Twelve phone calls…

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The first phone call I received was from the intern down at the medical admissions ward. She was telling me that a new patient had just been brought in, a young lady who had overdosed on iron tablets. “Alright,” I said. “You start seeing her and I’ll be there as soon as I can” It was Monday 16 June, Youth Day public holiday, and we were on call. It was 9pm approximately and I was upstairs in one of the male wards, having been called to see a patient who had pulled out his IV line. He was severely dehydrated, and the nurse in charge hadn’t managed to re-drip him.

 

 

The second phone call was from my consultant calling from the comfort of his home (a privilege that comes with being a qualified specialist), telling me what I already knew, that there was a an iron overdose in admissions, “How long are you going to be in the ward Dr Mukenge?” “Maybe 20mins doc” I replied,  “I have to put in a central line, Nurse in Charge is just preparing everything.” His concern was that we should give the patient deferoxamine as soon as possible. Deferoxamine is a siderophore drug that can be used as a chelating agent that removes iron from the body, preventing it from being absorbed in the gut. “You may have to transfer her to Livingston Hospital, if we don’t have any deferoxamine…” he said. “Sure doc” I hung up and got down to the business of the central line. I was inserting an intravenous line into the femoral vein in the patient’s leg, adjacent to his genital area. Back in my intern days halfway through my internal medicine rotation the head of my unit at the time once asked me if I knew how to put in a central line. At the time I didn’t, and he was displeased. He explained that being able to insert an IV line into one of the large central veins could be the difference between saving and losing a patient. That was then. These days I can insert an IV line into any one of the central veins with one hand tied behind my… no, that’s being unnecessarily flippant 😛 And besides, I digress…

 

The third phone call was one that I made once I got back down to admissions, I called the physician on call (POC) at Livingston hospital to ask if they had any deferoxamine in their admissions ward. “Ja hold on, I’ll have to ask the nurses” she said, before hanging up on me.

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I had a thorough look through the drug drawer in our emergency trolley, then took a walk to casualty down the corridor and had a look in their drug cupboard and emergency trolley just to make absolutely sure that what we needed for this patient wasn’t right there under our noses. No luck. I then walked back to medical admissions intending to make another phone call. When I got there another new patient had arrived. She would need to be seen. She was a lady who had been referred to us earlier by the surgeons at Livingston hospital. They expressed, over the phone that they were somewhat aggrieved (read here: pissed off) at having been tricked by the casualty doctors from our hospital into accepting this lady as a bleeding peptic ulcer. She was most certainly not they claimed, her chronic rheumatoid arthritis was her main problem and she had to be seen by a physician (ie yours truly, on this specific night). After assessing her I had to admit that I agreed. There were no special findings on examination. She had very typical arthritic changes of the hands, almost textbook in fact, and she complained of pain in the joints. These are not reasons to go to hospital in the middle of the night however, so what was wrong I wondered. I logged onto the computer to check her blood results and there was a big clue, deranged liver enzymes with an obstructive picture. Some sort of drug induced liver injury? She wasn’t jaundiced, so what was up with her…? I quickly admitted her to be reviewed by the consultant in the morning. She would at the very least need an abdominal ultrasound. Then I went back to the phone calls.

 

 

Phone call number 4 was one I made to the doctor on call at the intensive care unit (ICU) at Livingston hospital to ask if they had any deferoxamine. Reluctant to assist me as she probably realised it might mean transferring the patient to her, she suggested I call the pharmacist on call. Pharmacist on call eh? Hmm… “Nurse do we have a number for the pharmacist on call?” I asked, “There is a pharmacist on call?!” she replied incredulously, “That’s exactly what I thought” I said. “Haibo!” she muttered, as she scuttled off to that secret place that nurses go to find things that doctors are incapable of finding. She returned, sure enough with the telephone number of the head of pharmacy. By this time it was approaching 11pm and I was getting somewhat irate on behalf of the patient. The signs and symptoms of iron toxicity start out fairly benign and patients initially appear quite well apart from some abdominal discomfort and vomitting, but over time it can progress to a full-on gastroentiritis type picture, with bleeding of the gut, metabolic acidosis, and eventually neurological  findings, including decreased consciousness. Not a pleasant condition.

