Day in the life of a Paediatric Cardiology SHO
Today is a Thursday, so things start a little earlier than usual. Start time most days is 8am, but every week we have a meeting between the entire Cardiology and Cardiothoracic surgery teams and subspecialties which starts at 0730, though I’m running slightly late for that, not that I have much part to play as an SHO, other than to listen and hopefully get an idea of what our inpatients may or may not have happen in the near future. I’m also on the long day, so I don’t feel too bad that I’ve not managed to come the entire 30 extra minutes before my shift legally starts. This year, arriving for 0800 means leaving the house at 0710 or so, which is 30 minutes better than at my last hospital, but in a week of long days the extra 30 minutes on a Thursday get harder each week.
Registrars present various patients’ information and then consultants discuss the pros and cons of various medical and surgical approaches to make sure the best plan is taken forward and to ensure that is a plan that has come from a number of experts rather than just one. It is a good way to minimalise bias and means every patient operated (or not) upon essentially goes through an MDT of sorts, but it does mean that handover is delayed on a Thursday – usually (but not always) the inpatients get discussed early and then the consultant for the week signals for the ward team to leave and start handover in a nearby office. It’s Thursday anyway, and everyone on today was on the ward yesterday, so we know the patients well by this point and handover is reasonably quick, mostly updates from overnight and a reminder of pertinent action plan points.
After we have finished (this week with some reflection on an emotive and difficult case that had to go to CICU and is in precarious condition now- the night SHO has clearly had a tough shift, we had better check how they are feeling later on), the other SHOs on today and I head to the ward to prepare for ward round. It is about 0920 which is usually when we would start seeing patients most days (normally we have teaching or some other meeting between handover and rounds)which is good for a Thursday.
The consultant and registrar will stay to finish a couple of patient discussions in the meeting, so we should prep the notes, read obs etc for patients (all electronically here), do some urgent or quick jobs like scan requests and write a list of the ward patients who need an echo this morning so that the echocardiographer can get started.
Then ward round starts, today around 0930.
The consultant knows everyone well by this point in the week, the registrar is an experienced one and we have 3 SHOs today, plus one on Daycare, so this should be efficient. Having so many doctors my level is meant to happen every day (barring illness) but due to the way the rota has fell with leave, sickness and a rota gap earlier on this Autumn, this is the first time we have had this many staff on my shifts. Indeed, on most of the shifts, but personally it’s a nice change from the recent trend of being the only SHO which has a big impact on ones day.
We see all of HDU (our ward has 8 cardiac HDU beds and 16 non-HDU cubicles, officially, though sometimes we have to squeeze an extra HDU patient in) patients together then split the ward round. The other 2 go with the Consultant and I go with the Registrar. Anything we can do as we go along we try to, otherwise we make sure we mark jobs on our list as well as the ward round plan on the computer system we use. We alternate examining patients with our seniors so that everyone has an idea of the patients’ clinical state across the week as a whole, and so that we can learn, which to be fair we do. Every patient has at least one proper sign on examination and many are very interesting.
Our team sees every patient except for a few that are relatively medically well and “simple” patients, planned for discharge soon, whom are seen by the discharge team, led by a Specialty Doctor (though absent today) and composed of Advanced Nurse Practitioners. As the doctor is away, the Registrar on the ward checks the ANPs are happy and reviews patients when they are not. Some patients are also under subspecialty teams like Heart Transplant or Pulmonary Hypertension (and in a couple of cases, even non-cardiac specialties) who will also see them on the ward round.
Despite a few distractions, we are done by 11:30, and have requested several tests, asked some nurses for bloods that can be taken from lines or finger pricks, and liaised with teams we would like to review our patients or offer advice, which wouldn’t happen if there weren’t so many of us today. Now we have midday handover and get any plan points from subspecialty teams, updates from the ANPs and their patients and update the handover list and write a jobs list. The consultant has to leave after this for the ACTUAL midday bed meeting, which sounds awful – there are no beds in the entire hospital to start the shift, which means we have to get some patients out if CICU are going to be able to make any spaces (by stepping fit patients down to us) for any cardiac surgery today. These are things I never fully comprehended working in a DGH when we wondered why tertiary centres couldn’t take the patients we desperately wanted to send.
