Being on call is the most enjoyable part of my job. I am more stimulated, more on edge when I’m on call than at any other time at work. At this point any medic reading this is pulling a very ugly face in disagreement, but let me explain myself. When you are on call, you’re up and about, and the majority of the patients that you see are brand new (in a manner of speaking) ‘fresh’ cases and you have to apply yourself to elucidate a diagnosis. This is in contrast to everyday ward work, where most of the patients have a diagnosis and you’re just managing them until they are well enough to be discharged home. In the admissions ward however, when you walk out and say “Next patient please” you almost have no idea what’s coming. That makes it interesting, it is something to work on, something to figure out. The energy and stress levels (and excitement, to a certain degree) are definitely above normal. I really enjoy it. The problem though (and here ALL medics will agree with me!) is that we have to do this for 24hours. If you count in the post-intake work the next morning (you have to count it, it isn’t optional) it can actually add up to just under 30hours.
Not too long ago I was on call 4 times within a period of one week and a half…
We usually finish a call at about 11am, having started at 8am the previous morning. The immediate instinct is to then head straight home and pass out. This normally translates to 2-3 hours of sleep for me, after which I get up and try to make something of the afternoon or evening. That night you get a full night’s sleep and awake the next morning feeling like a million bucs, and you go off to work again. At work as the day goes on you notice that although you feel good for having gotten some good sleep the previous night, you’re not quite 100%. It is only after yet another full night’s sleep that you start to feel like a normal human being (in the sense that your brain and body actually do what you instruct them to do, and not a delayed slower version!).
This crucial second day post call (when I would normally start to feel like myself again) was stolen from me repeatedly over a 10 day period… 😐 I was on call on Saturday 19 July, then again on the next Tuesday, Friday, and lastly Monday 28 July.
During the second call (Tuesday) we saw a total of 40 patients. I have mentioned before that the average intake at medical admissions at Dora is approximately 30. Less than 20 admissions means that you’ve had an easy call. More than 30 and it’s been a hard one. It also depends on how sick the patients are. You could see only 12 patients but if 2 of them are DKA’s and/or you have someone with decreased consciousness on a ventilator you’ll work pretty hard all night, regardless of the low numbers. So 40 patients was a big night… At about 5.30pm the intern turned to me and said something implying that he had a feeling that we were in for a rough one that night. I didn’t reply, mostly because I agreed. You sort of have a sense for that, when on call, all of which (semi-superstitious as it is) is easy to confirm in retrospect of course.
In a way you learn to deal with the tiredness that comes when you’re currently on call but your body hasn’t quite fully recovered from the last call. You push on and keep working. But the weariness does come across in different ways I think. Like maybe you become irritable… Earlier on during the call I had some tense words with the Nurse in Charge of my ward over the phone. She called me from the ward saying there was a patient that had been discharged without a proper referral note. She was supposed to be followed up at eye clinic or something. Why hadn’t they gotten one of the doctors who was working in the ward during the day to do it, I asked? It was just after 5pm at the time and there was literally nothing I could do about it then. I hung up the phone. I think that I was in the right, but the aggression was probably unnecessary. Later that evening I was obviously still cranky, I refused to accept a referral from psychiatry. The doctor on call for psychiatry called about a patient who had a seizure in their ward. This was a 30something year old lady who had major depressive disorder and epilepsy. She had overdosed on her anti-epileptic medications and as a result had been admitted to the psychiatric ward. The psychiatrists had stopped her anti-epileptics as her blood levels were obviously high on admission. After a few days her levels decreased and became sub-therapeutic, hence she ‘fitted’. So we know the reason she had the seizures, why then should I have to admit her?! “Pull bloods for levels, restart the anti-epileptics and we’ll come and see her when you have the results..” I said. We got off the phone and I carried on seeing new patients. She called me again about 20minutes later, and said that she had just spoken to her consultant, who also happens to be the head of department (HOD) for psychiatry. She said that the matter was not up for discussion, the patient had to be transferred to the physician on call. Sensing that I was starting an inter-departmental incident I accepted that they transfer the patient over to medical admissions. We would pull the blood levels and observe her for further seizures, and sedate her if necessary.
