A series of unfortunate events: A weekend of night shifts

10th-12th March 2020

Act I: Friday and Saturday

A weekend of night shifts. Night shifts are a curious adventure. The mundane jobs are removed and often you are dealing with the sickest patients in the hospital. For this you need to be wide awake and ready for anything.

I arrive on Friday evening quite nervous as I had not yet done night shifts in my current hospital. I was not sure what to expect. I am greeted by a large team of staff including ten doctors, four advanced nurse practitioners and one clinical support worker. Five doctors are designated for the coronavirus wards which now span the entirety of the upper hospital floor from ward 202-220. The remaining five doctors, including me, are assigned to look after the remaining wards. I am assigned five wards, housing some of South East Scotland’s sickest surgical and medical patients. That’s approximately 150 patients. No small feat.

I sign into the shift, grab a radio and a pager, and nervously take a seat amongst my colleagues. I recognise no one. We start by taking a handover of the wards’ sickest patients and note any outstanding jobs between 2100-2200 before heading off to complete our jobs and review patients. I quickly take a few minutes to introduce myself to the rest of the team. They’re a friendly bunch and I am grateful for the wealth of senior support on for the weekend.

Friday and Saturday night go without too many hiccups. A few sick patients to review and a few paperwork jobs. I even get a chance to take a nap during the early hours of the morning on Saturday.

Act II, Scene I: Sunday, Patient I

Sunday however was amongst the hardest shifts I have undertaken during my time as a doctor. Three severely unwell patients took up my entire night. The first patient that I was called to see had reduced blood-oxygen saturations and an increased respiratory rate. The patient could only give me a limited history, in part due to breathlessness and communication difficulties. My examination yielded some crackles in the lungs and I suspected that the patient was severely dehydrated. I increased the patient’s oxygen, gained IV access, took some bloods and prescribed IV fluids for the dehydration. With my initial management underway, I had some space to think. I suspected a chest infection so I ordered a chest x-ray for the patient and called my senior to get some advice. He suggested starting the patient on IV antibiotics for a hospital-acquired pneumonia. I was happy that the patient was now stable and on appropriate treatment.

Act II, Scene II: Sunday, Patient II

During the course of seeing the first patient I had been called twice to remind me that there was a patient on the next ward over who was also unwell and needed to be seen. After spending 90 stressful minutes with the first patient I headed straight away to see the second unwell patient of the night. The patient had been transferred from intensive care back to the ward earlier that day. When I entered onto the ward there were two nurses standing worriedly by a side room. I guessed that this was the location of my next patient. I quickly donned the personal protective equipment that was now mandatory to wear every time anyone entered a clinical area – apron, gloves and surgical face mask.

When I entered the patient’s room I was instantly aware of why the nurses seemed so worried. The patient looked terrible. After six years of medical school and eight months of working as a doctor you know actually very little about medicine. However, one of the things you are trained to do is recognise unwell patients. The subconscious recognition is called clinical gestalt; it is simply clinical intuition formed from a gut feeling. That immediate instinct is an important factor for consideration for all doctors in stressful scenarios. My instant judgement was that this patient was deeply unwell and perhaps even required care in a high dependency unit once again.

The patient was sat bolt upright in the bed breathing heavily. They looked sweaty and slightly drowsy. Given the patient’s high temperature, fast respiratory rate and heart rate, I guessed that they were septic. I had to work quickly and with purpose. I ramped up the oxygen until blood-oxygen saturations were sufficient. Then I moved onto taking a basic history whilst I performed an initial systematic examination of the patient. Once again, I suspected a serious chest infection. I asked the nurses to take routine blood tests from the patient’s existing central line, a tube that is inserted into one of the large neck veins that can be used to take blood samples and give medications. I called my senior and explained the dire situation. He was aware of the patient and agreed that he would come soon to see the patient.

Not more than five minutes later the medical registrar, my senior colleague, arrived to review the patient. I was hugely relieved by the rapid response and support from my colleagues. The medical registrar assessed the patient before offering some suggestions on additional investigations including an arterial blood gas. This painful and tricky procedure involves taking a blood sample from the radial artery in the wrist but provides a wealth of information about the patient’s metabolic state and how well their lungs are working. The results were ominous. The patient was poorly oxygenated and was retaining carbon dioxide causing a build-up of acidic chemicals in the blood. After a call with the critical care team, the registrar informed me that the patient was to be moved to a high dependency unit for monitoring. This came as a huge relief as I suspected the patient would have continued to deteriorate on the ward without more intensive treatment and monitoring.

Act II: Sunday, an interlude

It was now after 0100 and I used a small break in my jobs to check on my first patient. I reviewed their blood tests and chest x-ray, which showed a worrying pattern of a raised lactate level, a high white blood cell count and hazy opacification in both lungs. The pattern was suggestive for COVID-19 infection. I called my senior who agreed that coronavirus infection was a possibility. I asked the nurses to speed up the infusion rate of the IV fluids given the patient’s dehydrated state and to treat the patient as a suspected COVID-19 infection.

