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  1. 1. YOU WILLSURVIVEThe guide for newly qualified doctors Compiled by Tom Nolan, Imran Qureshi, Sarah Jones and Daniel Henderson Edited by Sabreena Malik and Edward Davies Sponsored by
  2. 2. Are you out? Visit our website and see how we can help you UP FOR DOCTORS
  3. 3. CONTENTS Starting life as a junior doctor is one of the biggest challenges 1 INTRODUCTION you’ll face. Five or six years 2 ON CALL & NIGHTS of medical school can make 5 WARD ROUNDS even the keenest student feel institutionalised. Now, starting & NOTES work, suddenly everything has 8 COMMUNICATION changed. New people, new places, and new responsibilities. 10 DE-STRESSINGSelf doubt can creep in: How will I cope on call? How will 12 SKILLS STATIONI keep up on ward rounds? What if I prescribe everything 14 FIRST DAY TALEwrong? Don’t worry. Be reassured by the fact that everydoctor in the world has been through this and survived. 15 FIRST YEAR TALESMany of them contributed to this booklet. 19 USEFUL EXTRAS “You will survive” started out as a discussion threadthat received over a thousand tips and cautionary tales on 20 REFERENCEBMJ Group’s global online clinical community, doc2doc. INTERVALSFor this second edition, we have also included invaluable 21 PHONE NUMBERSwords of wisdom written by junior doctors for BMJ Careers. Good luck with the new job. I’m sure you, like most, willlook back on your first year with fondness. Make sure youlog on to doc2doc to tell everyone how you’re getting on.Fiona GodleeEditor, BMJ There are many things to remember in any of these situations, ensuring when starting out as a hospital doctor, complete peace of mind. but securing medical legal assistance We are delighted to sponsor this book might not be high on your list. You as it is full of valuable advice from your will have NHS indemnity for the work medical peers which we believe will help you do within your NHS contract but you survive some of the challenges of for disciplinary issues, GMC referrals, being a junior doctor. coroners’ inquests or fatal accident Jim Rodger inquiries, the NHS won’t help you. Head of professional services, MDDUS MDDUS members have 24-hour access to assistance, support and, if necessary, legal representation if they are involved YOU WILL SURVIVE | 1
  4. 4. ON CALL & NIGHTSPrepare yourself for your first on call with these tipsfrom those who have gone before youBefore that dreaded first on call youmay well feel terrified and completelyout of your depth. This is only natural.Remember, everyone has gone throughexactly the same feelings beforeyou–and survived.Adam Simmons, RochdaleWork steadily and efficiently,avoid rushing, and try to prioritiseappropriately. Do not work with oneeye on the clock. Accept that you willbecome trained, Pavlovian-style, toreact to crash bleeps and alarms.Peter Martin, EssexHowever inane the requests on the other end of the phone, remember each call is potentiallyfrom a person with genuine worries about a patient. Show your gratitude to nurses who flag upimportant problems. But also be aware of unreasonable requests, and stand your ground!Adam Asghar, YorkshireBe calm. It helps you deal with new problems in an organised, rational, logical, and safemanner. It also instils confidence in the people around you, from the nurses who will thenlisten to you and help you, to the patient who will not develop a fear induced tachycardia!Carla Hakim, LeicesterKeep a list of tasks with the times you were given them. Mark off when they have beencompleted. This way you will not forget anything, and handover at the end of the shift becomeseasier. Include patients’ hospital numbers in the list so you can check results quickly.Adam Simmons, RochdaleSmile over the phone at the nurse who adds another task to your towering mountain of work.Smile at your patients, and smile at your seniors who often demand the impossible. Remember,it is possible to enjoy this job even in the middle of a night on call.Andy Shepherd, Milton KeynesIt is normal to feel sick the first time you are on call.Claire Kaye2 | NEWLY QUALIFIED DOCTORS
  5. 5. ON CALL & NIGHTSDon’t be afraid: help is only a bleep away!Michael Haji-Coll, Chertsey Things to take Different wards have different layouts,When asked to a see a patient during the so you won’t know where all thenight, ask the nurse to do a fresh set of equipment is, or if the wards are fullyobs and any other relevant tests (ECG, BM, stocked. Save time by carrying somebladder scan etc) while you make your way equipment (ABG syringes, cannulas etc)down to the ward. in an on call bag, along with a smallShamil Haroon, New Zealand reference book (Oxford Handbook) and a chocolate bar.You are your patient’s advocate. Fight to get Michael Haji-Coll, Chertseythat x ray if it is needed, and listen whenthey tell you something they may not tell Some hospitals can be cold at night. Ifanyone else. Claire Kaye you have a quiet spell there is nothing worse than sitting in the mess feelingJust remember: ask, ask, ask! The only stupid cold, so bring a jumper. If it looks prettyquestion is the one you don’t ask. sensible then it’s probably fine to wearMaryam Ahmed, Wolverhampton down to the wards during the night. Jo Godfrey, SwanseaOn my surgical nights I told each ward thatI would do a mini jobs round at three pointsduring the night. This meant that annoyingjobs (writing up fluids, rewriting drug charts, doc2doc has over 28 000 registeredetc) could get done in a single sitting. On members and offers a quick and easysome very nice wards, the staff would get me way to get answers to your questionsa hot drink and snack ready for when I was from a community you can trustexpected!! • doc2doc.bmj.comCarmen Soto, Leicester Eating Busy or not, always have a break and eat when you’re on call. You will make yourself far, far more efficient and, if you’re any- thing like me, less grumpy. Helen Macdonald, Oxford Take some food: it’s surprising how hungry you can feel at 4 am when all the shops and canteens are closed. So go prepared. Mahomed Saleh, Coventry YOU WILL SURVIVE | 3
