Fate night

fatenight

Here is a tale that examines medical motivation, duty, sacrifice and the source of a doctor’s job satisfaction. It is inspired by a number of experiences, but the medical scenario is fictional.

An intravenous drug user, Sally, is transferred to the ward from Casualty. The ward doctor, Elaine, reads the notes: ‘diagnosis – sepsis, ?source.’ Antibiotics have been prescribed, the chest x-ray is said to be normal (Elaine is not so sure when she looks at it), the urine is clear, and there are no obvious signs of heart valve infection. It’s 4.30pm, and although Elaine shouldn’t really have to re-examine Sally so soon after the transfer, she does, just to make sure she’s alright. And she is definitely not alright. She looks nothing like the patient described by the nurse who provided the handover. Sally is drowsy, her heart is racing, she seems breathless. Elaine calls her registrar for advice, but he is stuck in clinic. Elaine works through the problem, and wonders whether one of Sally’s heart valves is infected after all. It is common for bacteria to travel through the veins into which heroine is injected, up to the heart, where they can settle and multiply, eating into the fragile leaflets of tissue.

What Elaine doesn’t mention to the registrar is that she has a date with her boyfriend tonight. It’s her anniversary, and they have a table booked for 8pm.

Elaine spends the next hour trying to correct Sally’s sagging blood pressure by prescribing fluids, then correcting her low oxygen levels by turning up the oxygen supply. She calls a cardiologist, and she agrees that an echocardiogram is indicated urgently. She, the cardiologist, is happy to do it after her clinic, probably around 6.15pm.

“Should I move her to intensive care?” asks Elaine.

“Get them to review her, but at the moment we don’t know which way she is going – it could still just be a bad urine infection after all, she might pick up later.”

Elaine calls intensive care and the outreach team give their assessment – the patient does not yet require transfer, await the result of the echo.

The echocardiogram, performed at 6.45pm, proves that one of the heart valves is leaking badly. It doesn’t identify a vegetation (a lump of bacteria sitting on the valve), but given the context of sepsis and drug use, it’s a fair bet that Sally has endocarditis.

“Is she worse now compared to when she came in?” asks the cardiologist.

“I guess so, because they didn’t tell us she looked this sick when they arranged the transfer to the ward. What’s going to happen now?”

“It depends. If the antibiotics don’t stabilise the situation and the valve continues to be destroyed, she may need a valve replacement.”

“As an emergency.”

“Errr yes. Don’t you think!” The tone is sarcastic. Elaine shuts up for a minute. She hasn’t seen this before. She watches as the cardiologist packs up the echo machine, then asks,

“What now then? Do you want me to do anything?”

“Well I think she needs to be in intensive care. Can you get them back, tell them what the diagnosis is…I’ll call the consultant myself when I’ve put this machine away.” It’s 7.15. Elaine texts her boyfriend.

The intensive care team agree that Sally needs to come round, but the bed is not yet ready. It will be another 2 hours. But the transfer is precautionary, she won’t come to harm from the delay

“She needs a central line.” says the registrar, “I can do it now-ish, before she goes round. I’ll do it in theatres. I’ve got another urgent review to do first…can you go to theatres and book it in?” Elaine nods, and hesitates by the door of the ward. This seems a good time to hand over to the late team. As she begins to bleep the on-call SHO a nurse runs up to her,

“She’s unrousable. I think it might be the Heroine, but she can’t have had any here. Her pupils are tiny. Can you see her?” Elaine hurries to Sally’s bed, and agrees. She asks for some Naloxone, the antidote to Heroine. The drug perks her up. But the underlying problem, the valve, is unchanged. A phone goes off, a nurse answers,

“Elaine, it’s theatres, they’re ready for the central line but you need to book it in before they call for the patient…”

Elaine hurries to theatres. She meets her registrar in the corridor. He asks what’s happening, and Elaine explains everything. Then, at then end, she says,

“I’m really sorry to throw this in…but I’ve got to get away for something.”

“When?”

“Well, half an hour ago.”

“What still needs to be done?”

“Booking this central line in, and handing over.”

“Look, I’ll book it in, you hand over, then go. Intensive care will take it form there.”

Elaine is on the phone to the on-call doctor when her bleep goes off.

