Ramiro's Day On the Ward (Geriatrics)

In this series of articles, doctors from across the UK talk about their experiences of medicine ranging from the surgical theatre to the outpatient clinic to the GP surgery to digital innovations. Dr Ramiro D'Abrantos is a junior doctor working in Essex.

My first unwell patient review as a newly qualified doctor.

Reflection

As medical professionals, we are encouraged to reflect regularly. This was my first reflection as a doctor. This reflection describes some of the fears that went through my head as I was making the transition from senior medical student to junior doctor: how and when do I get help? How do I explain to my seniors I was unsuccessful at a procedure such as taking blood or inserting a cannula? What will they think?


I learnt a lot at medical school. By the time I graduated I knew some of my fears could not just be taught in a classroom or lecture, but I would get to face them in my working life and get to learn from that experience. Luckily, this learning started very quickly.


Description

Third day as a newly qualified doctor. First night shift. On call covering medical and geriatrics wards. Bleep from nurse informing me a patient has a track and trigger (T&T) score of 10. I went to see this patient, to a ward I have never been before, and started an assessment. After part of this assessment and after being unable to find a vein for peripheral cannulation, I escalated and got help from the senior house officer, an FY2 doctor who had never worked in this hospital before. Together we continued assessing and treating this patient. FY2 doctor was unable to cannulate and we got help from the on-call nurse practitioner. FY2 escalated to the medical registrar who added a few items to the management plan and the patient improved.


Feelings

It was a very scary phone call to receive a few hours into my first night shift. As soon as I heard track and trigger of 10, straight away I had to pause for a few seconds whist on the phone, to put a response plan in action. Once I took the handover from the nurse over the phone, I felt unsure as to what the best course of action was. Should I call the medical registrar straight away and pre-warn them that I am about to see somebody with a score of 10? However, at this point I did not have much information, not even a basic assessment first. Was it then appropriate to pre-warn my first point of escalation, the FY2, that I was about to see a T+T of 10? Again, with little information. In hospitals where I trained, a score above 8 would automatically trigger a medical emergency team (MET) response. I also felt "ready", ready to put into practice the structure I had in my mind when reviewing acutely unwell patients.


I was scared - from a T&T point of view, this patient was very unwell. By this point I had very little experience reviewing unwell patients on my own, and now I was the first point of call and it was up to me to escalate and get appropriate help. I felt I needed help even before going to see this patient, but I was unsure asking for help before seeing the patient was the right thing to do.


It was not the medical part to this problem that had me thinking hard at first. As I made my way up the stairs it was the logistics of who to call first for help that presented the first challenge. New hospital, new environment, new job, new colleagues. I felt I had to get this right.


Evaluation

I carried out a review together with the nurse looking after this patient. Luckily this nurse had experience in the acute setting and offered to carry out many of the jobs I generated for myself. I concluded this patient was septic and needed urgent intravenous antibiotics. I also concluded I had to get help, firstly to make sure my plan was appropriate, secondly because I was not able to find a suitable vein for cannulation or venopuncture. I decided to call my FY2 first. I had a good overall picture in my head, and I had a plan. I did not feel it was necessary to escalate to the medical registrar straight away.



The good:

I believe my first review was comprehensive. I was working down an ABCDE structure out loud with the nurse to make sure I did not miss anything important. We also worked well together and split the tasks so by the time I had to escalate, many jobs were done or at least started. I was able to establish a good rapport with the nurse. I believe I stayed calm and focused. I also think I did enough of the review before calling for help, and it was an appropriate balance between completing a review to obtain information and taking the time out to escalate.


The bad:

My handover was not as smooth as I had in mind. Inexperience and nerves played a bigger part than I had thought. Together with the FY2 it took us a little while to get intravenous access. It was overall a slow process, many of the non-medicine tasks such as requesting tests took me a long time.


Analysis

I believe overall it was an adequate first attempt at this complex concept of reviewing unwell patients. There was a structure. There was a sense of team working. For two doctors new to the hospital, the non-medicine aspects of this situation presented several challenges. Knowledge wise, I think we knew what the patient needed, and all these things were started and given. It was reassuring that the medical registrar agreed with the plan we had formulated.


Conclusion

This first review re-emphasized the importance of tools and systems in medicine to stay structured and avoid missing things. These structures keep patients safe. This experience also showed me that it is okay to be unsuccessful when attempting procedures. I think this was a main worry of mine. I did not want to be calling for help just to get a cannula in, and being presented with an overweight, oedematous patient was not a good start. The FY2 also could not cannulate, and in a way, this made me realize that actually it was not me doing things wrong, maybe it was actually a difficult access situation.


A few weeks later I came across the same nurse. I explained that I was a new doctor and she commented that I had handled the situation very well and she had not realized it was my first week in hospital. This comment was encouraging.

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