Nights On A&E

NIGHTS

They actually weren’t that bad. I got through it. I’m out from the other side with all limbs intact. But it wasn’t easy. It wasn’t ideal to have to do nights so early into the placement but I guess I would have had to get it over with at some point.

The first one was really busy. I came on to several patients already waiting plus many waiting in paeds, so I got pushed over to help that side for a while. Having done GP, I knew how to examine kids but when it came to looking at a foot xray, I was lost. Who knew kids have barely any bones in their feet? And the bones they do have are all so far apart from each other.

I finally made it onto majors. Most of my reviews were for patients who had fallen. There seems to be a high proportion of the population who just fall over or collapse in the middle of the night. After the third one, it started to feel like routine. ‘Did you hit your head?’ ‘Did you lose consciousness?’ ‘Was there anyone with you at the time?’

I started to feel a bit more comfortable. I was still nervous, but I just got on with it. There were two registrars on overnight as well, so I badgered them non-stop. All night.

On the last night, I was talking to one of the registrars about one of my patients. She was an elderly patient from a nursing home who’d been brought in by ambulance. After I finished he looked at me, ‘so what do you want to do?’

‘…er… I want to admit her, I don’t think she’s safe to go home.’

He agreed, then told me that this was quite simple, she needed to be admitted. I didn’t need to discuss every patient. Cue crying emoji.

I guess on some level he was right. I just felt better getting a senior opinion. It’s much easier to admit people than it is to send them home. But I’m still mindful that there isn’t an unlimited amount of beds that I can send everyone to. The talking to made me a bit more hesitant to discuss the next couple of patients like I needed to prove that I had a few brain cells. I successfully discharged my next patient after doing all the tests under the sun to make sure she didn’t have an acute abdomen.

I think now I’ve got a better idea of what I’m doing and a better sense of who can go home and who can’t. And I know I can still ask. I just need to be a bit more independent in my decision making.

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A Bitter Pill To Swallow

a bitter pill to swallow

One of the good things about GP was that I could call my patients back for a review. For the most part, they were easily contactable and happy to come back to see me especially if I’d started treatment. It meant that I could build on previous consultations, I got to know the patient better and they weren’t lost to the wilderness the moment they left my room.

One particular patient I saw  a few times over the course of the four months. She had depression and was currently taking antidepressants. In one of our consultations she told me she was fed up: she felt the medication wasn’t doing much, she was going through a particular bad patch and she felt like no one was helping. She told me she had given up on the GPs and preferred to see me because she felt like I listened. This immediately made me feel more important and it made me want to give her even better care.

But, the last time she came to see me, it left me feeling a little frustrated. She was still in a rough patch. We had a really long talk about her life and she talked about all the things that were going wrong. She felt stuck and trapped in her own life. I tried my best to offer advice, but how much could I really do? I felt like I could at least try to tackle her depression. But she resisted all my suggestions. She didn’t want to change the antidepressants to a different type. She wasn’t willing to increase the dose of the one she was already taking and she wasn’t willing to try CBT or counselling. Essentially, we were stuck.

I became a bit discouraged and talked about it with a friend of mine. She said, that though I’m trying to help, I’m her doctor, I’m there in a professional capacity. I can help her by providing medical advice. It isn’t my place to take responsibility for her; she had to take responsibility for her own life.

And it made me realise why I was frustrated. As much as I wanted to help, her issues were mostly social and family-related made more complicated by her depression. The depression was the part that I could help with, but she refused all my suggestions. I thought I could make a difference and help ‘fix’ her issues. But I couldn’t help her, if she didn’t allow me to. And that made me feel stuck. So, what did I do? I left it up to her. She has the resources, the advice, the information she needs to allow her to make her decisions. It’s up to her now.

It made me realise that I needed to step back a bit and realise the boundaries of my professional capacity. I’m not a life coach. Or a friend.

It’s a bitter pill to swallow to realise that I can’t help as much as I’d like to.

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Every Day Blogging?

So I might have been a bit hit and miss with my posts in November. And now suddenly I’ve been thinking about every day blogging. Funny. I know Seth Godin seems to feel it’s a good idea. But I just wonder whether it’s fair to subject another human being to my thoughts. Every. Single. Day.

Instead, I think, just posting a bit more regularly is a good compromise.

