Bloods, sweat and…lots of tea: a day in the life of an on-call psychiatric trainee
21 October, 2020
Wonder what it’s like to be on call for a large psychiatric hospital? Trainee psychiatrist Dr Kay Sunderland takes us minute-by-minute through a fast-paced day supporting acutely unwell patients.
Dr Kay Sunderland
8am: I wake up to begin a weekend of 12-hour on-call shifts at my base hospital in Scotland. I make a cup of coffee and hop in the shower. Getting ready takes much less time in the middle of a pandemic as there’s only one outfit to choose from: scrubs!
9am: In the doctor’s mess, I meet up with the other junior doctor I’ll be working with over the next three days and we commiserate with our departing nightshift colleague, who has been awake for most of the night. We put the kettle on – an essential part of any long shift.
9.15am: Two cases are handed over “to be aware of”.
A male in his 30s (Mr X) – admitted in recent days with a suspected drug induced psychosis – has been displaying significant behavioural disturbance overnight. He has utilized the maximum dose of all additional short-acting medications available to manage his agitation and may need further discussion with seniors for consideration of transfer to IPCU.
A female in her 60s (Ms Y) – also nearing max doses of additional medicines – hasn’t slept overnight. She needs daily bloods, due to poor renal function and previous lithium toxicity.
9.30am: Our jobs book (which we use to record tasks handed over to the on-call team by other colleagues) shows a variety of bloods to be taken so we set off on a phlebotomy round.
10am: We arrive on one of the older adult wards to take a lithium level and are delighted to find that one of the nurses has already done it. As we go round, we’ve acquired some other routine jobs – more bloods, a couple of ECGs and some prescriptions as well as some swollen legs to be reviewed.
11am: Nurse from ward calls to remind us that bloods need to be taken for the female patient we were handed over. He mentions that she has been struggling to swallow, and asks if we can listen to her chest while we’re there to rule out aspiration pneumonia. We head over to the ward.
11.10am: Our patient appears delirious and is requiring a 2:1 observation. It’s quite challenging to get her bloods as she is agitated and moving around a lot – but happily her chest sounds clear. We agree to await blood results to see if we can identify a cause for her behaviours and encourage oral fluids. Should she deteriorate, we would need to transfer to the general hospital as we can’t facilitate IVs on site.
11.30am: While I label up the blood bottles, it’s a nice opportunity to catch up with some of the nursing staff and discuss the latest hospital gossip. Working in the community clinic for the most part, I don’t get to see them all as much as I used to. Communication is vital, not only in my role as a doctor, but also in being part of the hospital community as a whole. The job can be so hectic and stressful that it is all the more important to take a moment to check in with colleagues if a chance presents itself.
1pm: Lunch. Time to re-group and make a plan for the afternoon. We put the kettle on… again. A call comes through from the medical receiving unit looking for advice. While I’m on the phone, a medical emergency call comes through. I tell the medics I’ll call them back and we run (yes, run!) to the ward.
1.05pm: A patient has been found with evidence that they'd tried to seriously self-harm, but thankfully by the time we arrive, they have regained consciousness and don’t require any further treatment. After a thorough review and documentation, I pinch some chocolates from the nursing station and we go back to our lunch.
2.30pm: Call from the acute adult ward to say they’ve done a set of physical observations on the man we heard about at handover, and he’s tachycardic, tachypnoeic and hypertensive…with a history of the previous neuroleptic malignant syndrome (a life-threatening reaction to antipsychotic medications where the patient displays muscle rigidity, confusion, fever etc.). I ask them to perform a repeat set of observations and head over.
2.35pm: Carry out a full physical examination on the above gentleman. Due to his illness, his speech doesn’t make much sense but he denies feeling physically unwell. I can find no signs of infection, nor any abnormal neurological signs to suggest neuroleptic malignant syndrome. We ask that his observations be repeated and will continue to monitor.
4pm: Telephone call from Community Mental Health Team asking us to carry out bloods over the weekend for an outpatient whose clozapine monitoring bloods have shown that he is at risk of developing agranulocytosis – a reduction in white blood cells, secondary to the clozapine drug therapy. We arrange for them to come to the ward daily so that we can keep an eye on these levels.
4.30pm: Junior doctor from the ward calls after a consultant has reviewed Mr X. They’ve sent off urgent bloods and have asked us to chase the results. If his bloods are normal, a plan is in place for further medications.
5pm: We grab some dinner and hear news that there’s an admission coming in soon.
5.30pm: Eating disorder patient has a nasogastric (NG) tube in place for feeding. Nursing staff page us as they have been unable to obtain a sample of the stomach contents. As this might suggest the tube has moved and is no longer in the stomach, I agree to arrange an X ray to ensure it remains in the correct place.
6pm: New admission has arrived from Liaison – we attend to clerk in, complete bloods, physical and ECG.
6.30pm: Eating disorder patient’s blood sugar has been checked and it is below 4. She is refusing any oral treatment and has previously required IV dextrose to treat her hypoglycaemia. Radiology will not perform the X-ray overnight, so we run through our options for treatment and discuss what we can and cannot facilitate in a psychiatric hospital.
7pm: Bloods come back for Mr X. His Creatine Kinase (a blood measurement of muscle damage) is raised and therefore might support the working diagnosis of NMS. We call the psychiatry registrar for advice and plan to discuss the case with the medical team. While we are doing so, the nurses repeat his observations – his temperature as spiked and his heart rate is elevated again. We decide to arrange transfer to an acute hospital for further investigation and supportive treatment.
9pm: We hand over a review of the physical health of a patient that has required restraint from nursing staff that we haven’t had time to complete, and make sure to highlight the patients who will require monitoring overnight. We also put a list of bloods and other routine jobs in the book for tomorrow.
10pm: I get home and sit on the sofa, exhaling deeply, for the first time all day! Despite it having been a busy, and at times pretty stressful, shift, I feel exhilarated. And with that, I get up and go to bed, to prepare to do it all over again tomorrow.