Medicine "oop North"

[M Clayton]

After a week of on call nights, I was rewarded with the glories of a day off but not before a final night of mayhem.

Leaving Wednesday behind, I felt certain that I'd heard bowel sounds high up in Mr Y's chest and the chest x-ray showed what looked very much like small bowel all the way in the apex of the left hemithorax. I couldn't explain it and I really wasn't sure that I'd actually seen it. So, I did the sensible thing and showed everyone that walked by - general agreement was reached; those were indeed bowels in his chest. Now we had to explain why that'd be the case.

A hasty trawl through his extensive notes gave the answer. He actually has next to no Left hemidiaphragm due to a bizarre set of operative circumstances. It would appear then, that the bowel sounds in the chest weren't the key to answering why his chest drain had gone from being filled with creamy gunge to being filled with creamy gunge and air. I don't know and I doubt that I will - I started him on something to treat the presumed pseudomonas infection that his notes said had been grumbling on for weeks and passed him up the line. The reg was happy to sit on him and that was that. Did he go for surgery? Who knows?

Thursday evening was, without doubt, the worst of my nights on. It started badly when I wandered through the unit on my way to grab a quick lunch (at 3ish) and was grabbed by the day house officer. He'd been snowed under all day without senior cover and wanted me to help him clear the backlog of pending admissions before the consultant on call arrived for post take rounds. Foolishly, I agreed to stay and help. My presence was noted by the nursing and admin staff and before long, I was being pestered to do all the small jobs that really could wait - fluid prescriptions, amending drug charts, reviewing non urgent ecgs and filling in the crem form for the unfortunate chap from Wednesday. Ok, so the final task had a moderately high priority for the sake of the family so, once things had settled, I took my student down to the mortuary to complete the form.

Part B's an odd thing really. The most unusual question has to be the one which goes something like "Do you have any financial interest in the deceased?". It's amusing because, just for filling in the form, 65 quid in crisp, unsoiled notes will be handed to me in a brown envelope. Nevertheless, I'm not one to turn down money so I filled in the form, palpated the ice cold chest (for the pacemaker - they explode apparently) and departed. My student coped slightly better with the body than she had when this chap had expired but it was still pretty traumatic for her. Probably better she sees this sort of thing now though eh?

The brief respite brought by the trip to the mortuary was soon over and the night ahead loomed large. I'd still not managed to get changed and it seemed that stopping for food was definitely out of the question for the time being. Already, there were a few patients to be clerked and the boss was on his way to do the post take round - there was absolutely no way that we'd get them all properly clerked before he arrived so I did what I always do when this sort of thing happens... I took blood, inserted cannulae and gave analgesia. While doing that, I garnered as much info as I could without getting bogged down in chat.

And the night continued in much the same vein. Calls from various wards about any number of sick patients punctuated the madness and the single inability of one nurse to actually follow instructions meant that a sickish patient next door ended up monopolising more of my time than she strictly should have done.

"She's in a lot of pain doctor. It's not settled since you saw her - in fact, it's worse"

Her pain's worse after 10mg of morphine?!

"Oh no. She's not had that yet. I wanted to wait and see what you thought first"

You asked me to put in a new cannula when I wrote it up. She has a new cannula. Therefore, why hasn't she had it!?

And so on. Rinse and repeat for pretty much anything I asked her to do. <sigh>

I got very grumpy very quickly. I'm certain that I was hypoglycaemic after trying to do a day's work on a bowl of cornflakes and cup of apple juice but there just didn't seem to be a way to make time for a break. My SHO was lovely and, finally, sent me for my break. Overjoyed, I motored down to the mess and ate copious quantities of toast. And then I realised it was only 45 minutes before home time. I needn't have bothered!

[M Clayton]

The week of on calls has been followed by changeover so now I'm pretending to be a vascular house officer.

It's been a bit of a change for me - by and large, the firm's less well organised than upper GI and the patients tend to be sicker when they arrive. I've gone from having a planned morning ward round with the consultant, reg and SHO to turning up at 8 and waiting around for the staff grade to turn up when he feels like it. I've also gone from leading the ward round (Mr M was very keen that, as the house officer and person that spends the most time with the patients, I should take the lead) to being ignored - I print out the bloods daily and make sure I know what's been going on with each person but he doesn't actually care. I've tried to speak up and offer relevent, important information and end up being lectured on some tenuously related topic (example: "I've restarted this patient's warfarin and I'm monitoring her INRs every 3rd day since she's on it for AF" "Yes, yes, just give me a moment. You must check INR daily when you start someone on warfarin de novo and be very careful with heparin infusions" - rrrrubbish). So I've reverted to being a silent partner. I dutifully write everything down and I try to make sensible decisions during the day but even that doesn't seem to be allowed. The staff grade wants to know about everything before it even happens - it's very restrictive and I'm not going to lie; I'm finding it very difficult to deal with.