I know my timing couldn’t be better what with the fact I’m now on A&E. When will I have the time or the energy? Let’s see what happens. I’ve suddenly become more enthused to start writing more due to the realisation that if I want to improve my writing, I’ve got to put the practice in.

So here’s to more practicing.

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Limbo

I’ve been feeling differently lately. I can’t quite describe what it is.

Somewhere towards the end of F1 being a doctor just felt like… a job. Like I was just going through the motions. Before that, I remember having a sense of hope that the next shift would be better or the next placement would be better, I would be better. Whereas recently I catch myself just wanting the day to be over, the placement to be over. It’s like I’ve lost my sense of hope and curiosity and just replaced it with cynicism.

I’ve made the end of F2 my goal and that’s what I’m working towards. The enthusiasm to learn more about new conditions is waning.

I imagine it’s like the bit just before the end of a relationship. That limbo period where no one can muster the energy to try to make it work but then there’s also the fear of actually letting go. I don’t know how to get that energy back. I don’t know how to work up some enthusiasm again.

So recently, I’ve started working on my perceptions and just trying to be a bit more… grateful? positive? I don’t know. I’m trying to focus more on what’s going right, than what’s going wrong. I think it’s quite easy to feed and perpetuate negativity to the point that it just becomes a cycle, that snowballs. Who wants that? Instead, maybe I’ll try to take a bit more responsibility and not act like a helpless bystander to my own life…

Plus, I’m praying A&E will help me to feel a bit more rejuvenated

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The First Day

First day on A&E was intense, which I expected. Starting any placement was always going to be uncomfortable, and I’d been to the department enough times to know what I was getting myself into.

I was on an early shift, which meant I started work 4 hours before any proper induction to the department. Luckily, I had a mini introduction by one of the consultants, given a small tour and then started seeing patients straight away.

Switching placements so often is genuinely like leaving one job and starting another a few streets away. You need to quickly immerse yourself into the team and learn a whole new way of doing things, all the while trying not to step on anyone’s toes.

My first patient was a simple case of back pain (flank pain). I saw so much of this in the community I was happy to send him home. I’d taken a history and examined him thoroughly. To me, it was an open and shut case. Is there such a thing in A&E? The department seems to run on paranoia, the chance that something could be missed. I was told to start some investigations, which came back normal and then I was able to discharge him. Whilst I was waiting for this patient’s results to come back, I started seeing the next one. It got to a point where I was just juggling it all.

Another patient I saw had vomiting and diarrhoea for several months. I tried to take bloods and put a line in to give some intravenous fluids. And I failed to do either. 4 months of not laying an eye on a needle has made me soft. And my skills were not great to begin with in the first place. Plenty of time to practice though.

I managed to get to the end of my shift having consumed 200 ml of water. Luckily, I’m used to being in a state of sublevel dehydration so I wasn’t affected too badly. I know that it’s unhealthy and I’ll try to drink more water.

So overall an average start. It was never going to be a case of flying into A&E and clerking patients with my eyes shut. It’s going to take time before I become a bit more comfortable. It’s going to take a lot of asking too many questions, being embarrassed, learning form mistakes but most of all being kind to myself and not piling on unwarranted amounts of pressure. It would be too easy to become overwhelmed and overworked.

But we’ll try to avoid all that.

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GP Completed

Now that I’ve nearly completed four months of GP, the thought that keeps coming to my mind is: could I see myself doing this?

It’s always been easy for me to visualise myself as a GP. I’ve had numerous opportunities to be in consultation rooms as a student or even just personal experience as a patient. So, imagining it isn’t difficult. Plus, it’s always been in the back of my mind that if I did A&E and trained up to registrar level, I could jump-ship and become a GP later down the line. That way I could have the best of both worlds.

But do I want to, is the question. And the truth is I don’t. And there’s a number of reasons why, some that I’ve spoken about before. One of the biggest things I’ve found with this placement is how isolating it’s been. Being shut in a room for hours at a time has not been enjoyable for me. But I guess that’s just a matter of my experience. In comparison to the partners who own the practice, they’ve known each other for years and get on really well. They’re genuinely friends. How nice would it be to work with friends.