“Give us a minute, I’ll call you back on your extension.” she says to the on-call, then answers the bleep. It’s the intensive care registrar,

“You didn’t tell me her clotting was all off. She needs fresh frozen plasma, or I can’t do this central line. Can you organise it…right now?” And he hangs up. There is no conversation. Elaine gets back to the on-call, but the on-call is desperate to get back to a case in the resuscitation bay. Elaine must order the blood herself. She glances at her watch – it’s 7.55pm. She blinks back a tear. It was an important night…that’s all. It takes fifteen minutes to organise plasma. Then she prepares, finally, to go. A nurse approaches. Elaine avoids eye contact, but it’s absurd, she knows the nurse, and knows what it is about.

“Elaine….Sally’s sister has just arrived.”

“OK. OK. Give me a minute.”

Elaine calls her boyfriend. He is in the restaurant. Elaine reckons on fifteen minutes with the sister, to explain everything, then another forty to get to the restaurant. The evening is not yet finished.

Sally’s sister tells Elaine that there are two children, one in care, one still at home. She places a photo of the younger child on the bedside cabinet. Elaine looks at it, and wonders why someone so innocent, this two year old girl, should lose a mother to such a disease, a complication of addiction. Elaine feels a surge of warmth towards Sally, and chastises herself for worrying so much about her own concerns, the petty matters of her comfortable life. But still, it would be nice to get out of here now.

The handover is complete. The last remaining ties to the hospital, to Sally, are severed. Elaine has her coat on. It is 8.40pm. Her bleep goes off again, but it’s an outside line – ‘friendly fire’ as they say. Only friends and family, in general, know what name or bleep number to ask for through the switchboard.

“Hi, it’s Elaine!” she says, when the phone connection has been made.

“Ah, hello there. My name is David Banbury. I’m the cardiothoracic registrar on call at St. Thomas’s. We had a call from one of your cardiologists earlier to say there may be a patient who needs an emergency transfer. Can you give me an update?”

“Well, she’s going to intensive care.”

“I know. But I need to know how she is now, so we can arrange to get her over before she collapses completely. What’s her BP, pulse, renal function…What’s the history?”

“I…I don’t know all that.”

“Well can you find out?”

“…”

“Hello?”

“Yes. I can find out. How can I get hold of you?”

“I’ll give you my mobile. Are you on call?”

“No. I’ve stayed late.”

“Well I’m sorry. But this patient has one chance, and a small one at that if what I have heard so far is true. You seem to be the only doctor around who knows anything about her. Your cardiologist wasn’t even sure of the name!”

Ninety minutes later Elaine drive straight home. Her boyfriend has called to say he is leaving the restaurant, and he is waiting for her as she comes through the front door of their flat. She explains, he listens, as he always does. He understands why it was so important that she stayed, but makes the point that this evening was their third attempt to eat out together. The anniversary had actually been six weeks ago.

“It won’t always be like this.” says Elaine. He nods, but the look in his eyes suggests to her that we isn’t so sure…about anything.

“Well I hope she’s grateful.” is all he can add.

6 weeks later.

Sally is transferred back from the cardiothoracic unit. Her stay there has been a rocky one. Before the valve operation she arrested twice, and she remained on their intensive care unit for four weeks with complications, chest drains, resistant organisms, the lot. But now she is back. And not only that, she has been sent back to Elaine’s ward. She needs a side room because of the multi-resistant bacteria that now reside on her skin. Elaine is actually quite excited. She knows that she played an important role in Sally’s management…not crucial, not technical, not heroic, but important. She helped bring the major decision makers together on the night in question, and her clear reports, her calm referrals, ensured that the clinical scenario was accurately communicated and acted upon.

“Hello Sally.” says Elaine, on the ward round.

“Who are you?” asks Sally.

“Elaine, one of your doctors.”

“Well doctor, can you sort this f****** place out, they said I could have a telly in here but I still haven’t got one…”

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4 comments

  1. Good blog, Phil; however I wonder where the consultant was in this story? If I were the consultant responsible for this patient I would have been very unhappy to learn that she had been referred to another speciality team, ICU and a regional centre without my direct involvement. There is often a surprising degree of reluctance amongst junior and middle grade medical staff to involve consultants in the care of patients outside of ‘normal’ working hours. Junior doctors need to be properly supported by those with overall responsibility for patient care. We must not perpetuate the myth that ‘calling the boss’ reflects a failure on the part of the junior doctor.

