Dealing with Addiction Junior Doctors: Your Life in Their Hands

Trauma...

-Got a pulse, got a strong pulse.

-Any pain up here?

..tears...

That's all right.

..and intense pressure.

Changing the oxygen over.

Just another day on medicine's front line.

They're young, they're untested...

This is my first patient ever.

..and from their very first day, work is a matter of life and death.

-Don't let me die.

-I'm not going to let you go anywhere.

For a junior doctor, fresh out of medical school,

it's time to put theory into practice.

No, I haven't.

We're following seven junior doctors over their first three months on the job...

-Sharp scratch.

-Ohh!

It's all about the glamour.

It's all about the bums.

..where there's a first time for everything...

I didn't really know what to do. It's just having the confidence, isn't it?

..and first impressions count.

I'm afraid I didn't get it first time either.

First years Tom, Emily,

Jen, Tristan

and Ed have been on the wards for just four weeks.

For all intents and purposes, at the moment, he's actually having a heart attack.

We're just going to put the morphine in now. You might feel a little bit dizzy.

Second years Oli and Kiera have 12 months' experience.

Breathing now.

Don't need any more of them tonight, that'll do for me.

They are working here, at the Royal Liverpool University Hospital.

They're here to look after you.

But can they handle the pressure of being doctors

in one of Britain's booziest cities?

You think of it as normal, sociable. Going out drinking with friends, people might have a few too many.

But you see the real extreme end of it in hospital.

I started drinking again the other night. Just loads of blood came out.

I guess it's just one of those things

of working in a city where there's lots of people who drink a lot of alcohol.

It's the weekend in Liverpool, one of Britain's biggest party capitals.

MUSIC: "This Is The Life" by Two Door Cinema Club

But when lots of young people have one too many to drink,

it's up to the junior doctors to pick up the pieces.

SIREN WAILS

Second year Kiera has just started a night shift

in the hospital's emergency department.

Working with A&E probably has changed the way I feel about going out

and getting absolutely smashed,

as maybe you would like to do as a student.

It kind of upsets me a little bit

because I've seen the really negative effects

that can actually have.

Hello, there.

Kiera's first patient is no boozed up 20-something,

but an evening spent sampling the city's nightlife has still ended in a trip to casualty.

I had a couple of drinks, went into a bar, sitting on a stool,

had a cocktail, but it must have gone down the wrong hole,

and I took a fit of coughing.

I felt light-headed as I coughed.

-The next thing I know, I'm on the floor.

-Dearie me. You poor thing.

So you fell and you hit your face.

The next thing I remember is I woke up and there were people around me

and there was somebody wiping the blood from me and I couldn't move.

Then I could move and I was all right.

I think you've broken your nose there.

Oh, God.

Got a bit of a cut there as well. Been in the wars, eh?

Did myself a bit of damage there, didn't I?

You've done a proper job of it, haven't you?

But it's not just a broken nose that's concerning the patient.

The thing that is getting me is these sensations in me hands.

Extremely painful pins and needles which are shooting up from my fingers

into my hands, and it's very painful indeed.

Medical alarm bells ring for the junior doctor.

If you've hurt something in your neck, it might be causing you pain in your hands,

so we might need to get a bit of an X-ray of the neck, OK?

Can you just tell me...?

The tingly sensations could be a sign of a serious spinal injury.

It's extremely painful.

-On the back here?

-Yes, very sensitive.

-Very sensitive for me to touch there.

-It's very sensitive there, yes.

Very sensitive here and here, OK.

I think we probably need to get some sort of imaging on your neck

before I can assess you any further, OK?

With the scan over and the patient back in the bay,

Kiera can get on with the job of fixing his face.

I'm going to just pop a bit of local in that head

and put a couple of stitches in that, get you looking beautiful again, OK?

-HE LAUGHS

-Cheers, thanks!

OK, this is when the sharp, stingy bit is coming up now.

You might not like this bit.

Oh, God, OK.

Right. Just going to go for it.

Just go for it.

OK, sharp scratch coming up.

-That wasn't too bad.

-You'll start to notice it will be numbing soon.

You'll be pleased to know that everyone winds me up

for being a bit of a perfectionist with this.

-Probably what you'd want, I'd imagine.

-I couldn't care less.

Oh, fine, then!

You're going to do a good job.

It's an ugly face anyway.

Aww. Beauty is in the eye of the beholder, as they say.

Just going to have a little look inside now.

We've given it a good wash out so it actually feels OK.

-Can you feel any of this?

-No, you're all right.

Great. All right, sir.

Is the nose broken, is it?

Yes, your nose is broken.

I'm just closing up the skin on it now,

because it reduces the risk of infection

and it stops a lot of the bleeding that is going on.

You're going to have quite a nice black eye from this, sir.

One to show off down the pub.

Wounds, battle scars.

Perfectionist Kiera has stitching down to a fine art.

He's got a new nose.

But potentially there is a much bigger problem to deal with.

Got the results of his scan back

and we think he's had a small fracture to one of the vertebra in his neck

which is probably explaining the horrible sensation he is getting in his hands.