I’ve often wondered how GPs do the 10 minute slots. Being pushed from 30 minutes to 20 minutes had me ramping up the speed of my consultations considerably. A general run down of each consultation: I have a couple of minutes to read through the patients notes so that I’ve got some sense of their history, I call them in then wait for them to make their way down the corridor. I take a history, which takes time, I examine, which takes time. Patient has to get undressed then redressed and then sit back down to discuss a plan. I often have to look through guidelines for what to do next or what to prescribe, which takes time. Then I write it all up, some need further investigations, some need referral letters. It gets slightly more complicated with kids and people who don’t speak English well. Some patients come with a whole list of things they expect you to sort out as well. I dread the ‘…and also’ before the next onslaught of symptoms. I’m having to be a lot firmer and apologise and explain that time is not on our side. And there’s the consultations that you know that need that extra time. There’s the patient who is developing depression, there’s the lady who’s having to put her husband in a home because she can’t cope. Mental health issues shouldn’t be rushed or squeezed into a short time frame. I’d want to be the GP who did more than prescribe pills. I’ve enjoyed the times I’ve been able to have frank discussions, which has either shifted a perception or brought about a better understanding. But that time is a luxury. How could I do it with less than 10 minute slots?

It’s just down to the fundamental truth of whether I enjoyed the day to day experience. I’ve not enjoyed it enough to validate a lifelong career in it. It is what it is. So, for now, I know that GP isn’t the one. This is nothing against the staff or the GPs, they’ve all been amazing. This practice has been incredibly kind and patient with me. I feel like if there was ever a place that would have converted me, it would have been this one.

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A&E

I’ve mentioned in a previous post that I’d narrowed down my options to a very select few, A&E being the frontrunner. Essentially the only runner, because when it comes to the two other options my feelings to them are at best lukewarm.

And for a while now, I’ve felt like my path in medicine rests on whether or not I’ll enjoy A&E. So much so, that since the fourth year of medicine, I’d been trying to arrange a placement in the emergency department. Unfortunately, it didn’t happen.

When the time came around to apply for foundation jobs, I made it a priority to have a placement in A&E. How it works is that I had an option of 10 ‘tracks’ to choose from. Each track was made up of 6 different placements: a mix of surgical, medical placements with the odd psychiatry, paediatrics and other specialties thrown in. 3 placements for F1 and 3 for F2. Not all the training tracks had A&E but I sought out the ones that did and ranked them highly. I still had to rank all the other tracks in order of preference which was a game in itself. I had a list of ones I wanted to avoid. Vascular surgery, for example, dropped to the bottom of the list like a dead weight.

I did this with the hope that A&E would be for me, and I would live happily ever after. Or at least till the point I became too exhausted with it and then became a GP who occasionally dipped their toe in the ED department whenever the mood struck. That was my plan.

So now that it’s drawing closer, it’s starting to feel really real. I’ve built up a level of expectation over the years and now it’s nearly here, all of a sudden I don’t feel ready. It’s like I’m edging towards a big realisation which might be hard to swallow. I flip between excitement and fear. No in-between. Just a light switch, from one to the other.

It doesn’t help that my friends that have been on A&E for the past 4 months never fail to tell me how fed up they are of the random shift patterns or how tired they always seem to be. Or when other colleagues retell how horrific an experience it was for them when they did it. Or the fact that I’ll be heading in at the worst time of the year: winter.

Whatever happens, it’ll definitely give me a lot to write about.

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A Message To F1s

Suddenly, somehow we’re in the run down to the end of the first placement.

And at this point you’ve come accustomed to how your ward works, you’ve formed bonds with your teams and maybe even your consultants. But now it’s time to move on and remember a whole new set of names and door codes.

If you’re anything like I was, you’ve gotten used to the 9 to 5 grind mixed in with the night shifts and weekends. You’re still feeling tired all the time, but at this point it’s your new norm. You just get on with it.

Now, you don’t shake as visibly when you get called to see a sick patient, and if all else fails, you know taking bloods and giving fluids is nearly always OK.

Maybe you’ve started to have some niggling doubts crop up in those moments when you feel out of your depth. Your thrust head first into a bad situation but somehow you always muddle through.

You can’t remember exactly when in the past few months, your ideas of what it would be like to be a doctor were shattered. The rose tinted glasses have come off and you can see it all a bit more clearly. The disorganisation, the strain, none of it pretty.

Sometimes, you wish someone would tell you how you’re doing. Just a little word of encouragement or recognition, just so you know you’re doing OK. It’s nice to hear. But it can be few and far between. You’ve made it to four months, so well done.

