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It Begins

Although the embers of my OCD are still burning, the best way to manage the flames is to try and continue on as normal. But ‘normal’ now is very different from ‘normal’ two months ago. The key, I think, is to try and maintain some sort of routine, but this week things were thrown… erm… a little out of kilter, because I was starting my new job.

Last Wednesday, I packed a suitcase ready to travel down to London for my junior doctor post. Thursday was my first day as an FiY1 doctor at St Thomas’ Hospital. On a scale of 0 to 10, the amount of stuff I normally pack rates at ‘diva’ – sometimes it feels like I need an entourage. When I was at school (and in the first couple of years at university), I used to fill my backpack so full that I think it affected my posture. I was mortified of forgetting anything. My friends could push my bag and a small eccentric force would send me in an uncontrollable spin, ending in me falling over. Sad.

On Thursday morning, I fuelled myself with a hearty breakfast and made sure everything was order. My housemate, as always incredibly helpful, we went over a little mental checklist with me. I was dressed in ‘doctor clothes’ for the first time in a while: a shirt, chinos and smart shoes – although I realised this was probably going to be replaced by a set of scrubs as soon as I started working in the hospital. Fine by me: they’re incredibly comfy, well ventilated and saves me washing my clothes too often.

We walked over to the station together with my suitcase and bag in tow. The whole thing, frustratingly, didn’t feel like a goodbye although it definitely felt like something was changing. Instead of feeling firmly at Cambridge, I was now split between two places. I was still part of Cambridge University and still had a flat in Cambridge but now I was working at London. As much as I hate saying proper, final goodbyes, this was equally as emotionally unsettling.

We murmured our farewells to each other at the entrance to the station and gave each other an air hug. My flatmate turned and went off to do some shopping at the nearby supermarket and I trudged through the gates onto the platform.

I was about 10 minutes early; the train was there but the doors were not open. I stood and waited on the platform. It was warm, sufficiently so to create the uncomfortable moist feeling between your body and the strap of your bag. I was one of only three passengers waiting for the train to King’s Cross. We were outnumbered by Greater Anglia employees who were milling around with seemingly very little to do.

I have a habit of forgetting things, and this time I hadn’t let myself down. My friend had provided me with a set of disposable masks he had been mailed by a Chinese family whose son he tutors. I had placed several in my suitcase, but on the advice of my parents (and several ‘advisories’ on twitter), I had planned to carry one in my pocket to wear on the train and on the underground. The train was so empty I didn’t really see the point, but I decided to go along with it – partly because I had promised my parents to do it, and partly because I didn’t want to waste the masks I had been given.

I fumbled around in my pockets for the mask whilst waiting on the platform, only to remember I had left the bloody thing on the kitchen table. Typical. My housemate has previously remarked that whilst I look very prepared and organised, it’s all a facade to hide some underlying chaos. I think he’s right. Needless to say, I couldn’t be bothered to unlock and open my suitcase and grab one from my stash because I couldn’t remember exactly where I had put them.

The train doors flashed to open and I stepped on. I had the whole carriage to myself – I can’t remember this ever happening on the train between Cambridge and London, especially the quick one. It was eerily silent. The train itself was dark and gloomy and felt all the more oppressive because of the contrast with the bright outdoors. But, my spirits were high, if a little muted by the sustained flare of OCD. I was about to start a new job that I had dreamed about getting for the past two years, in a world-class hospital at a stellar location. There was a lot to be optimistic about.

The journey was quick, only 45 minutes. I sat and read a book. Part of me was tempted to go over some ‘junior doctor’ things, like prescribing VTE prophylaxis or fluids, but I couldn’t bring myself to do it. I figured there’s not much point of fretting now. The best thing to do is relax.

As we pulled into King’s Cross, I noticed the platforms were totally deserted. There must’ve been around twenty people in the entire station. Normally the main concourse is replete with commuters exhibiting varying levels of frustration and last-minute travel panic. Now, it was desolate. All the shops were closed. The taxi ranks were still reasonably busy, but definitely less than usual.

There were several signs pinned up around the station and in the adjacent underground stop: ‘Stay at Home and Save Lives,’ and ‘Key Workers: you can travel, Thank you.’ Upon seeing ‘Key Worker,’ I had a pang of imposter syndrome: I’d hardly describe myself as one when it feels like I can barely write a fluids prescription, let alone help manage someone in respiratory failure. I tried, with moderate success, to put those thoughts to rest. I’d received six years of training (nine if you include the PhD, but that makes me feel especially old) and I did know some ‘stuff’ that would hopefully be helpful. I’d been trained well. The underground was similarly desolate. The relative silence was interrupted by a loud, rather raucous announcement over the tannoy system: “I am a doctor. Please, stay at home and help us do our jobs” – or words to that effect. Cue the guilt, again.

