Trial By Fire
I.I.III
TRIAL BY FIRE
I was one of the lucky few to have my first on-call shift at the end of the week. This way, I had a glimpse of what I could expect from fellow colleagues who recounted their tales.
Judging from what I had heard, I should’ve been scared crapless before my first one. Some had to deal with patients on the verge of dying all on their own. Others were called in to review stable patients who were anything but. One had to perform cardiopulmonary resuscitation (CPR) on seven patients during one shift. Another declared some five patients dead. The next was attacked by a psychotic junkie. As different as their experiences might have been, there were three commonalities to all – they were all thrown in the deep end, they were all clueless, and they all needed help.
Despite that, what they did next seemed to shape what kind of doctors they’d become. Some found it too easy to ask for help – even when not entirely required. Some were too cocky or proud to ask for it. The rest? They assessed the situation and their skillsets, and went from there. I, for one, wanted to be part of the latter. Not too reliant on my colleagues and seniors, not too laissez-faire either. When faced with a difficult scenario, I’d stop, breathe, and think. Then, if I considered myself out of my depth, I’d call.
As confident as I felt about my approach, I can’t say I wasn’t at least a little nervous about my first night shift. You see, after 2PM, a group of some thirteen house officer are left to tend to the needs of an entire hospital – with some twenty wards full of needy patients. Of course, there’d be more qualified personnel on call – some on the premises taking care of acute issues, some off-site taking calls and coming in when need be. A hospital stripped down to skeleton staff – its function reduced to a seemingly bare minimum. Us lowly junior doctors would be the nexus between patients and doctors who actually knew what they were doing.
I can’t say this wasn’t the least bit disconcerting. Suddenly, finding myself stranded with twelve other clueless medics, I started to realise how comforting my seniors’ presence was during day shifts. Despite my reluctance to call on them and annoy them with endless questions, they were always there to guide me. Needless to say, we could still do that – but now we’d be consulting doctors we didn’t know from Adam about patients we didn’t know from Eve.
And finally, it was time. Much like a pig on its way to its slaughter, the second my day shift was over I made my way to the Doctors’ Quarters – victualled with a bag containing a change of clothes, food, and toiletries. Kinda felt like going on a weekend break – only my outfit involved a second pair of scrubs, and the room was a tiny, stuffy shoebox I’d be sharing with a colleague, the ensuite reeking of mould and ammonia.
Whilst the morning hours are usually unproblematic given that day staff are managing their own patients, it’s the afternoon when all hell breaks loose. Luckily, we had enough time for lunch. Also some time to chill and hang out, making idle chit-chat while trying to get our minds off our impending predicament. After an hour or two, we even began to doze off. We figured the hospital switchboard had our pager numbers wrong, or that maybe it was a slow and quiet day, or that on-call shifts weren’t really that bad.
But If there’s one rule that’s ubiquitous in hospitals, it’s that you never say the S word. Or the Q word, for that matter. The second you utter those syllables, crap hits the fan. As it did in my case. “ROMPO-POMPO-POM-POM” went my pager – my heart pounding in my throat as my eyes dropped to the floor. It was time. I had to get off my ass. I had to be a doctor. And, worst of all, I had to be a doctor who knew what he was doing. I called the ward. “Hi, I’m the doctor on call, you paged?” I whispered, gulping and clearing my throat. “Hi, yes doc, we have some bloods for you to take…”
Phew. My first call was a simple one – the commonest request junior officers have to deal with on most on-call shifts. Easy enough. That said, I can’t say I was too elated about bloodletting. So far, I had tried it a few times and still struggled. Whilst in most hospitals it’s usually nurses who take bloods, here in Malta this job falls to junior doctors during on-call shifts. During the day, we’d have phlebotomists doing our dirty work. But after that? it was all on us.
With that, I made my way to the ward, which happened to be on the other side of the hospital. And, with the hospital being a huge one, it made for quite the exercise – especially when you have to cross it a hundred times over during one shift. I guess that’s one way to get your 20,000 steps in, huh?
The second I entered the ward, I was welcomed by a nurse who told me I needed to take some routine post-op bloods from a patient. All disoriented, never having entered that ward before, I had to have her guide me and show me around. With everything set up by the patient’s bedside, I introduced myself to the patient and told her it’d be a simple procedure – all the while nearly wetting my pants.
