Black Wednesday

Every doctor remembers their first day...

The first Wednesday of August every year has a name in medicine: "Black Wednesday." The day thousands of newly-qualified doctors walk onto wards across the UK and become, overnight, responsible for real patients, real decisions, with real consequences.

This...was my Black Wednesday.

A morphine prescription that broke me, a ward round that humbled me, a radiologist who sent me packing and somewhere between the pride of my first blood test and my first failure, the quiet realisation that five years of medical school had prepared me for almost none of it.

Transcript

SPEAKER_00 0:01

This is the first episode of the Diary of a Resident Podcast. This podcast will be a platform for me to bring into spoken word my real and honest experiences as a doctor in the United Kingdom. My career as a doctor is relatively new. I've finished my foundation years and I'm currently on a specialty training program. The butterflies when writing the letters DR in front of my name remain well and truly fluttering in my stomach. But it is not an exaggeration to say I've seen a lot in my relatively short career. For now, I don't think I'm ready to introduce myself properly. You'll simply have to take my word that I am a doctor in the UK, working in the National Health Service, and that my stories are the realest things that I know. Whether I will one day expose my personal identity remains an undecided issue. I'll update you all as soon as I know. Episode 1 Black Wednesday. Wednesday the 2nd of August 2023. I set my alarm for 7 a.m., an hour and a half before I needed to be on the ward. I lived only a five minute walk away from the hospital, but I was determined to eliminate any possibility whatsoever of being late on my first day. Naturally, I woke up at 6 53 a.m. The sun was out in a beautiful clear sky. I knew they called it Black Wednesday, but I think the weather had something to say about that. I hopped out of bed with a slight spring in my step, made my bed, ensuring the duvet was correctly laid out with no creases and nothing to suggest someone messy had slept here. I was a doctor now, after all. I put on my neatly folded clothes, which I had ironed the night before, and placed my yellow name badge on. It read Hi, my name is Doctor Doctor. I still couldn't believe it. I'd worked what felt like my whole life to get to this day, and I was finally here. I even wrote my name out on a piece of paper with my new title multiple times that morning, mentally conditioning myself, learning to turn my head to attention whenever anyone asked. Doctor, in my direction. Breakfast in belly, water bottle in hand, notepad and two black ink ballpoint pens. They had to be black, and you needed two of them. Pens had a tendency to grow legs and run away at moment's notice, so I was told. In bag, I made the five-minute journey to the hospital, straight onto the respiratory ward, where I would sow the seeds of my new career as a doctor for the next four months. By 8.20, I had made my way onto the ward and straight into the doctor's office. It was a small room, an almost perfect square, with four computers. I knew today our team was going to consist of two consultants, one trainee respiratory doctor, and three resident doctors, including myself. My first win of the day, therefore, was securing a computer. My early rise and meticulous timing had already borne fruit. The rest of the medical team entered over the next ten minutes. First my two FY1 colleagues, next the respiratory trainee, and finally the consultants. Should we start? the nurse in charge asked as she opened the door and entered our office. Please, responded both consultants in perfect harmony. I turned around in my seat to face the team, nodded my head, smiled, and asked myself, What on earth are we starting exactly? It was the board round, as I came to find out, that we were about to start. At the beginning of the day, we would go through all the patients on the ward one by one, with the consultants outlining their reason for admission, current management, and any outstanding tasks. It was my job as the resident to note all of these down and ensure that by the morning board round of the next day, the outstanding tasks section was all but empty. I had my notepad out once I realised what was going on, and I knew I had to start writing down important details. Patient name, location, jobs to do, tasks to chase. Much harder than I initially thought. Where's Side Room 7? I thought, and what does ward-based care even mean? Isn't everyone here being cared for in a ward? There were terms being thrown my way with an unquestionable confidence that I knew exactly what was being said. It took me a while, but after the third or fourth patient, I had caught up. I had a rhythm. Name, bed, outstanding