  6. 6. ON CALL & NIGHTSON CALL AND NIGHTSA night to remember with Mr MIt was 2 am when my bleep went off. It to review the patient.was one of the gastro wards. An elective “I begged To my relief, he waspatient had just been admitted from another him to come on the ward within 10hospital, and needed clerking in. I was as quickly as minutes. Fortunately,perplexed by this: elective patients don’t get possible to we managed toadmitted at 2 am, do they? review the stabilise Mr M such Mr M was a 70-something year old that he could go patient”gentleman who had been admitted as for an urgent CTa transfer from a nearby hospital for angiography, which revealed that he hadinvestigation of a suspicious “mass” on his suffered a tear in his cystic artery – henceliver. On examining him, there was nothing the PR bleed.much to find – his BP was stable, and he So, what did I learn from this experience?was apyrexial. He had some mild abdominal It taught me the importance of the doctortenderness and a few crackles at his left lung on call and the nurses on the ward workingbase, but nothing major. After clerking Mr together as a team to achieve the bestM in, taking his bloods, and writing him up possible clinical care. It makes such afor some IV fluids, I trundled off the ward to difference when everyone works in tandemcontinue my night’s work. so bloods can be taken quickly and IV fluids At 4 30 am I got a call from the same put up promptly. I also learnt the importancegastro ward that scared the life out of me! of involving senior doctors when you needMr M had just passed about a litre of blood them. This patient required review andfrom his back passage. I went to see him an urgent decision on his managementstraight away. To my horror, he was clammy, including his resus status. Never be afraid tosweaty, and peripherally shut down. His BP ask your seniors for help or advice, no matterhad crashed to 80 systolic. Thankfully, he how trivial the issue. The most dangeroushad two points of IV access. I grabbed one junior doctor is the one who doesn’t ask forof the nurses and asked for some Gelofusine senior help when it is clearly warranted!urgently. The nurse also offered to take the But above all else, as a junior doctor onpatient’s full blood count, clotting screen, nights, pray you don’t get asked to admitand a group and save. I noticed that he elective patients in the middle of the night,had been made “not for resuscitation” at who are stable on admission but then the hospital he had deteriorate unexpectedly rapidly! Nights “To my been admitted from. can be scary – but they do make us better horror, he Realising this patient doctors. Well, they have in my case! was clammy, was potentially peri- Declan Hyland, Liverpool sweaty, and arrest, I contacted the on-call medical SpR. peripherally • Register free to join the doc2doc I begged him to come shut down” as quickly as possible community at doc2doc.bmj.com4 | NEWLY QUALIFIED DOCTORS
  7. 7. WARD ROUNDS & NOTESIf you get chance to sort the following out before theward round, you can make it run smoother: Using SOAP1. Make sure all the notes are where they should be The mnemonic BODEX is a good2. Check all blood and scan results are in the notes safety net for ward rounds: Bloods,3. If you didn’t manage the night before, prepare TTOs Obs, Drugs chart, ECG, and X-Rays/ for the well, and phlebotomy forms for the sick imaging.4. Familiarise yourself with the history of any new arrivals. And when writing in the notes,Imran Qureshi, London remember SOAP: Subjective - How is the patientNever, never, visit a patient at the bedside without feeling? Retake any relevant parts ofsome tactile exchange. Human touch can be healing the history (e.g. do they have chest(for both doctor and patient). pain?)William Hall, New York Objective - How do they look? Write down the obs and yourSometimes patients decide to discharge themselves. examination findings.You cannot stop patients with capacity from going Assessment - Your impression ofhome. Explain the benefits of staying and also what what’s going on (e.g. pulmonarymight happen if they leave. Document clearly either oedema improving, no new issues).way. If in doubt, ask. Lastly, document your Plan.Heather Henry, London Will Buxton, Sussex Try not to give instructions over the phone without later writing in the notes. Adam Asghar, Yorkshire Never make up an examination finding that you didn’t actually examine. Rochelle Phipps, New Zealand Greet ward clerks, healthcare assistants, and nurses using their first names. They’ll love you and make your life easier. Preetham Boddana, Gloucester Rather than pondering for hours over a dilemma, discuss it with your senior. Most consultants would prefer for you to call them rather than for a patient to suffer because you are unsure. Matiram Pun, Nepal YOU WILL SURVIVE | 5