I strapped the tourniquet around her arm and had her pump her fist. A massive vein popped up in her cubital fossa – my sigh of relief probably not the most comforting of signs. I then unsheathed the needle and, without thinking much about it, jammed it straight into the bulging vein. Just like that, I had backflow – I was in. I connected the vacuum containers (vacutainers) to the tubing around the needle and found myself elated as I watched them fill up on my first attempt. All ready to go and revelling in my newfound confidence, I removed the needle before taking off the tourniquet – prompting a gush of warm, red fluid onto my scrubs. Rookie mistake. Nothing a band-aid and a few kilos of napkins didn’t solve, though.
As we both laughed it off and I was ready to make my way back, the same nurse called me back. Turns out she also needed a cannula on another one of her patients. Now this I was afraid of. I sucked at cannulation – big time. And, as fate would have it, the patient in question was grotesquely obese, her veins hidden under mounds of fat. I tried my best to get one to pop out – tourniquet, hanging her hand down low, having her pump her fist, slapping the dorsum, applying alcohol. Nothing. I could see the tiniest speck of blue on her forearm. I grabbed the smallest cannula and went for it. I got backflow. Then I pushed the needle a bit too much and suddenly, her forearm turned purple.
“CRAP!” I yelled to myself, undoing the tourniquet and applying pressure with gauze. “Crap, crap, crap! What do I do now?!” I chastised myself. By this point, the same nurse could see my panic-stricken face. She turned to the patient and said, “You’ve always been a difficult one – but we’ll manage!” At that, the patient gave me her best smile and flung out her other arm. It was basically a rehash of the first. Then a third attempt. Then I conceded defeat. I called a colleague with more experience, and she got it on her first try.
After my walk of shame back to the Doctors’ Quarters, I couldn’t help but feel defeated. But, as quickly became evident, one’s feelings don’t really matter when you’re covering the entire hospital and getting one call after another.
Next up were a few simple tasks – prescribing some pain relief (god bless paracetamol) and dosing warfarin (god bless guidelines) for some patients. Then there were those requiring more input – like a hypertensive patient (god bless amlodipine) and a hyperglycaemic one (god bless fast-acting insulin). And just like that, the first part of my shift was over and I could afford to rest a bit and ruminate on how things had gone.
I was managing so far. It wasn’t all too bad. Sure, I was still dejected about cannulation and worn out from running around the hospital, but all in all, it wasn’t too bad. My roommate and colleague’s shift wasn’t any easier. Sitting down and talking about it made us both feel a bit better – sharing how insecure and uncertain we felt about our management despite having followed protocol and done our best. I kept calling the wards to make sure my treatment was right – the patient’s pain had improved, the other’s blood pressure had normalised, and the other’s blood glucose had come down. Small things, sure, but they were wins in my book.
These were the things I’d have to live with from then on. The insecurities and uncertainties that come with the job. Not knowing whether you made the right choice. Not knowing whether things would work out. Not knowing what to do if they didn’t. There is no such thing as certainty in medicine – that I quickly found out. It’s the ability to do your best and follow up that matters. You prescribe a drug based on your knowledge, that of your colleagues, or according to guidelines, and you hope it has the desired effect. If it doesn’t, you reassess and reevaluate. The problem, I figured, is when you don’t have time to do so. What then? That’s where good handover comes in. To safety-net. For your sake and the patient’s.
Then there was the need to ground myself. I had made some good decisions and the patients were better off. But I knew things could turn at any moment. That’s where humility comes in. I knew my limits. I took risks, yes, but they were small ones and of little consequence – all backed up by my peers and nurses alike. I could make out the fine line between confidence and overconfidence. When I prescribed my first paracetamol, I went nuts combing through the patient’s notes for contraindications, then asked the nurses if that was okay – knowing full well they’d been doing this for years and ultimately knew the patients far better than I did. I was just a passerby, stamping my name on prescriptions I’d probably forget by the end of the shift.
And so, when it was time to start my the next part of my shift, I felt a strange sense of relief. I’d made peace with my insecurity and uncertainty – knowing they’d probably follow me through every on-call. And so they did.
