Paediatric Pearls

Things I have learned so far in kiddies ED:

1. Bubbles have magical qualities and fix tachycardias ALMOST every time.
2. There is no such thing as a “quick look” at a child in triage.
3. Play specialists = HEROES.
4. Early ametop application in triage is one of life’s greatest gifts.
5. ALWAYS take a second cap gas because the machine demands one as a sacrifice.
6. Sometimes kids just get rashes, and we don’t know why.
7. All children in London are constipated.
8. Parents never give paracetamol, for fear of us not believing that their child was in pain/hot. We berate them for it, and then don’t believe them that their child was hot at home if they aren’t hot here.
9. I can now identify which antibiotics someone has been given based on what colour it is, what it tastes like, and what bottle it comes in.
10. Suctioning bronchy babies and watching them instantly perk up before your eyes is one of life’s great pleasures.
11. Sometimes a sympathetic face and time to listen is all it takes. Parents’ scope to worry about their children knows no bounds, and reassurance costs nothing. Be patient.
12. A good number of midwives scales are broken.
13. If the umbilical cord looks infected, it usually isn’t. When it is, it is a BIG deal.
14. Getting a line into a 1 day old baby gives you the best high.
15. Paramedics and GP surgeries NEVER have paediatric sats probes and this frustration will be felt DAILY.
16. When you get cocky about your abilities you will inevitably do something insanely stupid like glue a child’s eye shut.
17. When you finally know the doses for paracetamol and ibuprofen without looking them up you feel like a GOD.
18. SOME babies ARE cute, and you have to remember to give them back to their parents when you are finished examining them.

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With apologies to Taylor Swift, I present to you the following.

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Nice to meet you, what brings you here?
I could ask you almost anything,
Rashes, fevers, diarrhoea?
Saw you here and I thought
‘Oh my god, hear that chest,
He should be the next assessed’
The triage nurse is looking stressed.

Bring you in, sit you there,
Talk to Mum about what’s going on.
Assess your throat, look in your ears
And I know you are quite wheezy.
So hey, let’s give some puffs,
I’m hoping ten will be enough,
Grab your spacer, come with me,
I can make your breathing better for a little while.

Cause you’re young and you’re breathless,
You come to A&E.
Run out of inhalers,
No time to see a GP.
Got a long list of visits,
They all say the same.
I’ll give you burst and steroids
You’ll be glad you came.

Find your tribe.

Choosing a specialty is a funny old thing.

We spend a lot of time in medical school, and post graduation, trying to decide which area of Medicine we are suited to. It is an important decision, as it decides your career path and length of training, and although there is some potential for movement, it often entails further years in training if you get halfway down one path and decide you would rather be on another.

Some people are fortunate enough to be certain in their career aspirations, and know which path they want to pursue. I was never like that. I have found myself ambivalent about the specifics of Medicine. Nothing particularly excites or drives me more than anything else. I am generally doing the job because it seems a waste of a medical school education to do anything else.

It is bizarre then, that I have chosen Emergency Medicine. Ostensibly, this is the most stressful, involved, high pressured area of Medicine. You have to know lots about lots of things and for someone unexcited by various aspects of medicine, seeing patient after patient with a cough or a toe injury or a rash is hardly enthusing. Intersperse that with the seriously unwell patients who keep attempting to die on you, and on paper it sounds even less like something I would enjoy doing.

But the people. My God, the people. I remember walking into my first ED job, seeing the nurse in charge rip the shit out of the on call doctor with a crass and frankly too easy joke, and thinking “I have found my tribe.”

I firmly believe that it is not the type of job that you need to base your career decision on, but the type of people you will have to work with. And there is no better bunch than the ED team. Nowhere else in the hospital do nurses and doctors work so closely together. The relationship can be beautiful. You have the opportunity to understand each other, and ED teams become like family (a replacement for the family you have at home that you never see due to an unforgiving rota).

