Oh What A Night!

NB: This isn’t meant to be a rant at other healthcare workers in particular, just me venting about some of the issues relating to working in a “multidisciplinary team”. I completely appreciate that every aspect of healthcare presents its own unique challenges, and that the two overriding factors which affect and unite us all are the public’s high expectations of us, and the government’s “bare-minimum” approach to both funding and staffing.

So. Here goes. Last night was easily one of the worst night shifts I’ve had, if not the worst. Nothing especially awful happened, it was just a never ending stream of constant difficulties. Firstly, when I arrived at the department there were already three patients on trolleys lined up in the corridor and two wheelchairs in the waiting area. The day crew handed over and explained the chaos, and then I went to resus to do an urgent chest and pelvis which absolutely had to be done round there as the patient was too unwell to come round to us. Fair enough, it was a trauma call after all. So I get round to resus and my trauma patient wasn’t collared or boarded, and wasn’t even hooked up to any monitors. When I asked why he couldn’t come to the department the nurse replied “He’s too unwell.” When I asked the patient how he was feeling he shrugged his shoulders and said “Not too bad, foot hurts though.” In the end I did the x-rays in resus, as they asked, because yes, it was a trauma call, yes he did have bruises on his pelvis, and we didn’t have room for him in the department anyway.

It’s exceptionally annoying when our colleagues lie to us in order to make life easier for themselves though, and we always find out, so it’s pretty bloody insulting. Most of the times I get a crappy reason for doing a mobile x-ray I take the time to explain to the referrer why we prefer patients to come to the department; it’s not because we’re lazy (although some radiographers are), it’s not because it’s easier (that’s not always the case), it’s because we actually give a shit about the radiation that we’re exposing ourselves and others to. When we trundle up to the ward with our trusty AMX (other models are available) we’re putting ourselves, other staff, and patients at risk. A radiographer’s best friend is the inverse square law (the further you are from the source of radiation, the better) but not all wards are set up to accommodate us. Hospitals are encouraged to squeeze as many beds as possible into every available space (as a side note, one of Trogdor’s board rooms is actually being turned into a patient area and having beds put in it) meaning that there isn’t always the minimum recommended 2 metres between patients. I’ve occasionally refused to perform a mobile x-ray purely because of the logistics of the ward- in one case the wall separating the patients’ bays was so thin that I would have been directing the primary beam at the back of another patient’s head. Nope.

So when I’m told “Mrs Smith is desaturating rapidly and is too unwell to leave the ward”, and I close the department (because I’m the only one there) only to find Mrs Smith sitting up in bed with a cup of tea and no oxygen mask in sight, it’s more than a little frustrating. Add to this the sheer unpleasantness for the other patients being woken up at 3am because mobile x-ray units don’t have a silent mode. This is a point I try to make regardless of whether the request is for a mobile x-ray; I know the medical registrar said that the chest x-ray was urgent, but it’s for a PICC line placement and you don’t plan on using the PICC before 8am so how about letting the patient sleep?

I think that “bullying” might be too strong a word in this context, but I honestly think that sometimes junior doctors aren’t allowed to use common sense as the pressure from their superiors is too high. A while ago I was chatting with a junior doc in resus while waiting to do an x-ray. She’d just had to abandon an attempt to get blood gasses because the patient was squirming in pain, so I asked if there was a reason why no one here tends to use local anaesthetic for the procedure. Apparently a friend of hers had asked the same question a while back and was told that if you can’t do it without local you can’t do it at all, or words to that effect. Apparently the patient’s comfort is irrelevant.

While the Daily Fail loves to scream about “Killing Season” every August, there isn’t a huge amount of truth behind the scare stories about junior doctors causing loads of extra deaths in their first few weeks. Sure there’s a statistically significant rise of about 6% in death rates in early August, but mortality and morbidity figures fluctuate all over the place throughout the year for a variety of reasons, and this is something which requires a lot more research before wildly labelling all F1s as Harold Shipman. Not that the Daily Fail gives a shit about the truth, of course.

