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Real life advice

Female junior checks notes with nurse

Read real life advice, stories and lessons from doctors who've been there and made it through their first foundation year.

  • Mastering the basics

    Approaching a sick patient

    There is no getting away from it: the first time the crash page goes off your heart will skip a beat and there's every possibility you might fill your pants!

    You feel the page vibrate first, then the dreaded monotone voice telling you 'cardiac arrest … ward 666'. At this point you stare at the nurse standing beside you at the coffee machine and look for some sort of guidance or instruction... and off you go, full speed along the corridors hoping to find ward 666.

    It is here I would offer my first point of advice - stop, take a breath, and relax.

    Before entering into the theatre of chaos that lies on the other side of the ward doors, just take a second, catch your breath and think - 'what am I going to do when I walk through these doors?'.


    Walk, don't run

    My advice to you would be to walk. Running will end in one of two ways:

    • you will slip and go hurtling full speed into a very solidly constructed clinical waste bin (been there, done that)
    • you will be so out of breath that you won't be able to communicate effectively with the nursing staff (who at this time will probably be more flustered than you)

    So, walk down the ward and, on the way, pick up a box of suitably sized gloves and put those on before reaching the patient. By the time you reach the patient you have given yourself ample time to remember the basics of what you must do now (such as ABC) and you have approached the patient in a manner which has left you fit to take control of the situation.

    Remember, you will most likely be the first there and others will be looking to you for instructions. You will be in charge and you need to be in a condition ready to do so.

    So, that's one aspect of 'approaching the sick patient'. Of course you won't see the vast majority of patients (or hopefully your first) as a consequence of the crash call.

    It is most likely that a nurse will grab you at 6pm when you are just finishing your blood forms before going home and tell you that 'Mr X has a SEWS of a 1,000 and looks blue.'

    Cancel your plans with your mates, as this one is going to take a bit of time.


    No experience more lonely

    At this point you will realise that there is no experience more lonely in life (that I have experienced anyway), as being the F1 on call for acute admissions.

    Forty patients to have ready for the ward round, your senior is getting hammered in emergency and you haven't the foggiest idea what to do with an unknown patient who has a SEWS of 10,0000 (note the patient is getting sicker).

    Then again, I would suggest that your approach to this would be exactly the same as the arrest patient. Nothing is to be earned from:

    • running
    • swearing
    • shouting at nurses (they will shout back at you and quite rightly so. Nurses are always right)


    Take time to look

    When on the wards and walking to the end of the bed, remember that the most important thing to do is look.

    Again, take five seconds, watch and listen. This will give you more information about the patient than the SEWS score.

    Then do the basic things well, in a confident and controlled fashion. The simple things to look for when first approaching the patient could make a very long list, so I have just put down a few things that you should remember to assess. They will tell you instantly how sick this person is and what you are going to need to do now.

    They all revolve around ABC. It's kind of like driving a car. At first you have to remind yourself to assess these things, but as you get more experienced you will notice and assess these things subconsciously.

    Once you can do this you have the valuable ability to 'identify the sick patient' and act on this quickly.

    • airway and associated sounds?
    • how much oxygen are they on?
    • breathing rate?
    • accessory muscles?
    • kaussmauls?
    • consciousness?
    • colour?
    • obs on the monitor?
    • urine in the catheter bag (colour and amount)?
    • pain?
    • what venous access do they have?
    • and do they look like death?

    Now that you have taken five seconds to look at the patient, it is time to continue your assessment.

    But, you should also simultaneously perform simple manoeuvres that will improve the patient's condition instantly, such as open the airway, increase the oxygen, position the patient, open fluids and so on.

    At the same time, you should continue your assessment: are they cold, clammy and peripherally shutdown?


    Do you need help?

    Now that you have an idea of how sick the patient is and you have started to treat them, the next question to ask yourself is 'do I need help?'.

    I would encourage you at the beginning of your career not to be scared to ask for help with sick patients.