From 1200 until 1700 we will work through a variety of jobs, which for SHOs here primarily involve: discussions with other teams,;requesting and chasing tests; reviewing patients the nurses are worried about (as the long day SHO I carry a phone they can call at any time, and they do); clerking, examining and admitting new patients from elsewhere or CICU; discharge summaries; and bloods. Any venepuncture or cannula insertion is going to be us, and after weeks of attempts and with cardiac pathology, many of our patients are pretty difficult access. At least 1 is impossible without ultrasound.
With 3 of us, and a helpful registrar and consultant, we are actually ok for jobs today, though again that is not always the case. Now there should be 3 of us more often, hopefully we will plan to get one SHO to clinic or theatre or another non-service provision shift. We actually get a sit down lunch and 30 mins of (somewhat interrupted) teaching from the senior doctors. The teaching can be sporadic depending on how busy everyone is, but it is usually very good. The Daycare SHO joins us for lunch and has a nurse specialist with them today, which means they have managed to get some time doing educational activities like going to catheter lab. For various confidential reasons we have to take some adult bloods today, which is surprisingly daunting: it’s been a while. Luckily, it’s not as different as I was worried it might be, and the veins are relatively huge!
At 1700, we hand over to the evening team, which is a consultant (who will be in hospital until night time and then on call overnight), a new registrar (who may be around or may – will probably- be desperately chasing around the hospital doing urgent echocardiograms in other wards and will definitely be answering a lot of calls from other hospitals) and me. The consultant on this evening often covers the ward and was on last night too and knows the patients well, but the registrar hasn’t been so we have an in depth handover and the rest of the day team leave at around 1750.
I have a list of things to achieve this evening, but we did the daytime jobs so without that overflow things are manageable. The biggest workload is tidying up the list which has been a touch neglected and is a touch out of date (and is important as that’s the mainstay of information for the on call consultant and reg), evening bloods (as you never know if they’ll take 5 minutes or 45 minutes and need just you or 2 people to keep the child calm, still and distracted) and admissions. Inevitably and annoyingly, due to bed-flow and the delay between discharges and being ready to accept patients, there are as many admissions with just me this evening as in the day when we were fully staffed, but they are all quite simple and stable, mostly post simple cardiac surgery today. There is also an unplanned cannula after a baby “lost” theirs. I try twice, without success (getting blood but losing my access) and my registrar is an adult-route trainee so this age isn’t their cup of tea. In this case, we rationalise their treatment and decide they don’t actually need it – a decision I probably ought to have made before trying.
At 2030 the night handover starts and I manage to finish off updating the list to my own pedantic satisfaction just as my replacement SHO arrives. The poor registrar doesn’t get a replacement – they do a 24 hour shift (taking bleeps and calls today before they started the evening ward cover aspect on top of that) and frankly don’t often seem to get to sleep for any substantial part of that. The SHO tonight has been away on leave and then on Daycare so apart from the long-stay patients they are don’t know much of the ward but with just two of us we get through the handover quickly. This SHO is very experienced and confident at running the ward at night. Whilst I saw and prescribed drug charts for all the admissions, in a successful effort to prevent handing over any jobs that I could possibly have done myself, and added them to our list, I didn’t get a chance to actually type their admission summaries. This means that I stay a little late, completely self-inflicted on this occasion as opposed to the times when there has been genuine clinical need, to finish them. My spouse will be frustrated and the other SHO tells me off as they should, but it doesn’t take long (I leave at 2145 rather than 2115) and I would have felt guilty if I hadn’t. This is an issue I, and we as a profession, probably ought to do more about, but at least my 4 long days are over and I have tomorrow off.