Day in the life of an ED ST4 Trainee

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Charlotte Elliott

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One of the many things I love about being an Emergency Medicine Doctor is that no day is the same. A steady constant is how mentally and physically exhausted I feel mainly because our shifts are getting more intense – more patients arrive at the front door than they used to, the rotas are seldom staffed well and due to lack of social care patients aren’t being discharged from the wards meaning there’s a wait for beds which creates crowding in the Emergency Department (ED). Despite this I feel blessed that I am able to make such an impact on people’s lives, see treatments make patients feel better, teach skills to others and work in an amazing team.

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I arrive at morning handover and it looks like the night team have had a busy night. The board looks all red meaning that most people are over their 4 hour breach time. It appears though that most of the patients in the department have been seen and referred onto a speciality but they are waiting for beds on the ward. This is a usual occurrence in the ED. As the day teams do their ward rounds we hope that beds will be created so those in ED can be moved to a ward bed.

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I don’t have time to linger on this thought for too long as there is a call from resus to see a patient.

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The patient arrives with the paramedics and I take the hand over – the patient is in a supraventricular tachycardia (SVT). They have had it before but this time it’s gone on for about 5 hours. Their heart feels like it’s coming out of their chest. I try to perform carotid massage to no affect. I try to do a valsalva maneuver to try to cardiovert the heart – getting them to blow into a syringe. None of these works so they need chemical cardioversion. They are patient as we insert a line into their vein and attach them to the pads on the defibrillator. I am essentially going to reset their heart. This is one of my favourite things to do as it usually works well and has an instant resolve for the patient. I warn them it will make them feel very unusual, like something bad is going to happen. I give them a bolus of adenosine and wait. Sometimes the patient will need a second lot. The beeping on the monitor slows and stops and then tries to beep at a more normal rate. I can see it on the patients face something is happening….. Yay! They are out of SVT and a repeat ECG shows a normal rate and rhythm.

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Not to linger too long on my success I am called to assessment where a man is bleeding out of his nose. In fact, so bad is the nose bleed that he is actually bleeding out of his eyes too. Reminded of a scene from a Netflix horror movie I take him to resus – firstly as this is a massive bleed and he will need intervention and secondly so that the other patients around him don’t have nightmares. He has his fingers over the soft part of his nose but it is still bleeding.  I discover he takes warfarin which is the likely culprit. The ENT trolley is wheeled in and I find a nasal pack. I insert it into the nostril that seems to be the culprit and the bleeding stops. He will need to come into hospital under the ENT team and have his bloods monitored.

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Whilst this was happening other patient has been moved into resus from assessment with a fast heart rate. I go in to see him right away as I notice that the heart trace looked unusual on his monitor. A weird skill of the job is blocking out all the beeping from the monitors around you but equally being in tune with them so you recognise if something is wrong! I can tell the beeping isn’t regular like it should be. I look at the monitor and it looks like they are having runs of ventricular tachycardia (VT). I feel a twinge of excitement which I always feel slightly guilty for – sometimes the worst things for the patient are the most exciting for us ED physicians. I am again reminded in my head of the ALS algorithm, give him amiodarone and speak to the medical team. I am glad to see later his rhythm has returned to normal.

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Resus has started to fill up now and we review the patients on the board to step down the patients that no longer need resus level care. The whole department has only been given 2 beds since this morning. As a result, patients are on the corridor still with the paramedics just waiting to get into a cubicle and have their care handed over to ED. This makes it challenging to see more patients as there is physically no room. It also means that the paramedics aren’t able to go back out into the community to answer calls which always makes me feel nervous – what if someone doesn’t get the help they need in time? Magically, there is a space on majors for a woman with sepsis who has had treatment in resus and appears more stable. It is important to keep resus beds free if we need them for the patients that need resus level care.

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The stand by phone goes off and we are expecting an elderly lady with a CVA. She takes the last resus bed which we only emptied moments ago. The lady is usually fit and well. Sometimes I feel a sadness I can’t really place when seeing and treating patients – I think it is seeing this woman with her husband who woke up well this morning and now here she is with a stroke waiting to be thrombolysed. I often think that this could be my family member and wish I did see my family more and sometimes resent this gruelling rota.

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A lady in another of the cubicles needs NIV – she cannot breathe, her ABG result is dreadful and usual medical intervention hasn’t worked. She is getting worse. There are no NIV machines in resus. There are no lung unit beds or ITU/HDU beds. A repeat gas shows she is not doing well and she looks on the verge of a respiratory arrest. There is a conversation between the ED and the ITU consultant about getting her to a bed and therefore her receiving treatment that she needs. There is no room on intensive care – they have been waiting on beds for their HDU patients since yesterday. The ED consultant even suggests just swapping one of the HDU patients for her – at least then she will get treatment! I think this is a brilliant idea but also highlights the struggles of the system. The ITU consultant goes back to the unit and within 20 minutes the patient is moved to HDU. I hear that within 10 minutes of her being on the NIV she looked a lot better.

 

Another stand by - a young man has taken an overdose of some potentially lethal substances but refuses any treatment. I try to assess his capacity but he refuses to answer any questions. He is becoming agitated so I give him something to make him relax but he flips and I think hes going to hit me. I take a step back and security restrain him. I am not usually scared or frightened but I am when faced with physical violence. I am called all sorts of names but I brush it off – I am only trying to help. After some further lorazepam we are able to take his bloods and do an ECG – he will need monitoring further though for up to 6 hours and I almost feel bad on the medical team as I refer him to their care.

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The shrill ring of the stand by phone again – this time for a dislocated ankle following a slip on the ice – not the first ice related injury we have seen today. It is a closed injury but the skin is in danger so it needs to be put back into position asap. She is mildly sedated and given some strong pain relief as I try to put her ankle back into place. It is really unstable and as soon as I push the dislocation in it slides back out again. I just have to use my hands on either side of her ankle and my abdomen pressing against her foot to make it more stable as the plaster is applied. The xray after reveals a broken fibular – it’s ‘just’ her ligaments that have gone on the tibial side where I found it was highly unstable. I refer her to the orthopaedic team – luckily there is space on the trauma list for her this evening which I think it an excellent service.

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I am thankful that it is 5pm and hand over time! I haven’t just had to deal with my own patients in the shift. Throughout the day I have been asked for advice from the junior doctors, asked to check ECGs, book xrays, listen to concerns from the nursing team, help relatives and give updates to relatives. I always seem to have one ear sifting through the noise to pick up on anything of interest that may need my intervention, a bed in resus, help to prevent a breach or to get a patient home safety. I sometimes find it hard afterwards to switch off my brain but for the last 6 months have become a lot better at this by attending regular exercise classes (Zumba, Clubbercise, Pilates etc) which allow me to forget the day and let off some steam!

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This evening though I am going to a boxing match as the ringside doctor. I have done this for a number of years and enjoy the different work place to the ED but still being able to apply my skills. After the pre-bout medicals are done, I take my place ringside. There are a number of good bouts this evening but thankfully all I have to deal with are a few cuts which don’t require any intervention. I like the atmosphere at the boxing and meeting people I otherwise may never get to talk to.

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I get to bed late but celebrate as tomorrow is my ‘weekend’ off even though it is Wednesday! I know that when I return to work it will be a completely different day to the one I’ve just had and that, for me, is one of the thrills of Emergency Medicine!