 

 

So phone call number 5 was to the pharmacy HOD. His phone was off, the call went straight to voice mail. I then explained myself to the matron in charge that night (phone call number 6). She gave me the direct cellphone numbers of 2 of the pharmacists who work at our hospital. I called the first (phone call number 7), and after ringing for what seemed like ages the call was finally answered by someone who was either drunk or very groggy from sleep (I’ll give him the benefit of a doubt, it was probably the latter!) It took a good three or four minutes of convoluted conversation for 2 things to be cleared up: firstly, he was not the pharmacist on call; and secondly, he was perfectly willing to give me the number of the person he thought was on call for the week. Having done that, I apologised for waking him up at such a ghastly hour, and we both hung up.

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I finally got through to the pharmacist on call (phone call number 8). By contrast he sounded fresh and very willing to help. What does a pharmacist do when on call? I wondered. Stay up all night at home waiting for one of the on-call doctors to call needing an emergency drug? Surely not. How often does that kind of thing happen anyway? More likely, they stay home and hope the doctor does not call! I don’t know, I must ask a pharmacist friend or colleague at some point. Anyway, he had what we needed. He rushed over to the hospital, asking that someone be there to meet him at the pharmacy. Nurse in charge sent one of the male nurses over. A little while later the pharmacist called me again (phone call number 9) saying that he was at the pharmacy, he had the drug but there was no one there to meet him. At the same time the nurse who had been sent to meet him called Nurse in Charge (phone call number 10?) saying that he was at the pharmacy but couldn’t find the pharmacist (I’m not making up any of this stuff! 🙂 )”He’s there apparently” I said to the pharmacist, “Have a look outside, he’s looking for you.” And it took 2 more irritated phone calls (Calls 11 and 12) from the pharmacist before he decided to just come to us himself and bring the 10 ampules of deferoxamine. Here I must explain, Dora is a relatively large hospital, as I’ve mentioned before, and the pharmacy is way on the other side. One literally needs to drive from medical admissions to get there. To make matters worse,  my understanding is that the nurse ended up at one of 2 entrances to the pharmacy and the pharmacist was at the other, resulting in that comedy of errors. It was about 1.30am when were finally able to put up the deferoxamine infusion for this lady. She was patient number 12 in what turned out to he a total of 19 on this call, a relatively quiet shift.

 

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So there you have it. 12 phone calls in one night just to take care of one patient. Being a doctor can mean having to perform the function of a glorified receptionist.

Doctors have a funny relationship with the telephone. I was in one of the wards not too long ago and, reading a patient’s file I came across a note written by one of the other doctors I work with. It read: ‘The neuro surgeon on call says I must get my consultant to call him back because I don’t sound like I know what I want…’ After having a little laugh to myself I proceeded to call said neurosurgeon. We were seeking clarity on the findings of a CT brain report. Specifically, can we give this patient warfarin which will thin her blood, when there is a risk that the possible vascular malformation in her brain might burst and bleed? “Ah yes I think another doctor from your side there previously called me about this patient but she did not present the case as eloquently as you have…” He actually said that. Well my English teacher would have been proud (no I did not say that aloud! 😛 ). In all fairness to my colleage though, one of our consultants (not wanting to make the call himself) probably asked her to call neurosurgery, and she not being clued up on the case, subsequently bundled the referral.

 

 

At every hospital I’ve ever been in, as a medical student and after I qualified I’ve always noticed that in a ward full of health care workers, both doctors and nurses alike will not jump to answer the phone. It’s a funny thing, we seem to always wait and let the phone ring for a good little while in the hope that someone else will pick it up or alternatively the person on the other end will give up! This I have realised, is because a phone call invariably means yet more work coming our way.

You can have a bit of fun with it though, I have discovered. “Nurse please just tell them I’m not here” is my most frequent grinning response to “Phone call for you doctor” The nurse will invariable have a quiet giggle (if she has a sense of humour that is 😛 ) and pass me the phone. Imagine the medico-legal ramifications of the doctor on call refusing to come to the phone to accept referrals!

I was on call again not too long and as is always the case at medical admissions the phone was constantly ringing. Doctors from clinics or GP practises in the area call to refer patients to us. I picked up the phone and the doctor on the other end started rattling off at a clip “Hi this is Dr So-and-So, is that the physician on call?… Ok good. I have a patient here that I want to refer to you, he has a…” I interrupted him “Sorry Doc, where are you calling from?” and he answered “Motherwell Clinic, oh yeah!” I don’t know how I stopped myself from laughing out loud… 😀

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