emergencyregistrar

Where I am currently living, there is a partial lockdown.

No more meals outside; just take-away food.

Much angst about job losses and income security amongst some people; I guess we are fortunate to be employed. I echo a phrase from my old mentor “without patients; we would be out of a job…”

It has been > 1 year since I have updated this blog.

I chose to keep this blog open as a source / repository for my future trainees / children.

I do wonder at times ; is there more to life than medicine itself ?

Should I embrace this wellness concept ? …

ON a more serious note; I have been watching lots of Radiopaedia lectures (subscribed) to some of them. GOLD !

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I reminisce when life was slightly simpler when I was a registrar…

I remember 2013; I was a freshly minted registrar at a place called Ipswich. Literally felt like I was thrown in a deep end. Fantastic acute medicine; and very steep learning curve.

I struggled to pass the primary exams then (I still hold resentment at a previous workplace in 2012 where I was not given enough leave)

But my struggle came down to focus.

I was fortunate enough to pass these exams by the skin of my teeth thanks to the amazing tutelage and assistance from the people then.

Ipswich has a very fond place in my heart.

My transfer of an intubated patient with multi-organ failure (on inotropes and all that jazz) to a tertiary centre… (which then became many…)

My first diagnosis of a ruptured ectopic pregnancy !

My foray into lung ultrasound.

My few neonatal resuscitations !

Now as a consultant I wonder how to pass on the wonder and expectations I have on the trainees… is it too much to expect a higher standard or enthusiasm ?

Most of us would be excited that SMACC is next week !

It is the last SMACC after all !

I have now been working as a consultant for the last 1 year !

Impostor syndrome occasionally prevails and pervades my ability to perform.

Sometimes I fumble upon describing a pelvis Xray accurately – fumbling the words “sacro-iliac” or “sub-trochanteric”

In moments of stress or high tension ; I would often default to :

a. the ZERO Point survey – espoused by the famous Dr Cliff Reid at Resus.me

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6166036/

I am now a FACEM. This is a long journey which started in the corridors of an emergency department.

I am now doing WBAs fr trainees instead of doing them with with other consultants.

I credit influential mentors and a great hospital system for influencing me.

The whole idea that I am now a specialist…is scary.

Sometimes I wonder, whether my behaviour and leadership example is appropriate for a  consultant. I can only continue to strive for my best. every day.

For the patients.

a lysed inferoposterior stemi…

an MTP joint aspiration…

4th MCP fracture > POSI

droperidol x3….

haemarthrosis knee

superior articular facet fracture of c7….

i thought i was okay; until someone asked whether “are you okay”

and reminded me that “i am awesome”

maybe i display a flat face when it comes to feedback

but deep deep down i feel guilty and stupid

and always blame myself for not being good enough

not failing to be a patient advocate

on another gripe

i have a theory that registrars of similar ethnic backgrounds treat each other like shit. just an observation. “can’t be accused of racism” right

Passed the osces !

this empty feeling remains….. I wonder why.

it is 14 hours to the OSCEs.

I sit here in this nice, sparkly clean apartment with my laptop on my thighs. Notes / books scattered on tables/floors.

The shirt/scrubs are ironed / hung on hangers….

The shoes ready. Next to the door.

People tell me that I am ready. I don’t. I really am not.

I had a rough few weeks. Personal matters.

For the first time in my life, I have actually thought about suicide. It is real. What if ?

Don’t worry (I have more reasons to live)

Just goes to show that even myself am not immune to these thoughts. Suicide is real. Depression is real. I used to think that people on anti-depressants don’t necessary need to be on them …..

I had few encouraging emails from old bosses :

the most encouraging one was “good luck” but the truth is “you don’t need any more luck”
“you are a FACEM”

now….to try and remember that we actually measure thrombin time for dabigatran and now Xa levels….

or which is Neer’s test again. or Hawkins. or Mcmurrays…

Look. Feel . MRI !

It is 9 days… to the 3 day extravaganza they call the “ACEM Fellowship OSCE Exam”

I have 2 more work days ; so that makes is to 7 days.

7 days to practice :

101 ways of taking various history and exam i.e. headaches/abdo pain/chest pain/syncope

dozens of various physical exams e.g. cardiovascular exam / knee exam

dozens of data interpretation

Hundreds of variants of Simulation scenarios

Dozens of communication practices

Hang..on..I should have practiced them for the last 4 years !

