Dr Doctor - how to accidentally save a life.

So this weekend on call has been my last two shifts in Elderly Care as an FY1 and it's been quite a weekend.

Yesterday was a very up and down day. It began sadly, with my first job being to certify a death. I then learned that we had also lost one of my favourite patients the night before, a dear little old lady with end stage renal failure who I'd spent a lot of time on Friday trying to make a little better - she had been vomiting and was feeling rubbish all day.

Apparently she had had a cardiac arrest overnight and the crash team had been called, resuscitated her long enough for her to see her husband to say goodbye. Her last words to him were "it's time to go, my love" before she promptly had another cardiac arrest. Heart wrenching stuff. Most of the medical team were in floods of tears at the time.

So I was feeling kinda sad around lunchtime. Sat myself down to sort out some bloods from a patient I had been reviewing when the crash buzzer went off in Orange Bay. Cue much running of personnel towards the room, including myself. It was only when I got to the patient's bedside and rounded the curtains to find three nurses hauling a very floppy looking patient back into bed from her chair that I realised I was the only doctor.

- Does she have a pulse?
- I dont think so, she just went all unresponsive on me, her BP was really low.

I stepped up to the bedside, frantically observing for signs of respiratory activity and felt for a central pulse. Neither were present!

- Is she for resus?
- Yes I think so.

So I started chest compressions.

- Lets get some oxygen on, can someone find me a defibrillator and stuff for IV access!

Miraculously oxygen, cannulation equipment and numerous extra pairs of hands arrived. Suddenly the Ward Sister rounded the curtains brandishing a DNAR form. While still doing chest compressions I confirmed that it was a form for this patient, and that it had been signed by a consultant.. so with a sinking heart I stopped.

However, the patient appeared to be breathing, and even better, she had a radial pulse!

- Er.. lets stick in an oropharyngeal airway and get some IV access, take bloods and get some fluids going..

At this point the Med Reg appeared - hurrah!

- Er.. so this patient just had a brief loss of output, she is DNAR but she got a few chest compressions from me before we realised that and now she's breathing again.

He smiled and asked for the notes. Repeat obs showed she had a systolic BP of 121 after half a bag of stat gelofusine, and 5 minutes later she was responding appropriately to voice!

I half thought she might pass away overnight, but was delighted this morning to find her sat up in bed, eating breakfast heartily and complaining to anyone who would listen about how her husband had had to go have a lie down the previous afternoon (not surprising given that all this kicked off at the start of visiting hours!).

She had no recollection of the event, and was very surprised to hear that "the doctor had to press on your chest to get your heart going again".

Dr Doctor "CARDIAC ARREST"

One of the other perks of MAU Nights is that you carry the crash bleep. It only went off twice this weekend.

The night before last we had been sat drinking tea in the mess (I had seized the opportunity after my haematemesis man went to theatre) and had to run to the other side of the hospital (made considerably easier by the fact it was 330am and the corridors were empty). Arrived somewhat out of breath to find one of the surgical patients being subjected to CPR and the usual accompanying flurry of activity. She was in asystole and the ITU and medical registrars made the decision to stop fairly soon after we arrived. Later found out that she had been due to go to theatre for an emergency laparotomy to relieve a probable bowel obstruction but had been sent back to the ward because our haematemesis man was prioritised ahead of her. Chances are had she made it to theatre she would have arrested on induction or on the table and would have died anyway, but had mixed feelings about it.

Last night the crash bleep went off at 630am and I had to run all the way to the same surgical ward (up several flights of stairs). This time I was running on my own and received a few strange looks from porters and cleaners on the way. Arrived to find two nurses performing CPR with rather poor technique, and noted that the one holding the airway had the facemask on the patient upside down! Rectified this and popped in an oropharyngeal airway then took over chest compressions as the med reg arrived. Patient was in pulseless electrical activity and we managed to get a pulse back on him which was a good feeling. Dont know the outcome as I returned to MAU before he was taken for a scan/to ITU.

Sat down to update the handover list near the end of the shift, somewhat tired by this point, and the healthcare assistant (HCA) next to me who was labelling some swabs said:

- How do you spell 'froat'?
- 'Froat'? Do you mean throat?
- Yeah froat.
- Er.. T-H-R-O-A-T.
- Fanks.

Dr Doctor - MAU Nights

I have once again been thrown in at the deep end, starting my placement in MAU on nights. I'm currently unsure what day it is. Having never done nights before this was all very new.  Main concern was how on earth I was going to manage to stay awake for 12 hours in the busiest department in the hospital and practise medicine to a reasonable standard on all the really quite unwell GP and A&E admissions.

Strategy for first night shift was to wake up mid morning, do lots of exercise to knacker myself out and then sleep for a few hours in the afternoon.

8pm handover resulted in me being assigned an entire bay of 10 patients to look after, and to clerk, treat and triage any new admissions to that bay. I also got handed an SHO bleep, and a crash bleep.

Patients in my bay included a paracetamol overdose (check levels, continue acetylcysteine), a young diabetic ketoacidosis (repeat blood gas, monitor blood glucose, continue fluids and insulin), a seizure ?cause (check bloods, arrange urgent CT and report), 2 young patients with severe community acquired pneumonia (for IV antibiotics), a tall thin young man with a pneumothorax (chest drain in situ) and one chap with terminal cholangiocarcinoma presenting with gastric outflow obstruction, vomiting and hypovolaemic shock (arrange erect CXR and AXR, NG tube on free drainage, antiemetics, fluid resuscitation, keep seniors well informed).

We also had three confused gentlemen, one of whom escaped from his bed around 2 am and, gown flapping the breeze, buttocks defiantly on show to the ward, pulled back the curtains of his neighbour and proceeded to relieve himself thankfully beside his bed and not onto him! "OI!! He's pissing at me! Bastard! NURSE!"

Around 3pm our bright eyed and enthusiastic Med Reg insisted on giving all the juniors a formal powerpoint tutorial on upper GI bleeding. Thought it was a nice touch that he made us all a big pot of tea to drink while we sat and tried to stay awake while he talked about the most recent papers in the field.

Around 6am the crash bleep went off so the Med Reg and I ran across the hospital and up three flights of stairs to find a proper cardiac arrest in full swing on one of the surgical wards. I joined in with chest compressions. The patient was in VF and was shocked 5 times before going into asystole. Resus continued and somehow he went back into sinus rhythm with an output. This was short lived however as he then went into VT. 7 shocks, many antiarrhythmics and some potassium later his heart decided to stay in sinus rhythm and the patient went to ITU. Apparently an echo showed a massive ventricular aneurysm, probably secondary to a huge heart attack, so sadly he probably wont recover from this.

8am handover involved presenting the sickest patients to the day team and then home to bed. All in all a good first night.