I took the Northern line to London Bridge, followed by the Jubilee line westbound to Waterloo. At any one time, there were between two to three other people in the carriage. Sometimes it was just me. I sat there, clutching to my case and bag, wondering and worrying about the people I was going to meet. They were going through an equally as bewildering time as I was. That was a comforting thought: to know that you’re never fully alone in your experiences.

I arrived at Waterloo and the station was similarly barren. I placed my student doctor lanyard on, looking rather preppy, but was promptly advised by a police officer to remove it because there had been reports of people snatching them. Grim.

It took me five minutes to walk over to the Education Centre, opposite an M&S (the socially distanced queue had become a familiar sight, winding around the corner of the street). When I arrived, I rather too hastily approached the reception desk forgetting about the two-metre rule, the extent of which had been very clearly demarcated on the floor. “Could you step back a bit please,” the receptionist asked, and I shuffled back with an embarrassed smile.

“Hi, uh. I am one of the new, erm, doctors.” It felt weird even saying it.

“Ah yes – go through to seminar room 1,” she said with a smile. I wheeled my suitcase into the room. The chairs were laid out approximately 2 metres apart, and save for the absence of desks it had the feel of an examination hall. I plonked my stuff down and sat down, exhaling and relaxed into the chair. I still didn’t feel very different to how I felt as a medical student: it felt like I was starting another placement. I was used to travelling around to different places, sitting through inductions etc. and this was no different.

I met another one of my colleagues in the seminar room, and we chatted about the usual things: where you’re from, where did you study, what speciality do you want to do, how do you feel about starting, how’s the lockdown. We soon realised we had been sent to the wrong seminar room when the adjacent room began to get noisy. The rest of our cohort together with the Foundation Programme lead were all next door. We entered a snacked on the standard fare of NHS sandwiches, fruit and some instant coffee.

The induction programme was busy – we had an introduction to the trust, advice about our payslips and contracts, stories from doctors about their lives as FY1s, and the more unsettling discussion on how COVID-19 was impacting practice. I say unsettling, although the doctors were quick to admit that both positives and negatives were coming out of the whole thing: teamwork, learning, solidarity with the public etc. It was true that the profession as a whole had never felt so well-respected. I had even seen a cartoon on Twitter depicting Marvel’s Avengers bowing to doctors and nurses in a hospital corridor. It feels weird to be lauded and held so highly when you are just doing your job. The narrative of NHS Heroes and being on the ‘frontline’ in a war against coronavirus didn’t really help. It made the pressure feel even greater. All I wanted was to not get in the way too much, learn a bit more about being a doctor and help out when & where I could.

I was due to start on Vascular Surgery, and the rota looked rather, erm, intense – more than anything I had been used to in Medical School. There were 7:30AM starts each morning, some late shifts and some weekend shifts. It’s probably a perfectly reasonable rota which any doctor would be expected to do, but… oh, the humanity! I now see why my dad advised me to take the final few weeks of medical school ‘easy,’ because the days were only going to get longer. Sure, my PhD involved long, busy days and, not infrequently, early starts and weekends, but it didn’t feel the same. I felt then that I had more governance over my time. If I came in on a weekend, it was because I wanted to in order to get ahead with my work. Now I was a little cog in a much, much bigger machine and I had to pull my weight.

The discussion of rotas, contracts and pay made me feel rather unsettlingly like an adult. I had spent the last third of my life as a student. Even during the PhD – when I was being paid an untaxed stipend – the transition from clinical student had been seamless and was part of a formalised programme. Now I could feel the responsibility of being a qualified healthcare professional weighing down on my shoulders.

Official confirmation of accommodation still hadn’t come through, so throughout the induction, I was rather anxiously wondering if I would have anywhere to stay that night. At the end of the lectures, roughly half five in the evening, it was confirmed that we could move into the hotel that was offering rooms for NHS staff – the Park Plaza no less, a posh Raddison right next to the hospital. Now, this I could get used to. I wheeled my case over with a few of my colleagues who I had met, many of them from King’s College London but others from UCL and Edinburgh. They were all very pleasant and but there was a sense that we were all a little bewildered, a little scared and a little excited about what we had let ourselves in for.

