How to be The Shop Floor Clinician

Once in a while we don’t have to be Epic. We can be a plain worker bee, low ranking, mission brown, a serf. We are permitted to hitch up our strides like peasants, and get on with the business of hoeing through the garden of the unwell.

Such freedom, you say. None of the high-level responsibility of being in charge of the department. No duty phone. No behaving like an epileptic desperado when asked to go to a flow meeting. Just good, honest toil.

I’ve been doing this job for a while now, and I’d like to share with you some of the wisdom I’ve attained over the years. I believe I may have something to offer – the wealth from my experience. We are now all schooled in wellness and life-balance, and I have taken this gentle, lapping mindfulness to heart. I usually start rostered days by rising at five a.m, meditating for twenty minutes, then fixing an oaty berry bowl of deliciousness, after which I write down a list of things that I craft into an acrostic poem; things about gratitude, goals for the day, things I can teach my juniors, things, other things, aphorisms. And I absolutely would do these things, except that I don’t. Ever. Most days I drive in, late and flustered, already slightly rageful at the insolence of traffic cones, unbreakfasted, in mismatched scrubs, and the most mindful thing I do is try and compose a humorous but slightly pathetic tweet whilst stuck at traffic lights, so that by the time I get into the heaving department, this place bursting at the seams with Very Unhappy People, I will have two, maybe three replies by kind people saying, there, there, it will all be alright. I hope to God they mean it.

I stride in fortified. I have four likes and a retweet. A record. Somebody cares for me.

Faced with a handover, and a to-do list that would make a self-help author blanch (shock this person, drain the CSF from another, placate this patient, find out what’s wrong with this one – please – and maybe this one too), I focus on the main apothegm that will get me through the day. Smile, be kind, and work on being only a minor train wreck. It mostly works.

I fire up the plough. I dive into the innards of people. On the whole my job consists of figuring out what is not wrong with people. I have become an expert in recognising the dark matter of the emergency pathology universe – once I know what is not, I can work out where to deal with what is. This should be simple, except my day is now less ploughing, more running in a blindfolded steeplechase, and not on horses, but cows with a particularly dementing strain of bovine spongiform encephalitis. There are barriers and pitfalls and lava pits and sink-holes. It is not pretty.

As a responsible leader, I do not look at social media while at work. Although perhaps I should reward myself with a little glance every now and then. This means pulling out my phone every two to three minutes to refresh twitter. I tell myself it’s to keep up with the erudite critical care information on this forum. I check my status. One more like. Because I am surreptitious about doing this, and also highly trained (and certified) in hand hygiene, I have taken to wiping down my phone with alcohol gel so many times, the skin on my hands is brittle and cracked, my pockets have an unsettling greasy feel to them, and the phone, while not quite tipsy, is almost unreadable.

I am very keen to teach the interns something. Five minute teaching, bed-side pearls, teaching on the run, that sort of thing. But thus far the potential clinical encounters have been a large-bodied nudist who is currently in dispute with God, several patients with hazy chest pain, a scandal involving a nursing home where one inmate swallowed another one’s tablets, and an extremely briefly run cardiac arrest. I offer nothing. When I do haul an intern aside, me sternly demanding this be a teachable moment, he presents his latest patient to me. I go in to see the patient. This is not the same patient he presented. Different story, different examination features, perhaps even different gender. I kindly confront him about this. He assures me it is the same patient. We sigh.

I, in the meantime, have a patient load all of my own. Decisions decisions. Much of my time is spent trying to work out which specialty team to speak to. Specialties are a broody taxonomy round these parts. I have become accomplished in defusing cantankerously answered consults. An ophthalmology registrar walks past. I know this because he is wheeling luggage, as though he’s navigating the duty-free stores at Heathrow, and he looks scared. I ask if I can help him. Turns out he is scared, and was trying to find the seminar room. Other specialties come and go. Most of them don’t really like us, often for no other reason than we add to their already over-burdened workload. It took me a long time to realise this. Most of them secretly think we’re quite competent, but are afraid to say so, as if this might somehow open the floodgates.

I see more patients. I listen to the shadows and the echoes of the stories in these brushes with humanity. I pull my notebook from my scrubs pocket, and jot things down. After all, I like to write, and these details are the lifeblood of novels. Unfortunately, when I take my notebook out on wash day, I realise I cannot read a single word of what I’ve written. Not one. I also have, on rotation, a set of books that I keep in the other pocket. Virginia Woolf, Keats, other small anthologies of poems. Like my extreme commitment to mindfulness, I read and reflect on these often. Which, actually, is also an Instagram-grade falsehood. Mostly they simply offer succour by being close to me throughout the long day, even if I never read them. I am a poor excuse for a novelist, I realise, and go back to focusing on being a doctor.

For an hour I look after the unbuckled body of a boy in a motorbike crash. I think he might die, and for the duration I have a nameless ache in my entrails, part nausea, part fear, that despite all I know and all I can do, it might not be enough. I might not be enough. He hangs on long enough to get to ICU. A minor success. Cases like this, however, feed on your adrenaline, leaving you tired and depleted. I wish, for the millionth time, that we had little rest-pods; white, comfortable, softly lit refuges, where nobody could reach you for twenty minutes. We don’t. Instead I buy another coffee.

I return to it. The training registrars with whom I work are quite brilliant. I learn bucket-loads from them, and I am sustained by their commitment and energy. We have this quaint setup where they assure me they are learning from me, and are grateful for the on and off floor teaching. They say this sincerely, and we all smile.

Emergency medicine evolves faster than Monsanto canola. It’s hard to keep up with all the latest and greatest (oops, better check twitter again), but, funnily enough, it’s the doing of the basics well that seems to be the most effective tool for the best patient outcomes. Perhaps there’s something to be said for us plodders, turning up again and again, year after year, just trying to do the best for the single patient in front of us. No system or institution is perfect. Ours certainly isn’t. But I honestly believe we do a very good job for most of the people that have the misfortune to hurtle through our doors on their bad days. Their days are our days. We’re in it together, we, the proletariat of medicine. I clock off, joining the queue shuffling out the doors in our overalls.

‘How to…’ An Instruction manual for those in Critical Care

• How to be EPIC
• How to be The Shop Floor Clinician
• How to Read an ECG
• How to be Kind
• How to be EPIC (in the time of COVID)
• How to be a FALCON