So, essentially, orthopaedics are going to take over care

of his fractured neck and we'll see where we go from there.

Despite the patient's prognosis,

he remains upbeat about the treatment Kiera has given him.

Wonderful service.

Thank you. It's nice to hear that.

It's not always echoed by most people.

As Liverpool recovers from a weekend of partying,

junior doctors Emily and Jen

are gearing up for a week of birthday celebrations,

as they'll both turn 25. Emily's comes first.

Oh, wow!

It looks quite nice.

Well impressed.

Dear Dr Phipps, happy birthday, hope you have a wonderful Thursday,

and I'll see you at weekend, love, Jamie.

I think I will be keeping it quiet.

Why?!

-I can't be bothered.

-Are you not a birthday fan?

I don't mind birthdays, I just don't think everybody on the ward needs...

But there's little time to open presents,

as Emily needs to put in a shift at the hospital.

And as it's her birthday,

she's hoping to avoid any of the more unpleasant procedures.

I'm not putting my fingers up anyone's bum, it's my birthday.

That's my plan.

The news of Emily's 25th birthday has reached the wards.

Ah!

-ALL:

-# Happy birthday to you!

# Happy birthday to you! #

-Can I have a hug?

-Happy birthday!

Thank you.

But the birthday celebrations have to go on hold,

as Emily has patients in need of surgery to see.

86-year-old Joe has been admitted to the ward

to have a growth removed from his bowel.

So, symptoms-wise,

have you noticed any yellowing in your eyes at all?

-No!

-Bit of a weird question, isn't it?! No?

The only thing I do when I get out of bed - shower, shave.

I don't look in the mirror and say, "He's gorgeous, him!"

You should do!

He's going into theatre today,

and Emily needs to do his pre-op assessment.

Are you allergic to any medication?

No.

-How are your waterworks? Any burning or stinging?

-No problem.

Can you lift your top up for me?

-Nothing to hide!

-No tattoos.

-No.

OK. Can I listen to your back as well?

Nice deep breathe for me.

I feel there is something there.

-It's the only part of my body where I feel there is something.

-Mmm.

I think you're doing very well.

So what'll happen is one of the registrars, one of the senior doctors,

will explain everything and answer any questions you have.

Oh, we'll see what we can do.

Emily's been offered the opportunity to observe Joe's surgery,

but she has opted to clear a backlog of work on the ward instead.

While some junior doctors would jump at the chance,

birthday girl Emily is clear about her future direction,

and surgery is not what she wants to specialise in.

I passed out a couple of times in surgery as a student!

It's really hot and sweaty

and you can't go for a wee, you can't have any lunch.

They have this thing called the diathermy

which kind of burns the tissue and stuff so it seals,

and it just smells like a barbeque but not in a nice way.

I'm vegetarian as well so it's just not that nice!

I have an issue with flesh. It's just a bit too fleshy, I think, for me.

But despite her issues with surgery, Emily still feels that choosing

to work her first three months on a surgical ward

has been a worthwhile learning experience.

I'm not passionate about the act of surgery itself.

I really enjoy the patients and the clinical problems they have.

So I feel like I'm still being really useful staying on the ward.

With the patient's operation successfully completed,

Emily's senior, Femi Oshin, takes some time

to catch up on her progress so far, and discuss her future direction.

Some people have no idea what they want to do

until the very last minute, whereas some people

are like, "I want to be a surgeon," from about six. It's weird.

Have you had any thoughts

on what you'd like to specialise in in the future?

Can we tempt you with surgery, perhaps?

Maybe not surgery yet.

Maybe I'll change my mind at some point, but at the minute

-I want to do public health with an infectious diseases focus.

-OK.

You have to do whatever you find interesting,

otherwise you'll very quickly find

that you don't enjoy yourself any more,

and people drop out.

I think my mind's pretty much made up about what I want to do.

But I'm not saying I'm walking around, grumpy, thinking, "Why am I doing this?"

Because, like I say, there's so much you can get out of a job,

it's not all about thinking, "This is what I want to do for the rest of my life."

Every job's a learning experience, so I'm getting loads from it,

even though it's not what I want to do.

While Emily contemplates her future,

over on the acute medical unit Ed and Oli are on the morning ward round,

where they are dealing with Liverpool's all too familiar problem -

alcohol-related illness.

The Royal Liverpool University Hospital deals with

the highest number of alcohol-related cases in England.

It's really sad when you see young people who have come in

and they've got liver problems or, essentially, incurable diseases because of alcohol.

It's worlds apart from Ed's last job in an Italian mountain village.

Of course, I mean, I don't want to pass the city off as a city of alcoholics,

because it's not true.

Unfortunately, it's just an important problem

and you've got to learn how to deal with it as best as possible.

Because of his inexperience of working in the NHS,

he'll be closely supervised by Dr Khan,

who's keen to see what Ed knows about chronic liver disease.

How long have you been drinking for?

-For about five years.

-How much do you drink?

Approximately a litre and half of vodka.

A litre and half a day.

Dr Khan wants Ed to examine a patient

who's showing some of the classic signs.

