ePortfolio

Everyone working in the ED should have an eportfolio. Whether you want to be an emergency physician or not, that is irrelevant. What is relevant and important is that your time is important and the time you spend (invest?) in a certain post, however long that may be, is valuable. You should be able to gain as much as you can from the experience, and not just have the experience to show for it, but should also be able to prove what your capabilities are.

What is a portfolio? It is essentially you, on paper. What you amount to, what your skill set is, what your experiences are, and what you will potentially bring to the table if they should hire you or atleast select you for an interview. So what does your CV show? Would you hire yourself if someone with your CV applied for this position?

The world is changing. It used to be that just putting on your CV that you have worked at this grand post for 3 years and 7 months, looks and sounds impressive (probably is!) but nowadays, it may not amount to anything. I have said this elsewhere as well, and I reiterate: if you have performed 500 intubations in your past experience as an anesthetic registrar, but have no formal paperwork showing your skill, proving that you are indeed capable of this feat, then you will never be considered superior or more valuable than, let’s say someone who has done 15, but is able to prove all of those with nicely signed off competencies for each one. Your CV will often be the judging point that decides whether or not someone likes you enough to consider interviewing you. If your CV doesn’t cut it, you won’t ever get a chance to come face to face with someone who you may need to impress with your skill.

So take your time, build up your CV. If you are in a non training, trust grade job; it doesn’t pay well, you are unhappy with the hours; make it a priority to get as many competencies signed off as you can. Whether there is a dislocated or fractured joint that you manipulated back into its anatomical position, or whether it is the skill of passing an IV line in an infant; whether it is asking for a colleague feedback from a nurse you have worked with, or whether it is an audit you did with a consultant, ask yourself: how does this get into my portfolio? You could just print out the findings from your audit and add it to your portfolio, but would it not look better if you were to get that same consultant who you did the audit with to sign you off and give his/her opinion regarding your role in the audit, and assess you on its various aspects? ePortfolios come with generic forms that assess all sorts of skills, including some of the ones mentioned above.  And because they are generic, they can be utilized universally. If you are competent to perform arterial blood gases in ED, and get signed off for it, and you end up in let’s say, gynaecology, the competency and skill remains the same; you can utilise evidence from your eportfolio to showcase your skill.

So don’t waste your time, your experience in any post is of value to the department you are in, but you should also make sure you tap into that value and are able to utilise that to maximise the benefits to yourself. There is no shame in asking for an assessment, or for feedback; just get their email address, most are only too happy to comply. Otherwise you will find yourself at the end of a 3 year 7 month placement, with nothing but a start and an end date to signify your progress in that post, and that is all it will ever be: a start and an end date. Make sure that does not happen to you.

Firecracker

So I was in Minors, and the next card I pick up is of a 68 year old male and I read the triage nurse’s notes and…I can not understand what she means by “linulated banger wart af n left hand, wounds to thumb and index finger”. So something happened in a different language that resulted in wounds to the thumb and forefinger of this gentleman. He did something to a banger? Did she mean a badger? This should be interesting. Could she have written it in a more confusing manner? Doubtful.

I called his name and he walked into the cubicle, with a blood-stained (soaked?) dressings wrapped around his left hand. I introduced myself and admitted downright that I had no idea what had happened to him, so could he tell me in his own words? He told me he was a farmer, and essentially to scare away birds and small animals, they light up this firecracker type thing at the end of a long rope, and with the help of the rope swing it up into the sky and it lands far away into the field, and explodes with a loud bang (hence called a banger!), acts as a sort of loud scarecrow, if you will. And what had happened today? “Well I have been doing this for years: I never use the rope, I just take it and light it in my hands and then lob it off into the distance. And I just have been very lucky these past 45 years!” So he basically miscalculated the timing this time, and it exploded in his hand before he could lob it. It now dawned on me what the triage nurse’s writing meant. lighted banger went off in left hand, wounds to thumb and index finger.

So anyway, I exposed his wound after donning some gloves. As I began to unravel the dressings my nose detected the heavy smell of burnt gunpowder/spent explosive caps in those toy pistols we used to play with as children. His thumb had born the most of it, with the nail literally split down the middle, the edges flaring up and out; the soft tissue of the pulp of the thumb was shredded, and all I could think of was how I was meant to stitch the nail back together, with no rest-of-the-thumb left to hold the sutures together.