Crossing the road around the Park Plaza hotel is a dice with death: despite the lockdown, there was still a fair number of cars zipping round the road. The hotel sits as a little island in middle of the road which meanders around it, like a river about to erode the last bit of land to create an Oxbow lake (GCSE Geography, I’ll never forget). We had a little bit of trouble getting to the hotel trying to find the best place to cross. Even the native Londoners were a bit confused.

Screenshot 2020-04-26 at 10.43.36

The Park Plaza hotel and the A3200 wrapping around it.

Eventually, we found the entrance. We showed our Guy’s and St Thomas’ badges (no longer ‘medical student’; now ‘FY1 Doctor’ with an equally as unfortunate ID photo) and the guard nodded politely and let us in. The hotel was NICE. In 2006, an old council building – described as one of London’s worst eyesores, see below – had been demolished to make way for it.

old_building

The old council building – with a omen pinned to the windows.

We walked into the lobby complete with a restaurant and bar looking out onto the hospital and Westminster Bridge. There was a table with lots of envelopes containing the keys for NHS workers. I held my breath, still half expecting that there had been some mix-up and I wouldn’t have a room. But luckily, there it was – “Laith Alexander.” Inside was the key.

We were all dotted about the hotel, although one of the other new FiY1s was in the room next to me. The room was lush, mainly because it was free. As you enter, there’s a living room with a TV and a large wardrobe. Passing through, there’s a bathroom with both a shower and a bath (I can’t remember the last time I actually had a bath). There were dressing gowns, toiletries towels and even sacred loo roll.

The bedroom has a king-sized bed. There’s large window, approximately three-and-a-half metres long and just under three metres high. My room looked south, towards the Evelina Children’s Hospital and with St Thomas’ A+E in full view. Not quite the Thames view, and I wondered whether those rooms had been reserved for consultants. Having said that, Big Ben is now enveloped in scaffolding so isn’t as pleasant a sight as it used to be.

view_room

The view from my room, overlooking south London.

I unpacked my stuff and made myself at home. The envelope containing my key also had several documents about staying at the hotel. It turned out, breakfast and dinner were also free. Great news, given that I hadn’t even thought about how I was planning to feed myself. Breakfast was being served from 6AM, and dinner from 6PM. It felt like luxury.

The hotel was laundering NHS uniforms for free – but unfortunately, not normal clothes (okay, okay, so maybe I was expecting too much). It was super expensive; you were better off buying a new pair of socks than washing them there because it costed £2.70. There’s also an argument for washing your clothes separately to other healthcare workers, who may have been exposed to coronavirus. So washing clothes in the shower it was.

I spent half an hour just enjoying my new digs. I washed my face, set up my laptop on the little desk, made myself a cup of coffee, turned on the TV and relaxed. Probably the weirdest start to a medical career in recent history.

That evening, I went for dinner. A staff member checked off my room and I joined the queue for the buffet. They had all sorts on offer. I thought to myself that I may as well indulge. I wasn’t going to have an opportunity like this ever again, in all likelihood. I had chicken wrapped in bacon with potatoes and mushrooms, followed by a frangipane for dessert (together with a cup of coffee as unfortunately I had carried my caffeine addiction with me). I sat down on a table two metres opposite a lady who was tapping away on her smartphone in between each bite of her dinner.

I placed my phone on the table and opened BBC news, to read about Donald Trump’s suggestion of administering disinfectant to treat coronavirus. You couldn’t make it up.  This is the problem when you have a real estate tycoon in charge of a country facing a global pandemic – contrasted with, for example, Angela Merkel, who has extensive scientific training. The doctor sitting beside Trump at the press briefing – Dr Deborah Birx – seemed ashamed each time the he turned to her. I had always thought of Donald Trump as a bit of a joke, but now his suggestions were simply dangerous. Let’s hope no-one actually takes his advice seriously (although, see here). 

Anyway… back to dinner. All the seats in the dining area were spaced out. Friends who were sitting ‘together’ were at least two metres apart, and had to awkwardly raise their voices to chat with one another. Many, like me, were sitting alone, happily enjoying their food whilst quietly reading or staring off into the distance, with a nice view of the hospital and the southern end of Westminster Bridge. Visible from the window was a flower arrangement had been erected outside the hospital, with “I <3 NHS” spelt out in blossoms of all different colours. 

