Interdependence - a tale from the wards

Originally published at onthewards | Medical Podcast, Blog & Online Community for Doctors

September 2019

Once upon a time – more years ago than I care to own up to – I was a freshly minted doctor. A newbie. I was pleased with myself because I survived the first day of internship, although the taupe-coloured trousers I had worn to work hadn’t fared quite so well. Day two loomed with a new challenge: my first evening ward-cover shift, which would run from the end of the regular day shift at four thirty until eleven o’clock. I was apprehensive but felt reassured by the weighty presence of The Oxford Clinical Handbook (a.k.a. ‘the yellow bible’) in my handbag (no smartphones in those days) and the knowledge that I had been preparing for this moment for years.

When I told my family that I was planning to study medicine, their response was to snort laughter and quip that I couldn’t even handle a bad smell. As someone who still can’t watch surgery on television, I had taken extra steps to make sure I was ready for the wards. At the beginning of third year, a friend and I set each other a needle challenge: a race to perform a series of procedures we thought we might need as interns. We had compiled the list with the neurology resident (who was supervising our clinical rotation) and had both crossed off a lumbar puncture by the end of term.

Momentum built when our classmates learned of the challenge and began to egg us on.

He inserted a nasogastric tube on the surgical ward. Hooray!

I removed a foreign body in ear, nose and throat clinic. Boom!

We struck needle gold the afternoon we attended pathology outpatients and were tasked with taking blood from local firefighters who were attending for their routine medical. They had veins like tree-trunks and were surprisingly willing participants in our mission.

Venepuncture – achievement unlocked!

Next stop – ambulatory care for cannulation, then respiratory clinic for blood gases. Soon we were ready for anything the hospital could throw at us. I grew up to become an emergency physician and my friend a neonatologist. These are both arguably specialties where you need to be comfortable sticking needles in difficult places, so the challenge must have gone just a little bit right.

My first evening shift was off to a cracking start. My pager bleeped – help required! I re-wrote a couple of medication charts, continued some intravenous fluids, stuck a patch on a patient with high blood pressure and settled into my new role. I was called to orthopaedics to resolve a husband-versus-wife dispute about whether he could eat chocolate on a clear fluid diet. ‘Easy’, I thought. I explained that chocolate is neither clear nor fluid. Marital harmony restored.

I was headed (meal voucher in hand) towards the staff cafeteria for a plate of veggies when the call I had been waiting for happened. ‘Are you the on-call intern? We need an urgent cannula on 7A.’ I took a deep breath, abandoned my dinner plans, and off I went.

The patient was about my age. He was lean and fit – a volunteer with the State Emergency Service – and his veins were a work of art. He was on high-dose heparin for pulmonary embolism and the line had blocked two hours ago. A new cannula was needed stat! I tried once, but the vein rolled away. I tried again and got a flashback but fumbled the push-button safety device and couldn’t advance the cannula into his vein. Remembering the ‘two attempts’ rule from orientation, I apologised to the patient, promised the nurses I would be back soon, and set off into the hospital, looking for help.

I poked my head into the resident lounge, where the medical registrar was sprawled on a grey vinyl sofa, eating Jatz crackers, drinking lemon cordial, and pretending to be engrossed in Lateline (not much televisual choice in the olden days). I asked him for help with the cannula.

‘Not my problem’, he said, without looking up. ‘Call anaesthetics.’

I paged the anaesthetics registrar, but the theatre nurse who answered told me she was busy with a caesarean section, and the ward cover resident was scrubbed in too. I decided my best option was to head back to the patient and try again.

I happened upon the surgical registrar outside the lift. He looked busy, but I had him cornered and it couldn’t hurt to ask. ‘It’s not really my job’, he began, but I told him about the patient and what I had tried so far.

With a shrug, he said: ‘Come on, let’s go and have a look together.’ The cannula was in about ten seconds later – the registrar was surprisingly nice about it. He spent a few minutes showing me how the safety device worked and giving me tips for getting cannulas in first time. ‘Don’t tell anyone I did your cannula’, he whispered, and left. This small act would become central to my philosophy and practice of medicine. Civility saves lives.

Fast forward nearly ten years. My career had taken many twists and turns. I started physician training only to discover I didn’t love it enough, then gravitated to the emergency department – the place in the hospital I had felt most at home as an intern. After time-out to do a higher degree, some policy work and a stint in medical education, I had decided to complete emergency specialist training. I was full steam ahead with critical care rotations and exams.