Like when I prescribed fluids for a hypotensive patient with acute kidney injury despite her having congestive heart failure and being overloaded. Or when I signed off an ECG as normal despite the patient complaining of chest pain. Or when I refused a head CT for an elderly man who fell and hit his head because there were no indications – much to the nurses’ disapproval. Or when I withheld antibiotics from a patient with a cough whose bloodwork was normal. Automatically, there’s this risk-benefit assessment running through your head. And when the balance doesn’t tip either way but hovers in the middle, there’s always one solution – consult.
It was during these moments that I had to buck up and ‘bother’ my seniors. As lowly house officers, we make such a big deal about bothering them that some would rather forge ahead alone and do whatever they think is best. I had a different philosophy. They were here to work. They were being paid to do their job. And if I needed their help to manage a patient, they damn well had to comply – not for my sake, but for my patient’s. Sure, some calls are stupid and unwarranted. But it’s better to voice concern than live with doubt and fear of having harmed someone. Or at least, that’s what I figured.
By my second break, I was a complete mess – hungry, thirsty, exhausted, drained, and ready for bed. We headed to the Doctors’ Quarters and ordered takeout, chatting about how everything had gone. Some were fine, others knocked out, all riddled with anxiety. By the time my food arrived, I was already being paged.
More bloods to take, ECGs to review, prescriptions to write, scans to check. Until I got a call I wasn’t expecting: “Doc, we have a patient for you to certify…” Certify what? It didn’t take long to realise what that meant. The moment I entered the ward, I felt the tension in the air. As if someone had died. Scratch that – exactly because someone had. I stepped into the room where a yellow, unmoving body lay, surrounded by family. Without a word, they parted to make space. He was in his seventies, shrivelled, wrinkled, toothless, his body twisted by contractures. His eyes were glassy and unblinking, his mouth wide open. “Is he… you know?” his wife asked. “I’ll have to check,” I whispered. I felt for a pulse, listened for breath and heart sounds, checked reflexes, then nodded gravely. “Unfortunately, yes. He passed away.”
He had pancreatic cancer – one of the most painful cancers to endure. In a strange way, this spared him further suffering. Or at least that’s what I told myself. Conjecture. A story to soften the blow. I asked if they had any questions, bowed my head, and left, their sobs echoing behind me. It’s funny how I had no idea who they were, yet I’d just given them the worst news of their lives. Funny how I did it with no training. Funny how I had no time to process it because I was paged while certifying him dead. Another IV line needed inserting.
The next patient was an old, semi-comatose man with veins the size of Texas – the perfect practice subject for my cannulation training – as inhumane as that sounds. I gathered myself. Stop. Breathe. Think. I sanitised my hands, donned gloves, prepared saline, applied the tourniquet, disinfected the skin, and opened the cannula. The vein popped up. I tethered the skin and advanced the needle. The second I saw backflow, I stopped. I was in. I retracted the needle while advancing the plastic cannula, blood spurting briefly before I capped it. Then I applied the dressing and just like that, I had managed my first cannula. Simple and easy.
You can imagine my sense of victory. To the nurse, it was nothing. Cannulae are sited by the hundreds every day. But to me, it was everything. Maybe I wasn’t so hopeless after all.
Back at the Doctors’ Quarters, I finally had a moment for myself. I went out onto the balcony and lit a cigarette. There, all alone, I looked out at the brightly lit skyscape – a view I’d come to cherish on nights like these.
At the break of dawn, I’d have to wake up for the last part of the on-call shift. I’d get a few hours of rest – but lemme tell ya, ‘rest’ isn’t quite the word I’d use to describe the time I spent in bed. Exhausted though I was, I couldn’t for the life of me fall asleep. First of all, my roommate’s pager kept going off. Second of all, I kept getting paged by mistake. And third of all, I was riddled with anxiety. What if I slept through the next part of my shift? What if my pager went off for an honest-to-god emergency and I didn’t pick up? And what if I’d done something wrong?
I spent a couple of hours tossing and turning before heading back to the wards for the final few hours of my on-call shift. By the end, I’d taken around fifteen bloods, inserted five cannulae, reviewed a dozen patients, written countless prescriptions, signed off ten ECGs, checked another ten scans, and god knows what else.
And that’s how my first on-call shift went. I didn’t have any crazy emergencies like you’d expect from a medical drama. Nothing particularly complex or extraordinary. Just an endless barrage of boring, menial tasks that left me feeling more like a robot than a doctor.