I&lt;3NHS

Flower arrangement outside St Thomas’ Hosptial.

After filling up on free food – an art that I had perfected over nine years of being a university student – I trudged back to my room and finished off some e-learning I had to do. Whilst the e-learning modules have in general been useful, I never expected so much of it. It’s crazy: and the problem is the modules are in lots of different places. Some of them are on the trust website, some of them are on an NHS e-learning platform, and others still are hidden away in emails and google forms that we had to fill in.

The following day, I went down for breakfast in the morning. The buffet was equally as extensive: I had a cooked breakfast for the first time in a while. The gentleman who served me was over-zealous with the portion sizes, not that I’m complaining. Not being one to leave anything on my plate, I devoured the whole lot. Brain food for the day of e-learning planned, and I joined my several of the other FiY1s to march down to the education centre and begin the computerised onslaught.

There were so many things to sort out and get to grips with. Unlike Addenbrooke’s, where everything was being done on one system called EPIC, there were several different systems one had to grapple with. The electronic record system, EPR, was different to the prescribing system, MedChart, which was again different to the system used for clerking called eNoting. You had to get to grips with each one.

Having done my modules, which took the whole morning to complete, two of the other FiY1s and I went to get some lunch at around one o’clock. We each grabbed something from the M&S and sat on the lawn just outside St Thomas’, adjacent to the River Thames. It was busy, filled with staff in various coloured scrubs. I wasn’t sure if the different colours had any meaning, or if they were just whatever the staff could get their hands on.

As we sat and ate, I was unusually mute, too busy contemplating what the next few weeks had in store. One of the other doctors I sat with was joining me on vascular surgery and we went together to the department after we finished, in time for a meeting at two. We navigated to where we were supposed to be, at the department of cardiovascular medicine on the first floor. We entered and spoke to the consultant’s secretary who told us to sit in the meeting room and await the consultant.

The department itself was quiet, with only the occasional person passing by. It consisted of a couple of meeting rooms, seemingly serving a dual purpose as storage spaces with bits of clutter marginalised to the periphery of the room, filing cabinets half open, old scrubs on the desks and bits of paper. On the book case were several old volumes of the Journal of Vascular Surgery which probably hadn’t been opened in years.

The consultant arrived, a very charismatic and charming man who was overseeing our placement. He explained that vascular surgery often had around 50 inpatients at any one time, and junior doctors had a tough time on the rotation because it was so busy. However, currently there were around one-fifth of the normal number of patients. The team was over-staffed.

Don’t get me wrong – I took this as good news. Firstly, it means there’s a slow lead in to being a junior doctor. It gives me time to pick up the ins-and-outs of the job in a relatively stress-free setting. Having the book knowledge is a small part of being able to do the job. You have to grapple with IT systems, understand how to order bloods and imaging; know who to ask for what and when; know how to write discharge letters etc. Not to mention actually being able to find your way around the hospital and pick up the right size scrubs. If the clinical work is a bit quieter, there’s a bit more time to iron out these teething problems.

We were both assigned to an individual junior doctor. The doctors are working a reduced number of days because of the small number of patients, so we were to join our assigned junior doctor in whenever they came in. But for the first couple of days, both of us came in to join on the ward round.

On Monday, the F1 showed us where the junior doctors’ mess was to get scrubs and print off the list of patients. The mess consists of a lounge, several computers and a small kitchen. Some of the doctors who must’ve been on night shifts were asleep, so we crept around quietly. On the desks, there was lots of free food – including those nice Quaker Oat breakfast squares, slipping one into my pocket for later. I grabbed a set of medium scrubs and got changed in the loo. They were so small – the scrubs were manufactured in China, so I can only assume that ‘medium’ in China is much, much smaller than it is here. I could barely get into the scrub top without introducing a small tear in the seam.

We went to the handover in the Cardiovascular Department. The registrar and consultant introduced themselves. Several of the consultants were tuning in via video link from home. They discussed each patient, most of it going over my head. I knew some of the acronyms – EVAR, CLI, BKA, AKA etc. – but the discussions about the intracies of each operation were too complex to register. I watched the FY1 attentively jot down jobs – check these bloods, ring this person, order this scan. A master in the art of multitasking, both planning her day and listening carefully to the handover meeting. That was going to be me soon.

