Black Wednesday
Dear Friend,
Happy Sunday to you all. I can’t quite believe that tomorrow is my final shift of internal medicine training (IMT) and last shift as an SHO. There have been some dark days over the past few years, but it is such a relief to have gotten through it.
In a few days, many of you will be starting your first shift as doctors. This Wednesday is colloquially known as “Black Wednesday.” In 2009 Dr Foster Intelligence published a report showing a rise in mortality rates during the first week of August. This led to the British press coining the expression ‘Black Wednesday’, describing the first Wednesday of August as the ‘NHS Killing Season.” The study examined 300,000 emergency admissions over 9 years and showed a 6–8% rise in mortality during the first week of August compared with the last week in July. This rise was attributed to the nationwide influx of new junior doctors. Subsequently, attention was focused on junior doctors’ preparedness to practice, including shadowing schemes and the provision of effective induction and mandatory training (MT).
Many of you will naturally be very nervous as all of a sudden you go from a student with no responsibility to holding patient’s lives in your hands. This is more so the case if you start on night shifts. That’s why this week, I wanted to share my experience of my first day as a doctor on the hepatobiliary ward at Hammersmith hospital. The take away point is yours hopefully can’t be much worse than mine.
The picture above is the one I used for my ID badge of FY1. I remember, turning up as a fresh-faced FY1 on the hepatopancreaticobiliary ward at Hammersmith Hospital in London. Hammersmith hospital is unlike other hospital in that it does not have an A&E. It is a specialist tertiary hospital for certain specialities such as HPB and renal medicine (a kidney transplant centre). As such, you often have to deal with the most complex types of patients – whilst this is interesting from a medical point of view, it’s not ideal for an FY1 on their first day.
Like many things you will discover in the NHS, common sense seemed to go out of the window. For some reason I was put on-call on my first day. Although I was an FY1, I shared the same rota as the SHO’s. So once a week, I would be responsible for holding the SHO bleep for surgery – and would have to respond to general surgery bleeps in the hospital. The main issue however was that the registrar was in theatre all day, and so I also had hold the HPB surgical registrar bleep on my first day. Being a mere FY1, I did not have the guts to say no to my registrar.
The problem with holding the registrar bleep is that as Hammersmith was a tertiary centre, I was receiving bleeps asking about HPB advice from the whole of north London. Thankfully, one of the SHO’s took over from me and explained all I needed to do was write down the details and I could discuss with the Registar after. This SHO also stayed 3 hours late to do the on-call shift with me all the way until 8pm.
Apart from holding the bleep, I had to learn how to use the online patient system. I prescribed my first medication, which surprisingly on a surgical ward was actually olanzapine (a patient’s regular medication) – I very quickly found out that the FY1’s job was to prescribe the patient’s regular medication. Surgeons are interested in surgery only.
I was also in a ward where the nurses did not do bloods or cannulas. And so, on my first day the expectation was there that I would do any bloods – let’s say when I graduated, my venipuncture skills were not what they are right now.
At the end of my shift, I sat in my car and just held the steering wheel for 30 mins, not knowing what had happened. I felt like the whole day was a blur. I remember phoning my mum and almost breaking down on the phone. And she just said one thing – it can only get better.
I look back 4 years later, having written a book, winning foundation merit awards and being a far more competent doctor – looking back at that first day it almost seems funny. I hope you all have a much better first day and aren’t thrown into the deep end like I was. But whatever happens, by the end of August, you’ll all be settled into your jobs and one day like me, you’ll be looking back on your first day with a smile.
P.s. if you are looking for a book to help you on the wards with all the knowledge you need to know as an FY1, check out my book below!
Best of luck!
Drug of the week
Ferric carboxymaltose (FERINJECT)
Ferric carboxymaltose is an iron replacement product and, chemically, an iron-carbohydrate complex which is used to treat iron-deficiency.
FERINJECT is given for the treatment of patients with iron deficiency, when oral iron preparations are ineffective or cannot be used.
It should be given with caution as it can cause skin reactions around the drip site, and discolouration of the skin, as well as anaphylaxis in some patients.
A Brain Teaser
A 25-year-old woman presents to her GP extremely concerned following some episodes of visible blood in her urine. She reports no urinary frequency and no dysuria. She has no significant past medical history but has been feeling ‘run down’ over the past few days with a cough, runny nose and a headache. Her abdomen was soft, non-tender on examination and there were no palpable masses.
Her observations are as follows:
- Heart rate: 72 bpm
- Respiratory rate: 16 breaths/min
- Blood pressure: 126/84mmHg
- SpO2: 99%
- Temperature: 37.6º
What is the most likely cause of her haematuria?
A: Bladder cancer
B: IgA nephropathy
C: Post-streptococcal glomerulonephritis
D: Trauma
E: Urinary tract infection
Answers
The answer is B – IgA nephropathy.
The answer here is IgA nephropathy. This would classically present as visible haematuria 1-2 days after an upper respiratory tract infection. The patient’s age also fits with this presentation since it most commonly presents in younger people.
Bladder cancer is less likely in this case due to the young age of the patient. Bladder cancer does tend to present with painless haematuria, so should always be considered as an important differential in patients presenting with haematuria, though in this case, it is less likely than IgA nephropathy. If it presents at an advanced stage, bladder cancer may cause pelvic and bone pain with weight loss and would typically be seen in an older demographic than the patient in this scenario.
Post-streptococcal glomerulonephritis tends to present 1-2 weeks after an upper respiratory tract infection and would generally cause more proteinuria as opposed to haematuria (though haematuria can also occur). Since this patient presents with concerns about blood in the urine and has been feeling unwell for a much shorter duration, IgA nephropathy is more likely. IgA nephropathy and post-streptococcal glomerulonephritis may both present following upper respiratory tract infection; the key difference is that IgA nephropathy would develop 1-2 days afterwards, whereas post-streptococcal glomerulonephritis would typically cause symptoms after a couple of weeks.
Trauma is another important differential diagnosis of haematuria, though there is nothing in this history to suggest it, and given the recent upper respiratory symptoms, IgA nephropathy is far more likely.
Urinary tract infection is a common cause of haematuria. In this case, however, she reports no dysuria or increased urinary frequency which would typically be seen in a UTI. As well as this, a UTI may also present with cloudy, offensive smelling urine and lower abdominal pain. In practice, the patient would likely have a urinalysis performed to rule this out before progressing to any further investigation.
