W MEDICAL
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THE JOYS OF BEING ON CALL
AND THE CHALLENGES OF EMERGENCY SURGERY
BY CONOR MAGEE MD FRCS, CONSULTANT SURGEON
It’s just gone 3 o’clock in the morning. You’ve crawled in to bed after a
long day and night of operating. You finally feel relaxed and know you’re
about to hit the most p eaceful and restorative part of your sleep - you can
feel your body finally loosening up - and then your mobile phone rings.
It’s loud - no matter which soothing ring tone you choose, it’s so loud
and suddenly you are awake. A jolt of adrenalin rushes through you.
“Don’t they know I’ve just got into bed and I’m knackered?”, you grimly
ask yourself. And then you answer the phone, catching it twice as the
handset falls from your clumsy grip. You take a breath before answering-
try to wake up, get the logical higher functioning part of your cortex
into gear, and not the ancestral reptilian hindbrain that just wants to get
back to sleep.
“Sorry to disturb you Mr Magee, but we have a problem…”, the voice
on the other end is apologetic but firm- there is a problem and your
job is to solve it. Thus begins another episode of on-call adventure and
emergency surgery. Being on-call used to be a factor in every doctors
working life. The mismatch between the sheer numbers of patients and
the scarcity of doctors meant that doctors had to work out-of-hours
to provide care. Traditionally, this was through an on-call rota where
doctors would cover emergencies for 24 hour shifts or 48-72 hours at
the weekends. My time as a junior doctor was in the 1990’s where my
first rota was a 1:3.5 - I would do 24 hours every 3 and a half days -
unfortunately if I wanted to take leave I had to swap my on-call with a
colleague and then pay it back - the reality was that I was working a rota
that was more like 1:3. Oh, and after working 24 or 48 hours I still had to
do my normal working day afterwards… My payslip assumed an average
working week of 72 hours (56 in a good week, 120 in a not so good week)
but the best bit was that after 40 hours work we would get paid half our
normal hourly rate.
Thankfully, junior doctors today don’t work such long hours, the increase
in the numbers of juniors and the implementation of European Working
Time Directive has moved everyone to a shift system. Although, this has
created more problems for many! Today there is a paradox that the only
doctors who remain on an on-call rota are the consultants - my colleagues
and I work a much more palatable 1:8 rota, although weekends are still
a 72 hour marathon.
Fortunately, the on-call rota is to cover emergencies and not the elective
operating and clinic lists. Emergency surgery covers a vast spectrum of
cases from simple abscesses that require drainage, appendicitis all the way
70 wirrallife.com
to the most challenging of abdominal catastrophes. The demographics of
the 21st century mean surgeons are seeing much older patients, often
frail and with complex medical problems that require emergency surgery.
The operation we have to do for these cases is usually a laparotomy (from
the Latin meaning opening of the abdomen) - making a long cut in the
midline of the abdomen. Through the laparotomy we are able to identify
and address the surgical problem - often removing segments of dead
intestine, creating colostomies or repairing ulcers (but hopefully not
all at the same time). As you can imagine such complicated surgery is
dependent not only on the surgeon, but also the skills of anaesthetist and
the intensive care teams.
That said, sometimes the on call can bring
some light relief - for some reason every few
months a patient will present with an article
stuck in a rather unpleasant place (can you
guess the article from the picture?). The
conversation between doctor and patient is
almost a folie-a-deux. The patient recounts
an unfortunate slip or fall whilst holding a
smooth narrow object (and not wearing
underwear) that, as bad luck would have it,
ends up in a place the sun does not shine. The doctor nods sagely and
empathetically, the sheer bad luck… Both know the real story of course
and the doctor promises it shall be removed as quickly as possible-
reassuring the poor patient that confidentiality will remain unbroken!
Such cases always make the on-call seem to
pass more swiftly, but if I am in the midst
of a particularly onerous weekend I always
remind myself things could be worse. In
late 1948, the American magazine “Life”
followed a country doctor for a week - he
was essentially on call for 50 weeks of the
year, 24/7. The photo shows him exhausted,
having a coffee and a cigarette after
operating in the early hours. I’ve been there,
every surgeon has, but at least my on-call
ends at 72 hours.
Mr Magee operates at Spire Murrayfield Hospital and can be contacted
there. He can be followed on Twitter @mageefrcs.