In other news, today I felt like Judas as I collected my 65 quid crem form money. It's a very odd arrangement - the mortuary don't call you to tell you it's arrived; you have to drop by and pester them and it all feels very cheap indeed. The money itself comes as cash - crisp notes wrapped in a brown envelope which is labelled with both the name of the patient and the doctor that filled in the form. It's almost as if they want to rub in the fact that you didn't earn the money by saving a patient, you were, in fact, paid for failing. I'm not sure what I make of it all really - I don't know why we're actually paid for doing these forms and I'm quite sure that I'd fill it in whether paid or not. Meh.

[M Clayton]

We'd already established that vascular patients tend to be sicker than your average surgical patient in the immediate post op period - if they're not diabetic, they have significant heart disease or they've had 15 strokes... commonly, they've got the full house - diabetic male, smoker with high cholesterol (statins make them sick), uncontrolled hypertension (despite 47 different drugs), 3 previous MIs (CABG on top) and a number of TIAs this year alone. They are never 20 year old athletes who can rock up on the day of surgery and leave the same day.

Mr B is one of these people. He has the added bonus of being completely and utterly stone deaf. Oh, and he has renal failure. He hates me because I only see him when he needs (a) bloods, (b) a cannula or (c) a catheter. None of these patient contacts fills him with the joy of Sunday and it's easy to see that he might have me marked down as a bit of a bastard. Other than that though, he's given me no trouble at all over the weeks that he's been here waiting for his foot to be chopped off. His bloods have been stable, his obs have been rock solid and he's complained little (aside from the aforementioned procedural moans and groans). So why the hell did he crash yesterday?

I knew the day would not go well when I was fast bleeped to the ward at 8:15 - that's right, 15 minutes after I'd arrived. I'd barely printed out a ward list and it was kicking off. This is never a good sign. I arrived to find the poor fellow surrounded by a gaggle of nurses trying to get a set of obs - his BP was unrecordable and he wasn't responding to noxious stimuli. I toyed with the idea of a cardiac arrest call but stopped short when we finally got some numbers - SBP of 50 mmHg, Pulse of 64 (astounding and I wouldn't have believed it had I not palpated it myself), Resps of 30 and no recordable SpO2. Mr B was quietly, and without fuss, slipping away. Autopilot kicked in and I began to get a handle on the situation - deciding that the pink cannula in his hand probably wasn't going to perform very well, I got in a couple of large bore tubes in his acf. I shoved him on high flow O2 (despite a total lack of a sats reading) ran in some stat colloids and got a minor response from him (still no tachy!), did an ECG (bugger all), had a quick listen to his chest and felt his tummy (nothing new), catheterised him and did a blood gas. I could find nothing to account for this total train wreck of an episode. So I called for help.

In rapid succession, my reg, my student and my staff grade arrived. Each wanted to do something different, so I left them to it and ran down the gas to ITU. First glances looked normal.... and then I noted that the Hb was 4. This chap had had a normal Hb just the day before. Where the hell had 2/3 of his haemoglobin gone?

The obvious answer was bowel but there really was no cause for an acute GI bleed. Back up on the ward, a veritable army of senior clinicians had descended - anaesthetists from ITU, our consultant, some passing physicians and the colorectal surgeon on call. We don't actually get that many consultants at the weekly directorate meetings.... I did what any sensible F1 would do at that point and made a quiet exit to chase urgent bloods and get the notes. I made sure to document everything I'd done and it actually looked pretty good on paper. I don't think I missed anything important and that seems to have been bourne out by the fact that, when they got bored, the senior bods all ordered that we carry on with fluid resus (as planned) and give him blood (7 units versus the 5 I'd cross matched, but we can't get it right every time) before deciding what to do next.

"Next" essentially involved trying to work out where all the blood had gone and that wasn't going to happen until he was stable. CT wouldn't touch him with a long stick and endoscopy wanted his BP above 100 systolic. So we spent the day battling with him. I'd get him stable, go and try to do something else and end up being called back. It got to the stage where I was so sure that he'd give up on me that I had the crash trolley moved into the room on standby.