His sensations were still remarkably intact, and the wound was oozing, but not profusely bleeding. He had a similar but smaller, less extensive wound on the index finger of the same hand, and a few other small spots that had singed or burned. He had full range of motion, surprisingly, of all interphalyngeal joints; nevertheless I realised I needed to get an x-ray done to rule out any bony injury, before progressing to the matter of how to fix this.

x-rays were requested, and they showed as expected a comminuted (read shattered) fracture of the distal phalynx of the thumb (an open comminuted fracture, since the skin/flesh was denuded over the fracture segment) and a simple fracture of the distal phalanx of the index finger as well.

Orhthopedics! My job was done! I bleeped the orthopaedics registrar (with half of my brain telling me it might get shoved on to plastics) but he very kindly agreed to come down to review the patient, and that was that. I decided to go take a break after this. But he had other plans in mind for me. He requested I do a ring block around the base of both the injured digits, so the finger and thumb would become anaesthetised and he could give it a good clean. A ring block is essentially local anaesthetic injected into the base of the finger or thumb in question, on either side, which numbs the nerves supplying the finger and you achieve localised sensation loss (temporarily) used mostly for nail bed injuries or nail-related procedures. I injected his thumb, not a problem, two jabs and all was amazing. I then moved on to the index finger, first jab was alright (3rd in total, including those of the thumb) but the second (or 4th?) as I was injecting it he said oh I feel a bit hot, and i feel a bit sweaty and I feel like I maybe am about to pass out and…oh here I go. And off he went. *kerplunk* fainted right in the chair. We quickly moved him onto a trolley, he came round quickly, very embarrassed. I re-assured him, even though I had just almost shit my pants thinking please be ok please be ok. My external facade was calm and cool, you gave us quite a fright sir, but you’re alright, don’t worry about it, these things happen  while on the inside I could feel my teeth clenched so hard I thought the muscle in my temple would pop out. The orthopedic reg was still stood in a corner, and he looked like he had shit his pants. I reminded him to come forward and continue. We administered the rest of the local anaesthetic, and the ortho reg happily cleaned the wound of any debris that may have collected in the wound(s), washed it with copious amounts of saline. He then cleaned the wound and dried it and applied an impressive dressing to the hand (the thumb and index finger were deemed best to heal this way). The rest of the plan of management involved IV antibiotics stat (he opted for gentamycin and flucloxacillin), and oral antibiotics to go home with (co-amoxiclav x 7 days), and we all remembered the tetanus toxoid, which was administered, and the patient went on his way. He was to return to orthopaedics fracture clinic the following week.

Take-home message: 1) Lie patients down when injecting them with things. However macho or well-adjusted to the pain or the trauma the patient might seem, you would be surprised at what a needle and the sensation of local anaesthetic being injected into any part of your body can do for your consciousness. *kerplunk*
2) never use ‘bangers’ or any explosives in your own hands, you may think you have it covered, but a firecracker in your hands might just be a case of having too much on your hands.
3) never question a triage nurse’s writing. or any nurse’s for that matter. Karma will hit you back with such a vengeance you won’t ever forget it.