  8. 8. WARD ROUNDS & NOTESBy the time you’ve found the notes and startedwriting, the ward round may have already movedon - these tips should help you get byAfter the ward round, discussand allocate urgent jobs. A low noteArrange another meeting for One of my lowest moments as a house officer was beingone or two hours before the on a cardiology ward round as the lone junior surroundedend of the day, and chase up by clever consultants and registrars. I was a few monthsoutstanding jobs. This should into my FY1 year, and it felt like I was in the swing ofavoid the need to hand over things. However, just as I was starting to write in the notesroutine jobs (chasing bloods of a patient, my registrar grabbed them from me andetc) to the on-call team. started writing himself. I felt so embarrassed - writingHeather Henry, London notes is one of the few things a house officer is expected to do without supervision, and yet I was obviouslyBe polite, inhumanly polite, rubbish at it. And this registrar was really nice, so iteven when you want to scream wasn’t like he was being cruel. He was just obviouslyyour head off after being frustrated at my incompetent note taking.bleeped for the 100th time. I have since learnt that writing notes is a more importantRoberta Brum, Brighton job than it seems at first. When you’re doing a busy on call, a good last entry from a diligent house officer can makeLearn to think critically and all the difference and save you precious time that wouldorganise your thoughts before otherwise be spent leafing through the entire set of notes.speaking. Communicating So what makes a good note entry?with colleagues will then • A problem list (see opposite)improve. • Documentation of how the patient is today. Note downPeter Martin, Essex vital signs, any history or examination that is performed on the ward round, and any discussions that have taken placeRemember the power of a between you and the patient (see SOAP p5). Recordingcareful apology (“I’m sorry what the patient has been told is useful for on-call staff.that happened”). This can • A clear management plan. Mark each task as “done” inavoid many complaints. the notes once completed.Sarah Jones, Nottingham • Different consultants and registrars like different styles of note keeping, so find out early on what they expect.When communicating with If you are in any doubt over what has been said on thepatients, give them time to ward round, don’t be afraid to ask for clarification–it’sabsorb everything you say. far better than writing something that makes no sense toAdam Asghar, Yorkshire anyone else. Gayathri Rabindra, London • Find your next job with BMJ Careers careers.bmj.com6 | NEWLY QUALIFIED DOCTORS
  9. 9. WARD ROUNDS & NOTESListen to the patient for they are telling youthe diagnosis. Diagnosis is 80% history.Be empathic, learn to read body language,and learn to control your own bodylanguage.Peter Martin, EssexWhenever I make an entry, I print myname, with my job description (shrink,Chief PooBah etc), date, and exact time.It is legible. I then sign. Many yearslater this may save my rear end. Somecontemporaries are less anally retentive, There is (or should be!) no such thing as abut I like my rear end intact. “routine” investigation. An investigationRoger Allen, Australia should answer a question, preferably one to which you already know the answer.Pre-empt questions: neurosurgeons Peter Martin, Essex.will want to know a patient’s GCS, serumsodium and INR; renal physicians will A three or four line problem list at the topwant to know the pH and serum of each entry gives me an idea of what I havepotassium etc. It’s like presenting pending for the patient and helps structurethe relevant findings from a physical my plan–especially when alone on a wardexamination in an OSCE. round. It gets easier if you do it every day.Adam Asghar, Yorkshire Tim Baruah, London SBAR - how to ask for help from a senior Situation: “My name is Dr X, FY1, and I’m calling from Ward X; I need to tell/ask you about X problem” Background: Patient age, reason for admission, relevant comorbidities, current issue, current obs, relevant investigations (ensure you have the notes, charts, and drug card handy when you call) Assessment: “Based on my findings I think the current problem is. . .” Recommendation/request: “I recommend we do X, Y, and Z; does that sound ok?” or “I request your advice” or “I request that you come to help” Before you put the phone down make sure you either have a plan that you understand or a guarantee (even better: an approximate time) that the senior will come to help. Ensure you document that you’ve contacted a senior; include his or her name, bleep number and the outcome of the discussion. Sarah Jones, Nottingham YOU WILL SURVIVE | 7
