The First Month of A&E Was Tough

The first month of A&E was tough. It reminded me of the beginning of F1: the sudden rise in responsibility, having to make important decisions, picking apart complex situations.

It was a difficult adjustment from GP. I was stepping away from a job that involved me sitting in an office for several hours with help just an arm stretch away and stepping into a busy Emergency department at the worst time of the year, in the midst of a bed crisis. Adding to all that, I had to quickly become familiar with all the new parts: learning new names, learning to code patients, learning what was OK and not OK.

Suddenly, I was responsible for making difficult decisions. Not that I never made decisions before. I made management plans for patients all the time in GP, but there the patients were rarely very unwell and the issues tended to be chronic. But those same patients would present to hospital, now acutely unwell. They’d come confused and disorientated. I’d find it difficult to understand exactly what was wrong and often I’d start treatment without the luxury of test results and very little to go on. I struggled with deciding who to admit. Who did I think would be safe to discharge back to their homes, where they lived alone, where there was no supervision? And that would weigh on me. It really felt like a judgement call, looking at each person and wondering what would happen if I sent them home. I’m still struggling with this.

The first time I ever cried at work was during that first month. It was a bad combination of a busy shift, an unwell patient and senior doctors I was nervous to approach. I was struggling to look after this elderly lady whose heart rate was over 140, the machine kept beeping, a few times, she’d suddenly slump over  for a few seconds whilst I examined her. My mind went blank. I didn’t know what to do. I felt clueless and I could feel myself panicking. I felt like I wasn’t doing right by this elderly patient who remained sweet and cheerful despite being so sick. It turned out OK in the end and we managed to bring her heart rate down slightly. I calmed down when I realised she wasn’t dying. But that feeling of panic and confusion stayed with me for a long time afterwards.

Christmas brought its own pressures, several bank holidays meant few other places were open and we saw an influx of even more people. The department was overrun: patients in corridors, waiting areas crowded and minimal hospital beds. When I eventually finished the shift and left the chaos, I walked out to a sea of ambulances. Row after row of neon yellow striped vans, waiting sombrely in the cold. And all I could do was be thankful I didn’t have to go back in.

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First Impressions of A&E

It always takes me a bit of time to get used to a new placement. That awkward settling in period, trying to learn the ropes and get to grips with ‘how things are done’, is never easy. Plus, A&E was bound to be a difficult transition:  high turnover and volume of sick patients, coupled with low numbers of staff. I knew that it would be very very different from GP.

For some reason, I had this idea in my head that A&E would run like a well-oiled machine, that it would be efficient. I don’t know why I thought that, because the reality is often very different.

The department is small which means it overruns with patients very quickly. All of a sudden there’s no where for us to see anyone. We have to squeeze people into every nook and cranny for a quick examination and then send them back to the waiting area until a bed becomes free. Then it all becomes disjointed. You can’t start treatment and you can’t really observe the patient because they’re back in the waiting area. The nurses won’t take responsibility for the patients in the waiting area which is understandable, because they have their patients that they’re already looking after. The most I can do is take bloods and beg the co-ordinator to find them a bed.

For the ones that do have a bed, I have to run around and look for the nurse responsible for them which is hard. I have to look high and low, far and wide. There are times when the response I get is: ‘you can do that yourself’. Yeah, I could do it myself. I could do it all myself, but then that takes away from me doing what I’m actually supposed to be doing. It feels like a tug of war sometimes, and I do end up doing things that other healthcare professionals could do. And when there’s a growing pile of patients to be seen, I can only hope that I’m not scrutinised for being slow, but what can I do?

My third eye is on the clock because of the four hour targets. A&E departments are supposed to see and treat patients within 4 hours or else they’re penalised. It’s something I’ve not really looked into, so I have a very blasé understanding of its incriminations. On the first day, after the consultant gave us a mini tour she pointed me towards the list of folders each representing a different patient and told me to start seeing people. I asked her whether I needed to be wary about the times. And she looked at me and asked pointedly, ‘what do you mean?’. I remember thinking I should chose my next words very carefully. ‘I mean the four hour targets.’ Her reply was, and please imagine the icy cold stare she gave me whilst she said this, ‘your concern should be patient safety’.

Maybe I was wrong, maybe the four hour wait thing wasn’t a big deal. Until I realised that every time a patient passed the three-hour mark, nurses, consultants and registrars would descend upon me  and want to know my plan for said patient.

But… it’s still early days, and I’m still adjusting.  I’ll just have to see what the next few months will bring.

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To Break Or Not To Break

busy

A&E gets busy. That’s not news. I expected A&E to be jam-packed, especially during winter. It’s cold, it’s slippery, people are more likely to get ill, which means more patients coming in.

During our induction, we were told we got an hour for our breaks because of how long the shifts are. The advice was to split the breaks and ideally have two 30 minute breaks instead.

Obviously, breaks are important, but I often find that there’s this catch 22. When it’s not busy, it’s much easier to take breaks but I don’t really need one. With less patients to see, I’m sat down more, I remember to water myself and have bathroom breaks. When it’s busy though, I’m running around a lot, trying to do several things at once. I get tired more quickly and that’s when it’s harder to take breaks, but that’s when I need them the most.

When it gets busy, we pick up the pace to make sure patients are seen. That’s when our sacrificial tendencies kick in and we drive ourselves to do as much as possible, as quickly as possible. Sometimes that means doing away with breaks (water/food) altogether.

It’s unhealthy but subconsciously it’s encouraged and respected. I feel like it’s either the culture amongst health professionals that we are taught or pick up from watching others do the same, or it’s the innate nature of the type of person who comes into this line of work anyway. And though it’s admirable, I wonder whether it’s actually more harmful in the sense that a) we’re more exploitable as a work force and b) more mistakes are made.

When it’s busy, my train of thought is more difficult to follow, I’ve touched on this before here. I’m more distractible, I end up doing the same tasks again and again, running around, chasing my own tail, racing everywhere but not getting much done. So, for me, taking a break is necessary.

Lately though, I feel like I’m extra conscious about taking my breaks. One passive aggressive comment in passing is making me rethink my stance on taking time out. I don’t want to feel guilty when I go on a break when there’s still a lot of people to be seen. But I know that I don’t have it in me to work myself to the ground. Especially in a department like A&E when a quiet shift is the exception.

Sometimes I feel like I’m barely keeping it together. And those small moments that I can take to give myself a breather are really necessary. So, I’ll continue to take my breaks, because I can’t do my best for patients or myself otherwise.

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