Psychiatrists only treat pure psychiatry. If a patient presents with a history or symptoms that are obviously indicative of mental illness (depression, mania or psychosis-often substance induced being the most obvious and common) and they find even the slightest derangement in any of the results of the blood tests the assumption is that the presentation has a medical cause and we (that is internal medicine) have to admit and manage the patient. Similarly, if a patient in the psychiatry ward has a cough, they won’t put the patient on antibiotics, they won’t so much as do a chest x-ray! They call us up and transfer the patient to us. To be fair this is not something that is particular to the psychiatry department at my hospital, it is what is done according to the national guidelines. In other words the psychiatrist was right to insist that I accept the patient. I know this but that doesn’t mean I have to be happy about it, and on a night when I’m so busy that I’m certain that neither I nor my intern will get the usual one or 2 hours of sleep, I certainly won’t cheerfully say yes to that sort of bureaucratic nonsense. The patient in question did not have any further seizures while she was in medical admissions. We restarted her anti-epileptic medications as logic (and the most basic common sense) would have dictated.
The night was very busy. In order to try to make our post call round a little more efficient, from about 5.30am after printing out all the patients’ blood results the intern went to the short-stay ward and brought back all the patients that were ambulent, and had them all sit on the waiting bench immediately outside the admissions ward so that at about 7.30am when we started the ward round with the consultant we would bring the patients into the admissions ward one at a time to be seen and examined by the consultant, a plan would be made for their management, they would then leave the ward and we would bring in the next patient. Naturally this could only be done with the patients that were well enough to be walked up and down. This was much faster than the usual method, where we as a team would go to the patient see them and then have to go back to the admissions ward to check their x-ray on the computer system (there is only one computer in all of medical admissions) and then all walk back to the short-stay ward to see the next patient (this is after having been up since the previous morning!) It was a better system, but we had so many patients that it still took us a hec of a long time to work through them.
Later on that morning I passed by my ward to apologise to the Nurse in Charge for my telephonic aggression the previous afternoon. She was very motherly about the whole thing, saying she understood, and that we were all under pressure. I got off easy I think, I have heard stories of other doctors having to conjure up gifts (in the form of chocolate cake, and the like 😛 ) as penance for not being nice to a professional nurse. Not long after that I received a phone call from my head of department, he was very unhappy. What was this about me not accepting a psychiatric patient, he wanted to know. I explained myself , admitting I had been in the wrong but that ultimately I had accepted the transfer. Not satisfied he continued to rant at me over the phone, I had never seen or heard him like this before. He calmed down a little after a few minutes, and asked me how the patient was doing and asked about her blood anti-epileptic levels. I explained that she was doing fine.
The reason he was so irate with me, he explained later in a much calmer conversation (during which I was very contrite) is because he would have to answer for the incident at the inter-departmental meeting later on. Although I have also heard from other doctors that have worked at Dora for a long time, that the HOD at psychiatry is a woman that is not to be trifled with and that our own HOD, while being an experienced, capable physician is of a somewhat meeker constitution, and it is debatable how well he would fare in a direct consultant-to-consultant pow wow.
We ended our round finally and I had one last task. One of the patients we had admitted was a young lady, HIV positive, in severe renal impairment, florridly fluid overloaded, and acidotic. She was known to the renal unit at Livingston Hospital (LVH) so I gave them a call and they said to transfer her over to them for renal dialysis. I have previously written at length about trying to organize patient care telephonically, and the inefficiencies thereof. Well the simple exercise of organizing to get her to LVH took 6 phone calls… I had to find out who the nephrologist on call was, I then had to get hold of him and explain the case. After he agreed I had to speak to the physician on call at LVH. She wasn’t very nice to me initially (this seems to be a recurring thing between me and whoever is on call at LVH POC.. but it is probably because she thought I was creating more work for her-which I kind of was, but that’s besides the point surely? 🙂 ) and lastly I had to call for the ambulance.
I was done with all of that by about 1.30pm and I left the hospital thinking that since I had the afternoon I should go and get some stuff done, maybe some grocery shopping, get the car washed, and other such admin. All of this instead of the obvious (to get some sleep!!) and after that I thought, I’ll get back and sleep for 2 hours and then go for a run. That was the plan. I was home by about 15.30, and fell promptly to sleep. I set an alarm for 2 hours later, and it may or may not have gone off, I will never know. I remember a brief phone conversation with Meryl, and I may have mumbled something uninteligable to my flat mate when he got back from work, but it is all a blur.
The next day was an average slow day in the ward. Got home in the afternoon and squeezed in a couple of hours of studying and I should have gone for a run but I didn’t, I can’t recall why…
I was on call again on Friday. Friday calls are supposed to be quite relaxed. Who wants to be sick on a Friday, let alone on a Friday night, right? It actually reflects in our numbers, some of the other doctors tell stories of Friday calls when they admitted 15 or 16 patients, or something along those lines. In contrast, our colleagues over at surgery have a much rougher time of it on Fridays. People become very excited at the end of the week, consume copious amounts of alcohol and inflict bodily harm on one another, keeping paramedics and trauma surgeons quite busy.
