Newbie

 

My first midnight ward round in the intensive care unit, and still pretty inexperienced. The patient in cubicle 4 was deteriorating. His oxygen requirement was maximal, the pressure settings on the ventilator had crept up. His lungs were stiffening, be it due to infection, fluid overload or a tense abdomen… I could not be sure. The last blood gas was dismal.

The nurse in charge, Tom, looked at me expectantly. I looked hard at the ventilator settings, at the squared off curve on the display that signified the depth and duration of each artificial breath. I had no idea. Tom was still looking at me.

“What do you want to do?” he asked.

I scoured my shallow memory for solutions: “Call the consultant, I guess.”

He raised an eyebrow. Wrong answer, clearly. Then I pulled the joker, the card I had used so many times before – as a junior house officer on the wards confronted by a severely agitated patient, as a short-lived infectious disease trainee in the micro lab, on the coronary care unit when presented with an horrific arrhythmia – – –

“So, err… what do you normally do in this situation?”

Translation: Help me out here

Tom whispered, “Do you want to consider a recruitment manoeuvre?”

Yes! The tunnel of my ignorance was illuminated. I considered it with quiet dignity, as though weighing up the pros and cons of this well known if exotic option.

“Err yes… good idea. They use that… here… do they?”

“All the time.”

I nodded. I had a plan.

“Right. Let’s do it.” Firm. Confident.

Tom’s arms were folded. There was no humour in his eyes. This was a serious situation. My hand moved towards the ventilator, slowly, automatically, under obligation rather than conscious control. Its fingers did not know what to do once they reached the control panel. The hand slowed, stretching the moment in time. Was that a smile tugging at the corner of Tom’s usually inscrutable mouth? The reprieve ended.

“And err… what do you usually start with…?”

“Have you done a recruitment manoeuvre before?” asked Tom.

“You inflate the lungs, put up the…”

“The PEEP.”

“Yes, the PEEP. For…”

“A minute.”

“Yeah, right. And PEEP of…”

“Whatever you like.”

“25, 30?”

“40.”

“Yeah, good. Then you…”

“That’s it.”

“Yes, of course. Good. Right, let’s… do you want to do it?”

He shook his head. He did not say it, but the movement was a silent version of ‘You’re the doctor… you do it.’

My finger hovered over the relevant dial. Tom watched. This was his idea. He had seen it done a hundred, perhaps a thousand times. He should be doing this. But this was an intervention. I had to take responsibility for it, I had to deliver it. I dialled up the pressure and pressed the button that kept it raised despite the alarms, forcing the ventilator to inflate those lungs and open up the air-sacs that had become clogged up and useless.

Nothing bad happened. In fact, it worked.

Next morning, I handed over each patient to the newly arrived consultant and the day team. We entered cubicle 4. I explained how the patient had deteriorated.

“And what did you do?” asked the consultant. She was scrutinising the settings, making a quick assessment as to the seriousness of the situation. Tom was not there, he was sorting something else out along the unit.

“Recruitment manoeuvre.”

She looked at me blankly for a moment. God damn it Tom! It was your idea. I knew it, I knew it was dangerous… I remembered now, it had been associated with pneumothoraces, burst lungs… I should have called. The consultant glanced at the last set of blood gases, and nodded.

“Good. Good knowledge.”

We moved onto cubicle 5. My mouth opened to say, ‘Actually it was Tom’s idea…’ but the moment had passed.

Tired and anxious to get home to sleep before the next night shift, I passed Tom on the way out.

“Thanks for the advice Tom?”

He looked surprised. It was nothing. This was a large part of his professional life. Sharing the knowledge of countless shifts with new, green doctors who by virtue of their medical qualifications were permitted to do things to patients even though they barely understood them. He shared that knowledge freely, to the benefit of patients yes, but also to the benefit of those doctors who were destined to move on after a few months, their experience augmented, magpie-like. I wondered what it was like for senior nurses, supervising doctors who if left unattended would fail, but without whom the correct decisions could not be ‘signed off’.

A version of this story occurs every time a trainee doctor enters a new environment. Medical students, take heed!

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