I have just finished a shift where it would be understandable if I was a broken person going home. Presentations were relentless, the board was out of control, not enough doctors, too few nurses, several angry patients – the usual ED shift. But instead, it was one of the better days I’ve had in a while. My personal life is a little rubbish at the moment and it is nice to be able to come into work, and have a good laugh with a genuinely great group of people. You don’t go into Emergency Medicine unless you are hardworking, sarcastic, fun, and have a thick skin.

I am in my 3rd year of ED training now, and during those years I have had to spend several months out of the department getting experience in other areas of medicine. And each time I have come back to ED I have felt the same sense of relief. Mainly the relief of no more ward rounds, no more clinics, and no more dealing with patients for longer than 4 hours (I have a ridiculously short attention span)! But also happiness that however rubbish the shift, however overworked, underpaid, generally under appreciated we all are, there will be piss-taking and merriment, and, if I have had time the night before, homemade cakes and biscuits. You can’t ask for more than that.

Welcome to A&E

confessionsofajuniordoctor:

I have no idea what it is that I like about Emergency Medicine.

The hours are terrible. The rota is indecipherable. You cannot plan to attend a friend’s birthday or a family gathering. Your social life is non-existent. The patients are largely rude, drunk, smelly and irreverent. There are never enough staff on shift. The urgent care centre referrals are sometimes ludicrous. The GPs send in UTIs as renal colic, PID as appendicitis, persistent patients that they can no longer placate. The specialty doctors think we are either lazy or lobotomised. You spend more time than you should at the centre of “specialty tennis”.

The four hour wait is a travesty. There are never enough observation beds. The pressure is immense. The clock never stops. There is always another patient waiting, another test to order, another result to check. There is always a diagnosis to be made, and treatment to initiate, a conversation to be had. You go from renal colic to brain tumours to heart attacks. You see depressed people, drunk people, old people, children. You see people at their worst. You see time wasters and hypochondriacs and then sepsis and deaths. You don’t have time to process. You don’t have time to think. You see, treat, refer, discharge.

People complain about the waiting time, disagree with your assessment, believe google before they believe you. You go home at night paranoid about the patient you sent home; constantly questioning your decisions, your abilities and your sanity. You see multiple patients simultaneously, you are a porter, a nurse, a cleaner, a friend, a confidant. You tell people good news, bad news, sad news.

You are charged with the unhappy job of treating people’s liver disease from excessive alcohol, lung disease from smoking, diabetes from overindulgence. People expect you to take responsibility for their lifestyle choices. You endure the abusive drunkards, the psychotic schizophrenics, the deranged elderly. You put up with the people who have neither an accident nor an emergency.

You exhaust yourself looking after these people, so much so that you go without food, without bathroom breaks, without the most basic of human needs. You are vilified by the media, who feel you are paid too much for what you do. You are misunderstood by friends and family who watch too much ER and Casualty. You become unacceptably irked by poor resuscitation techniques on TV shows. You complain about unnecessary attendances and then carry out wholly unwarranted tests because you are scared of being sued. You will inevitably have complaints filed against you for merely doing your job. You will make poor management decisions and people will die. You will make excellent management decisions and people will still die. You will defy the odds: CPR will work; the patient will recover from sepsis; be discharged from hospital, and then die at home a week later.

You will miss things. You will be wrong on a daily basis. Everyone thinks they know more than you. You finish a shift and barely have the energy to walk to the car; let alone drive home. You spend at least half of your days off comatose in bed. You don’t see your housemates for weeks due to opposing shift patterns. You do locum shifts during your time off because there are never enough doctors and you know how awful it is to work when they’re short staffed. The barista at Costa knows what sort of day you’re having based on whether you order a medio cappuccino or a double espresso. The packed lunch you brought 3 days ago is still sat in the refrigerator. Once you leave work you are unable to make the smallest of decisions because you have used up all of your brain cells.

You are stressed out, overworked and rarely thanked. And I can’t think of any specialty that I would enjoy more.

I wrote this post over a year ago. I am now back in ED as a specialty trainee, and the above is just as true as it has ever been.

I have loved this job in the face of so many reasons not to, and it will take more than contract changes or incompetent health secretaries to change that. Do your worst Jeremy, we will be doing our jobs long after you have finished doing yours.