    This is for two reasons:

    • if you don't watch seniors with sick patients you will not progress in your own ability
    • your seniors will want to know about sick patients, especially in the first few days of new jobs


    Confident, competent and controlled

    As you progress through the year you will get better at assessing and treating, you will be more confident, and you will be ready to make decisions.

    It is a steep learning curve so don't worry - soon enough you will be confidently treating patients on your own!

    I'm sure you will have read many articles on similar topics by people more experienced than me, and articles quoting ABC over and over, as this is very, very important.

    I hope I have given you all encouragement to be confident, competent and controlled in the first 60 seconds of looking at a moribund patient.

    These are the most important 60 seconds of the patient's care and you are in control of them. There's no getting away from it, you will be called to see sick patients so you might as well relish the challenge.

    Enjoy your first days and good luck!

  • Breaking bad news

    Specialty registrar 4 in general surgery

    To be a doctor is a privilege, undoubtedly, but it comes with responsibilities that can be, to say the least, onerous.

    Have you ever talked to a friend out of the profession and, upon discussing the breaking of bad news, they've shaken their head, stating, 'I could never do that' or, 'rather you than me'?

    I will not patronise you to tell you how hard this element of the job can be. To varying degrees you will already know. But I will say this is a chance to make a difference, to really be a doctor. For even in the giving of the worst possible news, it is the manner of doing so that can make such a difference. It is a defining point in the remainder of that person's life.

    While it is true that their personality, family support and other elements will affect how they deal with the news, it is also true that you can affect in what direction they choose to set off.


    We need to talk

    The imparting of bad news is a key role in a doctor's job.

    It is a communication skill that, like all others must be learnt and honed. Medical schools have focused intently on communication in recent years and post-graduate college exams will involve a communication element. This is evidence of the recognition, albeit perhaps delayed, that such skills are central to our work.

    Though it may be awkward, the only way to learn is to watch those who are more experienced. Like any other skill in our profession, you must observe and note that which you consider good and that you would hope to imitate.

    You have to be in the room when bad news is broken, as unobtrusively as possible, and only if the family or patient have no hint of an objection, but you must be there.


    Be prepared

    No one should ever be alone when ill tidings are in the air. This includes you. Patients should have the opportunity to have someone with them and so should you.

    In general practice this may not always be easy but in hospital, a nurse or other colleague should always be there. They may help if you falter and, if you have to leave for elsewhere, they can stay awhile. This allows a feeling of gradually withdrawing rather than a wholesale 'Right, that's the way it is, we're all off then.'

    If an interpreter is required, make it your responsibility to ensure they will be there, and make sure you discuss with them the salient points that will be covered before seeing the patient. Like you, the interpreter must be prepared; must think about how they will phrase things, what words they will use. Bear in mind that they may have significantly less training and support in breaking bad news.

    You may feel the news is coming from you but it is the interpreter's words they will hear and it is to them that they will turn and direct questions. Do not forget how the situation may affect the interpreter.


    Did you look after my dad?

    There are several sources of advice on structuring the meeting. The Oxford Handbook of Clinical Medicine (the infamous 'Cheese 'n' Onion') gives advice on breaking bad news and included here are a couple of additional references that can be accessed online. These may be useful to skim over at work before such an encounter. The key elements are constant.

    Introduce yourself and do not be tempted to obfuscation if asked direct questions.

    If you have never met the patient before and you are asked 'Are you one of the doctors who looked after my dad?, explain that you are not but that you are the doctor working this evening and you did not want the family to be kept waiting.

    Throughout the dialogue always use clear and direct language. Euphemisms are best avoided.

    The embarrassment and hurt that can be caused when elements of the conversation are misconstrued can be more damaging than the entirely natural grief and distress that will be caused when the plain and unavoidable facts are made clear.

    Have a plan for further meetings, referrals or palliative care treatment that you can discuss. This gives a more positive slant to the close of the meeting. Always document all such encounters and the salient points in the medical records.


    We did everything we could

    Breaking the news of a death follows a very similar pattern. An establishment of their knowledge of the seriousness of the illness or trauma if you do not already know the family is essential.