tasks. Name, bed, outstanding tasks. But before I could start feeling comfortable. Sorry, Doc, can you prescribe some more or more for bed nine? Of course, I responded, turning my chair towards the computer and staring blankly at the electronic program we used to prescribe medication. Now very aware that the seat I had chosen was in the direct line of sight of anyone who entered the room. I found the patient on the system, clicked their name and pressed the enter order button. Here we go. Five years of medical school, sleepless nights, blood, sweat, and tears. I was ready for this moment. I typed morphine, and to my horror, no less than twelve formulations of morphine appeared on the screen. Five milligrams, ten milligrams, twenty milligrams oral solution, solution for injection, modified release. Oh my god, I thought. Which one do I choose? Why did the patient even need it? I didn't ask for God's sake, how silly. And what was their kidney function like? I thought a patient with poor kidney function can't have morphine. I'll end up overdosing them and that could be really dangerous. I should ask for help. But wait, I'm a doctor now. How could I possibly look my seniors in the eyes and ask about a morphine prescription? It's 2.5 milligrams, mate. Choose the oral solution, and his kidneys are fine. Came to the rescue the friendly respiratory trainee who clearly saw that I was struggling. Thanks, I said, letting out a breath of relief as I said it, to make it clear to him that yes, I was struggling, and yes, I was really grateful. With the board round done, now came the time to start the ward round. The ward was split into two, side A and side B. There would be one consultant seeing all the patients inside A, and the other would be reviewing those inside B. You can come with me, said one of the consultants. I'll take the other two, said the other. The spotlight was really about to be on. There would be no other nervous resident for me to blend into on my side, side A, as it turned out. Just me, the consultant, and the respiratory trainee doctor. At least he would be there. He'd proven an invaluable asset with the earlier morphine prescription, so I knew he could help me if I got stuck. My job was to record the details of the wardround, and have all the scans, blood results, observations, and any other important bits of information ready to ensure the consultant had everything they needed to make a plan. With this came the realization. The challenge was that each of these important pieces of information existed on different programs on the computer. For each of them I had different login details, which I had luckily noted down on my phone. It took a while, but I managed to get everything ready before the consultant came. You ready? Yes, sir. What are the inflammatory markers looking like? Good. Seems like they're downtrending. Great. Let's switch this patient from intravenous to oral antibiotics. Next. Show me the X-ray. Uh here it is. It looks like some consolidation in the right lower lung. Right lower lung? Hmm. What could be going on here, Doc? The word doc landed square into the centre of my chest. Hmm. Um what could be causing a new right lower lobe pneumonia? Think, doc. Um aspiration? It looks like from the nurse's notes the patient was vomiting yesterday. Could she have aspirated? Good. Take some repeat bloods for today and review. I'd expect the inflammatory markers to shoot right up for this patient if she has indeed aspirated. And what antibiotics is she on? She's not on any, sir. What? You see, Doc, this is the kind of information that is important. You need to keep your eyes peeled for it. Give him some comb oxyclaive, please. Okay, sir, but he is allergic to penicillin. Okay, so what's the alternative, Doc? Um is it clarithromycin? Excellent. Prescribe it, please. Halfway through? Almost done. This is not going too badly. Right. Now show me this patient's CT scan. Should have been done this morning. It hasn't been done yet, sir. What do you mean it hasn't been done? Did you not call the CT department this morning to get it scheduled? A pause. I had no response. I looked at the wardround notes from the previous day and saw it. Resident Doctor to Chase CT scan in the morning. I hadn't reviewed it. That's actually my fault, sir. I didn't hand that over to the new doctor starting today. He couldn't have known. I'll get it scheduled myself now. The respiratory trainee. Again. I felt terrible this time though. If I had taken more care, he wouldn't have found himself in what was now an awkward situation. Get it done, please. The ward round was over just on time. I mentally inspected myself for theoretical wounds, like in the movies when a character has just sprinted through no man's land, dodging bullets, and when they reach the other side, they check themselves over. Conclusion?