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    1. Thanks Chris, this scenario does beg the question – what about the consultant? I see arguments on both sides for the consultant in charge of the patient to be there advising and helping Elaine, but the most honest way to answer it is to ask myself ‘what would I have done if I had been told about this situation at 6.30pm, on the way home?’ and I think the answer is – if I was reassured that the patient was being managed appropriately, and that Elaine was able to cope, I would not see a compelling reason to turn around and come back. It sounds mean, but that’s probably the truth.

      This raises good questions about the role of the consultant. Is it to coordinate care, delegate efficiently and ‘manage’ the patient in a way that ensures safety, or to provide direct care and hands on support to trainees, including encouragement and reasurrance? The latter require physical presence, a willingness to muck in, and an acceptance that emergency situations may require extended working hours on a regular basis. It’s a balance, but in the current era of directly delivered consultant care, most have no qualms about rolling their sleeves up. It’s often the most enjoyable part of the job! Why then would I not have turned the car round to help Elaine?

      There are several reasons:

      1) Out of hours (assuming I wasn’t on call) I would need to know that my presence was actually needed for patient safety or clear clinical reasons.

      2) Part of being a trainer is to allow trainees to experience the stress of managing an ill patient on their own, as long as they can escalate and recieve help when they need it. Knowing when it’s OK to allow a trainee to do this is part of the trainer’s skill. They must be able to ensure an environment of ‘controlled risk’.

      3) What about her date? Knowing that she was late for an anniversary meal probably wouldn’t have led to me returning either…how mean is that!? I might have suggested she contact the on-call team to hand over more assertively. After all, in a 24 hour service it should be possible to hand over a sick patient even part of you feels duty-bound to see the job through to the end.

      Thanks for the comment Chris, it’s a really important point.

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  2. Interesting point. As an St3 in Elderly Medicine who has been doing MedReg shifts since 2008 (acting up early and a PhD), there’s a number of reasons why I’ll pick up the phone. I’m aware I call more than average and I am not sure if this is an issue. In this case there was no question about what the correct treatment was, nor whether it was appropriate to give the patient such treatment, so whilst the consultant should be informed, I would not have thought it would have made a great deal of difference and I wouldn’t have expected them to come back in.

    Firstly because I don’t know the best way to treat a patient and need advice. This is probably the rarest reason for ringing The Boss. This is fairly rare with general medical patients, but certainly more common when covering another specialties patients particularly at a teaching hospital. The last time I did so was when I was asked to review a post natal patient with an unusual endocrine presentation and the medical consultant was an endocrinologist.

    Secondly when I want to have advice on the appropriateness of treatment and whether escalation to ITU is appropriate. I’m always acutely consciousness that the consultant is responsible for this decision, not me, which is something I’m not sure that all other registrars take on board.

    Thirdly when there has been a disagreement about care, and I want to ensure that the consultant (who is ultimately responsible) is comfortable with the way I’ve handled the situation.

    Fourthly when there’s a policy that the consultant has to be called before ‘X’ happens, this can be a CT scan or transfer to ITU/another hospital. So you end up making calls to inform consultants of straightforward decisions on sick people e.g. ‘This previously healthy young man with a severe pneumonia has a pO2 of 6 with 15L of oxygen, there’s been a medical emergency call, ITU reg is is here and thinks they need intubation, do you agree we should transfer him to ITU?’. I think that the case you describe matches this situation quite well.

    And fifthly I sometimes ring for selfish reasons, because I am anxious about a decision and I know that if I discuss it then it isn’t my responsibly and I don’t have to worry. This is a new thing, and I never used to do it before going out to do research. Since returning from research I’m struggling with semi-pathological anxiety about my own decisions, and I often find my weekends totally ruined by ‘stewing’ over a decision I made on Friday. I’m recognizing that this is an issue and trying to take steps. But I know that a 5 minute phone call on a Friday at 6 will save me having a weekend of doing nothing but worrying about a decision. (If you have any tips that would be great!, but I probably need to discuss this with The Boss).

    Like

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