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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Good Doctor

good doctor

Recently, I reviewed a patient in A&E with abdominal pain. She was with her husband and neither of them spoke English well. When I was taking the history of her symptoms, I tried to break down my questions as simply as I could. Plenty of gesturing and as much non-verbal communication as my imagination would allow. With all of that, it was still pretty difficult. Some of her answers were conflicting which meant I had to go back and clarify things again and again. After that I examined and took some bloods. I explained that we’d run some tests and then I’d come back to discuss it all with them. Her husband called me a good doctor and thanked me.

I didn’t really register it at the time. I sort of responded with an absent-minded smile and placed them back in the waiting area. After blood results came back and she’d had an x-ray to rule out anything serious, I explained that I was treating her as a urinary tract infection, again with a lot of gesturing. Then both her and her husband thanked me so emphatically and kept calling me a good doctor.

And that’s when I realised that they really meant it. The first time the husband said it after just taking the history and examining his wife, I hadn’t taken it seriously because at that point, I hadn’t actually done anything. When it was all done and I was sending them home with antibiotics they were so grateful and kept on praising me. I didn’t feel like I’d done anything to deserve so many compliments.

Maybe they appreciated how much effort I took to take her history despite the language barrier. Maybe it was the way I communicated, or how I spoke.

Am I a good doctor? I don’t know. Sometimes on a bad day, it doesn’t feel like it. Some of the shifts I’ve experienced haven’t all been sunshine and rainbows. And on those days, days that are just a series of consecutive blows, where it feels like I can’t seem to do anything right, those days are the toughest. And I feel like anything but a good doctor.

I know I get a lot of my self-esteem from doing things well, whether it’s writing, baking or fixing a patient’s problem and sending them home. Being a good doctor though, is more than just being a nice doctor, I think you need to have good clinical skills as well. I just don’t think I’m there yet. And I know it doesn’t help to compare, but some moments I can’t help but look at other F2s. Ones who seem to have everything together and go about everything so confidently. On those days that I’m feeling low, that really helps to cement those feelings.

This week, I’ve tried to put things into perspective. I’ve been a doctor for nearly 17 months now, I can’t expect to know everything and be everything. It’ll take time and a lot of patience.

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Less Than 1%

So, last month was the time for applications. I spoke about it before here. The end of November was the deadline for all applications to be submitted. All anyone was talking about were exams or applications. I got swept up in the sense of urgency and with all that energy, I started feeling a little unsettled. I was watching everyone else running around, making decisions and it felt like I was missing out on something.

Some of the other F2s encouraged me to apply, and then defer a place later on. And that’s when I realised that not even 1% of me wanted to. Will I regret it later? I don’t know. But I know I’ve made the right decision based on how I feel at this point in time.

I think what made me anxious, is not having any sort of plan or direction for the next year. And I love direction. It’ll be the first time that I’ll be free to choose, without the constraints of time or any other pressures.

There are some ideas, but at present, it’s all disjointed. I want to travel, I want to write, I want to move to a different area in the country, but I also want to move to a different country. How do I make it all fit?

It’s all unclear. I just need some clarity to figure out what it is that I want and I’m just wary of wasting time. I don’t want to be 5 months into my F3* and be watching reruns of friends on the sofa.

Although, that actually doesn’t sound all that bad.

*colloquial term to describe a gap in training taken after foundation programme (F1 and F2) is completed.

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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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