A Day in the life of an A&E doctor

6:14 am – Eyes open. It’s still dark. Baby is asleep today, has not yet woken me up. Surely I still have enough time before to go back to sleep before I have to get up at 6:15am? Looks at mobile phone – an addiction – and an instant regret (along with a wave of anger) as I realise – I bloody woke up 1 bloody minute before my alarm went off. SH*T! *sigh* *longer sigh* Trudge off to get ready. I only slept 4 and a half hours ago, studying till almost 2 am! I should shave, but I am so angry, I decide not to.
6:43 am – sitting in the car with my cup of tea, trying to warm it up enough to hold on to the steering wheel without my fingers freezing off. And we’re off. *music coming from an unknown radio station – ‘keep bleeding’ aaaah keep keep bleeding’ in lurrrvvvveeee..’* It’s too early in the morning for Leona Lewis. oh. right. It’s Valentine’s day. Sheesh. Gotta remember to …do something or other. Flowers? Dinner out? Make dinner at home? hmm… *yawwwn*
7:00 am – walk onto shop floor (what the A&E centre of gravity is called, basically the work space) and find 7 patients waiting (OH SH*T!) and the night registrar dealing with a critical patient from before my shift started. There is a good overlap of shifts so I have started and the night team haven’t yet finished – well, in a manner of speaking, officially they still have an hour to go, but they have had a horrible night (I stifle another yawn) apparently from the looks on their faces, so I start seeing patients in time order. So…
7:01 am – Paeds! Start off the day with a kiddie, usually they’re cute and adorable, but  being sick isn’t how you want to picture them. Oh well. I go into the paediatric area of our ED – the nurse informs me my patient is in cubicle 2. I put my name on the board against the patient’s name so they know to hunt me down should I dilly-dally or skive in any way, God forbid! And then I go see Coughing Allnight (not her real name), an almost  3 year old female known to have asthma who was playing gleefully in the play area, talking to the nurse and what I assumed to be mum but was informed was her godmother. Play and talk was interspersed with bouts of horrible chesty sounding cough, that I agreed sounded bad enough to come to hospital with. Godmum reported that the child had been staying with her overnight since child’s mum was at work, and patient had been “coughin’ something’ nasty!” She had been unable to sleep, which basically translated to everyone in the house not being able to sleep. I probed a bit further – when did the cough first start? Oh about a year ago. It took me willpower than I would have expected to not walk out the door. I persevered, and figured out that for the past year she has had several bouts of sore throat and lower respiratory tract infections, that set off her asthma, ends up with her having a cough more often than not, and last night seemed to be particularly bad. Child is not febrile, her observations are all within normal limits for her. Most importantly, she is eating and drinking normally, interacting appropriately and seems (on my review) a happy child, preferring to play with all the various toys in the toyroom. I examine her fully, look for a rash, listen to her chest for a wheeze or crepts or anything sinister, like whether or not she is having increased work of breathing (she is not) and look at the back of her throat, ears and nose (and head and shoulders knees and toes, knees and toes!). She is able to speak in full sentences, and tummy is nice and soft. I reassure mum…no GODMUM. Monitor her inhaler/spacer technique, and give her my opinion regarding it being very likely a viral URTI – I do hasten to add that I would still like to discuss it with my seniors and if they agree with me then I will be sending her home. There was no need for antibiotics, something godmum wasn’t happy about. I told her to avoid very cold water to drink for her, and she reassured me that the patient gets bottled water to go to the daycare with her. I discuss the case with the night reg, who by this time looks like she is about to pull her hair out (but she doesn’t) and listens to me calmly and rationally, asks a few questions, and agrees with my assessment, and I hurry to bid the patient adieu. The nurse repeats a set of observations, and off she goes, while I hunker down to write up my patient’s notes (so tedious so early in the morning, I think I have arthritic fingers early mornings, so difficult to hold the pen – yes, we have to write everything by hand, followed by, wait for it….) and also an online discharge summary that will go to her GP. Basically a quick summary of what she presented with, what my review found, what we did and what we recommended. And I leave the pads area go back out into the majors area, to pick up my next patient.
7:29 am – ANOTHER PAEDS! love it. As I walk back to the Pads area – I notice 2 things: one, I remember how I used to be scared of paeds having no idea about how to assess babies and children, and what’s normal and what’s abnormal (everything seems to be a possible diagnosis or a symptom, or it can be normal! that’s not confusing at all) but now that I had had my son, I had gone through almost all the things parents go through from newly born to infant to screaming toddler. PS: I love my child, believe me. two the nursing shifts are changing, and there is an onslaught of all levels of staff and fresh faces and wafts of coffee and mint as I walk towards paeds. Still half an hour to go before the doctors morning shifts arrive. I shake my head and go see Wokeup WithaRash (not her real name), an 11 year old who woke up at 3am and felt quite itchy over her abdomen and flanks. Saw that she had a rash, texted mommy who was at work with a picture of the rash, mommy rushed home, found the rash had worsened to involve more body parts, and her lips were swollen, so rushed to ED, where she was given some antiallergic meds and some steroids for a presumed allergic reaction as soon as she came in, so that unfortunately (or fortunately, whichever way you want to look at it) by the time I saw her at 3 hours and 20 minutes, her rash had disappeared and so had the swelling. She looked completely normal to me, but I went through the motions of taking a history (it transpired she had had a sandwich at a popular sandwich shop the evening before, and tried out some new bread that had nuts and seeds in it) there was no shortness of breath, I asked mum whether she thought daughter’s voice had changed (it had not) I examined her fully with mum and a nurse being present in the room as a chaperone; I sent her home with advice and counselled mum about any red flag signs to look out for. I rushed to complete the written notes as well as the discharge summary. *that’s two down, and not even an hour. good job, but don’t get complacent, these were quick and easy cases, I’m lucky*
