There it is. Anxiety strikes. Just as I walk through the door having driven home after fifty eight hours of work in five days. It had been a good week, hard work and demanding but enjoyable and rewarding. My anticipatory joy for the coming weekend is quickly swallowed and replaced by a wrenching fear, knowing that this feeling is going to plague me until I’m back at work on Monday, when any little worries can be put to rest by checking. Until then? The cool shiver trickles down my spine while my stomach proceeds to churn itself into an ever tightening knot.
“Did that patient’s dalteparin get prescribed?”
I ponder the thought for a little while, allowing the anxiety to chew it over as I have a shower and get changed. I’d written on my list to prescribe it, along with all of her other regular medications after her operation, however when I came to do it, I saw that all her medications, and the dalteparin, had already been written up on her chart by somebody else. Because I didn’t actively do the job myself, I have no memory of doing it, and so no amount of ruminating and rewinding through memories of the day is going to help reassure me.
What happens if I had misread, and it hadn’t been written up? Most likely nothing, but possibly the patient gets a deep vein thrombosis and throws a clot to her lung. It could kill her. It probably won’t, but it could. If I were working tomorrow I could check when I get in – one missed dose is hardly an issue, but it’s the weekend, and I’m not on for three days; a significant time not to be sufficiently anticoagulated. I almost certainly remember seeing it.
Shit. This isn’t going away. No amount of dredging up memories of the day, desperately sifting through images of drug charts and interactions with nurses will shift this worry. The hospital is a twenty minute drive away. I could go back and check. It’s now half eight…
I decide to message my colleague and friend who is on call this evening. I begin by apologising profusely that I was being neurotic and worrying about whether I’d missed something. She was totally understanding and happily obliged, confirming that dalteparin had in fact been prescribed, and not to worry, and that was that.
Or so it should have been. However the anxious wrench wasn’t loosening. Why wasn’t the worry drifting away like cramp gently massaged from a panicked muscle? I actually asked myself out loud, “What are you worried about now?” I waited a little longer.
“Was it the right dose?”
Oh come on. This is insane, even for me. What kind of moron worries like this? Even if the dose isn’t quite right (which it 99.99% likely is, given it’s supplied as a damn proforma and all you have to do is click OK), the nurse dispensing it will notice it’s not the normal dose, check the notes, and ask the doctor on call to check it. Even if the nurse doesn’t do that, and gives the incorrect dose, then the likely outcome is she definitely won’t get a clot, but she is marginally more likely to bleed for a longer time should she spring a leak. Which almost certainly won’t do her any harm.
I phone the ward. The staff nurse kindly checks for me. “Yes it’s been prescribed at this dose. Wait, it’s been stopped. Oh no, it has been prescribed.” I thank the nurse, put the phone down and take a deep breath, knowing that moment of hesitation, of possible error, by the nurse had doomed me to an evening and possibly a weekend of fear. I waited. And waited. And waited. I stood staring blankly at the wall in front of me as my squirming insides boiled and the sweat began to slide down my neck. I looked at the keys sat in my clammy, shaking hand.
Since it was Friday night it only took me eighteen minutes to get back to the hospital. Eighteen minutes filled with cursing my wretched conscience for wasting so much of my life worrying unnecessarily. Sure erring on the side of cautious is what you want in your mother’s doctor, someone who’s willing to put in a little extra effort to ensure everything is as it should be, that no harm was being done, but this was beyond useful. This was debilitating. Eighteen minutes of hating that I was like this, that I couldn’t be like all the other doctors who seemed to be able to switch off at the end of their shift and leave all their concerns at work, trusting that the on call team can handle any problems until they return. I bet they never woke up shaking at three in the morning because maybe they had misread the CT report and sent someone home when they actually needed urgent surgery, despite the fact that at least two other people will have checked the report as well, and the nurse wouldn’t allow someone to go home if they’re clearly unwell and need surgery. It’s supposed to be a team effort for exactly this reason, so there isn’t the opportunity for just one person’s mistake to screw everything up. God I’m an idiot. I had asked a few colleagues whether they had anything like it, and a couple had admitted to the occasional worrying about whether they’d forgotten anything, but not this level. Not this ridiculous. A sharp pain told me I had been clenching my teeth so hard that my jaw had cramped, and I suddenly realised I was gripping the steering wheel so hard my fingertips had gone numb. I’d also not taken a breath for about a minute.
It’s a lonely existence when you panic about everything, desperately trying to figure out every possible eventuality for your actions like a crazed early-edition chess algorithm. You lock yourself away in the safety of your own skull like a little kid with a photo album and you start flicking through memories of the day, checking and checking, searching for mistakes. You spend so much time in your own head worrying, that you then don’t feel like you’ve paid sufficient attention to what you’re currently working on, so afterwards of course you worry you did that wrong too.
Needless to say when I got up to the ward at ten o’clock on the Friday night, my patient was happily asleep in bed having received exactly the right amount of dalteparin. I felt the clenching vice of the anxiety slowly release, and wearily wandered back home to bed, cursing myself once more for having given in to the monster yet again.
What can I take from this experience?
- I knew I would sleep better having reassured myself
- I got to drive my car on empty country roads in the dark, which was fun
- I realised that I can’t rely on trusting that someone else has prescribed something for me, even if I see it written on the chart. If I’ve been asked to prescribe something, I need to go to that patient’s chart and consciously process the fact that that drug has been prescribed and at the correct dose, and then tick it off my list. It’s hardly the most efficient way to do it, but it’s the only way I’m not going to spend the rest of the evening panicking about it
- I should probably do something to try and get rid of this anxiety
When injecting lidocaine as a local anaesthetic, it’s really rather important that you don’t give too much, what with the whole making-the-nerves-stop-working aspects of its pharmacological profile.
When given locally it’s a terrific anaesthetic, however if too much is allowed into the general circulation, everything gets a bit tingly, the brain goes a tad bezerk and heart decides to stop cooperating. In essence, don’t give too much.
So how much to give?
Well on it’s own, Lidocaine doses shouldn’t exceed 3mg/kg however when given with adrenaline, to induce vasoconstriction and thus limit systemic spread, the dose can be increased to 7mg/kg.
How to remember this?
Li-do-caine = 3 syllables
Li-do-caine-ad-ren-a-line = 7 syllables