Thursday 8am: Doctors and midwives muster in the obstetrics unit. David studies the latest test results on women in the ante-natal ward. The signs are that it will not be very busy.
David delivered nine babies, six of them by Caesarean section, during one continuous 50 hour- stretch, earlier this month - all on three-and-a-half hours sleep. That was busy. 'Suicide weekend', as it is known in the trade, lives on, despite government initiatives to make junior doctors work less dangerous hours.
'Occasionally, I worry about slowing down, when every task takes a little longer than it should,' David said. 'As a house officer I made mistakes. I put too much insulin in someone's drip once, but I realised in time that I'd done it. Potentially, that would have been fatal. Around 85 per cent of gynaecologists have legal actions pending against them at any one time. I have had one, but it didn't come to anything.'
Ward rounds should have been under way. They cannot start without John Smith, the consultant obstetrician and gynaecologist - he is stuck in traffic.
8.40am: Labour ward round. David joins in discussion of individual cases. Teaching during the rounds tends to happen in corridors, partly to help dispel the impression patients sometimes get that they are simply bundles of symptoms. But most wards now comprise single-bed rooms, and cannot take swarms of medics.
David and his colleagues see patients including a diabetic whose baby is growing too rapidly, a well-known complication with diabetes; another with severe abdominal pain; and a woman having her first baby after an ectopic pregnancy, where the foetus began to grow in the wrong place. She wants to use a birthing pool.
9.10am: Upstairs for the ante- natal ward round. Then to post- natal ward where Mr Smith beams benignly at tired but smiling mothers. 'Well done]' he says, to one. David and Mr Smith talk shop between the congratulations.
11.15am: David goes downstairs to the Foetal Monitoring Unit, where women with potential complications can be checked without being admitted. He does cardiotocograph checks on a woman with blood pressure problems, and another diabetic. Then he tours the labour rooms. Only two are being used. 'Obstetrics can be 95 per cent boredom, 4 per cent excitement and 1 per cent sheer terror. But in two hours' time this place could be full.'
11.45am: David watches an amniocentesis test being performed by Mr Smith, then to the intensive care unit to visit sick babies.
12.10pm: Casualty rings to ask him to attend a woman who has recently had a positive pregnancy test, but bleeding and has acute abdominal pain. David fears it could be an ectopic pregnancy.
He arranges for her transfer to the Samaritan hospital half-a- mile away, but part of the St Mary's complex, for a trans-vaginal scan. He briefs the senior house officer at the Samaritan on his diagnosis. (His suspicion was confirmed later.)
1.20pm: David arrives late for the Caesarean section meeting, a weekly working lunch for junior doctors, nurses and midwives to discuss good practice, review individual cases and plan for imminent arrivals. It is part of the 'medical auditing' that goes on throughout the NHS now. 'More fine-tuning than wrist-slapping', David says, eating sandwiches.
2.03pm: David is asked to see a patient who is causing concern to a more junior doctor. Then he is on the phone again to the cardio- thoracic surgeons, the 'chestcrackers' to other medical colleagues. They need to be on stand-by because a woman at risk of having blood clots move from her legs to her lungs is due in for labour. Checks on more patients.
4.15pm: More cardiotocographs, and patient notes to check. In one there is a sudden dip in the graph representing fetal heartbeat which quickly recovers. Probably nothing to worry about, but David makes a note to show the consultant.
5pm: A woman has started labour but it seems to have slowed. Tests show that it is satisfactory so far. A colleague rings David from the Samaritan about a patient with abdominal pain sent in by a GP. 'What? The GP didn't see her? He didn't give her a letter to take? Outrageous]'
5.03pm: Emergency bleep - false.
5.20pm: David starts preparing a lecture to a group of medical students that he should have started delivering 20 minutes ago. He had planned to set aside an hour to work on it. This the first chance he has had all day to think about it.
5.28pm: One of the two women on delivery ward needs encouragement. She has just had an epidural and is feeling low.
5.31pm: Half an hour late, the lecture begins in a room overlooking rush-hour traffic crawling through Paddington. 'Give me some examples of post-operative complication,' David begins. 'Death?' shouts a wag.
6pm: Bleep. David hurries out to answer the phone, and students start rifling through his lecture notes for the next questions.
6.15pm: David returns. His questions about sutures and urinary infections are mostly answered correctly.