7:51 am – Let’s see what’s next. As I am picking up the next card, Paeds nurse approaches me. Oh sh*t, what have I done (or not done?!) Coughing Allnight’s god mum wants a word with me, she is still waiting for a note from me, apparently having told the nurse that I had suggested the patient needs bottled water to take to her day care?! umm….no, not true. I took a deep breath, and explained to the nurse what had transpired. I then went and clarified to god mum who understood and finally left, and I returned (trying very hard not to roll my eyes!) to look at the list.
8:01 am – next on the docket – 80 something year old PR Bleed. Aaaaah, the joy. I mentally steeled myself for the task ahead, no way was I going to be able to get out of examining his back passage, when he was actually bleeding from his back passage. *sigh* As I put my name the board against the patient’s name, and note the time when I start seeing him (so important to know times – when the patient arrived in the department, when he was seen by one of us, if discharged or admitted what time the decision was made and when did the patient physically leave the building, along with the time of any review requested, or opinion sought, or advice asked or provided – you are against the clock from the time the patient enters the department, till they are no longer your responsibility (when they have left). As I walk in to his cubicle, I see the morning cavalry has arrived. Coffee. Mint. crispnessfreshnessmorningness. Eurgh. and if only I had waited a few more minutes, someone much fresher would have picked this one up. Sh*t!
9:00 am – Took me a long time, I know, but the man’s history was extensive! Was on warfarin for a long time, that had caused his diverticular disease to become prone to bleeding, had had 6 PR bleeds in the past, one requiring transfusion, the last one was when he was off the warfarin, and he had now recently started a new anticoagulant, apixaban. He had had x2 episodes of fresh blood instead of stools when he went to void this morning. He was quite stable, and it seemed like a straightforward surgical referral. I did the needful, arranged blood, sent off samples, after examining him and reassuring him. Discussed it with the consultant (who had just arrived on the shop floor), who agreed with a surgical referral ASAP, and I mentioned I had not done the PR (examination of the back passage) and was it necessary, since the patient was known to have this previously and unlikely for it to be anything else. But I knew, and he knew I knew, what his answer was going to be. Oh Sh*t. I hung my head and went to …do the needful. Took a chaperone along, even though the patient insisted he didn’t require one. Sure enough, as I knew, there was nothing new to be seen or felt except for the expected fresh blood. Moving on, bleeped surgical reg, kindly accepted, thankyouverymuch. I need a wee. quickly complete the written notes, and try to find a computer to complete the discharge summary. As I am waiting for a computer to be free…
9:15 am – *gasp* IT CAN’T BE! Dare I say it out loud? Excitement prevails as there are no patients currently waiting to be seen. That is no way means the department isn’t busy. No. It just means that temporarily, we seem to be on top of things, and the number of doctors in the department is equal to or greater than the number of patients waiting. This almost never happens, so I might just go to the loo… oh sh*t! red phone! *sigh* The consultant looks at me, and says “You look like you are almost done with that discharge summary, how about you take this next patient coming in to resus? Her name is SepsisLowGCS lady (not her real name).” “Sure!” Groan.
(red fone is the resus/critical case phone, paramedics and air ambulance etc ring up on this phone to give us pre-alerts about incoming patients that they are on the way to us with, so that we can prepare beforehand the adequate staff and resources to be allocated to the area. Sepsis is the body’s response to an infection, and a localised infection can cause widespread multiple organ effects; GCS is the Glasgow Coma score, which is a score given to all patients to indicate their neurological functioning or deficit – optimum for me and you would be 15 out of a possible 15, indicating alertness- well maybe less than 15 for me currently! and lowest is 3/15, indicating comatose states.)
10:35 am – Sepsis lady sorted. Focus was her lower limb cellulitis bilaterally as well as a chest infection as shown on her x-ray, as well as a urinary tract infection. Wowzers. It took me a while because a few things needed to be done. And since I was relatively new to the department I needed to ask for things and where they were kept and asking for help; discussed it with 2 of the morning registrars just so they could tell me whether or not they were happy with my management. Then also discussed it with the consultant who was loitering with intent wanting to know my plan. Appropriate antibiotics prescribed, iv fluids begun, patient was catheterised, bloods sent off and wounds re-dressed. Job well done, why thank you. Am I forgetting something? There was something I needed to do. Oh well, I need a wee, my bladder is about to burst. As if on cue – the SepsisLowGCS lady starts complaining of chest pain (GCS had now improved to 13) and so that entailed a further assessment(oh sh*t!), ECG, bloods being added on, medications added, re-assessed, stabilised, before being sent to the ward. Phew!
