Restarting
RESTARTING
Once the meeting was over, the head of department accompanied me to the shop floor. That’s what we call the actual place where we see patients.
It had been just over a year since I had stepped into the ED, and it was already completely different. As I had learned during my time as a junior doctor, patients would be classified according to the Emergency Severity Index (ESI), with ESI 1 patients requiring immediate life-saving intervention and ESI 5 patients requiring no resources beyond clinical assessment and therefore not needing emergency care. Patients with different ESI scores would be seen in different areas. The basic configuration of the ED was as follows:
- Emergency Department:
- Resuscitation Area: ESI 1
- Area 1 and Area 3: ESI 2
- Area 2: ESI 3
- Minor Care Clinic: ESI 4 and ESI 5
- Paediatric Emergency: Patients aged 16 years or younger
Whilst the new observation ward would ease pressure on the inpatient wards upstairs and allow for fewer long-term admissions, it also meant less space for us to see patients. I wasn’t too happy about these changes, but I figured I’d have to see them in action before I could judge.
The rest was pretty much unchanged. Patient triage notes would be placed in a rack based on time of presentation and severity. We’d then pick one up, assign ourselves to the patient on the system, and start our review. Here, we wouldn’t have our own firm – instead, we’d be working within a shift group, ensuring senior support at all times. As a junior doctor, I’d be tasked with seeing patients, taking their history, examining them, booking investigations, consulting other specialties when needed, and then either admitting them to hospital or discharging them. Simple enough.
As a BST, I’d also be expected to manage more unstable patients and review patients seen by junior doctors. Not quite so simple. But, as the head of department emphasised, that wouldn’t be the case for quite a while. In fact, for now, all I’d be expected to do was shadow one of the seniors around – at least for a couple of days.
The First Patient
I tagged along with Dr Moon, an HST who would be the shift lead of my group – one who was renowned for being among the best and with whom I had never worked before.
Our first patient was an 80-year-old man who had come in with palpitations. He had a heart rate of 135 beats per minute (a normal resting heart rate is generally between 60 and 100 beats per minute). I stood at the back as Dr Moon took the history – pretty much like I used to do on a daily basis as a medical student.
Turns out, the patient was already known to have atrial fibrillation (AF), a condition in which the electrical activity of the atria – the upper chambers of the heart – becomes disorganised. Because the atria no longer contract effectively, blood can pool within the heart and form clots, increasing the risk of complications such as stroke. In addition, a persistently elevated heart rate means the heart is working overtime, potentially leading to symptoms, cardiac dysfunction, or heart failure if left untreated.
There are several ways of managing AF. First, it’s important to bring the heart rate under control. In patients who are haemodynamically unstable, or in selected cases of new-onset AF, doctors may attempt rhythm control using medications or electrical cardioversion – which basically means shocking the heart. In patients with AF of more than 48 hours’ duration, or where the onset is uncertain, rate control is often preferred initially – mostly cause the risk of clotted blood shooting off into the circulatory system is too high. Long-term management may also include anticoagulation to reduce the risk of stroke.
Luckily, this patient was already taking both rate-control medication and anticoagulants. From the history and examination, it was quite evident that he had some kind of chest infection – a likely trigger for his fast AF.
Tired of standing around at the back, I busied myself by obtaining IV access so we could send blood tests and start treatment as suggested by Dr Moon. Sure enough, his inflammatory markers were elevated, and a chest X-ray showed a developing pneumonia. We started him on antibiotics and admitted him for further management and observation.
Where I Belong
And that was that. The first case was done. Without wanting to come across as arrogant or pompous, I asked Dr Moon whether I could start seeing patients myself.
Apart from feeling like a dead weight, I also felt I could hop right back into the game. Of course, I knew I was rusty, but that’s how I’d get back into it anyway. Plus, by taking an exhaustive history, performing a thorough physical examination, and knowing I could discuss anything with Dr Moon, I knew I’d be fine.
In fact, he told me that would be even better than shadowing him. And that’s exactly what I did I picked up one case after another, always making sure to discuss my patients with him or anyone else willing to have me. By the end of my shift, I had already seen an average number of patients. I gotta admit, it felt so, so good to be back.
Also very tiring. I had forgotten how physically draining working in the ED could be. You’re on your feet most of the time, running around the entire department trying to get things done. But it’s also what makes it so damn fun. Honestly, you don’t even notice the time passing.
Ready for my first day of work to be over, I bid everyone adieu and stepped out of the hospital. I couldn’t help tearing up. “This is where I belong,” I repeated over and over, my body covered in goosebumps. I hadn’t felt anything like that in years. In fact, the last time I had felt that way was probably during my ED rotation as an FY and while hanging around the neurosurgical operating theatre before that. As much as I’d miss neurosurgery, I knew I had made the right choice.