-Can I have a feel of your tummy?

-Yes.

-Thank you.

Just tell me if there's any pain.

Yeah. All there's sore.

What are the other signs you'd find in the tummy in such a patient?

Well, I would expect to find tenderness

around the liver area.

So what happens to the liver?

In the long term, it can go towards cirrhosis

and in that case, it gets harder.

Ed's holding up to scrutiny,

but there's an obvious clue in the diagnosis of the patient's condition

that Dr Khan thinks he's overlooked.

What are spider naevi?

Spider naevi are another sign typical of alcohol intake,

depending if they are vascular abnormalities...

Has she got any?

That's one.

That's...

That one is.

-That, to me, looks like...

-Not that one?

With people from Liverpool twice as likely to die

from an alcohol-related condition as those from the rest of the UK,

it's an issue that Ed's going to have to grips with.

'I really need to get into revising

'serious complications of alcohol intake,'

because I know a bit,

but I must be more proficient than that

because it's such an important issue here.

Thank you.

I find it very sad, because after a certain point,

it's just difficult to get your health back.

With their shifts over, Ed and some of the other junior doctors

are back at the house with a surprise for Emily.

-ALL:

-# Happy birthday, dear Emily

# Happy birthday to you! #

Aww!

You know you're old when your cake feels like an inferno.

Oh, my God, that's amazing.

-Oh, shit!

-ALL LAUGH

That was hair on fire!

Oli nearly got his fireman on there!

-About to pour beer on it!

-One more, Emily, then your wish.

But the surprises don't stop there.

So, Emily, since you're now 25,

I have a rhyme that I've written that is quite appropriate for the moment.

It's a bit grim and it's about the menopause.

Hot flush, open the doors

Make way for the menopause

If you thought PMT was bad

Found yourself flustered and mad

Just wait till this one takes its toll

You see red and heads will roll

If only your oestrogen would come back

Your ever drooping once-hot rack

But fear not, you are still strong

It's just the change and won't last long

Of life, you still have much, much more

You're still all woman, hear you roar.

Thank you very much.

'I feel like I have just grown up in the last few weeks,'

and it's such a surreal feeling,

kind of being independent and having so much responsibility

and not quite knowing what to do with it.

-Happy birthday!

-ALL: Happy birthday!

As Emily celebrates a birthday night in,

back at the hospital,

Tristan's shift is only just starting on the acute medical ward.

The patient's stable, it's just that I think that she's got a large left-sided haemothorax.

As part of the night team, he'll be on the front line

for any emergency bleeps across the hospital.

Being on the crash bleep is a mixture of apprehension and excitement.

I mean, obviously whoever you're going to see is going to be ill,

which is very bad for them.

You sort of hope that you can rely on your training

to remember everything you're supposed to do.

Tristan is coping with the pressure of being a junior doctor,

but he has a lot more than his patients to juggle.

I'm married to Jenna. We've been married almost six years,

and we have a daughter called Lottie

and she's almost two years old.

Uh-oh! Watch out for the tickly trees!

Uh-oh! Uh-oh! Watch out! Watch out! Watch out!

Time with Lottie is very important to him.

Now starting to actually work as a junior doctor,

the balancing act between father and doctor will be a lot more difficult.

I'll be missing Lottie and Jenna a lot.

My greatest fear about being a doctor would be

'making a mistake or missing something that's really important.'

There's going to be a sharp scratch, OK?

Try and stay as still as possible. Ready?

'It is a big responsibility'

to be in the position to give people medicines

which have side effects, both predictable and unpredictable,

or to do procedures,

and even minor things can have rare but serious consequences.

So we're just going to use the local anaesthetic first. Is that all right?

If I didn't know a risk and something happened to a patient,

I think I'd feel very guilty that I exposed them to that.

Tonight Tristan must face his fear

of dealing with seriously ill patients.

It's not long before he's called to another alcohol-related casualty.

Sounds like you've been having a horrible time. You feeling rough?

I keep getting blood in the back of my mouth.

Did you tell the doctor that before?

Yeah.

I'm getting frightened now.

I'm scared I'm going to die.

-Is that just because you feel so rough?

-Uh-huh.

You're in hospital, so you're in the right place.

The man admits to drinking a bottle of vodka a day

and he is now vomiting blood.

Little scratch.

Ah!

Right, we've got a sample of blood.

I'll go and get this analysed

so we can see how you're doing, cos what we want to make sure

is that your blood is not too acid or too alkaline.

I'm so frightened.

Don't let me die, doctor, please.

-Sorry?

-Don't let me die.

We're just sorting you out right now. We've given you some anti-sickness.

We're going to get you some fluids. We'll give you some antibiotics

-and I'm sending these blood tests off as well.

-I'm frightened.

We're not going to let you go anywhere.

I'll let the doctor that's been looking after you

know you're still having some pain and that you're really worried. OK?

See you later.

The results of the man's blood tests have come back

and Tristan's concerned.

He reports his findings to the registrar, Dr Abraham.

-Can I just mention something to you? Is that all right?

-Yeah.

