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A Small Part

The past week has been my first immersive experience of life as an FY1. Working closely with a stellar, patient and thoughtful F1 mentor, I’ve been effectively doing the job of an F1.

What does that mean? As far as I can discern, it entails copious amounts of documenting, significant periods of time spent waiting for ward-rounds to begin, frantically trying to understand what’s going on with which each patient, fluids prescriptions, VTE assessments, and filling in discharge summaries and ‘to-take-out’ (TTO) forms.

The amount of diagnostic and management skill has, so far, been small. This is to be expected, because the early weeks are about learning the mechanics of the job. The book knowledge is in my brain (somewhere), but now it’s about translating that into action. For example, I’ve read time and time again about fluids assessments, the different types of fluids, their indications etc. but when I was actually doing my first fluid review and looking at a patient’s fluid balance chart, I felt a little bit out of my depth. It’s not exactly complicated – check the patient over, add up all the fluid in, take away all the fluid out and make sure you have a look at their electrolyte levels. The anxiety of making a mistake blunted my mental capacity to do even basic arithmetic – I had to check and recheck before I was satisfied. It turned out, had I looked carefully, that a nurse had already calculated it for me at the bottom of the chart…

For the standard shift, we get in at 7:30AM and print off the list – provided there is a printer working. Then there’s the handover at 7:45AM, where all the consultants virtually tune in and discuss new admissions, complex patients or patients they’ve been asked for an opinion on. After that its the ward round – this can last anywhere between an hour to several, depending on how many new patients there are and how complex each individual patient is.

The ward rounds are particularly intense and stressful. I’m a pretty speedy touch-typist (possibly the only benefit that has come from whittling away countless hours of my life on video games) but even I struggled to keep up during the ward round. You have to have multiple electronic systems on the go: one for medications, another for blood test results and another still for typing up the notes. The consultant leading the ward round expects you to have everything ready for each patient. In fact, part of the reason behind why the start time is early is to have time to prep things before the ward round – what did the most recent blood test show, has there been any new scans, what have other teams said in their reviews.

Whilst ITU is much busier than normal thanks to COVID-19, the general amount of ward work is less than what is normally is. Vascular surgery is only really accepting very unwell patients. Most of the routine cases are no longer in hospital, partly because people are avoiding admission and partly because the hospital is no longer doing elective cases. I was told that vascular surgery can have upwards of fifty patients, but now there are less than half of this. In some ways, it’s a great environment to learn because the clinical demands are less and our F1 mentors have more time to walk us through things. We do encounter some COVID-19 positive patients, who require full PPE. Whilst it takes some getting used to, after a while donning and doffing becomes second nature. I haven’t come accross any shortages yet, although sometimes it can be a pain to try and locate where the masks are on the ward.

I did have a few ‘asked to see patient’ experiences, usually because they are spiking temperatures, showing high clinical warning scores or experiencing pain. In each case its about identifying an underlying cause, treating the underlying cause if possible, and providing symptom relief. The algorithm is relatively straight forward but you have to be comprehensive in your assessment to make sure you don’t miss anything. The PPE makes things difficult, having to fumble around untangling your stethoscope from the plastic apron or resisting the urge to fiddle with your mask. To the patient, you become faceless, so I think it’s important to take time to introduce yourself – first & last name – and try to sound upbeat and optimistic if the setting is appropriate.

Vascular patients are often medically complicated – pathology in the arteries of their legs usually means pathology elsewhere. Their surgery is but one part of their admission, as you attempt to optimise other co-morbid conditions and investigate anything abnormal that hasn’t been picked up previously. In this sense, there is a lot of medical management as well as surgical. Each patient has a complex history, with intricacies that must be managed on an individual basis. Yet as I mentioned previously, it is often the case that these have coalesced leading to one of a discrete number of vascular issues prompting their admission. Part of the job is understanding the causal factors that led to their current health state – and I don’t mean that in an aetiological sense; rather, in the broader biological, psychological and social sense. This is why I think all doctors should have at least some understanding of psychiatry, where the biopsychosocial model is so often emphasised. For instance, “having poorly controlled diabetes” is only a proximate explanation behind someone developing foot ulcers. But you have to ask why: why do they have poorly controlled diabetes, why aren’t they adhering to doctors’ advice, why aren’t they able to make the lifestyle changes they need.

Of course, over the time span of one hospital admission you can only do so much. I’ve begun to appreciate the limitations of hospital medicine. You can resolve an acute issue and you can try and rectify as many of the problems that I mentioned above, but whether your efforts will make any long-lasting difference is difficult to say. The long term prognosis depends far more on their situation at home, their support networks and the care that is available to them than most things you can do in a hospital. Sure, an amputation can save someone’s life – but what happens afterwards? There is rehabilitation, risk factor management, pain control, psychological support – all of which is crucial if you want your intervention to really have benefit. Beyond resolving acute pathologies, it is the social and psychological aspects that have to be right. As a junior doctor, you have a small but crucial part to play in all this because you are often the small cog in the centre that coordinates everything and keeps all the teams talking to each other. You make sure the podiatrist knows what the consultant has done, and that the nurse knows the plan, and the GP surgery is aware of everything that’s happened in hospital. It’s a lot of responsibility, even if its not exactly what you were trained for as a medical student (nor is it what you signed up for when you applied to medical school).

It’s fascinating to me that whilst the ‘final common pathway’ amongst the different patients is so similar – typically foot ulcers or gangrene – the individual driving factors are so diverse. In some cases, it sounds like they’ve just had bad luck.

Thus strangely are our souls constructed, and by slight ligaments are we bound to prosperity and ruin.

Mary Shelley, Frankenstein

It is with admission to hospital that the biggest risk factor for mortality is introduced – there is a risk of ‘decompensation’ after simply being admitted to hospital, aside from the risks of hospital acquired infections, medication errors and the like. Facing significant pressures, hospitals are pressurised to discharge patients as early as possible without addressing ‘long term’ problems in health, assuming that these will be dealt with down the line. The combination of impaired function following hospital admission, together with lingering long term health problems, results in patients who need lots of care on discharge. The hospital and community teams do stellar jobs, don’t get me wrong. But the situation feels unsustainable, especially when district nurses have had their funding cut yet are simultaneously dealing with more and more frail patients.

Of course, when you’re in the thick of it none of this really crosses your mind. When you’re on your shift, you’re thinking about ordering the next CT scan, taking the next set of bloods or who you’re going to ask for advice when you can’t manage the unwell patient. You just plod on. After only one week, the feeling of being a small cog in a much bigger machine is both daunting yet humbling. I tell myself that the difference I make may be small, but it is important. Taking those five minutes to explain something. Stopping and listening. Not being afraid to ask for help or advice. Speaking up if you think something is going wrong.

It isn’t just what you say anymore. It’s what you do.

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