    When you state that the person has died, do not rush to say any more than 'I'm very sorry.' Even if the news was expected there must be some time to allow it to sink in and nothing you say in those first few moments will be taken in. Do not be tempted to go into great detail unless the family request it and question you.

    A further meeting later that day or the next may be the time to discuss matters in depth. I have seen families in bleary bewilderment while someone tries to describe in detail why the emergency surgery was unsuccessful. Anatomical terms, operative equipment, procedural names - the whole works. This is rarely appropriate.


    It hurts me too

    News of a terminal illness affects the patient, their family and friends, and you. Do not forget you.

    You cannot tell someone they are going to die, regardless of whether you've known them a year or a day, without feeling its impact.

    You may relate it to a friend or family member, to a case you've seen before, you may play out entirely imaginary and upsetting stories of how it will affect their family. Even if you attempt to not think about it, then, in doing so, it is affecting you and, more importantly, you are not dealing with it.

    Remember the advice you give your patients and take heed of it yourself. Take advantage of the friends and colleagues you have.

    Patient confidentiality must be maintained but you can still talk about a difficult day or having to tell someone terrible news.


    Key part of being a doctor

    Do not feel that you must shoulder the burden alone. The entirely natural reaction will be to be upset and disheartened.

    Take a few minutes before carrying on with the rest of your work and be aware it may continue to preoccupy you throughout the day.

    It is tempting to avoid these unfortunate situations and to let someone else break the news. I would encourage you not to do this. This is a key part of being a doctor and goes hand-in-hand with the accompanying privileges of being so intimately involved in caring for people.

    Developing these skills through reflective practice will help improve your confidence in such emotionally charged settings and further your professional development.

  • Surviving the night shift

    Specialty trainee 6 in General Surgery

    If upon considering nightshifts your first thoughts are tinged with apprehension that is only to be expected. If your consequent thoughts are vats of coffee, ProPlus, matchsticks for eyelids and drawing pins in your shoes, then you are setting off on the wrong foot (and a soon to be a bleeding one at that).


    Know your enemy

    Your enemy is not that scary consultant in emergency, it's fatigue. Let's not get physiological about this but your body is fighting to tell you to sleep. Outside it is dark, your hormones are in flux and a baseball programme is on Channel 5; you should be hugging teddy. But if you equip yourself properly for battle, nightshifts can become some of the most fruitful times of your early career.



    Trying to sleep before the first nightshift is hard and there are a multitude of techniques that each individual will advocate as the most successful.

    Caffeine-laden comestibles are best avoided. Drink water and fruit juices to combat dehydration and 'slow release' foods such as nuts and dried fruit.

    Tempting as it may be, a night of drink and dance until the sun glints on the rooftops will not best prepare you for the ensuing nights of work and concentration. A lie-in followed by an afternoon nap is probably a suitable way to ease into a new sleep pattern.

    Your bedroom needs to be just that; a room with a bed for sleeping. I find blackout material taped over the blinds helps plunge me into foetal darkness. You may prefer an eye mask, and earplugs for when your neighbours all decide to Hoover at the same time.

    You must remember to eat, and getting your shopping done to cover the period of your nightshifts will save an exhausting traipse round the supermarket post-shift, or an infuriating early rise in the evening to shop pre-shift.


    Reference books, pens and cereal bars

    A brief period of heart-pounding alertness will signal an even deeper tiredness and the inability to sleep in the morning.

    Water and fruit juices to combat dehydration and 'slow release' foods such as nuts and dried fruit are good. Cereal bars are always handy to carry in a pocket to munch on between wards. Ideally you'd have a veritable banquet laid on by the HDU staff each night as I happily experienced once, but I can't guarantee it.

    Make sure you have all the usual tools of your trade: stethoscope, pens and the rest. You'll see lots of the usual night's call - dropping BP, decreased urine output, chest pain, falling Sats and requests for night sedation.

    Read up on these beforehand if you need to and revise your resuscitation guidelines.

    Carry a helpful book that you trust, such as an Oxford handbook or good on-call book (pocket-sized preferably). And if your hospital or NHS Board has a prescribing guide then take that too.