His pH is 7.3. He's quite sick, I think.

Tristan's discovered the patient's blood is too acidic,

which can be fatal.

He's shaking, but I think he might be withdrawing as well.

So whether that's from infection or alcohol withdrawal, I don't know.

I don't know if he is septic.

I don't know if... Yeah, it's here.

Anti-sickness, please.

The only way we can get anti-sickness into you

without you throwing it straight back up would be to get an IV cannula.

In the interim,

I'll see if we can give you an injection for the sickness.

-OK.

-And I'll be right back.

'He's being sick all the time.

'He's throwing up some sort of half-digested blood.'

We need to get IV access

so that we can give him anti-sickness, pain relief,

antibiotics - the whole lot, really.

And that all hinges, really, on finding a good vein

and getting a cannula in.

'When dealing with the sort of patients that come in with alcohol problems,

'it's easy to slip into the attitude that they're a hassle.'

But a lot of the people who have these sorts of problems

have been in terrible situations.

Tristan's shift should have ended an hour ago

but he's pressing on and fitting a fresh cannula

so the patient can get the life-saving drugs he needs.

Please bring your arm around here.

And Tristan's late finish hasn't gone unnoticed by his senior.

Thanks very much for that, Tristan. I'm glad you were here.

'Quite impressed, really.'

I only realised half an hour ago

that he stayed an extra hour and a half

to get all the other follow-ups done as well,

in terms of investigations and procedures,

so that is impressive, yeah.

Being an inner-city hospital,

and one with certain social problems that are quite rife in Liverpool,

you get to see a lot of sick people,

which is obviously a terrible thing

but really important to learn from, so you can deal with those problems.

SIREN WAILS

A new day,

and not all of the junior doctors are dealing with alcohol cases.

For first-year Tom on the cardiology ward,

it's another day, another vein.

See you in a bit.

His next patient has recently had surgery

and he needs to fit a cannula.

He's found needle work trickier than most, but a month into the job,

he's hoping that this time it goes without a hitch.

How long has that been in there for?

I think Friday night or Saturday.

You'll have to have another one in

cos we have to give you the antibiotics.

But from the outset, it's becoming clear

that Tom is the one being examined, and not the patient.

So you like giving banter out but you don't like taking it, do you?

-What do you mean?

-Ah. I do fortunes.

-You do fortunes?

-Yeah.

I've never met anybody who reads fortunes before.

-Do you really?

-That's how I know.

Cos you go dead shy when you're out, don't you,

-having a little banter with all the lads?

-Put it in this one here.

-I've done a few of the nurses in here as well.

-Have you?

-Yeah.

How do you...?

"How do I know," you were going to say then, weren't you?

I know, yeah. I just shouldn't have asked, should I?

THEY LAUGH

-So you're enjoying being a doctor?

-So far, so good, yeah.

-Good.

I'm just only starting to feel like one now.

-Cos you'll go far, you know.

-Do you think so?

-Yeah.

You want to keep your vein in one place.

Just, obviously, it's a sharp scratch.

-And we're in. Quick and painless.

-What?

-I said quick and painless.

-Yeah?

-You're like, "Yeah(!)"

-You need to let go sometimes.

TOM LAUGHS

-You're reading my fortune while I'm taking your blood.

-Yeah.

There's something quite poetic about that.

I can feel that going through you - that's what I'm like.

See? You're shaking now. That's cos I'm telling you bits, isn't it?

There we go, got it in.

I'm right, though, aren't I?

I... You're freaking me out!

-OK, that's all sorted.

-Thank you very much.

I'll stick a little date on it so we know when it went in

-and I'll stick this down with tape like last time.

-Thank you.

-That's everything.

-See, now, you never hurt me like the other ones.

-You're saying all the right things, aren't you?

-Yeah.

So don't forget what I said.

I won't. Nice to see you.

-Thank you, and you.

-Take care.

Luckily for Tom,

the psychic predictions didn't distract him from the job...

and he's got a new fan in Cindy.

Usually they hurt me, and it didn't hurt at all

and he's just put a new one in

and I can't believe I've just had that done without, "Aargh!"

or screaming or anything. He was so gentle.

He's a fun guy,

but if a woman was to approach him

and say, "Come on, let's have a dance," he'll run a mile.

Do you get what I mean?

He's a bit funny, and he's a bit...

He's... What's that word? He's very preserved.

He doesn't show his emotions.

It's the first time I've ever had my fortune told

by a patient or by anybody.

Apparently, outside of hospital, I'm a very quiet person.

And this is news to me.

He knows I'm right, really.

With Tom's golden future in medicine written in the stars,

over on upper GI, Jen's predicting a tricky start to her day.

She's been called to an elderly woman

who needs a catheter fitting to her bladder.

It's really difficult

to actually tell which hole it's going in.

It's the first time that the usually unflappable Jen

has tried this procedure on a female patient.

WOMAN LAUGHS

Do you know how many times I've done that?

I'm just going to go and get another catheter, OK?

So far, no success.

I think it might have been in the wrong hole.

It's definitely trickier than a male!

Just bash the males in. Not literally, of course, but...