  10. 10. COMMUNICATION Do not book urgent investigations on the Breaking bad news system and just wait; find out the protocol My advice on breaking bad news is: for urgent investigations in your hospital and • Don’t beat around the bush follow it. • Don’t use euphemisms Heather Henry, London • Don’t talk to fill the silence. People hang on to hope until the last, so Nurses have long memories. Always treat be kind and compassionate, but don’t them with respect, and they will help you out delay the message, and say clearly that the of all imaginable (and unimaginable) tight person “has died.” Allow time for this to spots. sink in, and then offer to answer questions Rochelle Phipps, New Zealand or be of other assistance. It is useful to have a nurse with you to remain with the Never judge any senior or junior by the bereaved if you are busy. impressions and conclusions of other doctors. Rochelle Phipps, New Zealand Bhavjit Kaur, GreenwichBe nice to everyone in the hospital, even the porters – it makes it so much easier to get thingsdone. It is so true that people will do you favours because they remember you as the doctor whoalways smiles and says “hi”.Maryam Ahmed, WolverhamptonWhen requesting an investigation you are communicating with another professional, tell themclearly why you are requesting the investigation.Peter Martin, GP, Essex • Want to know more about pay, working conditions, or what it’s like to work in certain specialties? Find out all this and more in BMJ Careers focus at careers.bmj.comBe polite: remember the medical world is small, andpeople have long memories.Be concise: most on-call registrars or consultants will begrateful for a brief but detailed summary of the patient youwant them to see or review.Be precise: know exactly what it is you want doing, whenyou want it done, and by whom.Mahomed Saleh, UHCW8 | NEWLY QUALIFIED DOCTORS
  11. 11. COMMUNICATIONMaking a splash on nightsOn my first night on call as a surgical FY1 I done a bladderwas called to see an agitated, tachycardic, “I was promptly scan. I had toand mildly hypotensive patient who was soaked by the sheepishly say wesecond day post-op after bowel surgery. 900mls of urine hadn’t thoughtThe nurses informed me he had only before I’d even of that. By thepassed 10 ml of urine in the last 4 hours. I time the SHO gotran from the opposite end of the hospital withdrawn there we’d doneto find a clearly sick and possibly septic the catheter. a bladder scan,patient. ABC assessment was good (except The patient which showedfor his tachycardia). He was experiencing breathed a sigh over 900 ml.abdominal pain but was too agitated to of relief and The cathetertell me more than that. On examination he thanked me, clearly neededwas guarding around his lower abdomen; changing as itit was very tense, but he still had bowel and the SHO was completelysounds. His fluid balance chart (not fully walked in to blocked. We setcomplete) showed only 1 litre in (over find me covered up the trolleythe past 24 hours), and only about 500 in urine!” ready for meml out (all day) from his catheter. Culprit to pass a newfound: “He’s hypovolaemic,” I thought. catheter, disconnected the catheter bag,So we gave him a 500 ml Gelofusine bolus and deflated the balloon. I was promptlyfollowed by a 6 hr bag of Hartmann’s. Over soaked by the 900 ml of urine before I’dthe next hour his agitation worsened. even withdrawn the catheter. The patient I called the surgical SHO who, after breathed a sigh of relief and thanked me,shouting at me for having woken him, and the SHO walked in to find me coveredpromised to come, and asked if we had in urine! My key tips for anyone approaching their first set of surgical nights: • Perform catheter flushes and bladder scans before panicking about fluid balance • Seniors may be asleep but they are being paid to work, so don’t feel guilty about waking them up if you’re unsure about something • Always have a spare change of clothes or know the theatre changing room code so you can get changed if you get covered in blood, vomit, and/or urine. Sarah Jones, Nottingham YOU WILL SURVIVE | 9
  12. 12. DE- S T R E S S I N GBeing a doctor can be stressful; here’s how tomaintain a good work-life balance doc2doc has several non clinical forums including book club, cycling, and travel forums • Organise your annual leave early so you can plan when and where you’re going to go on holiday for that all important stress relieving break. Adam Simmons, Rochdale Remember, stress makes you make mistakes. The best way to relieve stress is to take your work easy but responsibly. Take feedback or comments positively. Food Don’t let any irate comments or remarks Don’t drink so many caffeinated drinks, bother you too much; they come and go. you will feel better with fewer. Don’t be You should be more worried about your tempted by sugary foods when stressed. patients and the care you give. Instead eat some protein with some fruit Matiram Pun, Nepal or other healthy combination. Take a break for meals; don’t skip them. Finally, Most importantly, try to have a life outside when things are getting to you on a busy medicine, as medicine is a profession that shift, take half a minute to take a few deep easily takes over your life. breaths and release some tension before Tiago Villanueva, Portugal diving back into the jobs. Susan Kersley Know when to hand over something that takes you beyond your limits. Otherwise Have food with you at all times to avoid you will walk through the corridors with protracted periods of hypoglycaemia. That the hospital’s problems on your shoulders, liquid yoghurt or those all-bran biscuits in and that’s the med reg’s job! the pocket of your white coat are priceless. Adam Asghar, Yorkshire [Liquid yoghurt in a white coat? Sounds like an accident waiting to happen - Ed] Work hard, play hard. Exercise is probably Tiago Villanueva, Portugal the best destressor. Alcohol is probably Always have breakfast as you just never the worst. Do NOT self medicate with know when lunch will be. hypnotics or antidepressants. Seek help if Maryam Ahmed, Wolverhampton necessary; do not be embarrassed. Peter Martin, Essex10 | NEWLY QUALIFIED DOCTORS