Act II, Scene III: Sunday, Patient III

It was now 0200 and I had not had a break since the start of my shift. I used the moment of quiet to go to the night staff office and to have some food and rehydrate. Around 0230, the nurse who was coordinating medical jobs requested that I see a patient with a body temperature of 33C. “It’s probably nothing”, she said. Unfortunately, this was far from the truth…

When I arrived to the ward, recharged from my break, I found the patient on continuous monitoring and extremely short of breath. Their breathing was laboured and they looked extremely unwell. A nurse was by the patient’s bedside wrapping them tightly in blankets. They were slightly cold at their hands and feet but had a strong pulse, which was reassuring. I requested a Bair Hugger for the patient, a plastic blanket that expels warm air to help patients in surgery to maintain their core body temperature. I tried to talk to the patient but they were agitated, confused and highly distressed. They continuously fought to pull off the oxygen mask and monitoring equipment. I was upset to see the patient so distressed, but I got on with rapidly assessing the patient, gaining IV access, taking blood tests and administering controlled oxygen therapy and IV fluids.

The Bair Hugger arrived and I worked with the nurse to set up the heating device to warm the patient. I then called my senior colleague, once again, for his advice. After carrying out his suggestions I went to reassess the patient. When I arrived back to see the patient, I saw that their blood pressure had now dropped to 70/50. I went to feel the pulse and could barely feel the rapid, thready beat at the wrist. Shit.

I had two options, dial 2222 and put out an emergency peri-arrest call which would summon the entire night team of doctors in the hospital, or call the medical registrar and ask him to come and assess the patient immediately. I chose the latter option. I am deeply conflicted by my choice in that moment. It would have been appropriate to put out the peri-arrest call. However, I feared being wrong regarding the patient’s situation thus inappropriately summoning a team of doctors, pulling them away from their own sick patients. My gestalt, that gut feeling, said that this patient might die and needed urgent help, however I wasn’t brave enough to make the arrest call. I now recognise that in these moments I must have the courage to make a big call for the sake of the patient. I will learn from this moment.

The medical registrar arrived within minutes. As he assessed the patient I could tell that he too was worried; I could sense it from the grim expression on his face and the despairing tone in his voice. He checked the patient’s paperwork to confirm that there was a Do Not Resuscitate order in place, a form that states that cardio-pulmonary resuscitation (CPR) would likely be futile in this patient, and inflict significant and life-threatening damage even if successful. He offered his opinion that the patient was likely at the end of life and suggested to the nursing team that he be moved into a side room and to focus on keeping the patient comfortable. He prescribed medications to help ease the patient’s agitation and left to type up the notes. I felt despair. Could I have acted sooner? Would it have changed his outcome? No, but I felt a sense of regret and sadness regarding the outcome of the situation.

I made sure the patient was comfortable and less agitated before heading to the night office for a quiet and reflective moment. I think the staff could tell that I was upset. I had been away for several hours on a task that was initially assumed by my colleagues to be a simple one. A kind member of the team asked if I was okay and what had happened. I expressed that I was upset about the situation and that it was a tough night. I started to recount the events of the past few hours, when another staff member interjected, “Why did you use a Bair Hugger?” I explained that I thought it was clinically appropriate given that the patient was hypothermic and distressed. He continued to press me, explaining that I was wrong to use the warming equipment. “You’re just warming up a dead man”, he stated. He continued to argue his point with a series of insensitive and crass comments. I chose to end the debate and leave the room.

I visited a friend working in a different department. She kindly offered me a cup of tea and a space to vent about the situation. My despair had turned to anger. How could he be so challenging about the situation? Healthcare is supposed to be a caring industry, a vocation founded on compassion and kindness.

At around 0600 I went to check on my terminally ill patient. They were settled now in their new side room. I spoke with the nurses who informed me that the patient’s next of kin, their sister, was imminently arriving on the ward. I called the medical registrar to update him and suggested that I would like to speak with the patient’s sister to inform her of the patient’s deterioration overnight. The registrar offered his support by coming up to sit with me as I took on the sensitive consultation. The consultation took around half an hour. It was a difficult discussion but I am glad I did it. It was comforting for me to be able to provide support for the patient’s family that morning. I found the discussion to be deeply rewarding and gave me a sense of closure on an otherwise difficult situation.

Act III: A time for reflection

Medicine can be a challenging career. There are difficult moments to the job: dealing with sick and dying patients, upsetting encounters with patients and staff, the continual worry of making the wrong decision, and the effect this might have on patient wellbeing. In these moments of stress, it is easy to forget the great points about being a doctor. However, there are many great aspects to being a doctor: being involved in a team, caring for people at vulnerable moments in their lives, and opportunities for continual learning.

One of the benefits of my blogging experience has been to write about both the highs and the lows of the job. I have found it to be cathartic, and it allows for reflection to develop my clinical practice. The challenging aspects are hard in the moment but can be useful to reflect upon, an opportunity for personal growth. Reflection, whether it be talking with a colleague or writing in a diary or blog, is an important tool for coming to terms with difficult days like Sunday. It keeps us sane, healthy and reminds us why we do the things we do. We do it for patients and we do it because we care.

Fin.

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• How to get tested for COVID: Our household’s story
• Protecting healthcare workers during a pandemic: How are need to do more to protect those at the frontlines