They haven't got any size 12s.

The nurse is really good, though.

She's hoping that a different size catheter is the answer.

Push it in as much as you...

No, it's not going in.

-It's OK, don't worry.

-You're fine, don't worry.

Yep. We're there!

Finally, success!

Like every junior doctor,

Jen's realising she's still got a lot to learn.

I think as each day passes, you do start to grow in confidence

in the tasks that you're used to doing every day.

But all the time,

you meet new challenges that you've never done before.

So I've been doing this job for a month now

and I've never done a female catheter

so it would have made no difference if I'd done it on day one or day 30.

After his run of late shifts on call,

Tristan is back to the day job on his usual ward of gerontology,

which specialises in care of the elderly.

Having impressed his seniors over the past few weeks,

Tristan's been given the responsibility

of leading his own ward round.

I'm feeling pretty good this morning.

We're just about to start the ward round, which I'll be taking today.

I'm the only one from the team here this morning, so...

Yeah, the pressure's on.

All ward rounds in the hospital start at 9am

and must be wrapped up by midday,

so it will be a race against the clock for Tristan

to get through all his patients.

It's due to start in about five minutes

so I'm just trying to get everything organised

so I can just have my head in one place.

It's 9am,

and Tristan starts bang on time.

Looking good.

But there's a technical hitch.

Computer's not working. Good start.

I'm just waiting for the computer to load up.

What's the time?

We're 15 minutes behind already.

Finally, he's on his way.

SIGN CLATTERS

Careful, there's a Wet Floor sign here. Looks dry.

It's not been the best start,

but he could still make up the time

-if he could just stop the small talk.

-Hi.

Hello, Bridie. Morning, Edith.

That's amazing, Mary.

It got pride of place, then?

Oh, gosh! I've got a hole in my trousers.

I've got to sort that out.

How do you feel you're doing?

Do you feel like it's a little bit easier to talk?

INDISTINCT SPEECH

Sorry?

INDISTINCT SPEECH

With just 20 minutes until the midday deadline,

Tristan's still optimistic.

Yep, we've seen several patients so far on the ward round. It's 11:45.

So obviously slower than the consultants would do it

but I think we're not doing horrendously so far.

I don't know. What do you think?

You're doing well. Still a long way to go.

I think that's code for, "It could be worse."

Finally, Tristan finishes his ward round -

an hour and a half late.

And his timekeeping has not gone unnoticed by his senior, Dr Scott.

Tristan did well running his own ward round.

I think if I would identify any one area for him

that he'll need to work on,

it will be the amount of time it takes him to do the ward round.

"So confirm arrangements for...

"..district nurses

"and package of care."

He took longer than the actual session lasted.

His introspectiveness, I think, is what slows him down,

as well as a certain lack of experience,

but as he trains and as he gets more confident,

he'll come up to speed very quickly.

Right, well, thank you so much

and I'll keep you updated, OK?

See you later.

It wasn't a stressful thing to do but I knew there would be a lot of work

and time would inevitably pass faster than I was hoping

and, you know, it's important to get everything right for the patients.

It is a good experience doing a ward round

because you really have to think for yourself. You can't switch off

and just let some of your seniors give you a list of things to do

and do that. At the end of the day,

you actually have to make some decisions.

Back at the house, Jen's having a day off from the daily grind

of ward rounds, catheters and cannulas.

Like Emily, it's her birthday this week

and she's expecting some very special visitors.

DOORBELL RINGS

Mum and Dad, Chris and Christine, have driven over from Manchester

and they come bearing gifts.

Hello. You all right?

-Happy birthday.

-Happy birthday.

-This is a big card.

-That's my choice.

Oh, God! It's awful!

'I am close to my mum and dad.'

All my birthday cards this year

are going to be addressed to Dr Jen or Dr Jennifer

or whatever they want to call me!

'So, yeah, I think they're pretty proud of me.'

JEN LAUGHS

When I saw that card, I thought,

"That's the worst card I've seen in my life, so I have to buy it!"

It is probably the best worst card I have ever seen.

On her seventh birthday, she got a nurse's outfit

and she said, "I want to be nurse when I'm older."

I said, "Why don't you want to be a doctor?"

-So from point on, she wants to be a doctor.

-Yeah.

And she's never given up the determination from the age of seven.

Now she is a doctor at 25.

So she sticks to what she says she's going to do.

-Yeah, yeah.

-She always has done.

Back at the hospital,

and so far, it's been a steady day for Oli in the acute medical unit.

Yeah, it's been quite a nice, relaxed day.

Did a ward round, had some jobs to do, did them,

had some really nice teaching at lunchtime, which was nice,

and then, this afternoon, just tying up loose ends.

I'm bored! There's nothing to do.

But the peace is soon shattered with an emergency crash bleep.

ALARM BLEEPS

Whose patient is it?

The man, a heavy drinker, is having a seizure.

-Are you all right to set up a BR... a BM on him?

-Yeah.

-Cheers.

For second-year Oli,

patients like this have become commonplace on the wards...

'He's a chap who's known to have alcohol withdrawal seizures.'