  13. 13. DE-STRESSINGGet to know your fellow house officers.Sitting in the mess or accommodation Exerciselounge moaning and laughing about the Join a gym or take some other form ofday, and commiserating about shared regular exercise. When you get crashexperiences, was one of the best ways I calls you don’t want to be too tired by thehad of coping with stress in my FY1 year. time you get there to be of any use!Few people can empathise with your Imran Qureshi, Londonsituation as well as those going throughthe same thing. It is also important to get Take a few minutes a couple of times athe balance right; too much medicine in day to walk as briskly as possible fromyour life can drive you crazy. one end of the hospital to the other,Gayathri Rabindra, Sidcup preferably outside. Susan KersleySleep is more important than partying, evenwhen it seems like you have no life. Youdon’t, but eventually you will, so don’t ruinyour mental health before you get there.Rochelle Phipps, New ZealandMake sure you get a good night’s sleep beforeany on calls. Planning a night out with yourcolleagues can motivate you.Kiki Lam, BlackburnWear comfortable shoesand laugh a lot.Rochelle Phipps, Jobscore - peer reviews of hospitalNew Zealand doctor jobs Jobscore has relaunched with a cleanerGive yourself credit; you’re look, new features, and easier, more user friendly navigation.better than you think. Based on 50 specific medical criteria, itMahomed Saleh, UHCW provides a constantly updating picture of UK medical posts.Read fiction. Anything. • Sample at jobscore.bmj.comWilliam Hall, New York YOU WILL SURVIVE | 11
  14. 14. SKILLS STATIONTips for cannulating difficult patientsGrossly oedematous patients are difficult to cannulate because it is difficult to even see a veinto puncture. You can get around this by placing the tourniquet tightly, high up on the patient’sarm, then pressing very firmly but gently on the dorsal surface of the patient’s hand for, at thevery least, 1 minute–the longer, the better, though. This pushes all the fluid away and shouldleave you with a clear view of a juicy, fat vein! You must have your needle ready, though, becausethe fluid can return very quickly and obscure the vein again.Warm water can make veins visible and palpable. Get a small bowl or beaker (the ward shouldhave plastic ones) and fill it with water that’s hot, but bearable. Explain to the patient what youwould like to do and why you are doing it. Then place the tourniquet high up on his or her arm,and ask them to submerge his or her hand in the warm water. Keep it there for 5 minutes. Theheat should bring the veins up for you to puncture.Gloves can have a great tourniquet effect–not by using them around the arm, but by gettingthe patient to wear one. Estimate the patient’s glove size, then give him or her a glove one sizesmaller to put on, explaining that it will be quite tight and what you hope to achieve. Removethe glove after 5 minutes and cannulate away! You can also combine this with the warm watereffect.Robin Som, Cambridge ...and how not to do it • Tell patients it’s just a tiny scratch before you go digging into their flesh in every possible direction. • Prepare your patients by telling them they’ve got difficult, narrow, and wiggly veins. • Tell the patient you got into the vein but the tiny little valves on the veins are blocking your plastic cannula from moving in. • Tell your patients they have fragile veins when you give them a great big haematoma.If all else fails, call the friendly on-call anaesthetist (don’t call the same anaesthetist twice inthe same day; never call them within the same hour; get your fellow house officer to be thebad guy). You know you’re in trouble when the on-call anaesthetist tells you that they are nota cannulation service . . . then you think subcutaneous morphine or fluids, supplemented withregular diclofenac intramuscular injections, might just be the easier, or, realistically speaking, theonly option you have left.Yee Teoh, Kent12 | NEWLY QUALIFIED DOCTORS
  15. 15. SKILLS STATIONThree questions to ask yourself and the wardstaff at the beginning and end of the day: Get rid of the bubbleAnybody sick? Anybody new? Anybody going Arterial blood gas analysis of a patienthome? with severe pneumonia showed aMahomed Saleh, Coventry normal pO2, which I was initially satisfied with. However, on reviewing the patient I found him clinically worse Confirming death than the blood gas suggested. I repeated the ABG myself to find that patient If asked to confirm death, you need to write was severely hypoxic. I later found out the following in the notes: that the person who ran the first blood • Asked to verify death gas analysis had not removed the gas • No response to painful stimulus bubble from the syringe. • Pupils fixed and dilated Lessons learned: always remove the • No heart sounds (for 60 seconds) bubble from blood gas syringe and treat • No breath sounds (for 60 seconds) the patient, not the test result. • No carotid pulse (for 60 seconds) Farhat Mirza, Gillingham • Time of death (HH:MM on DD/MM/ YYYY). Have you registered for job alerts Note whether there was a pacemaker from BMJ Careers yet? palpable (for whoever does the cremation Take the hassle out of your job