My first ever referral

'Mr D is bleeding tears. Can you come and have a look?' the nurse said with some panic in her voice. Me eyes went wide opened, and my first thought: Exorcist!

Nah... it didn't look like that at all. We had a look and the nurses pressured the SHO to get him seen by an ophthalmologist. It was a very busy day and I was asked to make the referral. I foolishly agreed.

Firstly I needed to know who to call as my hospital has no ophthalmology service. We have an eye team from a DGH 10 miles away who runs an outpatient clinic here, but then just last week I heard another doctor arguing on the phone as they would not accept in-patient referral from our hospital. At the back of my mind, I remembered when I have had my placement at the eye hospital (the tertiary eye referral centre in Manchester) I was repeatedly told by a keen registrar about an interesting case from my hospital. I wonder if they would that a referral from us? So I googled and found their phone number. I just tried my luck and asked if they cover in-patient referral from my hospital, and they do! The nurse passed on the phone to the on-call registrar.

That was when my palpitations began. You might think, what is so difficult about making a phone call? Well, doctor to doctor conversation follows a specific format and I have seen many miscommunication happened over the phone. You'll be surprise if I tell you how many times I've seen people getting really pissed off and having a fit on the phone. I'm just terrified to be reminded of that. I think my SHO assumed that I know how to do it and pretty much just said to me 'Can you do the ophthalmology referral to Mr D?' and left. So before I called, I read Mr D's notes and checked the eye complaint several times. Then, I remembered a registrar who grumbled 'these SHOs are referral patients to us without even seeing the patients themselves first'. So I thought I ought to quickly take a history and examine Mr D's eyes before I proceed.

The on call registrar was not too bad actually. He said hello, and then just let me present the patient for 2 minutes without interruption. Then he gave his ophthalmology opinion and recommendations. He said he's very busy but will try to come over and see the patient. I thanked him and hang up. Relief! Apart from my stress induced slurred speech (had to say chloromphenicol for three times before I get it right) it was not as bad as I expected. The only thing I got told off was that I didn't check his visual acuity (I did, just not using a snellen chart!). I documented almost every word that was exchanged - probably not a usual practice but I just want to be extra extra careful.

As always whenever I'm involved in patient care, I learn by leaps and bounds. For a start, I am twice as alert. I double check, no actually, I triple check everything. What for? Well, to make sure that I don't look too stupid, but more importantly people supervising me will often trust my words and judgement, and plan their management from what I have told them. If I've made up something in the history for example, the diagnosis and management will be based on those false information. They say we shouldn't bring patient issues home, but I always go home with nagging questions in my head. Have I done everything right? Or more importantly have I done anything wrong that could have harmed the patient? And to follow on, what would I do differently next time? Every single involvement with patient care is indeed a huge learning curve for me.

So for today, in hindsight, I could have done much better. Especially because I've just done an ophthalmology placement, I should have been able to get a better history, do a more thorough examination of the eye and come up with a more accurate diagnosis. I just forgot to take a moment to gather these thoughts. And I forgot that the receiving specialty doctors always want to know 'what do you think it is?'. The registrar must have thought that this is such a crappy referral. Today's experience also further reiterates to me that surviving as a junior doctor is all about communication, resourcefulness and being a little thick-skinned. It was a valuable learning experience for me. Definitely will be better next time.

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