I'm just having a look at his latest blood results.

..and he's fast becoming an old hand at treating them.

Last lot of Librium was at 12 o'clock.

We give him Librium straight into his veins, which is

something you give to alcoholics to help them when they're withdrawing.

Keep a close eye on him, do some more blood tests,

and just see how he gets on, really.

The negative affects of alcohol cost the NHS £164 million every year.

Yeah, they've gone to find it, yeah.

A sobering thought for any new junior doctor

experiencing the dark side of the demon drink for the very first time.

It puts a lot of pressure on the doctors,

particularly trying to manage people who are very drunk.

As a junior doctor, not really being exposed to those pressures before,

it can be quite difficult for them.

I suppose it's a side of alcohol that a lot of people don't see

unless you work in a hospital. You know, you think of it as normal,

being sociable, going out with friends, having a drink.

People might have a few too many, but this was...

I think you see the real extreme end of it in hospital

and there are physiological effects

that perhaps the general public don't see very often.

And it can be quite shocking at first

but I think you get used to it after a while. We see quite a lot.

We see so much of it, it's like...

It just becomes quite common.

In a way, it's sad that it's happening so much

but that's just the nature of where this hospital is

and some of the surrounding areas.

People living in socio-economic deprivation,

who probably have nothing else in their lives, they turn to drink

and it's like... It's an addiction, like anything else, it's a disease

and we treat it like any other disease -

just patch them up and help them along their way.

As Oli deals with the after-effects

of the city's high rates of alcohol abuse,

first-year Ed is dealing with a very different kind of medical case.

He's about to face one of his toughest tests yet

and perform a tricky medical procedure called a lumbar puncture

for the first time.

We're going to ward 7B,

where this patient has been transferred,

and we're going to do the lumbar puncture there.

Ed's keen to show senior medics that he has the right clinical skills,

so this opportunity is a big deal for the Italian junior doctor.

She's here. I think she's here.

He's had a lot to prove since, in his very first week in the hospital,

he was asked to leave the emergency department

as a second-year junior doctor

and become a first-year in the acute medical unit.

'I'm not completely glad the fact that I was moved back'

from Foundation Two in A&E to Foundation One training.

'But I'm really glad of how things turned out in the end.

'It's been steady and positive.'

It's been good since then.

Yeah, I think his confidence was initially knocked

cos he'd started in A&E

and he had to be moved to the acute medicine unit.

But I think, as time has gone along, he's been supervised closely,

we've given him more and more responsibility

and I think he's relished it.

The procedure Ed will do today involves drawing fluid

that surrounds the patient's brain.

I have an aneurysm. From the veins in me brain.

And they want to know whether it's bleeding.

I've been getting violent headaches.

Have you got plenty of gauze and...?

What this test will determine

is whether any vessels in the patient's brain have burst.

Are you able to bend your legs as much as you can?

It's an invasive procedure so Ed will need a steady hand.

Before he starts, Dr Ahmed offers some important words of advice.

And then when you withdraw, you actually infiltrate.

So you've created a space and you're putting the needle in.

Erm, no, I haven't.

But I will absolutely do my best.

He's prepped and ready to drain the fluid.

-Is it OK?

-Yes.

Yup.

-Is it OK?

-Yes.

We're getting there, eh?

Ed has extracted the fluid he needs...

..which will now need to go off for further tests.

-Any pain at the moment?

-No.

-OK. We're getting there, eh?

It's been a textbook procedure for Ed.

And all that's left to do now is inform

the patient of the potential side effects.

Now, you may experience a bit of headache.

That's a good point.

But it may vary a bit in its... kind of headache.

It's... A common complication of this procedure is headache,

so let's not worry about it at the moment.

-Thank you very much.

-No problem.

It's a small slip-up, but Dr Ahmed's still pleased.

It was obvious he was still learning

but he did the procedure well and he got the fluid in the first attempt.

I am sure if he does more procedures, he will become more confident.

It went well and the patient is quite happy.

He was quite confident, wasn't he?

Well, I knew there could be complications

and one of them is that you can become paralysed,

so he had to know exactly where to go.

Successfully completing the lumbar puncture

has given Ed a boost of confidence.

It's rather an invasive procedure so, you know,

it's something that you learn going through your career

and, yeah, it was good. It ticks a box, a very important one, so I'm happy about that.

And he's keen so share the good news with fellow junior doctor Oli.

No, she was fine, and in the end, she also told me that it wasn't painful.

No worries. Is that the first one you've done?

That was the first one, yes.

It's good that you got to do it.

-Will you be confident doing it on your own next time?

-Well, I'll try!

-Well, have a nice afternoon.

-See you later, man.

-Bye-bye.

Very pleased for Ed. It's fantastic. Really good news.

Glad he got it and glad it went without a hitch. Fantastic.

There are continuously moments when I have self-doubts

that my knowledge is not up to what I would like it to be.

Now I feel I am starting to help the team.

I can see that people are giving me more responsibilities now.

While Ed's belief in his medical abilities is growing,

first year Tom is feeling a little nervous about his next challenge.

