This is a reflection on a week in time recently where I ended up doing three “Duty” shifts.
That means I’m running the floor. I work in a tertiary referral centre, so a hospital that accepts the more complicated stuff. It’s also a trauma centre and covers an area the size of England…
We have 15 operating theatres, 2 interventional radiology suites for vascular and interventional neurology, 1 radiology suite for CT guided procedures, 1 GA endoscopy suite, 1 obstetric theatre and occasional cardiology interventional and paediatric oncology theatres and finally MRI and CT cases that appear now and then.
There is an “acute” theatre which accepts all specialities with urgent cases and “trauma” theatres which are mainly doing broken bones and fractures from 2 year olds with bent wrists to 94 year olds with fractured femurs. These cases are stratified into now, within an hour, within 4,8,24,72 hours.
Due to our hospital site now being too small for the workload, we have to run so called “twilight” lists, which are evening elective lists. They often cause issues with adequate staffing. That geographical constraint is likely to be eased by the building of a new hospital in the next few years, but that hasn’t been future proofed for capacity as far as I’ve heard…
But as the duty anaesthetist my role is to co-ordinate all those moving parts to ensure patients that need an operation get an operation. We are nearly always constrained by capacity and if not capacity then nursing staff and if not nursing staff then skill sets…
The other part of the role is to ensure the anaesthetic staff have the support they need and get a break during the day sometime.
And the last bit is to manage all cases that are “remote” that is not within the main theatre complex eg radiology. This role now made immeasurably easier by the provision of an “outside’ anaesthetist.
The role is a double edged sword, although more improved recently due to an uptick in staff numbers. Some days can be reasonably cruisey, the case load not too high, no one has called in sick, there aren’t cases outside of theatre that need sorting, extra urgent surgery isn’t incoming.
Other days, not so much…
I have to cater to the demands of multiple surgical specialities. The surgical specialities cater to the demand of, hopefully, their patients. So when they’ve been waiting hours to get a case to theatre I hope their ire is due to patient advocacy not egocentricity. But the surgeons have been in the system for years and are often profoundly frustrated by it too.
Because the system is set up the way it is, an historical thing, the elective lists take priority over urgent cases. Blame the government for punitive targets and funding elective surgery over urgent surgery. 60-70 percent of our work is urgent. So despite constant demand on ICU for beds, the inevitable ebb and flow of acute work, non-urgent surgery will still take precedence on occasion.
Believe me I understand you have rearranged your life, work, child care, psyched yourself up, waited months if not years for your surgery. But if you’ve waited three days with a broken jaw or ankle, or a stone in your kidney or your child can’t have an MRI and I know that. That’s difficult for me.
With many hours of work and only so many hours available in theatre, something has to give. That’s either the patient who gets postponed or for those that can’t be postponed it’s the staff – working extra.
The surgeons can be fickle with their availability due to other commitments which can lead to skepticism on my behalf: “oh so now it’s urgent?!”
So I regularly make decisions about priority of patients for surgery. Despite the fact that i have never met the patient, a conversation with the surgeon can clarify that but surgeons are happy to berate me for making the decision, but rarely do they want to speak to each other to decide clinical priority…
I had never been formally taught conflict management, or theatre management or how to deal with the stress of multiple conflicting priorities… I have improved that by using my medical simulation and debriefing skills.
It’s also not a role I ever anticipated as an anaesthetist in training and certainly not one I’d choose! Some places I’ve worked have had an amazing theatre sister who chose to do the job all week. She was awesome! Never seen a surgeon doing it though, too sensible probably.
There are a smallish group of us who do it regularly so I guess I must have some skills – but by the end of the shift which is shorter than a theatre shift – I am brain fried.
It can be incredibly varied though. Putting cannulas in babies, regional blocks in patients with broken ribs, helping colleagues, advising junior colleagues, anaesthetising a pregnant woman within 10 minutes of meeting her, rushing to recovery to see what the “red bell” is about, giving random phone advice to doctors in the country and organising, organising, organising. Or my favourite – delegating.
So what am I reflecting on here exactly? Not sure really – it’s just a situation I find myself in that is stressful at times and to write about it is cathartic.
The number one thing though and I do strive to fulfil this tenet: Communication is key and when communicating “don’t be a dick” is also key. A bona fide lesson for life…