The Big Leagues
THE BIG LEAGUES
I thought the transition from BST to HST would be little more than a title change. I’d remain in the same group, I’d do much of the same work, and I’d treat the same patients. Of course, I’d be paid more and work somewhat better hours, but I’d also be expected to guide junior doctors and take the lead on occasion.
I thought it’d be little more than a title change. I thought wrong. Very wrong. You see, I somehow expected the department to realise that the person who had just finished his basic specialist training was very much the same person who had just started his higher specialist training. And, once again, I was very wrong.
Turns out, the second you become an HST, you’re suddenly treated as a senior doctor – with all the newly added responsibilities and burdens that come along with it – even though your knowledge is pretty much the same as it was the day before.
From One Resus to the Other
There were plenty of new responsibilities too. On my very first day as an HST, I was assigned as the resus doctor. Lo and behold, the second I stepped in, I was instructed to go to resus, where a patient was not-so-patiently waiting for me. Now mind you, I had been in resus before – plenty of times – but always with senior support readily available. This time, I’d be the one initially managing the patient and making the decisions. And while that’s exciting and thrilling for an emergency physician, it’s also kinda scary.
Luckily, my first patient had something I was all too familiar with: SCAPE – sympathetic crashing acute pulmonary oedema. It’s an extreme form of hypertensive acute pulmonary oedema in which a surge in sympathetic activity causes marked vasoconstriction, rapidly increasing afterload and driving fluid redistribution into the lungs. These patients often look absolutely moribund – as was the case with mine – but, when recognised and treated promptly, they can turn around remarkably quickly.
The priorities were familiar: non-invasive ventilation to support breathing and recruit the lungs, alongside aggressive vasodilation to rapidly reduce afterload and take the strain off the heart. Diuretics could also be used if there was evidence of true fluid overload, although SCAPE itself is often more about fluid redistribution than simply having too much fluid on board. It was one of those presentations that looked terrifying but had a treatment pathway I knew well. And, thankfully, this guy improved quickly.
That’s more or less how the rest of my shift went. One acutely ill patient after another – most I managed independently, some with help from my seniors. But all in all, I did well. The cases that stumped me somehow stumped my colleagues too – which was generally a good sign that it wasn’t a matter of ineptitude or ignorance, just medicine being all weird and wacky.
The Other Side of the Ladder
A few days into my new training post, we got a new batch of junior doctors. As you can imagine, these guys had no idea I had only just climbed the ladder, meaning their expectations of me were quite high.
They’d come up to me with all sorts of questions. Questions I might not always have known the answer to, given that I was still a trainee myself. That said, junior doctors had already come to me for advice when I was a BST, so it wasn’t something completely new. The difference was that now I wasn’t just handing out free-of-charge advice. Now I was one of the seniors. There was more responsibility attached to whatever I suggested, and if I was going to advise on a management plan, I often needed to review the patient myself first. Suddenly, my opinion carried more weight.
This, of course, meant I’d have to ration my time between my patients and my juniors’ patients. Not the simplest of tasks – especially when I’d already have my hands full. And, as I quickly started to realise, no matter how good or knowledgeable a junior doctor is, there were plenty of things I wanted to reconfirm for myself before making an important decision. Having heard about mishaps where decisions had been based on incomplete or inaccurate assessments, I made it a point to review patients myself whenever their management depended on it.
Delegation was essential, but safety always came first. And let’s face it, I do have some trust issues. I tend to believe what I see and hear for myself.
Learning to Let Go
While taking on some of the juniors’ workload, I was now also granted the privilege of having juniors assist me. Now this was something that took a little getting used to.
Before, I’d start and finish a patient myself with little to no help – and that’s exactly how I liked it. I trusted my history-taking and examination skills. I’d do the blood-taking and cannulations myself, and I’d rarely have any trouble. I’d order the investigations I deemed necessary. I’d come up with evidence-based management plans. I’d perform certain procedures skilfully, efficiently and without delay. And I’d hand over patients properly and without any hassle. Granted, I wasn’t always completely self-sufficient, and I always asked for help when need be. But that was how I liked working.
