Tonight I felt like a Doctor...

“Most doctors are prisoners of their education and shackled by their profession.” ― Richard Diaz

Monday August 8th, 2018. That is the date, when it happened. I walked into the Paediatric Emergency Department as an intern. No longer a medical student with limited responsibilities and an early dismissal time. That night, I found myself a prisoner of my education and surprisingly shackled by my new profession.

I realised that the mould I had decided within myself to break, was beginning to settle. My environment was doing its best to imprint its treasured norms not only into my mind but also my heart.

It was my encounter with a parent and her child that made me realise that I now wore loose shackles of medicine. Her tiny hand, warm smile and vivacious giggle despite her ill-appearance broke the trance that I unknowingly had fallen into.

Hopefully this post shares some tips on staying afloat in the fun world of the Paediatric Emergency Room while ensuring you're remaining true to yourself, your morals and values and your God-given purpose while taking initiative.

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Nick had been out of work for three weeks. He had known the downsize was coming, but he hadn't expected to be caught in it. What's wrong with me?  Nick thought. He rationalised that he needed to get his resume updated before he started looking for a new job, but he knew that was just an excuse. He just couldn't make himself get started. 

Each morning he'd vow anew to check out leads, make phone calls, and get in touch with agencies and headhunters, but first-there was always a "first"-he had to run by the church to help repair the roof, or he had to mow his yard, or he had to go by the gym to work out his sore muscles, or he had to sit down and figure out a new budget...

Nick knew he couldn't keep putting off his job hunt. "Help me, God," he prayed. He picked up his organiser and started making notes.

Everyone has something in his life that he seems to put off doing. It may be finishing a college degree, buying a house, or applying for a promotion. It may be something simple like painting the house, cleaning the garage, or balancing the check book. Ultimately, if some project never gets accomplished you have no one to blame except yourself. What a waste to look back and say, "If only I had..." Make yourself accountable to God to get yourself moving. -Renewing Faith 2017 Planner

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As the first point of patient care, working in the Emergency Department requires honesty, accountability, strong attention to detail and the ability to take initiative.

You will often be faced with persons and their egos which may lead to a delay in patient care and hence overall patient satisfaction and/or survival; do your best to maintain professional rapport, however you're not required to accept that type of behaviour as normal or adequate. 

These two weeks in the Paediatric Emergency Department has taught me: 

1. How to listen to patients (and their parents)

2. How to differentiate the battles that I can fight and those that would require referral to the "David" of the department and 

3. How to tame my shaky hands when unruly, frightened adolescents wiggle and continuously scream "doc, dat needle hurt!"long after the anaesthetic has been applied and taken effect and all sutures have been tied off, covered with topical antibiotic cream and secured with Bactigras paraffin gauge dressing and an IV 3000. 

THE DO's

1. Know your schedule.

By the end of this series of posts, I'm going to sound like a broken record, but I cannot say it enough. Know your schedule.

The rotation through our Accident and Emergency (A&E) Department is short and done in shifts. It is vital to know when you're expected to show up as some senior personal won't send you an email or any form of notification regarding which shift they have scheduled you for.

How it works here, is simple. For each specialty rotation there is one selected Consultant who is responsible for the interns/house officers. They are the persons everyone in the department goes to when they have an issue with the group or simply want to comment on how good the group is doing. That person is also responsible for the scheduling of the interns and organising our class and final examination.

As each section of the Paediatric department has their own expected work report times, the intern coordinator doesn't schedule you for a particular shift during a particular area of the rotation, that is done at the discretion of the persons in charge of that area.

For example, A&E has two shifts from Monday-Thursday, two shifts on Friday and one shift on Sunday and Saturday. Monday-Thursday you can be scheduled for the morning shift  or the evening; 8a.m.-4p.m. and  4 p.m.- 12 a.m respectively. On Friday the morning shift starts at 10 a.m. and ends at 6 p.m. with the night shift staying the same as Monday-Thursday. The weekend shift is from 8a.m.- 4 p.m.

Knowing your schedule allows you to mentally and physically prepare for your time in the department. It can also allow you to check (and see with whom you'll be paired with) if a printed schedule is available.

If you're switching from one area say on a Tuesday (which is how our switches happen every two weeks), use the Monday evening to find out where and when you're to show up. It helps with saving gas and allows you to make the most use of your time. Imagine, you've been scheduled to work on Tuesday night and you show up at 8a.m. thinking you're to work the morning shift. What a waste of sleep time and gas. Don't give anyone anything negative to say about you if you can avoid it. We all know there are lots of haters in the world.

2. Get Oriented

Maybe it's just me, but I like to know all the nitty gritty about any area I'm scheduled to be in for a certain period of time. It just makes the transition easier and affords me the opportunity to focus on  patient care without wasting time looking for things that I would need to perform my tasks during my shift. 

Since this part of the department is very different with its own set of needs and management, it is good to have a senior person give you the run down of how things work. 

