You decide! Trainee doctor Nina Charan finds herself involved in four challenging scenarios. At the end of each paragraph you must choose the correct course of action and click on your preferred option. Make the wrong choice, and the scenario ends – with a summing up page.
A relative who insists on concealing the truth from a dying relative; a colleague who has no insight into his lack of skill; a consultant who makes the wrong call; an opportunity to show her independence… each of these situations demands self-knowledge and sensitivity.
The four scenarios – click on one to start. By keeping this page open you can come back to choose a different scenario at any time.
There is also a paperback and e-book available on Amazon.
This takes us back to Nina’s early years in medicine. She was a pre-registration House Officer, or Foundation Year 1 doctor in modern parlance. Always keen to develop and push herself, she encountered a patient who’s condition tested her in a number ways, not least in the area of self-knowledge – knowing when to give up and ask for help.
In her first year on the wards Nina answered a call and attended a patient. It was 2.30AM. The patient was 50, cirrhotic, being treated for sepsis, and deteriorating. His blood pressure was 65/40, he was drowsy, jaundiced, barely passing any urine through the catheter. Nina examined him, reviewed the bloods, and talked to the nurse in charge of the ward. The blood pressure was never greater than 85/60 anyway. The team had only just changed the antibiotics. And he was confused all the time, the nurse said. Nina considered what to do…
2. Get on and treat him
3. Call for help
4. Leave the patient
Nina fetched a bag on fluid and stayed with the patient while she squeezed it into him. First she gave 250mls, then another 250mls. His blood pressure barely moved. She reviewed the antibiotics he was on and upscaled them. She decided this was bad sepsis. There was nothing written the notes about limits of care. This was his first hospital admission, albeit at a late stage of his alcohol induced disease. Another 250mls of fluid. That was three quarters of a litre in total. Blood pressure up to 75/45 for one reading, then down to 70/40. Getting somewhere? She wasn’t sure.
6. Persevere, continue treating
12. Call for help
“Hi, it’s Nina, the house officer on call for the wards.” She was nervous, she always was when calling seniors. And she had never worked with this registrar before
“Hi. Marcus here.”
“It’s…I’ve got a patient on ward 8, he’s sick, and had a low blood pressure…”
“Ok. Stop. Start again. What’s wrong with him?”
“Sorry. He’s got cirrhosis, he’s been in for four days on antibiotics, and tonight he’s worse. The nurses called me. He’s hypotensive, 65/40, MET scoring 8, and…”
“What have you done?”
“What have I done?”
“Yes. What treatment have you given him?”
“Well, I called you…”
Nina heard a long sigh, and regretted her call. Then the registar opened up, all guns…
“You can’t just shout for help without making an assessment and starting some therapy! He needs resuscitation, doesn’t he? So treat him, and let me know what happens. Give him some fluid. I’ll be in resus.” The phone went down.
Nina sat back and wondered. The patient was too sick for her level of experience, she felt sure. But then again, she hadn’t tried anything yet.
18. Try to resuscitate
7. Call the registrar back and insist that he come
Nina made the decision that his condition was not significantly worse than it had been. The incoming shift of nurses were just a bit horrified by the look of him, hence the call.
She left the ward and returned to the ED. Half an hour later a crash call came through. Ward 8. Her heart sank. She ran there. The rest of the crash team arrived with her. The patient was in full arrest, and they could not get him back. The registrar, Marcus, was told by the nurse that the patient had been reviewed just 30 minutes before, for a low blood pressure. He took Nina aside and said quietly,
“We’ll need to discuss this tomorrow. Why didn’t you do anything?”
Go to 5
Nina was called in to see her educational supervisor. They talked about the case. In retrospect it was very difficult to explain, and to justify her inaction. She was made to go on an ‘Immediate Life Support’ course, to reflect on the case in a written report for her portfolio, and to learn from it. Her name was mentioned in faculty meetings, and she was watched very closely for the rest of the year.
Go to Summing Up
Nina gave the situation some more time. So she gave more fluid, another 2 litres, and multi-tasked for an hour – reviewing other patients, then rushing back to see this man. It felt like he’d become a project. She wanted to sort him out, and prove to herself that she could. After the 2 litres had gone in the blood pressure was marginally higher. She anxiously reviewed the fluid chart, and shook the catheter tube to see if there was more urine to drip into the hourly measure… there was next to nothing. He might be on the brink of responding. It takes time, doesn’t it, for the fluids to kick in?
10. Keep treating
11. Call the registrar for help
Marcus arrived, exuding reluctance. He looked at the patient, reviewed the recent blood tests and pronounced,
“Yeah, he clearly needs to go to intensive care. Good call. Can you call the ICU registrar and get them up here? I’ll wander down to the unit and discuss it too. But give him some fluid will you, we need to show we’ve at least tried to resuscitate him a bit. But it won’t save him from an ICU admission. Give him a litre stat.”
Nina didn’t know want to think. The patient needed a registrar review, but he seemed unimpressed. Should she have done more first? She made the call, and an hour later the patient had been moved. He was safe now, in the right place. But for some reason she didn’t feel as though it was a job well done.
Go to 8.
Two days later Nina took her place in the canteen queue. There were two registrars in front of her, chatting. Neither of them was Marcus, the registrar who had been on call with her the other night. They were talking about the juniors, and Nina listened in.
“They just haven’t seen it, that’s the problem.”
“Barely any nights on their own…”
“A few. But they just refer it up the line, they’re not able to make a diagnosis. I mean, Marcus was telling me about his night shift earlier in the week. There was a sickie, the House Officer was called to review him – he had sepsis, he was proper sick – and she just called him! Did nothing. Acopic. The patient was fine, because Marcus sorted him out, but she, the House Officer, didn’t try. She didn’t learn anything out of the encounter…”
Nina’s eyes misted, and she left the canteen unable even to say hello to the flatmate she passed.
Go to Summing Up
Nina completed her run of night shifts and the following week was back on the wards as usual. On a ward round with her consultant she sensed hesitancy in his instructions, and previously unheard intensity in his questions. It was as though he trusted her a little bit less. When she looked at him quizzically once too often, he said,
“Sorry Nina. I’m not testing you. But I recognise that this is a busy job, and that you’ve been given a hell of a lot of responsibility. I’m just a bit worried that you’ve been given a bit too much…”
“Did Marcus speak to you?”
“He did. He told me about a patient who should probably have been escalated a bit sooner. I’m sure you’ve been reflecting on it already…
“I have. I shouldn’t have carried on so long… it’s just, I’ve had patient sicker than that here on the ward and I thought I could manage it…”
“Well. We all have bad cases now and again. You just need to find the right balance between independence and self-knowledge! Don’t be afraid to call. It’s the safety of the patient that is paramount.”
Go to Summing Up