We saw 29 patients on this call, a welcome respite from the madness of the previous call. And speaking of madness and crazy times, I did receive a call from psychiatry again. They had a 30something year old man that had been transferred from LVH. He had a history of multiple previous admissions for substance (read: marijuana) induced psychosis and his latest presentation was no different. He had been transferred to Dora because he was from our drainage area. In the ward he had developed dyskenias (involuntary muscle contractions) and they suspected he was developing neuroleptic malignant syndrome (NMS). This is a rare phenomenon that can be a side effect of antipsychotics. It involves severe muscle rigidity, a raised body temperature and blood pressure instability. Asides from stopping the antipsychotics, the management is mainly supportive, keeping the patient’s body temperature down, IV fluids and a drug called dantrolene can also be used. So NMS is a syndrome that can occur as a side effect of medicines prescribed by psychiatrists and it has to be managed by the physicians…
I kept him in the medical admissions ward. He had no further dyskinesias that night, but they did recur unfortunately the next morning, and we had to admit him to one of the male wards.
During the same call I got called to one of the male wards about a patient who had jumped out of a window (the medical wards are on the first floor). What kind of a patient jumps out of a window? A psychotic patient. What is a psychotic patient doing in a medical ward? I hear you ask… He has a lower respiratory tract infection, which needs antibiotics, which cannot possibly be given by psychiatrists…
Crazy doctors, and patients aside, we also saw a 30something year old lady who had previously had TB. She presented with a 4 day history of shortness of breath. She was clinically wasted, and somewhat dyspneic. Her chest x-ray showed a pneumothorax on the left side. Roughly speaking, this is when there is air between the chest wall and the lung. Not a healthy situation. It can occur spontaneously due to the changes in the lung of a patient that has previously had TB, or a long time smoker that has emphysematous lungs. The lung ‘collapses’ away from the chest wall, and this effectively decreases the amount of air that can enter the affected lung, hence the shortness of breath. The potential danger with a peumothorax, is that the ‘air pocket’ between the lung and chest wall can get bigger, making the patient hypoxic.
Our lady was not overtly distressed, her blood oxygen saturation was 99% in room air (anything above 90% is acceptable).
The next morning I inserted an intercostal chest drain (ICD) into her. This involves inserting a drain (tube) in between 2 ribs into the chest into the space between the chest wall and the outside of the lung, and stitching the the drain to the chest wall. Over time air is sucked out of that space through the tube and into a drainage bottle. I did this insertion under the supervision of my intern and the doctor that was next on call. This is because funnily enough, with all that I had seen and learnt at Bara hospital before, I had only once or twice had the opportunity to insert an ICD. Both times it was under the supervision of a registrar. I had never done one on my own so I wasn’t comfortable doing it during the night on call. The intern had done a few during his first 2 months at Livingston Hospital and the other medical officer had inserted plenty. I inserted the ICD successfully, and that was the end of that call.
I am happy to say that I saw that lady in the wards sometime during the next week, the ICD had been removed because a repeat chest x-ray after a couple of days showed that the pneumothorax had resolved. She looked better, less short of breath.
I got home at about noon that saturday, got the obligatory 3 hours of sleep and actually managed to get myself up for a 14km run that evening. Being post call, it was a sluggish effort, quite possibly the slowest 14km ever run through the streets of PE on a saturday evening :-P. I just felt that I had to, having not run since the previous Monday. Sunday morning came and I slept in till about 9am, taking full advantage of not having to be up for work or a call. After eventually dragging myself out of bed at about 9.30am I did about 2 and a half hours of studying. I have been going through Ganong’s Review of Medical Physiology for the last few months at a veritable snail’s pace. I am currently on the 3rd chapter out of a total of 7. I put in 2-3 hours of studying 2-3 times per week. Sometimes I’m lucky if I get one good study session in the whole week. There is so much to get through, it is actually a little bit scary. There are doctors out there who are married with kids and they manage to do this. I have a much simpler life than that and I don’t know how they do it! This is what I feel I have to do though, just to take the first steps towards becoming a specialist physician one day… Having said that I have given up on setting myself a time by when I have to finish, I will simply keep studying until I’ve covered enough material that I feel ready to register for and write the internal medicine primaries.
I was on call again on Monday 28 July. We had another quietish one thankfully, 26 patients admitted. No psychiatric referrals this time. After that I wasn’t rostered to be on call again for an entire week. The crazy times I was happy to note, were over for a little while…