PHY week 6. “Hey it’s Monica, the Clin Onc Reg”

…is how I answer bleeps when on-call.

Registrar of the Week (Pre-Game)

Two weekends ago, I did my first weekend On-Call at Southampton. The big event was getting a patient with lung cancer who got caught in the middle of a perfect storm of recently having a cycle of chemo-immunotherapy, then becoming neutropenic and ending up with Norovirus. The result being a woman with septic shock and terrible electrolyte imbalance, needing intensive care support. Any instance wherein the ICU team accepts any of our patients (appropriately of course) is always a big win.

Last week, whilst in clinic, a patient walks in looking awful, has been vomiting at home. Her son showed me her most recent blood sugar readings, these were off the charts. The machine couldn’t read the high numbers. I managed to get her accepted by Medics for assessment as I suspected Hyperosmolar Hyperglycaemic State – a diabetic emergency. Any instance wherein Medics accept any of our patients is always a big win.

I also looked after a patient who had immediate suprapubic pain after antegrade stents being inserted. The stents failed shortly after insertion. Kidney function worsened – bladder not filling, Cr 500, eGFR 9 overnight. With good advise and logistics working on my side, the CTKUB confirmed stents were in place and can’t see blockage. Bilateral nephrostomies were inserted at 4 pm. Any instance wherein procedures for our patients get done on the same day they were requested is always a big win.

I felt pretty chuffed about myself. Then Reg of the Week happened.

Registrar of the Week

More commonly known as ‘Reg of the Week’ or ‘ROTW’ or being ‘On-Call.’ To me, it is ‘my most favourite week.’ Alternatively, it could also escalate to ‘the shittiest week ever.’

This week was my first full Reg of the Week in Southampton. What is quite different is that as a Clinical Oncology Reg here, you only deal with the Clinical Oncology patients, the Medical Oncologists look after their own. This is different from Portsmouth wherein you look after both.

In Medicine, the word ‘Quiet’ is like ‘Voldemort’ in Harry Potter. Nobody likes saying it, nobody likes hearing it. Monday to Wednesday were Quiet (I can say that now). It was very odd. It was just not what I was used to, as in Portsmouth. I found myself wandering the halls, desperately looking for jobs to do. One of my other Reg colleagues said ‘Monica, you look like your adrenaline is not being pumped enough.’

If it’s adrenaline you want, it’s adrenaline you get. Thursday came around and it started with planning for a patient transfer for emergency radiotherapy for cauda equina syndrome. Then a patient who desaturated and deteriorated pretty quickly, who I suspect had a massive pulmonary embolism (sadly passed away), then neutropenic sepsis, then frequent vasovagal episodes that initially looked like seizures, then someone with a blood pressure of 200/70 (wide pulse pressure), then someone who had purple finger tips (Buerger’s disease) with low blood pressure then plain old sepsis. All in a day.

I was anticipating that Friday would be a ‘when shit hits the fan’ kinda day. Conventionally, all the cord compressions get referred on Friday at 4 pm. But there was none of that. Instead, it was a ‘when shit hits the fan’ kinda morning. Five new admissions to review (handed one to another Reg) – luckily, two I already knew about, one was waiting for a procedure then home, left me with one – post-radiotherapy odynophagia. Phew.

But wait there’s more. The hardest one was a patient sent from another hospital for emergency radiotherapy but it turns out, he had deteriorated further overnight. By the time he got to us, he was already dying. But no one alerted us. So as Reg of the Week, I had to break bad news to the patient and his family (who I only met 15 minutes before) that the radiotherapy will now be futile in his current state. I made the decision of not sending him back to other hospital, we will now start end of life care. Yea, that one’s gonna linger for a while. Throughout the day, I kept thinking on how I could have made that situation better. (Of course, all was discussed with Consultants).

And just like that, it was 1700 on Friday afternoon. Reg of the Week was over (til the next one). Time for the Post-ROTW PTSD to take over.

The biggest lesson this week yet…

On Tuesday morning, I attended a virtual Wessex Exam Skills course, in hopes that I can improve my exam technique – given 3 failures of the Physics exam. One of the advice was that download the syllabus (which I have) and compare the feedback report to see if you identify weak topics. I keenly did this during one of the breaks and lo behold…

I was actually okay in the first few topics. Then about 50% in the middle and just dropped off towards the end. 2 possible reasons, I most likely don’t focus on the last topics enough and perhaps I am more tired towards the end of a 2.5 hour exam. A perfect storm of poor performance.

Now I can’t help but relate this to the way I run marathons, positive splits is not part of my vocabulary. I always start out strong, then compromise around the middle and then just slow down towards the end.

So after this discovery, I am changing gears. I am going to read up on the last topics and focus building knowledge around that.

Facepalm moment: I should have analysed the exam feedback a while back.

Also, I should also view my previous race metrics in more detail. Maybe I am not as serious about races as others and don’t really go beyond looking at my Finish Time. But hey, I can only improve if I engage and learn with my previous shortfalls. Otherwise, I’ll just be doing the same thing over and over again.

Rest assured… I have started zero-ing in on Quality Assurance, Radiation Protection, and Radiotherapy sources.