small medic mini-blog

regional teaching today. being for novices, it meant that “airway day” was all about the basics of induction of anaesthesia and extubtation.

they got a consultant to talk about front of neck access, a very rare event overall in most anaesthetists' careers, which my colleagues found super interesting, and I found devoid of self-reflection

in contrast the talks about ventilation and preoxygenation which people usually zone out at – I found really interesting. proper applied physiology, that. and extubation – the boring bits that people tend to overlook because it's not as flashy as intubation, but is equally a high-risk event.

#anaesthetics

Whinges to follow.

I had no department induction because “I'm not new to the department”

tasked to do pre-op assessments, told I could do some e-learning, having had zero feedback I hope the day anaesthetists enjoyed my shitty assessments with loads of detail (apart from where teeth are, what's up with that)

wanting to be involved with cases, but not even knowing there were cases overnight until I stumbled across them... please. I will cannulate and art line whoever. Anyone.

and emergency medicine, ie my parent specialty, constantly being slated

I get it, my regs have to scope me out, as do I, but I was expecting more. to find things difficult because there were lots of new skills to learn and the intensity of the work, not the constant defense of my specialty and my place on the team and asking permission to do simple things

(my supervisor and I talked about belonging, early on this year. ED recognises (kinda) me as one of its own – that I'll be coming back to them eventually. the tendency on ICU and theatres is: anaesthetics trainees are a known quantity – the favourite children – and most of the seniors know exactly what they need from training. most of the seniors don't know what signoffs ED trainees need, don't think much of EM as a specialty anyway, and keep saying “you're not going to use it anyway”, as if that precluded actually training a trainee)

#anaesthetics

There's something rather satisfying about being one of the many sets of hands to stabilise someone really unwell on ICU.

“Did you save any lives this week?” my parents often ask. Well, not directly. It's unlikely any one thing I do directly saves someone's life definitively. The seniors might, by spotting a pattern in a critically unwell patient and acting promptly. The nurses might, by actually giving the treatments and – well, good nursing care goes a long, long way.

Did I save any lives this week? Not directly. Not dramatically. But I did put in the lines to allow for lifesaving renal replacement and vasopressors, I guess. I did keep things safe as much as I could (prescribing, handovers, making sure there were good senior plans for important things). And if that sounds like working on a regular medical ward, then yes, it is! The stakes tend to be a little higher (if you don't fix the problem, that's it – you can't escalate to anyone else. (Transfers don't count)

It's changeover week, and I leave having learned so much, done quite a lot, and received overwhelming kindness from unexpected corners.

#ICU #reflections

I am weirdly verbose (at least online), despite not actually being that verbal. (I sometimes involuntarily speak really quietly at the end of a night when I'm shattered)

I think I'm wanting a debrief, or at least some sort of decompression for the rather eventful night.

we joke about british-isms minimising disaster but, genuinely: * patient heading for a crash intubation: “in trouble” * horrendously unstable patient who's been mismanaged for their entire hospital stay: “in a heap”

#ICU

Being on ICU with a bunch of IMTs has... its advantages: they enjoy making sense of someone's incredibly complex history, calling tertiary centres and looking at old clinic letters, and some are not particularly interested in doing lines

we are complementary

(I know how to dig into someone's records if needed – of course! but it's not my favourite place to be)

Read everything. Solid advice for young writers and artists, to gain as much variety in exposure to art, history – everything.

This is here because... this applies to medicine too. Emergency medicine, I think, values as broad an experience as you can get. The more you get exposed to, the more you see and hear, the better you recognise patterns

Apart from time, what I've found helpful is:

reading and listening to people talking about medicine

talking to specialties about our referrals – not just “yes” or “no”, but what they would do, how they interpret investigations and so on

The “old school” doctors often lament the cynicism and disillusionment of current junior doctors. It is fairly uncontroversial that doctors from a couple of generations ago were expected to have a broad skillset and knowledge base, even within specialty, often having had much more gruelling hours and levels of cover that would be considered safe nowadays. Again this doesn't seem to apply as much to emergency medicine, but specialty doctors nowadays are expected to have a narrow range of skills. Perhaps on a system scale this is more economical. But I think, as individual doctors, we only lose out when we limit our

If only I could actually remember all these things.

You can usually tell the mood in the department early on, right from the peripheries. When it's busy, patients sit in beds out in the corridor; specialty staff are stuck down in the department; the waiting room heaves and it is standing room only. Tempers flare. And, factually, it is worse for patients.