search form), then sign, name, and date the notes, by setting up alerts from BMJ Careers. and provide a clear contact number (in • Registration is fast and easy, sign up case the bereavement office need you). today at Sarah Jones, Nottingham Look underneath those dressings I was clerking a patient with sepsis who had subtle signs of a chest infection but not enough to explain the degree of his illness. The patient also had a dressing over his foot. In his letter the GP had written that he had examined a small ulcer on the patient’s foot, which he thought to be healthy so had applied a fresh dressing. For this reason I did not examine the foot. Later, when the consultant asked for the dressing to be removed, we saw green discharge from the ulcer and cellulitis around it–quite embarrassing for me. The lesson I learned was always to look underneath dressings, even at the cost of annoying the nurses. Farhat Mirza, Gillingham YOU WILL SURVIVE | 13
  16. 16. FIRST DAY TALEA first day to forgetI started in the Eastern General in Edinburgh pressure, which was initially normal, andon Sunday 1 August 1976, and experienced my did an ECG, also normal. I was doing a wardfirst death from medical error on the Monday. round with my consultant, and he went overMaybe this explains the rest of my career—as to look at the woman. It seemed odd thatan editor and busybody, rather than practising she should be so deeply unconscious after adoctor. simple test, but he didn’t think it necessary to I wasn’t totally terrified on that Sunday do more than monitor I had done a couple of locums, but I was Slowly people began to realise thatpainfully aware of my many deficiencies. something terrible had happened. TheInterestingly in retrospect, I saw those senior consultant arrived and immediatelydeficiencies as entirely my fault. It never grasped the seriousness of the woman’soccurred to me that it was a failure of the predicament. Now her blood pressure wassystem to leave somebody so inexperienced beginning to drop. The most likely diagnosiswith so many responsibilities. Indeed, I knew was that the needle had gone right throughabout body systems but never had considered the sternum and penetrated a major artery.that the hospital might be a system. So it turned out. That first day was quiet. My main job was The woman was rushed to the intensiveto admit a woman in her early 40s who was care unit, and cardiothoracic surgeonscoming in to have a specimen of bone marrow were called from the Royal Infirmary,taken from her sternum. She was being about four miles away. The surgeonsinvestigated for pernicious anaemia. Such a opened her chest, but it was too late. Shepatient would not now be admitted, and I don’t exsanguinated.think that anybody takes bone marrow from I’m not sure what happened to the Irishthe sternum anymore. This story explains why. medical student, but Phil, who seemed I don’t remember the woman clearly, but I remarkably unfazed by the whole experiencethink of her as ordinary and essentially well. at the time, subsequently became anShe certainly wasn’t sick. I think that she was anaesthetist, an alcoholic, and a druga mother. She was under another consultant, addict. He went to prison for driving whileso I didn’t see her again until the following disqualified, was struck off, and died moreday. than 10 years ago. All this may have been The other doctor, Phil, who had also just nothing to do with the death of the womanstarted, was responsible for doing the sternal but more with his drinking as a student. Wepuncture, and because he had done several as dissected the same body, a great bondinga student he got a medical student from Ireland experience, and he spent most of his first termto do it. She was rather tentative and didn’t at medical school trying to drink 100 pints ofmanage to draw any marrow. So Phil took over beer in a week. The first time he got only as farand rapidly filled a syringe with marrow. as the high 80s but the second time he made Seconds later the woman “fainted.” It was it. He was a laugh, was Phil.rather a heavy faint—so they took her blood Richard Smith, Clapham14 | NEWLY QUALIFIED DOCTORS
  17. 17. FIRST YEAR TALES“Doing the job of your dreams and learningsomething new every day”The busy on calls, moments of intense allowing me to be thoroughly systematicpressure, and facing difficult situations while managing acute medical andwith little experience to fall back on have surgical problems.all contributed to a steep learning curve, The most important aspect of this yearwhich every FY1 trainee encounters. has been reflecting on my attitudes and During my haematology rotation, seeing beliefs, and how these have played anthe effects of cytotoxic drugs on patients important role in realising my careerand being able to provide medical and goals. On several occasions I have had toemotional support was enlightening. communicate very difficult information toOwing to a prolonged hospital stay with patients and their families. This has beenmany patients experiencing severe illness, challenging but extremely was vital to develop an open, trusting, I can fully appreciate the importanceand supportive rapport. of being an effective team player, Colorectal surgery was my last rotation; developing good communication skills,with a high turnover of patients, good and always having a patient centredorganisation and prioritisation were approach.essential. Being mostly ward based, I The skills I have acquired as a juniorappreciated having done my medical doctor have been invaluable.and intensive care rotations beforehand, Nida Gul Ahmed, Lincoln YOU WILL SURVIVE | 15
