A day in the life of an on-call consultant anaesthetist
05:30: Tap on the shoulder. 'Daddy wake up! I've got an important question!' At this dreadful hour on a Saturday, I already know that my four-year-old daughter and I will disagree on the definition of important. 'What's the fastest thing in the world?', she is wondering, 'Is it a bullet train, the fastest car in the world, or Ed Sheeran?' As my mind boggles, I remember that I am on-call from 0800 and could have done with at least another 90 minutes sleep.
24 hours on-call - a complete lottery. A nightmare for the control freak inside every anaesthetist who wants to be able to plan everything to the last detail, but also (I'm pleased to realise after six years as a consultant) still a source of excitement - who knows when you might get to do some properly good, consultant-level life-saving stuff?
08:00: Booked - a peri-anal abscess in an obese, bearded chap, an appendix in an eight-year-old girl and a 'hot' lap chole. Possibly not consultant-level life-saving stuff, but I have a CT1 on-call with me for theatres and there's nothing that I can fairly let them do entirely on their own. I need to balance allowing them develop their own skills and confidence, the provision of training, and patient safety.
09:00: Sent for 'the abscess'. Wondering why we don't say 'the patient with the abscess', I wander up to the labour ward to review the patients on the obstetric HDU and to ensure the locum has arrived. Like many departments, we are carrying gaps in the trainee on-call rota. Regular locums who know the unit are a real help, but a locum doing their first shift who is not familiar with local processes can really add to the consultant's workload. Today's one is a regular, but I've not met him before. A chap in scrubs with a non-Trust ID badge has his feet up in the handover room.
'Are you the obstetric anaesthetist?' I ask. He looks at me. I haven't got changed yet, and am wearing jeans and a leather jacket (because I am cool). 'Yes. And who are you?' comes his airy reply.
I tell him I'm the on-call consultant anaesthetist. His spine straightens and his feet return to the floor. I ask a midwife if she think the jacket makes me look younger and am disappointed with the answer.
12:00: Abscess and appendix are done and we have induced the (patient who needs a) lap chole. The CT1 is engaged in some rather vigorous mask ventilation. I remind him that we should minimise the pressure as much as possible to avoid insufflating the stomach before laparoscopy. 'Don't worry,' he tells me, 'I'm getting the hang of this now.'
12:15: 'Can we have a nasogastric tube please?' asks the general surgeon. The CT1 has the good grace to look sheepish. I tell him not to worry and suggest he goes for lunch while I attempt the most challenging procedure in anaesthesia - siting a nasogastric tube after a patient is intubated. Luckily it goes straight in, but the whole theatre team agree that when the trainee comes back, we'll pretend it took forever and there's now blood in the patient's airway and I have done my back in. I worry about bullying and harassment claim.
13:15: The gallbladder has been identified but remains resolutely intra-abdominal when the doors between the anaesthetic room and theatres suddenly swing open like a Western saloon. The outline of the on-call vascular surgeon is framed in the doorway. The general surgeons pause, the image on the stack system pauses, even the ventilator pauses mid-inflation.
The paramedics have called ahead to resus - there's a query leaking AAA on the way in.
I wonder whether I should point out that it's a patient with a query leaking AAA but he's already gone.
Cue an uncertain 20 minutes where it's not yet clear if we'll need to open a second theatre, which scrub team will need to be called in, and who will anaesthetise this potential AAA. Can I leave the CT1 to finish the lap chole so that I can start off? Maybe, but I will still need a second pair of hands. Is my ICU colleague in the building? Yes, but still doing the ward round while the registrar is seeing some referrals. Will I have to 'phone a friend' who's not on-call?'
Luckily it becomes clear that the lap chole is coming to an end, and there's no news yet about the AAA. I tell the trainee to beware of 'phantom' cases on emergency lists and to consider ignoring pretty much all cases until booked. Before that, they are just rumours.
14:00: The lap chole is extubated and I still haven't heard about the AAA. I wander to ED resus. The patient has already gone to SAU. They've had a CT abdo. I look at the images with the radiologist, pretending I can interpret them. Yes, they do have an aneurysm. No it's not leaking, but yes, they do really, really need a poo (the patient, not the radiologist). Maybe I'll wait a bit longer for lunch. The vascular surgeon calls me to let me know that the aneurysm is not coming to theatre.
15:00: Although I live just a few miles from where I work, I cannot reliably get back across town to the hospital in the stipulated 30 minutes on a Saturday afternoon. Therefore, I am imprisoned. A good opportunity to make progress with the endless amount of admin that comes with being a consultant.
19:30: I walk to the canteen to get some dinner. The shutters are down. Opening times Saturday 08:00 - 19:00. Sigh.
20:15: Home. Eating.
04:00: Ring ring. Ring ring. 'Hello doctor, it's switchboard, I have the theatre anaesthetist on the phone for you.'
04:30: I'm back in. A young lad, after an extremely refreshing volume of alcohol, got bored of waiting for a taxi and decided to drive himself home. This went well until his progress was impeded by several parked cars and a rather immovable brick wall. Because he had managed to climb out through the shattered windscreen and his vital signs were stable, the ambulance has brought him to our Trauma Unit, rather than taking him directly to the nearest Major Trauma Centre. However, in the three hours that he's been in ED, his lactate has risen, his blood pressure has fallen and he's becoming less responsive to fluids. The consultant surgeon is in and wants to take him for an emergency laparotomy. The ICU and theatre trainees have assumed he is bleeding, cross matched blood, repeated gases overnight and prepared drugs for RSI and haemodynamic support. I meet everyone in the anaesthetic room, including the patient who remains strongly self pre-medicated. Judging by his age, I wonder if he was out celebrating passing his driving test. The case goes well, but we do need to replace blood after a couple of litres of his own is removed from his peritoneal cavity, having oozed out of some ruptured mesenteric vessels. It appears clotted, so we agree that running a TEG is not necessary.
07:00: We're coming to an end, and it dawns on me just how tired I am; the adrenaline surge of the emergency has gone. I get a text from the incoming consultant anaesthetist, asking what is booked and saying that they'll come in for 08:00 if I'm in theatre. I gratefully take her up on her offer and reflect how glad I am that we split on-call weekends to ensure that none of us work more than 24 hours straight.
08:30: Home again for a rest. A fairly typical on-call, I suppose. Some major stuff, some minor stuff, some rest, some stress, some plate-spinning, some really impressive trainees and some good humoured team working. I have mostly enjoyed it, but I'm also glad that, by definition, it's the longest possible time before my next weekend on-call. Maybe I'll go to bed for a quick nap, but what is this small figure running towards me? 'Daddy, I've got another important question. Is 20 a big number?'
Maybe not!
Written anonymously. Article originally published in Anaesthesia News, June 2018.
Cartoon courtesy of Eoin Kelleher, Trainee Committee.