As the intern in A&E, during the shift you're scheduled for, you're responsible for the following things: 

• Seeing the patients before being asked to,
• Present (Discuss) all patients to a senior person before initiating treatment,
• Manually log all persons seen for the shift in the patient log book (physically write each person's name and particulars along with the nature of their injury, the service provided and the disposition),
• Manually log all patients who had cultures done that are needing follow up in the culture book,
• Check the culture book before the end of the shift and update (transcribe their report) it. In the event a patient's results need to be acted upon i.e. Blood culture grew a bug, inform your senior and contact the patient so they can be treated if warranted. 
• Ensure the dry-erase board is updated at all times with the names of the patients who are currently being treated in the department or those who were admitted. This makes for a smooth handover and reduces mismanagement or a patient being overlooked from one shift to another. 

Also, in terms of being oriented, know where your supplies are kept. 

Our department has a cupboard that is usually locked at the end of the shift, that houses hard to come by supplies such as culture bottles, paediatric specimen tubes, aerochambers and other tools for educational purposes and even paediatric textbooks, computer mouse, diagnostic kits and working staplers. I sensed your eyes widening at the 'working staplers', trust me, it's hard sometimes to find a stapler. 

What I did at the beginning of the shift especially if I worked the night shift, was to stock up all of the trays and storage units on the floor with supplies such as sterile urine cups, IV catheters of various sizes, made splints for the night and stocked the cabinets, ensured we had specimen tubes for the basic laboratory investigations we ordered as well as ensured there was more than enough biohazard bags, gauze, heplocks etc. 

The last thing I wanted was to be unprepared in the event a trauma rolled in. I never got to experience a paediatric polytrauma, but following my shift one night, another Physician did and she was more than grateful to us for leaving the area stocked, clean and organised. 

3. Document! Document! DOCUMENT!

Practice proper documentation of everything! 

Some services are riddled with Senior House Officers with inflated egos who have a misguided sense of their duties. If you haven't encountered any as yet, prepare to meet one or two during your time in A&E. 

Get in the habit of documenting when you sent a page for a referral, when that page was answered, by whom and a synopsis of what was said. Document when they showed up and what was done and what was to be done in the future if they failed to document it. The last thing you want is for the next doctor following you to not know what was done or to be done for a particular patient. 

It's best to have some form of documentation (preferably in the patient's file) of the overall management in the event legal matters arise. 

If your hospital has certain policies regarding documentation, familiarise yourself with it. The one thing I wish our hospital was good at is providing Standard Operation Procedures for each department and the common scenarios encountered. Why? Because it would allow for standardised care and something to stand on if someone ever questioned why you did or did not do something. 

4. Do ask for feedback

As you move through the various areas, remember this is all another rung on the ladder of continuous learning. 

Speak to your seniors. Develop a professional relationship where constructive criticism can be given and where you are comfortable growing as a Physician. 

Ask them for advice for improving your histories in the department as A&E focuses more on the abbreviated history. Try to utilise your seniors for your success. These are the big kahuna's of the field, adopt their good practices and forget the rest. 

The Don't's

1. Don't Waste Time!

The main purpose of the A&E department, be it adult or paediatrics is to provide quality care, reduce turnaround time and to ensure overall patient satisfaction. 

Be efficient and try to get the patient in to be consulted, examined and treated in a timely manner and out if possible. 

2. Don't pick fights with Senior House Officers (who aren't aware of their roles or responsibilities)

This may be easier said than done but ensure you approach every Goliath cautiously especially if they are not in the same department as you. 

It is easier to report any issues, document the situation and its outcome and remain professional than to argue with someone whose main goal is to make life difficult for you. 

You will quickly recognise the culture of each specialty and each person based on their position in the hierarchy. 

3. DO NOT CONFORM

Do not be quick to settle. Three months in any place can start to feel normal. Be true to yourself and your morals and the overall purpose of you being there, which is to learn, advance in your career and to provide adequate and professional quality patient care. 

4.  DO NOT vent to everyone

Be wise with whom you confide in. There are lots of 'news toters' lurking around just waiting to start some confusion. 

If you can, start a journal and learn a new skill. Write down your experiences. Be cautious with how you vent on social media as well. 

You may not be aware, but most areas conduct evaluations of their staff, interns included; these evaluations at the end of your internship may work against you or for you. 

Be mindful that what you may mention to someone 'in confidence' may end up hindering your progress. 

5. DO NOT order unnecessary tests

Your patient is your answer book. In A&E, learn to be smart with your diagnosis and your differentials. 

Based on their vitals, the presenting complaint and the history of the presenting complaint you should be able to determine what tests you need to order to confirm your suspicions. 

It's up to you Sherlock to pay attention to the clues. 

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All in all, it's a great experience! 

In summary, be prepared and remember you're going to be faced with patients who you just don't know what's wrong or where to start. But remember, you're not alone. 

Be sure to: 

1. Create lists: they will help you stay on track
2. Keep busy: with purpose, but enjoy the downtime
3. Always be bold enough to ask for feedback and to speak up if you're uncertain why you're doing something or being asked to do something. 
4. Take the initiative but don't overstep your boundaries.