  18. 18. FIRST YEAR TALES“Will I ever get good at this?”As a 12 month old baby doctor, I’ve had somedevelopmental milestone delays, but I’m starting towalk after a long “bum shuffling” phase learningorganisational skills. At the start I was very apprehensive about mycrash bleep going off. Well, I’m a bit sorry to saythat I now love crash calls. I may still be nervous,but the adrenaline rush is invigorating. My firstever chest compression began with the sound ofa cracked rib and the two minute cycle exhaustedmy arms, but the sweet sound of an output anda pulse brings a smile to my face. I was called toanother patient who arrested in the ward toilet.He didn’t make it, but I still thought that I could do this sort of stuff forever. Does thatmake me weird? There is a lot wrong with the F1 year: portfolio stress, getting blamed foreverything, fatigue, worry, arguments, constant pining for annual leave, and that oldchestnut, death. But all that is forgotten when I’m dealing with an emergency and Iremember for a few short minutes at least that I wouldn’t want to do anything else.Clinton Vaughn, Surrey Are you using Twitter? • Get instant updates from the doc2doc community at“My mind went blank—all those lectures on fluidbalance and I still couldn’t think of what to give”There is nothing like learning on the job. Looking back I recall my first week as terrifying—I even feared fluid prescribing,which like many other things is now second nature. As the weeks passed I gainedconfidence and picked up the tricks of the trade, quickly realising that as long as thejobs got done everything remained sweet. From putting out blood forms to ordering chest x rays, managing acutely unwellpatients, and making nerve racking telephone calls to the on-call registrar, I fulfilledmy role. Not a day passed without an exciting moment or a learning opportunity.Omar Barbouti, Kent16 | NEWLY QUALIFIED DOCTORS
  19. 19. FIRST YEAR TALES “Having half expected “There’s something aboutto be a glorified medical the pressure of beingstudent, I realised expected to know that cansomething had changed” make you crumble”This has certainly been a year of learning to It can also ensure you learn something andswim at the deep end. learn it well. My first night shift was spent covering The foundation year really lived upa medical ward just after Christmas to its name, providing the foundationswhen there had only been skeleton staff to build my career on. The gear shiftfor four days. It was emotionally and from medical student to working doctorphysically draining and made me want to ensures there is plenty of responsibility,walk away from my medical career and and with it pressure. Each specialty Inever look back, but I realise now I am have rotated through this year has givenbetter off for it. me different perspectives of hospital Call me crazy, but I have gone from medicine.fearing night shifts to welcoming them It hasn’t all been fun andas a pleasant change. Yes, I still feel that games, but every day hasbleeps could be used as instruments of been packed withtorture, but there is a surreal tranquility new learning andabout walking down dimly lit corridors practising a hugeand talking in whispers. The satisfaction range of skills.of accurately assessing and managing The workloadan acutely unwell patient, inserting a is immenselydifficult cannula, or being offered a well diverse andbuttered piece of toast are bonuses. has included Having said that, it never ceases to being the firstfrustrate me how the day you finish on scene atyour set of nights is called “time off.” crash calls;Surely giving me 23 hours to readjust my navigatingsleeping patterns does not equate to a the murkymini holiday? waters of medical Foundation year has taught me how ethics; auditingto be a doctor in more ways than one; and administrativeclinical knowledge, although important work; and holding ain its own right, has almost been less dying patient’s hand in his lastrelevant than mastering a calm and moments. Week by week I have feltconfident approach to the most stressful myself becoming a more competent andof situations. confident doctor.Yasmin Akram, Birmingham Ali S Hassan, Kent YOU WILL SURVIVE | 17
  20. 20. FIRST YEAR TALES“My confidence was destroyed when I was toldthat the previous FY1 doctors were the best theconsultants had seen, and had worked to thelevel of senior house officers” Difficult, stressful, and sometimes negative experiences from the past year tend to stay with me, more so than the numerous exciting, fulfilling events. Memories include being unable to cannulate patients, making inadequate referrals, or watching patients improve medically, then suddenly deteriorate and die. Positive moments include talking to patients and relatives, and being thanked for clarity and empathy; patients recovering after being seriously unwell; and being complimented by consultants and registrars for doing a good job. I have enjoyed and benefited greatly from the camaraderie between FY1s, and I have been fortunate to work within good teams, as well as with some great nursing staff. My most interesting conversations have been in the evenings or at night—making it almost worth being at work during antisocial hours. With each new rotation I initially felt out of my depth, and yet by the end of four months I became more confident and was able to make more independent decisions. Tabassum A Khandker, Surrey • Keep up with new research on doc2doc’s online journal club doc2doc.bmj.com18 | NEWLY QUALIFIED DOCTORS