Sometimes, in this mess, the word “difficult” (or challenging or rude or...) gets brought out. Because some people end up expressing themselves loudly, and that is intimidating. Lots of them express a fear of getting lost in the system. When it is crowded, and it's taken longer than they expect to be seen, a few people have come up to staff to make sure they haven't been forgotten. (They haven't, 99% of the time. It genuinely is a stark matter of supply and demand.)

I think it's the same with children who come in with “behaviour escalation”. They fall between CAMHS and medical services, but neither thinks it's their problem to solve. I suspect this is because neither has particularly good solutions for it. Yet they undeniably are “difficult to manage”, hard to put in a box, sometimes end up hurting themselves.

I think all of them just want to be heard.

Even in a district general hospital, each patient makes up one of 60-120 patients in the department at any time. By my estimate, I spend maybe 20-25 minutes actually seeing and examining patients; the rest of the time is spent in front of a computer, so away from patients, documenting, referring, requesting scans, chasing bloods... All “behind the scenes” work, and from the outside, looks like inaction.

How do we fix this? Can it be fixed? What happened if patients were given a more granular breakdown of progress? How do we even communicate the hundreds of tiny steps needed to decide on disposition? How do we make people feel heard?

#reflections #clinical-communication

done!!!

I'm not done with medical nights just yet, but I rather enjoyed this set of nights – good team, good reg, and while staffing was lighter than usual, our ward cover overnight is ridiculously good for similar hospitals.

there were some very unwell patients, with a variety of pathologies, and we as a team did deliver some genuinely lifesaving care (this can be rare!)

there was also the usual frustrations: unprofessional behaviour, people trying to shift risk and blame to doctors for no discernible reason, not getting any rest with back to back emergencies. The latter, of course, being unavoidable sometimes; the former, systemic problems with no single solution.

sometimes it's about winning colleagues over to the side of the evidence. The temptation to just do something about asymptomatic hypertension is great. I have been guilty of succumbing to the “5mg amlodipine in the middle of the night”, a medication that will certainly not take effect by the time the nursing staff next take the poor patient's blood pressure. And yet, it's a strategy that just makes the healthcare professional feel better for having done something.

Sometimes, though, there's a glimpse of the type of medicine that compelled me to go for emergency medicine training.

Joining a colleague at the bedside of an unwell patient, and just getting stuff done. Putting the evidence together to try and figure out what was going on and how to improve their physiology.

And sometimes we (the medical team) actually arrive to a patient in the middle of a life-threatening pathology, have the means to correct it and can immediately see the result.

What a privilege it is! this is the meat and bones of acute medicine and it is brilliant when it works.

(the heart and soul, of course, being rather different. I'm sure I'll talk about it one day, it's very Pratchett)

First concert event of the year the week before last.

Unusually, we had training earlier in the day before the concert in the evening – a nice touch, I thought – meant that we could practice on site. also, because it's hard to get mojo barriers (the crowd barriers that you find at concerts), and our mockup has been broken multiple times by larger members of the team. As I've found, I've found it hard to mock-up, or break down, the physical skills and movements for the thing that worried me most – crossing crowd barriers. so I've been winging it, basically.

As luck would have it, I was placed in a team with the tallest people around, both during the training and the actual event…

The height difference is usually nothing more than a funny quirk, a visual joke. Sometimes even a benefit. Tall members mean they can reach and see things I can't, or catch me where I'm weak. And it was good for those pesky barrier crossings because they could spot me.

Halfway through the main act though, I realised the two tall lads were talking to each other, then to me as an afterthought. It's easier for these tall guys to take up space, to be noticed, to be recognised as The Medic. More of an art to deflect attention.

MRT days make me mindful to be assertive. I am naturally quite soft-spoken and averse to conflict. But the more “go with the flow” I am in MRT, the easier it is to ignore me. Not that I must be heard at all costs. But this extends to being kept in the loop. As much as I can interpret my team's actions because we have a shared mental model, I appreciate sharing that communication…

*He's a student HCPs, and I find they fall easily into a clinical lead role. Those who started volunteering as first aider without necessarily a clinical background tend more to find the operator role more natural, I think.

When you're physically small, it takes effort to occupy space and be heard and lead. Especially when it goes against your own nature. It's not just an amusing look…

#crowdmedicine #MRT #volunteering #personal #reflections