as necessary to prevent errors
By Monday morning we were all frazzled – I’d lost count of the patients and problems we had dealt with, the patients who had died, the admissions and therapies started and the slew of clinical problems and disasters we had averted. We stopped taking call but our day did not finish then and for us Monday was a regular working day dealign with the normal work load of admissions, award rounds treatments and patient management. It was only at 5pm on Monday evening we finally stopped work and handed our patient cover over to the new on call team.
There was some solace in the genuine feeling that you were making the difference in people’s lives but much like Deepak Choopra I struggled with what I was actually delivering – was this really healthcare

In the end, after six years of studying, medicine was turning out to have too little to do with healing and making people happy. It had to do instead with my work in the hospital, into their lives, pronouncing a few of them, the most unlucky ones, as expirations. I thought about myself a lot before I forced myself to sleep, but, on reflection, I didn’t think about my patients much. We had all met and parted in a few moments. It would have been hard to look at them directly. 

What of the interaction as defined by Hippocrates

Even though a patient may be aware that his condition is perilous, he may yet recover because he has faith in the goodness of his physician…I will keep pure and holy both my life and my art.

I did not have a good feeling about the interactions – the fleeting exchanges with these people who were trusting me with their lives and the lives of their family. And as technology and innovation continued its march the reality of the practice of medicine changed

Practicing medicine as we do now makes a doctor’s life as nerve-racking as a soldier’s. It consists of an endless struggle to conquer disease, and to keep at this, a doctor must deny to himself that disease, and to keep at this, a doctor must deny to himself that disease ultimately wins. If you feel called to practice medicine, these are not the kinds of thoughts you permit yourself. But doctors do face up to them from time to time and wonder what the work is for

I had some great experiences – I had some awful ones and I continue to be part of what I consider an honorable profession and one I am privileged to be a contributing member . In fact on a recent flight there was a request for a doctor – a lady suffering an attack of pancreatitis but fortunately we were not far from our destination and my contribution was small and mostly not medical in nature helping to control and comfort for the short period of time till we arrived and then hand the patient on to the ground emergency medical staff. That transition proved to be sub-optimal and it was well over an hour before she was taken care of – I stayed of course, wanting to be sure that her care was transferred to the healthcare team on the ground. The following day I received a note from one of the flight attendants that made my day. She had searched for my name and found me and sent a note to the Nuance Web site thanking me for my assistance and complimenting me for my “display of genuine heart”. My contribution was not so much medical although that had played a part in the diagnosis, assessment and review of treatment options and the course of action. But what had made the difference was compassion – the focus on the person (and in this case there were two people and I ended up helping her companion navigate London Heathrow airport late at night to get her out to the accommodation they had booked). I had never doubted what I would do and was upset for this lady and her companion who’s holiday was not starting off well. This is why I did medicine – I wanted to be the contributor, the person caring for the patient. It is this fundamental aspect of medicine we seem to be loosing site of – I can certainly accept some blame – I have a keen eye towards technology and possibilities it offers – but at its hearts medicine is about people caring for people and providing the support that in many cases is the difference between a good or bad outcome (at least perceived by the patient anyway). In fact I tweeted something along these lines earlier this week:

People forget what you said and what you did but they remember how you made them feel
— Nick van Terheyden (@drnic1) November 4, 2013

People forget what you said and what you did but they remember how you made them feel

As Deepak Choopra quotes:

Rejoice at your inner powers, for they are the makers of wholeness and holiness in you,
Rejoice at seeing the light of day, for seeing makes truth and beauty possible. 
and he ends with

a physician must trust in Nature and be happy in himself

As a guding light that works for me – hope it works for you too

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