  21. 21. USEFUL EXTRASFrom the hundreds of other tips we got ...Gradually, you will become more familiar with “what happens next” in any situation, andyou will grow more confident. Then you will get overconfident and cocky and make an errorthat shakes you (hopefully not a serious one). You’ll go back to being uncertain about whento be scared, but not quite as uncertain as before. Over time this will build up into a corpus offamiliarity, humility, and confidence that you can depend on.David Berger, North DevonEveryone gets frightened and tired, and feels like an imposter at some stage. Work within yourcapabilities, never be afraid to admit you just don’t know, and you will be fine!Rochelle Phipps, New ZealandDrug companies lie occasionally and mislead often. Do not obtain your information fromrepresentatives. There is no such thing as a free lunch. Read the evidence for yourself (critically).Peter Martin, EssexThe earlier your supervisors know about a problem, the sooner rectifying attempts can bemade. If you are given a ridiculous rota, come up with an alternative and present it to thoseresponsible for it. You may not achieve instant success, but you can strive to improve patientsafety and working conditions, rather than grinning and bearing it.Adam Asghar, Yorkshire You are an FY1 - not superman - and people know this; mistakes are expected. This is how you learn. Ask for help, and you will usually get it. If after the first few weeks you still do not like your job, talk to someone about it. If you bottle things up you are in danger of becoming ill yourself. Catriona Bisset, Glasgow Organise an audit early as it may take time to gather information from notes. Re-auditing is important to complete the audit cycle (and impress at interviews). Kiki Lam, Blackburn Don’t be afraid to “blow the whistle” if you witness a dangerous incident. Adam Asghar, YorkshireMost importantly. . . it gets easier! - Claire Kaye YOU WILL SURVIVE | 19
  22. 22. SCO R I N G S YS T E M S R E F E R E N CE INTERVALSPatients in AF: aspirin v warfarin (CHADS2) Community acquired pneumonia (CURB65)Congestive heart failure 1 Confusion New onset 1Hypertension (treated or not) 1 Urea > 7 mmol/l 1Age > 75 yrs 1 Respiratory rate > 30 1Diabetes 1 Blood pressure Sys < 90 or dia < 60 1Stroke/TIA 2 65 Age > 65 yrs 1Score 0 = Low risk Score 0-2 = Mild to moderate CAPScore 1 = Moderate risk – daily aspirin Score 3+ = Severe CAPScore 2+ = Moderate to high risk – warfarin(if not contraindicated) Abreviated mental test (10 point AMT)Seek senior advice before starting treatment Age 1 Date of birth 1 Year 1 Time of day (without using clock) 1Wells scores: Place (city or town is acceptable) 1for PE Monarch (or prime minister) 1Clinical signs of DVT 3 Year of World War I or II 1Alternative diagnosis less probable than PE 3 Counting 20-1 (can prompt to 18, e.g. 20, 19, 18) 1Heart rate > 100 bpm 1.5 Recognition of 2 people (e.g. doctor, nurse) 1Immobilisation or surgery < 4 weeks ago 1.5 Recall of 3 points (e.g. address or 3 objects) 1Previous DVT/PE 1.5 NB: Variations exist; this is a guide.Haemoptysis 1Cancer 1 Pancreatitis scoring (Glasgow system) PaO2 < 8.0 1Score <2 = Low probability of PE Age > 55 1Score 2–6 = Moderate probability of PEScore 6 + = High probability of PE Neutrophils (WCC > 15 x 10 9 /l) 1 Ca2+ <2.0 mmol 1 Renal Urea > 16 mmol/l 1for DVT Enzymes LDH > 600 IU/l or AST > 100 IU/l 1Active cancer 1 Albumin <32 g/l 1Paralysis, paresis, or recent plaster Sugar BM > 10 1immobilisation of the leg 1Recently bedridden for > 3 days Score 0-2 = Mild to moderate pancreatitisOR major surgery within 4 weeks 1 Score 3+ = Severe pancreatitis (may require HDU/ITU)Localised tenderness in area of deep venoussystem 1 Chronic kidney disease (CKD) stagingEntire leg swollen 1 Stage 1 GFR > 90 ml/min with structural/ biochemical abnormalityCalf swelling by more than 3 cmcompared with the asymptomatic leg 1 Stage 2 60-89 with an abnormality (as above)Pitting oedema – greater in the symptomatic leg 1 Stage 3 30-59 ml/minCollateral superficial veins – non-varicose 1 Stage 4 15-29 ml/minAlternative diagnosis as likely or more Stage 5 < 15 ml/minpossible than that of DVT -2 Labelling someone as having CKD requires two samplesScore < 2 = Low probability of DVT at least 90 days apartScore 2+ = Moderate to high probablility of DVT Online GFR calculator: | NEWLY QUALIFIED DOCTORS
  23. 23. E S S E N T I A L T E L E P H O N E NUMBERSAnaesthetics Medical managerA&E x ray Medical recordsAnticoagulation clinic Medical registrarAnticoagulation nurse MicrobiologyBed managers Mobility physioBiochemistry on-call MRIBiochemistry OTBone scans OutpatientsBreast nurse Pain teamCardiology Palliative careCardiology clinic PathologyCare managers PayrollChest clinic PGMCChiropody PharmacyCoroner PhlebotomyCT PhysiotherapyDermatology clinic PortersDiabetes nurse Pre-opDietitians RegistryDoppler SALTEEG Surgical managerEMG UltrasoundEndoscopy Vascular USSEye clinic X rayFacilitiesGUM clinic SURGICAL WARDSHaematologyHearing & balanceHistologyHistopathologyHuman resources MEDICAL WARDSITITULiaison psychMDM coordinator YOU WILL SURVIVE | 21