Against all odds, we got him stable for long enough to make it to endoscopy. There was one condition on the part of the nursing staff - I'd have to escort him in case he went off on the way. :s

We made it to the endocscopy suite (via some nifty secret back way - must remember that for the future) without having to do too much. I swapped a bag of saline for some volplex half way there but no riding the trolley whilst pumping his chest ER style (thank god!). Disappointingly, there was no clear culprit on the scope - a small DU but no evidence of active bleeding. So, not upper GI... where else then?!

Back on the ward another litre of fluid heavier, Mr B was stable(ish) and ready for the remaining 3 of his 7 units. I handed him over to the night staff and fully expected him to be dead before I'd had my tea....

[M Clayton]

Surprisingly, Mr B was not dead on Thursday morning. In fact, he was quite a lot better than when I'd left him on Wednesday evening - the 5 units had been transfused and he looked pinker and his blood pressure was stable at least. He was even well enough to bitch and moan when he saw me step onto the ward for rounds! A repeat haemoglobin measurement that morning showed a healthy improvement and everything appeared settled. All smashing stuff... except it wasn't. The nursing staff reported multiple episodes of malaena overnight and Mr B still complained of abdominal pain. My repeated suggestion that we organise some urgent imaging or a transfer to the Nurse Enhanced Unit (Low Level HDU) fell on deaf ears - the anaesthetists were happy that the problem was solved and my bosses were keen to move ahead and amputate the forefoot as planned. Nobody actually seemed at all keen to investigate why a previously healthy individual dropped half his haemoglobin in one go - the pathetic looking duodenal ulcer was being blamed and that was that. As the most junior member of the team, I had no choice but to follow the consensus and do my worrying in private.

Thursday passed off without any real problems. I felt like crap owing to a combination of factors - man flu being a large component with the continued lack of support from my seniors being the rest. But, the work was done and Mr B seemed pretty well when I left that evening.

Friday morning started out how I've rapidly come to imagine my dream day would begin - the staff grade had phoned in sick and the night staff had nothing at all to hand over. To top that, there were 4 expected discharges and, in a flush of optimism, I'd already completed the discharge summaries earlier in the week. It was shaping up to be a nice, relaxed day with no possibility of being stuck late (I had a particular need to be away on time on Friday - perhaps more on that later). I'm sure you'll have realised by now that there's no way on Earth that I had a nice day - after all, I tend not to blog about the dull crap that frequently fills my day (well, maybe I make it sound like it when I write, but I do try to pick out the select moments from my life for the sake of interest).

I did a ward round by myself and everyone seemed pretty stable. Mr B had dropped his BP to around 80 systolic but it was hovering around that level and his other obs were pretty good (still no tachy!). He did look a bit pale though so I foolishly took off a quick blood sample for an urgent Hb - cue much protestation and crying from Mr B. Honestly, I have a lot of sympathy for the guy; he's not well and I'd be mightily pissed off if all that ever happened when i saw me was a painful procedure but he must have the lowest pain threshold known to man. He cried when the nurse removed the tape that held on the cotton wall ball at the site of one of his ABG attempts... By the by, I asked the nursing staff to keep a close eye on him during the day and to let me know if there were any concerns.

Half an after the blood was sent to the lab I received my confirmation - his haemoglobin had once again dropped to ridiculously low levels. It wasn't as bad as Wednesday but, considering he'd had 5 units of packed cells, it was pretty dire. I phoned the transfusion lab to order some more only to be told that his crossmatch sample had expired at 9am and I'd have to try and obtain a fresh sample for them. FFS - the guy had precious little circulating blood as it was and they wanted me to take more!? I impressed upon them the urgency of the situation and managed to secure a promise of immediate crossmatch once the sample was sent. I wimped out of doing it and had the on call SHO get the blood for me whilst I tried to get in touch with the consultant looking after Mr B.

Predictably, the Consultant was unavailable (apparently, in Paris - nice for some) and nobody else seemed to want to get involved in making decisions. I plumped for starting more fluid resus, getting the blood going and trying to hunt out some senior support. The arrival of the blood slip implied that bad things were happening at the lab level - only 2 of the 5 available units were going to be type specific. Mr B doesn't have particularly rare blood and the very fact that 3/5 of the order was going to be made up of House Red (O Neg) implied that we'd already managed to exhaust the supply of Mr B Positive with the fun and games of Wednesday. We (we being the ward staff and I) settled down for a long day of battling to get something done and I reviewed everything already done. Repeat gases (with added tears) showed nothing obvious and the imaging department still weren't happy to take him for scan - something about him not being stable enough to go into the CT....