Now that would change too. I’d be assigned a junior who would help me out – or at least that would be the idea. With some of them being relatively inexperienced, sometimes their histories and examinations might not be quite as accurate as I’d want for my patient (like the famous breath sounds…). Their cannulation skills might still need some work (all those haemolysed samples…). They might order investigations I don’t think are necessary (friggin’ D-dimers!). They might reach for drugs a little too readily (everyone’s so NSAID-happy…). Certain procedures might need refining (awful suturing techniques…). And crucial details could occasionally disappear somewhere along the handover (like why we’re actually admitting the patient to hospital…).
I might sound like I’m being being too mean or sitting on some kind of high horse, but I’m not quite judging them for it. Doctors make these kinds of mistakes – especially when they’re just starting out. I know it mostly cause I was one of them myself, and I’d made plenty of those same mistakes. But having grown so used to working independently, I had to readjust and learn to be more patient. Plus, it gave me a good incentive to spend more time guiding them and showing them the ropes.
And, as I quickly came to realise, I could work far more efficiently with a junior doctor by my side once we got into a rhythm. Slowly but surely, I realised that teamwork truly does make the dream work. Sorry for that – but it’s true!
Running the Areas
Then came the part none of us newly appointed HSTs were particularly excited about – leading the areas. During night shifts, weekends and public holidays, we’d be expected to take the lead given that the department runs on a smaller team.
As new HSTs, we’d usually be assigned to lead Area 3 – the part of the department generally dealing with the less immediately critical patients, predominantly ESI 3 to 5. And while that meant we were less likely to be simultaneously responsible for multiple crashing patients, the compromise was volume. Far more stable patients could accumulate in the area. And that was assuming triage had accurately reflected how sick they were and nobody had deteriorated while waiting.
As the lead of an area, I’d have relatively few patients assigned directly to me. Instead, I’d delegate cases to the BSTs and other junior doctors while maintaining oversight of what was happening across the area. To alleviate the workload, we also did what we call a first assessment – a brief initial history and examination aimed at identifying which investigations could be started while the patient waited for a full review. Ideally, by the time they were formally seen, some of the results would already be available, helping to speed up the eventual clinical decision-making process.
Though they wouldn’t technically be my patients, I’d still carry responsibility for overseeing what was happening across the area – even when there’d be fifty people waiting to be seen. I’d also be a point of reference for the other doctors. And the patients. And their relatives. And with stable patients being far more numerous than unstable ones, that’d be quite the task. With so many patients and limited resources to accommodate everyone in a timely manner, it’s more than understandable that patients and relatives became frustrated.
And I get that – I wouldn’t wanna spend half a day in a waiting area full of sick people either. That said, there isn’t much we can personally do to make beds, staff or space appear out of nowhere. And though we try to explain that as kindly as possible, that’s not always easy to do when we’re constantly barraged by angry patients or relatives demanding to be seen ASAP. Little did some of them realise that it’s more than our pleasure to see them, sort them out and send them on their merry way ASAP too.
That, unfortunately, is a fight we’ll never really win – try as we might. We can easily be seen as the ones who don’t want to help, even when the very pressures frustrating the patients are also preventing us from doing our jobs as efficiently as we want to.
The Cost of Moving Up
So yeah, though I’d had an inkling of what these new responsibilities might have had in store for me, I can’t say I was expecting quite such a leap into the deep end.
The slight increase in salary and the questionably better shift hours paled in comparison to the extra stress that came with the training post. But hey, that was the cost of specialisation. In medicine, the higher up you go, the more responsibility you’re expected to carry. That’s simply part of becoming a senior doctor.
But honestly? I wouldn’t have it any other way. I simply loved it. Because, stressful as it is, this was how I’d grow into the doctor I’d always wanted to become.