Emergency Medicine – First Day
II.IV.I
FIRST DAY
The day I started my rotation at the Emergency Department (ED), I could hardly believe it. It felt exactly like when I had started neurosurgery.
First of all, this was gonna be my last rotation ever as a house officer. There I was, having barely even started, and I was already at the top of the junior doctor ladder. Then there was the fact that I’d loved emergency medicine from the very first time I studied it in med school. And lastly, this felt like the climax of my medical training – everything I had learned over the previous two years would finally come together here, where patients presented with every complaint under the sun. I just couldn’t wait to start!
I have to admit, my first day was a bit all over the place. The moment all of us new house officers walked in, we were bombarded with information about how the system operates. First up was patient triage using the Emergency Severity Index (ESI):
- 1: Patient requires immediate life-saving intervention.
- 2: Patient is high risk, disoriented, in severe pain, or has vital signs in the danger zone.
- 3: Multiple resources required, but vital signs are stable.
- 4: One resource required.
- 5: No resources required.
Patients would then be streamed into different areas based on their ESI score:
- Emergency Department 1 (ED 1):
- Resuscitation area: ESI 1
- Areas 1 to 3: ESI 2
- Emergency Department 2 (ED 2): ESI 3
- Minor Care Clinic: ESI 4 and 5
- Paediatric Emergency: Patients aged sixteen and under.
As junior doctors, we’d only cover ED 1 and ED 2. Triage notes would be placed in a rack according to time of arrival and severity. We’d pick one up, tag the patient into the system, and start our review. There were no firms here – instead, we worked in shift teams with senior support always available. We’d take a history, examine the patient, order investigations, consult when needed, and then either admit or discharge them.
Well, simple in theory – not quite in practice. Given that it was our first day, we were each assigned a consultant to discuss cases with. Mine took his job quite seriously – almost too seriously I’d say. I’d review a patient, present the case, and then he’d re-review them himself.
And with that, I could finally start seeing patients. The first case I picked up was straightforward – a man in his sixties presenting with chest pain. He was stable and otherwise asymptomatic, and his ECG had no alarming features. I sorted him out quickly and, while his bloods were pending, I picked up a second case: a young woman with an asthma exacerbation. I took bloods and started her on some nebulisers and she immediately felt better. I’d been told to start off easy, but with two patients awaiting investigations and nothing more to do, I decided to pick up a third case – a young man who had sustained a head injury. He was neurologically intact and only required observation.
All the while, I had to report back to the consultant who’d have to drop everything he was doing to re-review the patients in question. I have to admit that it made me feel untrusted and, somewhat incompetent – especially when patients inevitably changed parts of their story the second time round, something I later learned happens to everyone. I knew it was my first day, but as obnoxious as it might sound, I felt I’d earned a degree of independence by that point. With the rack overflowing, I thought his time might have been better spent elsewhere instead of babysitting me, stepping in only when needed.
Luckily, he agreed with my management plan for all three. In the meantime, I grabbed the fourth patient and by the time I sat down to write his note, the first patient’s blood results were back. His troponin, a marker of cardiac injury, was off the charts. His ECG was normal, suggesting a non-ST elevation myocardial infarction (NSTEMI). A heart attack. I spoke to my senior, started dual antiplatelet therapy and anticoagulation, and discussed the case with cardiology for admission.
That’s when it hit me. When I realised I had an NSTEMI on my hands, I had to let go of everything else in my hands. The other three patients, however, were still my responsibility. If something were to happen to them, it’d still be on me. Thankfully, the other patients remain stable and their investigations were reassuring – giving me time to catch up and sort them out. Much like I had been advised, moving forward I wouldn’t be picking up more than two or three cases at a time. If all hell breaks loose – which is not uncommon in the ED – you really need control.
For the rest of the shift, I worked two cases at a time. I was busy but in control. I wasn’t running myself into the ground or leaving patients unattended while firefighting another. It worked – I was in control.
And control seemed like a luxury here. All throughout, I’d been constantly overstimulated. Machines beeping and alarms going off, nurses asking me to do this and seniors commanding me to do that. One patient needed bloods, another needed reassessment, a consultant asked for help with a cannula, another patient suddenly deteriorated. It was all I could do to stop my head from exploding. While I like being constantly on the go, this was something else entirely.
And I loved it! By the end of the shift, I was already on a high. I knew this rotation would be the perfect place to sharpen my skills while doing something I genuinely loved. I still remember leaving hospital that day – my skin covered in goosebumps as I looked back on all the patients I helped and all the things I learned. In just one day…