Now, I’ve always appreciated vascular surgery as being an important speciality, but it is not my thing. I’ve never liked feet, let alone gangrenous toes and heel ulcers. The cases that were coming in, although small in number, tended to be the ones that needed urgent surgical intervention. This included people with big venous blood clots, expanding or symptomatic aneurysms, or arteries so clogged that only a trickle of blood was getting through to perfuse the limb – called ‘critical limb ischaemia.’

In medical school, I had reduced vascular surgery down to a discrete number of pathologies. There are roughly three key venous problems – clots (thrombosis), varciose veins and thrombophlebitis (inflammation of veins) – and four key arterial issues – peripheral arterial disease, aortic aneurysms, dissections and carotid artery disease. And indeed, these accounted for the bulk of what we were seeing.

The team were lovely and made an effort to integrate us from the beginning. Inevitably, however, I still felt like I was in the way: I hadn’t yet shaken that all too common medical student feeling. It was mainly because I still didn’t know what I was doing. I could barely start the computer for the ward round without running into a problem with my login. St Thomas’ has several different IT systems to grapple with – electronic patient records (EPR), eNoting and MedChart – which all work in different ways and have their own idiosyncracies. There is meant to be some cross talk between them, and sure, sometimes when you use EPR it opens the right patient in eNoting, but a lot of the time it doesn’t. I could have a little nerd-rage about IT systems in hospitals, about how they are all different, about how the ones in primary care don’t always talk seamlessly to those in secondary care, about how they are such a pain to use… but I’ll spare you the rant.

The majority of the ward round was spent on a ward newly coopted for vascular patients, amongst other surgical specialities. I think the usual vascular ward had been commandered for COVID-19 patients. There weren’t many people to see, and the remainder of the morning we spent looking after outliers. They were scattered on a number of different wards. I like to think navigation is one of my strong points, but it’s all too easy to get lost in St Thomas’. A compass would’ve been helpful. I made sure to glance out of the ward windows to orient myself along the Thames, Westminster acting as a reference point for ‘East’.

When one patient on the ward round needed a cannula for radiological contrast, I volunteered to do it. I  had done quite a few cannuals in medical school. I think of myself as moderately competent – no means an expert, but not totally helpless either. The cannulas in St Thomas’ were different from the ones I was used to in Cambridge. They were pre-attached to tubing so there was barely any preparation needed – it basically comes ready to be inserted.

Masks were being worn on the ward by most people. When seeing patients, we were also putting on a plastic apron, goggles and gloves. You get used to the PPE pretty quickly, although it was a bit of a faff donning and doffing each time you saw a different patient. My skin quickly dried out from repeated use of alcohol gel and handwashing. Inserting a cannula carries a risk of body fluid exposure, which meant an additional layer of PPE was needed: instead of wearing a plastic apron I needed to wear a fluid repellant gown.

I introduced myself to the patient, aware that he had no idea what I actually looked like, hidden behind my mask & visor and enveloped in a plastic blue apron like something out of the film Contagion. I tightened the tourniquet around his arm and palpated for a vein, convined that I could feel a small one in his elbow crease. After cleaning the area, I inserted the cannula, but no luck. I fished around with the needle for about two minutes, and suddenly, miraculously, there was a flash of blood. In my excitement, I advanced the cannula but in slightly the wrong direction, not following the course of the vein, and clearly busting it in the process. I withdrew the needle looking for blood tracking along the plastic tubing, but nothing. I sighed.

Luckily the F1 was on hand, and she managed to expertly site the cannula in about half the time. “You’ll get used to it,” she said, “and they’ll be plenty of opportunity to practice.” I subsequently had an opportunity to redeem myself by successfully taking bloods from a ‘difficult to bleed’ patient, although I was told by a friend that every patient describes themselves as difficult and recounts how many staff failed to take their blood.

The wards were defintiely over-staffed and as interim junior doctors, we were supernumerary. Given all the concerns about social distancing, it sometimes felt slightly counter-productive huddling around the ward round computer and partially blocking the corridors. On the bright side, I definitely learnt a lot and had started to pick up the basics. After my first two days understanding how things worked, I had a few days off. Currently, I’m stuck in my hotel room in a rather gloomy London. I’m rather content, although I can imagine after a few days some cabin fever will probably settle in. I have plenty of bits and bobs to do in the meantime – books to read, things to write, thoughts to process. I’ll brace myself for the next shift, which may be slightly busier, as things look like they’re gradually picking up in the hospital.

Wish me luck.

 

 

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