I wrote this for anyone who’s finding the reality a little difficult, who feels constantly overwhelmed by the expectations being placed on them. If you’ve enjoyed your first placement, that’s great. If you haven’t that’s OK too. Either way it’s coming to an end. If you’ve found the last few months difficult, it’s because being a doctor is difficult. Plain and simple.

But it’ll start to feel a little easier.

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The Irony

As part of the two-year foundation programme, I’m based at one hospital site which serves a small town. Anyone who lives in this town and needs hospital care would come to this hospital. However, for the time being, I’m stationed at a GP practice not too far from the hospital.

During one of my morning appointments, I finished typing up the notes of the patient I’d just seen and clicked onto the next patient. How it works is that I have a list of appointments for the day along with the appointment time. When I need to access the patient’s notes, I double-click their name and occasionally a small grey notification box will pop up with some extra information or reminder or some warning. So, when I clicked on the next patient on the list, the helpful grey box popped up letting me know that this was a consultant, who worked at the same hospital I was based at.

To any other normal individual, they would take this information on board and amend their communication style accordingly. I, on the other hand, start to overthink the situation, making it 10 times more complicated than it needs to be.

Two things immediately spring to my mind about why this will be uncomfortable. The first: speaking to another medic. I’ve mentioned a similar situation here. I just find the whole situation weird, whether it’s me that needs to see my GP or when it’s this type of scenario and the dynamic is shifted to me being the one with the responsibility. I can’t help but think of the irony when I’m sat across from someone who has 20 more years of medical experience. It’s like having your head teacher come to you with a math equation they need help with. It’s a different dynamic.

The second conclusion my mind jumps to is the possibility that I might run into this person again, when I eventually get back to the hospital. Very frequently people share deeply personal issues which I try to deal with as sensitively as possible. That comes with the territory but I can compartmentalise it to an extent and leave it at work with the understanding that I’m unlikely to come across that patient outside of GP. However, the stakes are higher when you see someone who works where you work.

Thankfully, it was blood pressure related. I’ve never been so glad for someone to come in with hypertension. I don’t think I had the emotional bandwidth to handle anything more complicated than that.

How did I handle it? I decided to just treat him like a normal patient and not let on that I knew he was a consultant. Might not have been my brightest idea but I went along with it up until the point where he sort of started using medical terms and I just shifted it slightly to accommodate that. I just never asked what he did for work.

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Applications

It’s around this time of year that F2s start to really consider what they plan to do after F2. This is also the time in the year when specialty applications are submitted. Those that are lucky enough to have known exactly what they wanted to do since they were 12 don’t have any difficulties with choosing and applying for their specialties. For me, it’s never been that clear.

There were specialties that were a No from the get-go. There were specialties that I felt more drawn to like paediatrics but upon completing a placement I’d realise that they weren’t for me. So, by a process of elimination, I subconsciously and consciously  whittled it down to a few options. A&E being one of the few, which is fortunate as I have this placement coming up.

To be honest, it’s beginning to feel like I’ve been holding out for A&E, like a sort of saving grace. I’m hoping for that eureka moment, the dawning realisation that I’ve found what I want from life, that missing puzzle piece that will sustain me until retirement. Obviously, the clouds will part, allowing a beam of sunshine to hit me like a spotlight. Unfortunately, I don’t think that’s going to happen. I think I’ll do the placement, I may even enjoy certain aspects of it, but eventually the mounting exhaustion of irregular shift patterns, manoeuvring the complicated bureaucracy of the four hour wait plus the incoming strain that winter always seems to surprise us with, will eventually tire me. I might be wrong. I’m just sceptical that any joy will be enough to squash the growing level of doubt and cynicism.

But now I’m at a crossroad and a decision needs to be made. Do I put an application forward or do I sit on my hands, allow the deadline to pass and ultimately choose to not go onto a training programme?  A few people have suggested another option, option C, to put in an application, experience the process and then back out. I’m not keen on that idea.

I doubt I’ll be applying for specialty training as it stands, A&E or otherwise. And though initially that made me feel slightly nervous, attending the ACW 2017 event this past weekend has put me in a different headspace. Speaking to a whole range of medics who were experiencing varying levels of frustration was intense but it was also refreshing to listen to doctors who had created new careers for themselves.

Which makes me feel really hopeful for life after F2. The realisation that if I choose to not apply then I can pretty much do what I want. It sounds a lot like Freedom.

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