I bravely attempted my biggest feat of the day at sometime around half 1 - I went to get lunch. All Junior Doctors know that lunch is a myth and any attempt to get some will be met with a flurry of "urgent" bleeps and general ward crap. Alas, it was to be the case that day too. Mr B had tissued his good cannula (the grey one I sited on Wednesday) and the bad one (the pink one I'd sited on Monday) was starting to look dodgy. Oh dear, oh dear, oh dear. Mr B has never been the best of candidates from an IV access point of view and acute GI bleeding hadn't improved that situation. I cried into my black bean sauce (exotic food is what our canteen does best) and binned my half finished meal.

Ambitiously, I went back to Mr B armed with big cannulae as well as small ones. I wanted, ideally, to secure some more large gauge access for the blood and an extra cannula on the other side for emergency fluids. I wasn't going to get either. The tissueing of the grey on the right had totally buggered the right antecubital fossa and nothing at all was palpable. He's been with us for so long now that we've messed with all the veins in his arms and some stage and they're now a mass of firm, clotted rubbish. The pink on the left had been an ill advised attempt at minimising distress back when he'd needed access for antibiotics only on the Monday. If I'd been able to go back that far, I'd have slapped myself very hard for even contemplating putting a pink in the elbow but hindsight is 20:20 eh?

Royally screwed over by my own actions, I had to admit defeat. The only problem now was getting someone to save me...

I won't bore you with the details but I spent 3 hours chasing seniors in a vain attempt to get anyone to be interested in the fact that Mr B was dying on the ward. I was abused by a very rude anaesthetic consultant (whom, I have since learnt, is a prize dick to all juniors) and given platitudes by critical care outreach (he was assessed by the anaesthetist yesterday and they said he was too well for HDU - yes, that was yesterday!). I spoke to the on call surgeon who agreed fully that something needed to be done and who then walked off without actually doing anything. I felt very, very alone and got increasingly more stressed. I wrote it all down, apologised a thousand times to the nurses for not getting it sorted and then, to my deep shame, I passed it on to the night team. He was their problem now.

Meanwhile, over on another ward, one of our other patients had passed away without a fuss. An expected death, for sure, but not one I could actually certify since she'd been to theatre twice in the preceding week. My overwhelming feeling at hearing the news? Anger. I was angry that, despite my best intentions, I wasn't going to get away on time and, at the very least, I'd be tied up with the coroner trying to get the cert done.

It's funny what a day of medicine can do to you.

[M Clayton]

Do you ever have the sort of day where nothing you do is right? Where your seniors criticise your every decision and fail to acknowledge when you've done well? Does the very ground beneath your feet crumble?

Well, imagine that that is the day you have to look forward to when you wake up and, what's more, at least 5 of the 7 will be like this. This is the life of a vascular houseman at York. It's hugely demoralising to spend the day being bollocked for doing something in good faith and the total lack of organisation means it's next to impossible to keep track of what you might be doing wrong. Our ward round with the staff grade usually ends with a list of jobs that will, by and large, be totally reversed when the consultants pitch up. This will be at an unpredictable hour of their choosing and they will decide, at random, to bleep you when they've seen 3 or 9 or none of their patients by themselves. Is it any wonder that little things get missed occasionally?

Anyway, enough moaning. On to other matters.

Mr B is still with us although he is now sans most of his colon. My frequently ignored comments about the bleeding probably being lower GI in origin turned out to be exactly the cause of the nightmare. Only 2 hours after I'd gone home on Friday, things came to a head and he embarked on an ambitious project to exanguinate... via his rectum. Accounts from the poor F1 on call suggest that the transfusion went in via the vein and came straight back out through the bowel. Clearly things had come to a head and the central line that I'd begged for all afternoon would have been bloody useful. It's just a damn shame it never actually happened then with the anaesthetist's comment of "He needs subcut diamorph, not a central line" no longer seeming as appropriate. The team trying to stop him from dying had, instead, to make do with a tenuous green line in his forearm (inserted by aforementioned anaesthetist after 4 attempts - not so easy now eh!?) while urgent preparations were made to take him to theatre.