Phew.

The nerves are getting to me. Silently.

I just realised it has been 4 years since my last post !

In 2 weeks time I will be sitting my Emergency Medicine specialist exams.

I had some practice OSCE sessions with a colleague and gems from the consultants today were :

“Don’t do a core basic thing poorly – heavy weighting ”

“That stuff needs to come out – you know this”

“Knowledge needs to come out in a structural way”

“Show an overview of a big picture”

“Get all the ducks lined up”

“You do not get marks for what you are thinking only what you are saying”

“Make a consultant handover concise and precise”

“YOU ARE A Beacon of calm for prioritized actions”

“Deconstruct each step for procedures”

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I just finished a shift with 4 procedural sedations / 1 intubation :

a. Assisted in washing a middle aged man’s compound tib-fib fracture

b. Sedated an 85 year old female to wash a medial malleolus wound ; she had rib fractures and was recently in AF 2 weeks ago (she is on Apixaban)

c. Sedated a 40 year old 120kg lady’s tibio-talar dislocation

d. Intubated a young male with a GCS of 5

e. Sedated a middle aged lady to reduce a Colles fracture

With the primary exams out of the way…. new levels of expectations are set. Often in ED we do get difficult patients.
What if we encounter difficult staff ?
Often at a junior level ; whether you’re an intern or a registrar; you find your decisions overriden by a senior. Usually this is a good things
say for example :
you want to discharge the 80 year old female who had a FOOSH and currently has an undisplaced distal radius fracture (which is in a backslab). BUT your senior points out that she lives alone and would benefit from admitting her to Short Stay having allied health input to allow assessment for safe discharge … (physio/OT) as she lives alone and does everything on her own.

Now thats a good thing isn’t it ?
Most of us wouldn’t mind that, would we ?

Or the low-to intermediate chest pain (TIMI 0 ) we see in ED which we think should just get a repeat 6 hour Troponin and be discharged with GP to organise stress testing if the trop is negative….
(only to have a senior veto you and say you should refer to the medics for inpatient testin)

Once again….safe isn’t it ?

What if this was the OTHER way around … where a senior supervising member’s disposition is less safe ? or conflicting with yours…

At the shop I work at, during a day shift we have consultants covering the floor who often provide good support and advice. But this differ from SMO to SMO…. and often the advice can be conflicting.

Different EDs will have different sort of SMO covers.
Some models of care from my limited experience :

a. free reign – i.e everyone does their own shit and make their own decisions especially discharge dispositions (only if you are PGY2 and above)….. this is for super busy EDs with lack of medical/nursing staff

b. full control – – all patients will need to be run past the SMO on the floor…. (including fast track patients e.g. ankle sprains… “groan”)
very safe

c. registrar led teams – – – all patients will be discussed with the registrars on the teams.
a model demonstrated at the tertiary hospital I used to work. consultants allow registrars to make disposition and only step in when a conflict arise

How do we approach differences in disposition ?
What if there’s a difference and a concern about where the patient is going ?

Case 1.

A 39 year old man presents from a GP with referral ? pancreatitis (he had 3 days of upper abdominal pain) with a raised lipase of 800.
ON assessment today he is well albeit slightly nauseated.
All vitals normal (heart rate 70, normotensive and BSL 6)
Abdomen today some discomfort.
“today’s the best i’ve felt doc”

His lipase is 350.

The resident’s impression was that this was “ongoing resolving pancreatitis – mild with a RANSON score of 1 (raised WCC 3 days ago) and needs to come in under the surgeons for Ix ”
The registrar who saw him felt his abdomen —says “this abdo was soft —- SEND HIM HOME. HIS LIPASE is only 250. WHAT WOULD THE SURGEONS DO”

at this juncture the resident wanted to call the surgical registrar and get an opinion but his ED registrar vetoes that and removes the cannula and starts typing the letter himself.

Comment : conflict of different assessment and management opinions.

This case was resolved when the resident subtly blurted out the case to the consultant on the floor.
The SMO on the floor had a quiet word with the ED registrar and directly admitted the pt under the surgeons (with a new cannula the SMO inserted herself)
Needless to say the ED registrar never really spoken to the resident again.