Little bit scared.

All junior doctors are expected to do presentations

as part of their training.

Today, Tom will be giving a talk on pacemakers to the hospital's top consultants.

I think that, considering there's consultants there,

it's going to be tricky to be able to keep up with the pace,

in terms of what they can do and what they know.

If he succeeds, he will prove he has a firm grasp of cardiology.

Hoping nobody turns up so I can go home!

Morning.

Today, Dr Saltissi, one of the most respected consultants

at Liverpool Royal, has a front-row seat.

Tom will have to speak for ten minutes.

Thanks for coming. This is my case presentation

with kind of teaching notes on permanent pacemakers,

and I've entitled it Keeping The Pace Up,

and it's even more of a pun, as you'll see during the presentation.

The primary role of the pacemaker is to basically maintain a heart rate

which is adequate for function.

This is a case I saw - a patient who came in with chest pain.

He was 69 years old, usually fit and healthy, he's a runner. He hill-climbs as well.

But the grilling Tom was dreading starts almost immediately.

Before you go on any further, is there any association

between somebody who is a hill runner and an athlete

and a diagnosis of sinoatrial disorder?

If you're really athletic, you can get carotid hypersensitivity,

which can decrease the heart rate.

-Right, sorry, on you go.

-This is the ECG just pre-pacemaker insertion.

It's obviously...er, areg... irregular.

Yeah, it's the irre...irreg... Ugh! The irregularity of it.

I'm trying to think... HE MUMBLES

Well, there's not a lot abnormal there, is there?

It's basically a sinus bradycardia with a supraventricular ectopic beat there,

and you've got partial right bundle branch block,

you've got a slight fragmentation of the complexes,

but I don't see anything else on there, unless anybody else can see anything?

What are the sort of mechanical things that can go wrong?

What about the lead itself? I mean, will it always stay where it is?

-Erm...

-Well, in pericarditis, what sound do you get?

Just trying to think. I don't know.

-Did you read up about pacemaker syndrome?

-No.

-What are you going to be doing tonight?

-Reading up about pacemaker syndrome!

Can Tom pull it back in the closing minutes?

So what's your take-home message from this particular case?

Erm, in terms of...

OK, so indications for pacing, for bradycardia,

symptomatic bradycardia, is where the symptoms correlate with the bradycardic episode itself.

Usually transvenous will be the next option - again, a temporary option.

The pacemaker's outside of the body but the electrodes are put through the veins to pace the heart.

And, finally, permanent pacing.

-Thank you. It was a good presentation.

-Thank you.

You brought up some interesting points and stimulated our discussion.

-Thanks very much.

-Thank you.

He needs to speak more slowly.

He needs to project his voice better.

There were some important areas in there that he didn't really grasp.

I was really nervous and I think that one of the problems I have

when I'm really nervous is I end up speaking really, really quickly,

and I felt myself doing it at times and I tried to slow down.

You survived!

Obviously, there are quite a few things in there

that one would want to improve upon.

And he will improve as time goes by. But he's junior, this was one of his first presentations.

I think he did reasonably well. I think he can be pleased with that.

It's the end of another busy week for the junior doctors,

and the day of Jen and Emily's joint birthday party.

-I'm going to wear a dress that I bought.

-Mmm!

And sparkly shoes!

And it's time off from playing the part of a professional.

I've had enough!

LAUGHTER

Let's decorate!

Hold this up while I blow.

I think it's really important to have a life outside medicine.

It's very easy to get sucked in to the role of, "I am a doctor 24/7."

Oh, that's nice.

-Ooh, that's quite strong.

-It's not that strong.

Booze!

-Feel like a witch.

-That's really...

I really quite like that.

One person who will miss out on the party is second year Kiera.

She's back on nights in the emergency department.

Hello, there. Hello. Mr Mitchell?

Kiera's senior, consultant Kate Clark, has asked her to deal with

an urgent case of a man who's been admitted with chest pains.

It's much more likely to be some, you know,

lung-related type of pain than anything else.

So do a gas, get his ECG and chest X-ray done.

-And then we're going to see whether or not he needs a D-dimer.

-Lovely.

Will do, that's great. Thank you.

Junior doctors in their second year are expected to be able

to diagnose patients.

So what's brought you in today?

Every time I breathe, I'm getting pains up here.

-Pains there?

-At the back.

-OK, and no pain at the front of the chest?

-No.

OK, fine. How long that been going on for?

All day today, since I got up this morning.

-If you take a big breath in, does that hurt?

-Yes.

-OK.

Have you ever had anything like this in the past before?

-Only when I had a blood clot in me lung.

-OK.

-That was the only time.

And what caused that?

Pneumonia.

Kiera will need to investigate further,

as clots on the lungs can be fatal.

-See you in a bit, sir.

-OK.

A 42-year-old gentleman whose past history...

He's had a clot on his lung.

He's come in with a pain that he describes as worse when he breathes in.

That's a typical pain you expect with people who have perhaps a clot on the lung.

That's the most important thing to rule out

because, obviously, it's quite a serious thing if he does have that.