The nursing notes from those few hours give some indication of the chaos that ensued - lines of text referring to an escalating level of senior bleeps fill the page, urgent crossmatch samples being sent and, finally, at close to midnight, the transfer of Mr B, with continual monitoring to the theatre suite.

4 hours later, he was dumped in ICU with an ileostomy, his colon having been transected. It was touch and go time with the notes indicating a pervading sense of negativity amongst everyone involved. Yet, he's still with us and, against all odds, is doing pretty bloody well for himself. He's still as deaf as a post and he still doesn't much like me but I'm actually pretty pleased the old chap made it through. I'd be very pissed off after all that work I put in!

[M Clayton]

Mr B is emphatically not dead. I know this because he shocked us all by punching me in the head today.

He's been going off again this week although we're moving up the ABC priority list and, having had a major circulatory collapse, he's decided that this week will be breathing week. At some undetermined point over the weekend, he must have aspirated and his previously clear chest has turned into a crackling melting pot for god only knows what. Great stuff - all he needs now is a rip roaring pneumonia to send him on his way. In some ways, it would be the kindest possible thing. He's clearly hugely distressed by the whole affair and keeps trying to get up and go home - he'd make it too were it not for the fact that he has zero muscle mass left and what look to be 18 or so different tubes draining/infusing various fluids tethering him to the bed. He probably wouldn't know the way home at the moment either - he's been moved from ward to ward so many times, it's beyond the joke. ICU - HDU - General Ward - NEU - HDU - General Ward - Now back to NEU. It's just daft.

Rather foolishly, my seniors requested an ABG on him and, I might say, this is exactly the sort of thing that a person who knows they won't have to do it requests. Mr B had attempted to bite the radiographers that had come to do a portable CXR yesterday and this gave me a small clue as to his Ideas, Concerns and Expectations. Nevertheless, I pushed on in the vain hope that he'd be so out of it when I arrived that I'd be able to just get on with the procedure and get out. Alas, he was fairly lucid but still very deaf. I explained it to me and, despite groaning loudly, he agreed to left me have one go. I promised that one go would be all I'd need...

We started badly when he started screaming in agony at the skin cleansing stage. Alcohol wipes are cold but, to the best of my knowledge, not actually painful. So we carried on. The moment the needle pierced his skin, I knew that I'd really made a mistake. He howled like a banshee and, before I knew it, was pummelling at my head with his free hand. For someone so ridiculously slight and cachexic, he packs a mean right hook. There was real malice in it, I'm convinced of that much. The temptation to jam the needle in harder was fleeting but the realisation that he really has the shittest time possible came to the fore and I withdrew in shame.

My head was stinging, my ears were ringing but actually what hurt the most was that I'd let myself be bullied into doing something I hadn't wanted to do in the first place. The nurses now think I'm a monster and it's simply reinforced Mr B's already entrenched belief that I am, in fact, a total bastard.

Bad times.

[M Clayton]

I survived another weekend on call for general surgery and, despite the best intentions of the nursing staff, emerged relatively whole in a psychological sense.

Weekend days are always really busy since there are loads of crap jobs to get done - discharge summaries are the worst of them. How on earth you can be expected to write a meaningful summary when you've never actually met the patient is beyond me. But c'est la vie - we plod through the bloody things while certain members of nursing staff cluck at our shoulders - "come on, pharmacy shuts at 12!" (quite why the day teams couldn't write their own TTOs on Friday is beyond me...). Aside from that, the largest irritant is the near constant bleeping that goes on to "just remind" me of jobs that can wait all day if needs be (like prescribing warfarin for the 6pm drug round... especially when they're asking at 11am).

You just don't stop when there are 6 wards and a day unit vying for attention. Couple that with the management of acute admissions and you've a recipe for trouble. We frequently lurch from one sick patient to the next and it's all deeply unsatisfying stuff.

This weekend had the added complication of the fact that I'd agree to go out and help cover the final night of Hull Fair. On paper, this seemed like a good(ish) idea but, in practical terms, it meant finishing work and driving straight to Hull for a night of fun and games. That was then followed by a potentially lethal drive back along windy country roads at 1am - I'll admit that I don't remember very much of the actual journey but no sheep/pheasants/children were stuck in my front grill, so I can assume it passed without incident.