One thing which does increase in August though, is crappy x-ray requests, and while it’s frustrating and annoying, it’s our job as radiographers to vet these requests rather than blindly performing them. I know it must be hugely difficult to be an A&E doctor, especially early on in one’s career, but it’s almost comical how the requests pile in. So far I have seen two perforated bowels (colloquially called a perf) but I have probably done a few hundred x-rays with “?perf” on the form. This is basically like a cheat code for a chest x-ray, write “?perf” on the form, get  a chest x-ray. Write “?obstruction ?perf” and you’ll have an abdomen thrown in as well. And you can tell when the new doctors learn about this, because the requests come flooding in shortly after. Instead of properly examining the patient to give us a real reason for doing the chest x-ray (and there is usually a real reason) we get loads of these cheat-codes. A tip for spotting when this has happened: a genuine perforated bowel does not present with the patient strolling in to the x-ray room and making small talk. A real perf is generally accompanied by a patient curled into the foetal position, screaming in agony. Not always, but most times.

So as well as crappy requests we also had loads of patients turning up without wristbands, who we were unable to positively identify. Patients suffering from stroke, dementia, acute confusion (due to LRTI etc), and narcotic or alcohol abuse need to have wristbands on so that we can categorically confirm that we are about to x-ray the correct person for the correct body part. This is beyond essential, yet some of the nurses on shift last night didn’t seem to think so, and the worrying thing was that a few of these patients had clearly been administered drugs before coming to x-ray, something which really shouldn’t be done unless you can be 100% certain of their identity.

Then there was the abuse, a constant factor in this job, but it was particularly noteworthy last night. The first was from a group of “lads” who came along at about midnight with their friend who had banged his wrist earlier that evening: I was processing the x-rays of the patient I had just examined, and standing at the computer annotating the images. One of the “lads” loudly exclaimed that “she needs to get off Facebook and sort your wrist out cos I’m sick of waiting here”, a comment I had no choice but to ignore for the sake of professionalism. I helped my current patient put his shoe back on, and pushed his wheelchair out of the room, and was met with another “hilarious” quip from the group, which I won’t repeat. Then when I called in the injured boy for his x-ray, all of his mates tried to come into the examination room and didn’t like it when I told them that they couldn’t, so I said that he could have one companion to hold his hand if he was really that scared and that seemed to shut them up. The patient was actually alright when the door was closed, but then reverted to making obscene comments about me when he left the room. What a gent.

Not long after there was a middle aged man with a laceration to his arm, he wasn’t drunk (a usual factor in abusive patients) but he was really grumpy. I only had one image to do as we were just looking for broken glass in the wound rather than a fracture, but he was determined to make it a difficult one. First off he refused to let me remove the bandage, but his wife talked him round. Then he wouldn’t put his arm where it needed to be because he didn’t want me to touch it, and when his wife came to the rescue again, he got really arsey with me. I demonstrated with my own arm what I wanted him to do, but he wasn’t getting it, so I lightly tapped his (uninjured) elbow to show where it needed to be and he said “touch me again and you’ll regret it”. No swearing, no bravado, just a plain threat. At this point I figured that his position was good enough for what I needed so I set up the x-ray tube, ushered his wife behind the screen and took the image. Walking back towards him I gestured for him to lift his arm off the x-ray cassette so I could remove it for processing, he did so, but when I reached to pick it up he grabbed my wrist very tightly and said “put the bandage back on now”. I stood my ground and said that I’d like to make sure that the x-ray was ok before doing that, and he hissed something derogatory as I wriggled out of his grip and walked to the processor. His wife looked so embarrassed, I really felt for her. I only had to spend a few minutes with him, she was married to the guy.

Then at about 3am I had a patient growl at me when I asked his name. I phoned majors to ask if there was anything I should be aware of: “Yeah, he spits and will try to bite if you go anywhere near his head”. Thanks for putting that on the form, guys. I nearly found that out the hard way.

I also had a lady call me a stupid cow when I told her I couldn’t confirm whether her ankle was broken or not (it wasn’t), but she actually came back to apologise on her way out, which surprised me. Apparently the nurses in minors explained why I wasn’t able to tell her and she felt shitty about it so she wanted to make it right. That was nice.

So that was my night. Busy, but not the busiest. Just generally unpleasant even though I was working with fantastic colleagues (one with me, and one in CT), I dread to think how it would have been with others!

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