Certainly, I'm concerned enough that I want to rule this out,

because if we miss it, then it's quite a big thing to miss.

How are you doing?

We're going to keep you in to do a scan just to check that it's not...

-Overnight, or...?

-It'll be overnight, yeah.

-As we wait for the scan.

-Can't I have the...?

Can't they just discharge me till tomorrow?

-I'm thinking of me mother, you see.

-Yeah.

-Have you got anyone else at home who can look after your mother?

-Not at the moment, no.

I'd be very unhappy about you going, really.

I could...try and arrange something. I don't know, you see.

Well, I tell you what,

let me take your bloods and get your chest X-ray under way

and we'll have a little discussion about what we'll do after that.

Have a little think about what you can do. OK?

-What's up?

-Er...

-You look a bit worried.

Erm... I just don't like needles.

-You don't like needles?

-No.

-OK. You know that's probably what we're going to have to come and do now?

-Yeah.

OK, I'll be very gentle with you.

Every junior doctor must learn how to handle nervous patients

and Kiera's about to be tested.

I'd use a smaller needle than most, so...

SHE CHUCKLES

Every doctor says the same.

-What's that?

-"Only a little scratch."

That's it. That's the worst of it done now.

Well done.

-You all right?

-Yeah.

-Wasn't too bad, was it?

-No.

-Just like eating a bag of chips.

-SHE CHUCKLES

Kiera needs to act quickly to complete taking all

the samples she needs.

OK, again, sharp scratch coming up.

But as the patient gets increasingly anxious, she's under pressure.

Sorry.

Nearly done.

Sorry.

Struggling to get it on you.

Let's have a little breather for a bit.

HE MURMURS

Sorry about that. I don't usually struggle with this.

You must have deep ones.

It's crucial she completes the tests.

But can she persuade the patient to keep the faith?

Do you want me to have a go on the other arm?

No.

Take a breather.

-Oh, just keep on going.

-Yeah?

-Yeah.

-OK.

Sorry about that.

What do you reckon, this arm or the other one?

Don't know.

Take your pick.

Finally, success, as Kiera eventually manages

to get the vital blood sample from the reluctant patient.

All done. Right, press really hard on there for me

for about five minutes. Really, really hard.

Hard as you can. Well done.

Sorry about that.

Glad to see the back of me, eh?

Oh, it's just the needles. I really don't like needles.

Hopefully that's it now. All right.

If someone is scared of needles,

it's weighing up the risks versus benefits of them

having the injection or the blood test.

And he's absolutely got to have the blood test,

because if it is what we think it is,

then he potentially could be very poorly.

An hour later, with the test results complete,

Kiera's diagnostic hunch seems to be correct.

It's probably most likely that he has actually got a clot on the lungs,

so we've given him the treatment for that.

There was discussion with him as to whether he's going to stay in,

but he's chosen the sensible option and arranged for someone to look after his mum,

so he will stay in tonight, which I'm glad about!

There is quite a big difference between first year

and second year. I would say maybe the big thing

is there's quite a large step up in responsibility

and there's quite a lot more expected of you.

I feel as though I have the responsibility for taking

a lot of decisions, and it's quite a scary thing,

so, yeah, I do feel like a proper doctor!

While Kiera's embracing her inner medic,

the rest of the junior doctors are happy to finally

let their hair down at Emily and Jen's joint birthday bash.

We've decorated the house now. Just getting my clothes ready.

I've got my most eclectic shirt on for our tropical theme party.

Yeah, all we need now is the... the hordes!

Do you feel old now you're 25?

I actually feel younger. I was thinking about this.

When you're in med school, I think it was partly that that made me feel really old, like,

getting older in the year. Now we're, like, junior doctors...

-You actually feel younger.

-I feel younger. Because I'm just walking

around the ward like, "I know nothing!"

I know what you mean, but then you think, "God Almighty, 25."

That's like slap bang in the middle of your 20s.

Before we know it, it'll be 30.

It is weird, though, when you think about how long ago we were starting work, like, six weeks ago,

how different we were back then to now.

ALL: Happy birthday!

-Quarter of a century.

-Oh, shut up!

I don't really think we reflect our home personalities when we're at work.

We have to focus on our job.

We all love to have a laugh and giggle and be silly.

Next week on Junior Doctors...

Bloody towel. It's Tom's shit everywhere.

..long hours on the wards

are starting to impact on lives outside the hospital.

To be honest, I think Lottie's suffering a little bit

because I'm not around.

She just seems a little bit more anxious.

Any pain up here? Sorry.

Kiera's powers of persuasion are put to the test in the emergency department.

-Just need to...

-Can you just put it down for us, please?!

It's exam nerves for Ed when he goes on an advanced life saver course.

Charlie? Hello. Can you hear me?

This is the final exam. I'm just hoping for a decent scenario -

not fail miserably, murder my patient and end my career.

Come on, taxi.

And Oli faces one of the toughest exams a junior doctor can do.

The book I'm revising from, it feels like it is that big sometimes.

There's so much, I don't even know where to begin.

I've got a lot to try and fit into my head.

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