Getting up to go to work after just 5 hours of sleep is a soul destroying experience. I was very nearly on the verge of tears for the first 10 minutes or so - exhaustion and the knowledge that there'd be a pile of crap waiting for me on the wards made the temptation to roll over and ignore the alarm huge. But, I'm being paid to work and work is what I did. I didn't say I enjoyed it though...

In my tiredness, I managed to lose my steth. I last saw it when I pronounced Mrs C dead at 11:57 exactly and, after that, it vanished. By the time I twigged that I'd left it with Mrs C, she'd been packed up for transport to the freezer... I don't mind saying that I was pretty worried that my graduation present would end up being cremated or, worse still, found by a family member! Trying to get hold of the mortuary was a fruitless task and I had to go home hoping against hope that I'd find it before they did...

[M Clayton]

It's been what, a fortnight?

Since then, I've done a week of General Surgical on calls and had a glorious week of annual leave. There's little of real interest to report - the on calls were composed of the usual mix of dross (aka crap ward jobs that could probably wait for the day teams) and acute illness (aka "I need senior help now!") but I managed to get through it all in one piece. I'm also pretty sure that I managed to avoid antagonising the radiology department as well and that's a first for me when it comes to acute patients! Looking at the list, we admitted 65 patients over the 7 days and now, just over a week and half later, all but one of them have gone home. That's not a bad turnover rate by all accounts. I would take the credit but it's not as though I actually did the surgery...

My week of annual leave was spent in Germany with Nick. It was really good to get away from it all for a little while although I'm not sure I'd ever go to Germany again if it weren't for Nick. Don't get me wrong, the country's nice enough but, outside of the big cities, it's like being in a timewarp - there's bugger all to do!

I'm back with the vascular firm now and so far this week I've been dragged in to assist in theatre twice - both open repairs of AAAs. There's something a little bit satisfying about helping to insert a Y Graft (well, I say helping, I mean holding a retractor and the occasional bit of suture material while The Boss does his thing) and scooping out shit loads of grubby clot from the inside of a baggy aorta does give me a thrill* but I still can't get over the fact that I'd be so much happier on the other side of the blood-brain barrier. If nothing else, the irritation that is felt when you can't reposition your glasses when scrubbed is enough to put me enough off surgical specialities for life.

In other news, Mr B isn't dead yet. He's on the care of the dying pathway but is hanging on in there - quite why, I'm not sure.

*obviously this is a lie.

[M Clayton]

Let it never be said that the old don't have a sense of dramatic timing.

Mr B, bless his cotton socks, finally gave up the fight on Saturday.

If I didn't know better, I would swear that the cheeky little imp had waited until the very day that we took him off the care of the dying pathway and began to prepare to, once again, treat him actively. In spite of his obvious and utterly profound deafness ("HOW ARE YOU TODAY MR B?" "what?" "I SAID, HOW ARE YOU? DO YOU HAVE PAIN?" "eh?" "NEVER MIND MR B. CARRY ON") he clearly had been listening when I discussed the ethical dilemma afforded by keeping him on the pathway with a nurse. We came to the conclusion that him not dying relatively soon after being placed on the pathway meant that, in reality, he was probably being starved to death. Cue much discussion with seniors and the dietician (who steadfastly refused to get involved since "he's on the pathway!") and an eventual realisation that nobody actually wanted to make the decision to rescind the COTD pathway order. I decided that I'd be the one to do so... and then I wimped out and wrote him up for some rehydration instead. I figured that a couple of litres over the weekend might be enough to perk him up for the ward round on Monday - a bright eyed and bushy tailed Mr B might have been enough to convince the boss that treating him was a good idea.

It ended up being an academic exercise with Mr B choosing to expire as the nurse entered the room to run the first bag of fluid. You really have to admire that timing - it was exquisite. Couple that with the timing of his first major GI event (regular readers will remember that that happened half an hour before he was due to go to theatre for his foot amputation) and you've got a dramatic genius that wouldn't be out of place on Broadway.

Rest in Peace Mr B. You did us proud, old boy.

[M Clayton]

Another week in vascular surgery, another set of sick patients. It’s actually been a real challenge this week – at one stage, we had a seriously unwell patient on each of the 4 surgical wards and it was hugely difficult to manage.

Thursday was probably the worst day, although, on reflection it was only the death of a patient on the table that made it so. In terms of ridiculous workload, it matched Wednesday and Friday lacking only their stupid excursions to theatre.