SPEAKER_01 11:42

I was still intact.

SPEAKER_00 11:47

With the ward round done, the consultants left the ward, and now came the time for the clinical work to start. The time was 1 pm, and I had until 4.30pm, which is when the consultants would come back, to complete all the tasks, whilst also being available to respond to any emergencies if they became apparent on the ward. From this moment on, it was only me, my two F by one colleagues and the respiratory trainee. As soon as the consultants left, you could almost feel the tension in the room dissipate and hear the sound of our collective shoulders resting. Now off we go. I got all the equipment together, needle, tourniquet, sample bottles, gauze and tape, and made my way to the patient. Hello, I'm one of the doctors. Do you mind if I take some bloods please, my dear? Hello, young man. No, not at all, please go ahead, to which she then added, Oh, to be twenty years younger, and began giggling along with the patient in the next bed. Taking blood from a vein is a meticulous task. You have to first identify a vein which is plump enough for your needle to poke through, whilst also ensuring you inflict the least amount of discomfort to the patient as possible. During medical school, a doctor had once told me that the hands are the most painful, too close to quite a few bones. You should always try the middle of the arm first. And so I did. I placed the tourniquet on first. This will be a little tight, my dear, might be uncomfortable, but shouldn't be painful. You tell me if it is though, okay? Yes, go ahead, darling. I've had many of these unfortunately. The tourniquet was on, nice and tight just above the elbow. The rest of the arm started going red, and I had my eyes peeled, looking for any good veins to declare their position and candidacy for my first ever set of bloods as a doctor. And there it was, in all its glory, the medial cubital vein, the big vein in the arm. It's an excellent vein to take bloods from. It rarely moves from its position, very secure, so it won't run away from you once the needle is in. Also good volume of blood, so getting enough for a sample wouldn't be difficult. Okay, sharp scratch. They always say sharp scratch, but it rarely is just a scratch, the patient stated whilst giggling at me. The needle went straight in, and there it was, what we call flashback, where the blood from the vein enters into the transparent end of the collecting tube, an indication that you're in. I attached the bottles on the other side, and on it flowed, uninterrupted and to the fill line. Needle out, gauze on, tape applied, and tourniquet removed. I thanked the patient and made my way out, sample bottles in hand, holding them like trophies, a testament to my clinical excellence, ready to accept the inevitable and numerous praise. I put them in a bag and handed them to the nurse in charge. Here you are, bloods for bed too. Thanks, I'll send them now. She didn't even look up. An anticlimax. In my head I was screaming. I just did that, all on my own, on my first go. Clearly, it just wasn't that impressive. Taking bloods is the bread and butter of this job. I know that now. But at the time, it was my first piece of clinical work as a new doctor. And I was proud of myself. With my basking in clinical glory now complete, I moved on with the rest of the jobs for the day. One of which was the CT scan that should have been done in the morning, the one I'd missed. It was time to make my way to the dark embers of the radiology department. The radiologist is, in the most simple terms, a photographer on anabolic steroids. But before they surrender their photographic powers, you have to earn it. You have to discuss the scan with them, prove why your patient deserves it. Almost all radiology scans carry a risk, radiation exposure. An X-ray, minimal, a CT scan, significantly more. The fundamental question every doctor asks before any decision is whether the benefit outweighs the risk. Yes, the patient gets a dose of radiation, but if that scan uncoves a surgical emergency, they could be on an operating table within minutes. Worth it. The radiologist's job is to scrutinize your request. Make sure your cost-benefit calculation adds up. Their offices live in the dark underworld of the hospital, kept deliberately dark so scans can be reviewed with perfect clarity, no interference from outside light. Cold, quiet, slightly intimidating. And on my first day as a doctor, it was also the setting of my first failure. So the patient had a CT scan two days ago. Why do they need another one? Because it looks like they may have aspirated. Why? Well, the chest x-ray shows a right I know what the chest x-ray shows, but clinically, why do you think the patient has aspirated? Oh yes, sorry, so she's been vomiting overnight and then suddenly became unwell afterwards, needing a lot more oxygen. She was having fever spikes. We suspect that's when she aspirated. The radiologist considered my explanation, and the dark room somehow became darker. Request refused. But sir, my consultant made it clear this really does need to happen. You tell your consultant his diagnosis has already been proven by the clinical history and by the chest x-ray you already have. If you're suspecting something other than aspiration pneumonia, a CT scan may be appropriate. But for now, refused. Please leave my office. It felt like a fall from grace. Having only moments ago succeeded in one job, I had failed in another. I walked through the cold and dark corridors of the radiology department and started making my way up the stairs, the light through the windows of the double doors at the top illuminating the entire staircase. I felt both ashamed and embarrassed. How would I tell my consultant I hadn't been able to schedule the CT scan? It was already supposed to have happened in the morning, and now it didn't seem like it was going to happen at all. I walked back onto the ward and back into our office, sat down and waited for the clock to strike 4 30. It was 4 15. The other jobs had all been done. Bloods were taken, the results were reviewed, discharge letters written, family conversations had. Done. He's awaiting transport. And did you update the family? Yes, they were pleased to hear he was improving. And the CT scan? He clearly knew I hadn't managed to get it done. So um I went and spoke to the radiologist, and he didn't feel that the scan was was what? Appropriate? Well, in his words, the consultant's hand rose, stopping me mid-sentence. But I was surprised to see a small, noticeable smile on his face. I also realized I was sweating. Relax. I already spoke to the radiologist. He's particularly pedantic when it comes to approving scans. The scan's happening later, and I'm on call tonight, so I will review it myself. I sat back in my seat and I was no longer sweating. My first day was done. But the truth is, as I made the short five-minute walk back home, I didn't feel a sense of having really survived anything. I stared straight at the pavement as I took my steps, replaying in my mind the events of the day. It wasn't until I got to my front door that I realized I had a smile on my face. I walked in, took off my work clothes, prepared my clothes for the next day, had a shower, put on a pair of shorts and a t-shirt, heated up some leftover spaghetti bolognese, and sat in front of my TV watching Rick and Morty for the rest of the evening. And that is when I realized this is now my life. This was my version of the 9-5 that everyone talks about. Just a doctor who goes into work, does his job, and comes home. I could not have been happier. The stresses of the day all but melted away, and at around 10 30 pm, I tucked myself into bed under the neat crease-free duvet and went to sleep. I would soon learn that the stresses which had so preoccupied me that day were no stresses at all. Not for what I was about to experience over the next four months.