Hospitals had changed. Over the years, they were gradually protocolised, digitised, networked, streamlined and economised. When I was a junior doctor, things were done in person. On after-hours shifts, I weaved through the wards asking nurses what needed to be done (often sharing a cup of Milo and some chat), with only urgent tasks communicated via pager. A walk to the imaging department was required to order an x-ray. Blood gas samples cocooned in ice were hand-delivered to the laboratory.

With no option to log in from rooms (or home) to check up on a patient’s progress – or to transmit images via text message – senior doctors were more physically present. Interactions with real people around the hospital generated camaraderie and a sense of shared purpose, even though, like now, behaviours were occasionally less than perfect.

Many changes in hospital practice have been positive, resulting in improved safety and efficiency. To some extent, however, I feel that this has come at the expense of human connection.

We have less face-to-face communication; we’ve lost private spaces to laugh, cry and debrief; and we find fewer opportunities to build and nurture relationships – factors which I believe were protective for me during my early career, and which I work hard to provide in the emergency department where I am now director. I can only imagine how it feels to spend entire shifts primarily interacting with an electronic task list.

A different hospital. A different city. A different state. I was the senior registrar in intensive care, leading the medical emergency team. We were on the cardiothoracic unit, in the early hours of the morning, treating a patient in cardiac arrest. The team was on fire. Within minutes she was intubated, ventilated and had return of spontaneous circulation – but she continued to have anxiety-provoking runs of ventricular tachycardia. I had just inserted a subclavian line to deliver amiodarone and inotropes when the surgeon arrived on the ward. He smiled at me. ‘I think you’ve paid me back for that cannula now, Clare’.

And that’s the point. To quote Disney’s High School Musical, ‘We’re all in this together’.

You and me. Our families and friends. Our colleagues, our patients and our carers. Our communities. Together.

My journey has been shared with a lot of people. Many of them won’t remember me, some of them will, and most of them have quietly changed my life in beautiful, tragic and extraordinary ways.

The midwife, who I had looked after as a patient, who delivered my perfect baby daughter. The registrar, who had once been an intern in the emergency department, who anaesthetised me when I needed surgery. The critical care team at the hospital where I worked for many years, who helped my family find a tiny sliver of silver lining in an otherwise very dark cloud, when they expertly facilitated my uncle becoming an organ donor, a few days after he was struck by a car.

My mentor and friend – a senior emergency specialist – who entrusted the care of his dying father to me one busy New Year’s Eve. The nurse unit manager, who kept tabs on my welfare following a spectacularly difficult shift. The pharmacist, who helped me to understand how to prescribe gentamicin. The switch operator, with a smile in her voice, who knows the secret goings-on of the hospital. The people who cook the food, sort the rubbish, code the data, maintain the equipment and get far less recognition and thanks for their important work than I do.

The accountant, who helped me write a business case for an extra trainee, who told me about the death of his infant sister, on the other side of the world, many years ago – his motivation for working in the health system.

In my experience, everyone who works in a hospital has a back story.

The boy from my school, a super-hero on sports day, house captain and prefect, who died from a heroin overdose a few years later, alone in the stairwell of an abandoned hospital. My colleague – a fellow trainee – who drove into a pole at high speed late one night – a shift I will never, ever, forget. Their stories, along with countless others, each contribute a significant chunk to my ever evolving ‘why’.

Every friend and colleague who has answered my questions and listened to my worries. Every trainee and student I have supervised. Every patient I have seen – something was learned from each and every one.

All of us. Working together. One great, big, glorious ecosystem. Like the humungous fungus Armillaria ostoyae, we humans may seem separate on the surface, but we are connected by deep roots hidden beneath our forest floor. We have far more in common than not.

We live in times when we celebrate the art of saying ‘no’. There is no doubt that maintaining appropriate boundaries is important, and there are times when we need to prioritise our own self-care over the demands of others, but there’s a catch. Every single one of the most fantastic experiences of my personal and professional life budded from a decision to say ‘yes’, often in response to a simple request for help. Enduring friendships, satisfying challenges, important learnings, exciting adventures and career-defining opportunities – all of which have positively enhanced my wellbeing.  Yes!

In the words of Aretha Franklin, ‘You need me, and I need you.’ Next time someone reaches out to you, dig deep and connect with your ‘why’. Reflect on times when you have needed help, how that made you feel, and be grateful for all the people who have contributed their time and energy to your journey. Approach your work (and life) with curiosity, empathy and kindness. Say ‘no’, politely – when you have to – but sometimes, just sometimes, please say ‘yes’.

*Details of patients and events have been changed for privacy reasons.