6.50pm: The lecture ends. Back in the delivery ward, Mr Smith is leaving. 'When you get to my age,' he tells us, 'you get to go home.' David returns to the ante-natal ward for routine checks, then to the labour ward to see what's happening.
8.20pm: David is eating take- away curry in the junior doctors' rest room. He contemplates the Caesarean section he will have to do around midnight, and talks animatedly about his first experience of the operating theatre. 'When I was at Cambridge, I was fairly dismissive of surgeons; to me they were the butchers, the technicians. I wanted to be a physician, a renaissance man, bringing together the best of the arts and sciences.
'Then I was watching an operation for the first time and the surgeon asked the students for an assistant. I volunteered like a shot, 'Give me that knife]', and off I went] Why do I like surgery? I am never more focused, never more awake or more conscious than when I am doing surgery. It is tactile, useful and there is certainly an aesthetic quality to surgery.'
9.55pm: A baby is born to a woman who came in around 6pm. No complications. David's main concern now on the delivery ward is on the woman who wants to use the birthing pool. She felt unhappy about her epidural earlier. She has been in labour most of the day, but the contractions have been slower than expected. David bleeps the on-call senior registrar. An anaesthetist is summoned. They decide the woman will almost certainly need an assisted delivery. Within half an hour, David has decided against a forceps delivery because the cervix has not fully opened.
10.45pm: David, his senior house officer and the midwives have changed into 'battledress' theatre gowns. The pace quickens. The woman is prepared for theatre. Phones ring every few seconds. Between flurries of calls and consultations with colleagues, David paces up and down, deep in concentration.
11.40pm: It's a boy. Crying lustily. Caesarean section completed within 35 minutes. All well. Three more women for the labour ward.
11.45pm: Brisk walk downstairs and across the covered walkway to Casualty to examine a woman who is five to six weeks late with her period and suffering abdominal pain. Miscarriage or ectopic pregnancy suspected. David books her in at the Samaritan.
Friday 01.45am: Another patient, nine weeks pregnant, to be seen in casualty, now bristling with activity. A man comes up to the staff desk demanding two injections of insulin and gets abusive. The junior casualty doctor smells alcohol on his breath, and tells the man he is not convinced he is a diabetic. Waiting time is running at up to four hours, the sister says.
2.30am: The second Caesarean section of the night looms, to minimise the risk of passing on a viral infection from mother to baby. David is back on the labour ward, discussing the options with colleagues. The labour is becoming more intensive.
4.30am: David has completed his second Caesarean of the night. Another boy. All's well.
5.30am: Mr Smith appears to attend an unexpected breech presentation. David continues completing and updating case notes. Every conversation with patients, and every medical intervention has to be recorded in detail.
6.40am: David slumps into a chair in the midwife's office, looking shattered. How does he feel? 'Tired, but I'm okay. It will hit me tomorrow. (He actually meant 'later today' - in less than three hours' time he is due to take an ante-natal clinic). I will be a bit slower, but I will explain that I've been up all night.'
David's wife, Sarah, 33, is a senior registrar in radiology at St George's. 'It's impossible to synchronise our working hours so we don't have much time off together,' he says. 'We've just managed to buy our first house and we have only been able to do it because of the increased overtime that we now get. I earn about pounds 35,000 although the basic salary is about pounds 22,000. Once the contracted hours go down, the pay will go down. But I would rather have the hours.'
6.50am: David is looking crumpled. He goes to find somewhere to sleep and asks a midwife to wake him in half an hour.
'The hours some of these young doctors have to work are really terrible,' says one member of the team. 'I know the consultants say they used to have to do it. But they never had to carry bleeps. They at least could have some privacy and the pace was quite different.'
Compared with many hospitals, St Mary's has made strenuous efforts to reduce the juniors' working week. From April, periods of continuous duty will be pegged at 32 hours, or 56 hours at weekends.
7.15am: Back on the labour ward, David checks the women's progress. One of the three newly arrived women in labour is causing concern. He prepares to hand over to the next shift.
8.30am: A fresh team takes over and the cycle begins again. David has a shower and heads off to the Samaritan for an outpatients' clinic.
His marathon working weekend runs until tomorrow morning. 'There's an ultrasound training session on Monday afternoon, but I think I will go home and sleep.'
Today, David is working another 24-hour stint on the labour ward, having spent yesterday providing on-call cover at the Samaritan. One week in every five follows this pattern - 92 hours working from Thursday to Sunday.
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