11:00 am – I look at my phone and there are 2 missed calls from my mother in law (unusual, at this time of day) and 17 new whatsapp msgs from my wife (usual at any time of day or night!).  But there are no signals for me to call anyone back while I am in the department – is that fortunate or unfortunate, I never know, so I text them both saying I am unable to chat right now, and is everything OK. Wife tells me an issue regarding a missed council tax payment, letter received this morning blah blah blah, court summons etc, and hadn’t I paid the tax? EVERYTHING SUDDENLY COMES TO A STANDSTILL FOR ME. Oh my god. I am going to jail. Sh*t! I looked at my wife’s messages again. She had sent a picture of the letter. Last date of payment was a month later. She had read the date wrong. And I had already paid it off, so why was I scared? I didn’t know why they had sent me a reminder then, and I needed to get to the bottom of it. I needed to get to the bottom of it BEFORE picking up a new patient. I looked around for the consultants (there were 2 by this time) one was dealing with a difficult chest drain in rests, and one was having a very detailed discussion with one of the other patient’s relatives about end of life treatment. Who do I interrupt for permission to go outside the department and make a few phone calls? As I am contemplating my options I see a third consultant, who gives me permission to leave for a few minutes, I don my coat and go outside, find out from the council what has happened, sort everything out, reassure my wife that all is well with the world, and order is restored. My legs feel like jelly as I go back to the department. Crisis averted
12:00 pm – COPD lady is my next one. Worsening shortness of breath and a cough despite being on antibiotics. I assess her quickly, feel that she is actually clinically not too bad, and may actually be at her usual baseline. I decide I will wait for her bloods to come back, request a chest x-ray and counsel her that if everything is alright on her bloods and CXR, I would be quite happy for her to go home. I quickly write up the notes (bladder is about to burst by this time!) and ask the consultant if I can take a break. They realise I should have gone earlier, and apologise for not sending me sooner for lunch. I mention I have a supervisor meeting at 1:30 pm, just for them to be aware. They remind me I also have teaching today at 2:00 pm, and to be back from my break in time for the consultant’s handover at 1:00pm. Sh*t. I rush off.
12:30 pmAaaaaaaaaaahhhhh….FINALLY relieve my bladder.
12:35 pm – Grab my sandwich that my wife (love her!) packed for me, and head out to meet a friend from another department for lunch. We go to the canteen nearby, shoot the breeze, and all too soon it is time for me to go back.
12:55 pm – walk back to the department so that I can be in time for the handover.
1:00 pm – waiting for handover to begin.
1:10 pm – Still waiting. Why did I have to rush back from my break when they are late themselves? In the meantime, my patient’s had her X-ray, and her bloods are back, both of which are unremarkable. I contemplate whether I should wait for handover, or just send the patient home. I decide to discuss it with the consultant, who agrees to send the patient home like I had planned, but with COPD outreach team input now, to see if they can tweak her inhalers or if she can be supported further in any way in the community. First change of plans regarding this patient. I decide to do this after handover.
1:15 pm – the new consultant finally arrives, out of breath – couldn’t find parking. Handover done – I discuss my patient again, new consultant advises COPD outreach won’t be available to come round to ED today – To arrange for community followup tomorrow, and to send home currently with antibiotics and steroids. Change of plans x 2
1:20 pm – I speak to the patient. Inform her about the x-ray and the bloods. reassure her. mention the plan by the consultant. she reports she does not want to see the COPD team, as they had come to see her 2 years ago, with a promise to see her again every 3 months, and had not seen her since then. She reported she felt well enough to go home, and the only reason she came in to ED was because her doctor sent her. She herself had no concerns. Change of plans x 3. I relayed this to the consultant, who agreed.
1:30pm – I quickly complete the patient’s notes, remove her cannula and let the nurses know. Am I forgetting something? No time to think about it though, I am a minute late for my supervisor meeting!
1:32 pm – Arrive for meeting at the consultant’s office – out of breath, and late. Sh*t. Talk talk talk. plans. aims. concerns. advice. yakkity yak yak. blah blah. more talk. exam. studies. competencies. good evaluation. don’t be complacent. blah blah blah.
2:07 pm – yikes! late for teaching, it was supposed to have begun 7 minutes ago! Sh*t! Run to the conference room. Arrive late. Arrive out of breath. And very confused as everyone is sitting there discussing head injuries and anticoagulants and various guidelines for various INR levels and various anticoagulants and who to observe and who to send home and who to scan and what to do after the scan if its normal etc etc. Missed the start of it so took me a while to get my bearings. This went on for an hour and a half. *yawn* *snore* *sigh*
3:30 pm – finally free. day over. change scrubs into day clothes. literally run out of the department. I realise as I reach the parking lot – sh*t! I didn’t complete the discharge summary for the COPD lady! As well as SepsisLowGCS lady! Oh well, will get to it tomorrow.
3:45 pm – arrive home. unlock the front door and wife is standing there with the biggest smile on her face, looking radiant and an expectant look on her face – “Happy Valentine’s Day!” OH SH*T!