So, Thursday. Audit day happens once a month and attendance is compulsory for all of the general surgical doctors, anaesthetists and most of the senior nursing staff. Audit day is a very bad day to get sick at York District Hospital. The majority of the junior medical staff have now worked out that the best way to deal with audit day is to have someone bleep you out of it before it gets going too heavily. I'd made such arrangements with the on call House Officer (the only person with a decent excuse not to go to audit) on Thursday, knowing full well that there was plenty of work to get on with on the wards.

When the call came, however, it wasn't the on call House Officer. It was Ward 16 and, therefore, was probably real work. When I phoned back, the nurse picked up after just one ring. They never ever pick the phone up after one ring. Normally, they bleep you multiple times from the same extension (or, just to mess with your head, they move to another phone on the same ward) and then when you try to ring back, one of three things happens:
1. The line is inexplicably engaged. For the next half hour.
2. The person that answers the phone has no idea who bleeped you or why and is unable to actually find that person on the ward.
3. The phone rings indefinately and you arrive to find "Dr bleeped at so and so hour - did not respond"written in the notes.
A nurse that hangs around and answers quickly wants you to do something muy importante.

Nurse: You need to come to the ward now please. Mr T has had another bout of haematemesis, he's in a lot of pain and he really doesn't look well.

I think for a moment, trying to remember what I can about Mr T. Ok, 3 weeks post AAA repair, swinging pyrexia presumed to have been a graft infection, treated with vanc, getting better, recent CT showed no evidence of graft trouble... So haematemesis is new.

Me: Ok, what are his obs?
Nurse: They're being done now but I really think you should come.
Me: Right. I'm on my way. Make sure you get his obs, have his drug chart and notes ready and have someone find out where the crash trolley is right now.

On arrival on the ward I realise that Mr T is in Mr B's old room. The Room of Death is a cursed place - each and every one of the patients that I have certified on Ward 16 has been stone cold in that room. I'm considering asking the nurses to put other firm's patients in there before the Police start knocking at my door. I also remember that my student has been saying she's got a bad feeling about Mr T for the past 3 weeks (although, in fairness, she says that about all of our patients) - she may actually be right about this one.

Mr T is sick. He is pale, he is clammy and there are 3 of those cardboard vomit bowls - you know the ones, you've probably worn one of them as an amusing hat at some stage - full of nasty, partially clotted bloody vomit. I play the usual game of ABCs and manage to get in a couple of grey cannulas (go me!). I'm about to push fluids heavily when a little voice at the back of my head mutters something about aortoenteric fistulae and higher blood pressures meaning quicker death. I settle for getting his BP out of his boots and into the 90 - 100 mmHg range. For my next trick, I placed tubes into all the hollow bits I could find (ie, I passed a catheter and placed an NG tube, but that sounds less exciting) and then I called the consultant on call. Naturally he was still in the audit session and, naturally, he was eating a cake (whilst we juniors respond to the stick, the consultants work better when offered the carrot). He told me to carry on playing and he'd get back to me in ten minutes.

Ten minutes passed.

Consultant: I've organised an urgent CT scan for Mr T. You have to escort him down to the Polo of Death and I'll see you with the results. Don't let him die.*

Great. I love escorting critically ill patients in tiny lifts and along narrow, phoneless corridors.

We made it to CT and back without too many problems. I may have nearly killed us all by dropping the oxygen cylinder when transferring him from the trolley to the scanner table (oops!) but he remained well behaved throughout. I even let myself think I might have done a good job...

Not good news from the xray docs. Despite it not being there on Monday, Mr T had a riproaring graft infection that had eaten its way into his bowels. The blood we were seeing at the top end was only the tip of the iceberg. Bugger etc.

Back on the ward, it appeared that a large number of people had taken the opportunity to use Mr T as an excuse to get away from audit. My staff grade had appeared, along with the consultant and no less than 3 members of anaesthetic staff. I gave a handover of the faff to date and waited for the praise. Instead, I got told to fetch some orange cannulas because my greys weren't adequate and to cross match more blood because the 8 units I had cross matched were also not adequate.

Apparently, the Big Plan at this stage was to rush Mr T to theatre, whip out the graft and do something called an axillo-bifemoral graft. This is complicated surgery to when elective and since Mr T is knackered, he will almost certainly die. This is laid out before him and his family (such as they are) and he accepts it all with remarkable grace (that may have been the morphine talking). Essentially, he gives The Boss carte blanche and, before we know it, we're consented and prepping in theatre.

This will not end well.

*I may have paraphrased slightly.