    First-night nerves

    Be on time and write everything down. Make sure you know who else is on with you and who to contact if you have a problem.

    I worked with a registrar who, on the first night, would head off saying: 'Call me if you need me'. He would then lope down the corridor before coming back and asking: 'What's my page number?' Invariably the junior wouldn't know it and hadn't thought to ask. Make sure you do.

    Get a good handover from the evening shift. It is tempting to be magnanimous and say graciously: 'I've got it, you head off'. Resist this admirable temptation and find out what is left over from the previous shift - problem patients, tasks to be completed at certain times overnight or results that must be available for morning rounds.

    Tiredness breeds laziness. Strongly resist the urge to cut corners and ensure you write fully in the notes. Three in the morning is rarely a good time to drastically change a patient management plan unless your seniors have approved it.

    Don't let the night shift be lonely: there are plenty of other people in the same boat, wandering the hospital. Help those around you and they, in turn, will help you. Teamwork is especially important at night.

    Napping may be of benefit for periods of 20-45 minutes. Longer may lead to deep sleep and grogginess on waking. Times are changing and on-call rooms disappearing but you are entitled to breaks and these may be used for naps if you want to.

    Remember to eat, drink and use the 'facilities' as mother might say.

    Although there is often a pleasurable sense of autonomous working at night, you should be well supported by an experienced team including more senior medical personnel on site.

    Remember the maxim: Get help sooner rather than later.


    The morning after

    Keep in mind the tired and emotional state that you may occupy come morning. A particular diagnosis or event may elicit a hyped-up mood, or a sad event may hit you harder than you feel it might on a day shift. Taking pause to talk these over at handover in the morning or with a colleague coming off shift will help to clear your head.

    Driving home after a nightshift puts you at an increased risk of being in an accident. Ideally, take public transport home or rest before driving. However you make your way home be aware your alertness is not functioning at peak capacity.

    For all kinds of good reasons don't stay up watching daytime TV. This is also not the time to make that trip to the bank, return those books to the library or meet that friend for lunch.

    Have a light meal, turn your mobile to silent, set an alarm and head to your well-prepared, dark and peaceful, bedroom.


    And in the end

    Getting back into daytime mode can be difficult and you'll feel discombobulated for a day or two.

    Try having a brief sleep in the morning, a nap late afternoon and a good attempt at a proper night's sleep that evening.

    Although daunting, nightshifts can provide excellent opportunities to improve clinical and diagnostic abilities. So grab your stethoscope and a banana, and get stuck in.

  • Preparing for the ups and downs

    Core trainee 1 in Psychiatry

    What would a doctor in my position usually do right now?' I asked the surgical ward sister, simultaneously pleading for divine intervention. My source of help turned out to be dressed in blue - the nurse who had seen it all before, including terrified F1s faced with their first sick patient on call. 

    After I'd stabilised the patient with significant help I went home, feeling like a failure, a fraud and wanting to quit.

    The F1 year is all about peaks and troughs, good days and bad days...

    Fast-forward four months and I’m managing considerably sicker patents without any help and feeling pretty good about myself. Instead of running straight to the registrar for help, I spend a few minutes thinking about the situation - do I need help with this or is it something I can handle myself? 

    If I'm out of my depth and the patient isn't about to arrest then I find it is a good idea to do bloods, order x-rays and generally get the ball rolling, so when the registrar gets there they've got something to go off.

    The F1 year is all about peaks and troughs, good days and bad days, hectic days and busy days, but as the weeks and months go by you become an F1 machine. The bleeps that once filled you with dread don't anymore and you've seen most of the common stuff. Now the prospect of something unusual is actually quite interesting.

    It is a massive learning curve but it does get easier, just ask F2s and registrars. Don't be afraid to ask for help, particularly at the start. In a year's time you'll be amazed by how far you've come while realizing there's still so so far left to go. 

    F1 is simultaneously the worst, best and most memorable year of your life; enjoy, it won't last long.

    Oh, and one final thing, it's a cliché but crucial - be nice to the nurses!