Another day, another training…

Attended another training/teaching day sponsored/arranged by the deanery – was a very, VERY useful and informative day – and though it dragged on for hours, it was very interesting and explained quite a few things that I had not known previously – gist of the major salient points of each of the talks are listed below – may expand on 1 or more of these topics in the near future – so inspiring!

There were 4 speakers

PUBLIC HEALTH PROMOTION – how to explore facets of public health while in ED, because most people interact with someone in the ED, and that may be the only point of medical contact they have had up until that point.
smoking cessation, weight loss, exercise, pre-diabetes identification –
screening programs are fixed, inflexible , protocoled care, applied across a particular age group- safeguarding, frailty, VTE, dementia screening, hypertension, alcohol issues, obesity, domestic violence, smoking

case scenario of overweight person presents with orthopaedic problems, upon discharge do you speak to them about their weight? as an ED physician

case scenario of unwell child who has never been vaccinated – what will you do? How do you approach the subject with the parent, or do you even approach it at all?

case scenario of alcoholic patient with head injury – would you address the alcohol issue? (unit is 8 gm or 10 ml) 25 in whiskey, 10 in wine and 40 in spirigel
alcohol problems discussion
(having withdrawal symptoms when not drinking is being dependant on alcohol)
who should you be screening for problem drinking – selected presentations
how do you ask for alcohol intake?- use PAT scale – CAGE questions are useful in establish alcohol related problems.
important because intervention is helpful

PUBLIC HEALTH AND EMERGENCY MEDICINE
as doctors/physicians it is our ethical duty to reduce injury and illness, wherever we interact with patients.
we tend to have more interaction with the general public
you are more likely to see violence/injuries than the police – some studies show more than 3 times!
how can you help as doctors? injury survielance, mandatory reporting, better design, improve treatment, collate data and improve conditions – location of assault, date/time of assault, weapon, age
is anonymous,
crime rates went down because of data collected due to targeted policing
what are barriers to implementation? – police expectations, IT issues, governance, receptionist, leads
pitfalls – mission creep, fatigue, silos
conclusion? violent injury surveillance and control is effective in reducing violence. implementation can be challenging

QI (Quality Improvement)
audits are important but rarely work
why do they fail? – tick box exercise, temporary staff, lack of feedback, career advancement a priority rather than care advancement, lack of collective responsibility (if your rotation ends, the audit ends with you, no continuity)
has now become quality assurance rather than improvement. “maintaining/meeting set standards” rather than “improving the standards”
RCEM guide to QI is the QI bible.
do less, do it better
choose a standard to improve:is it important?, is it fundamental?, is it fixable?
talk to the stakeholders (nursing staff, frontline staff, triage, juniors, etc), ask them why this is not happening – how to improve conditions?
measure the standard
intervene to implement a change, and then re-measure after a suitable timeframe.
establish or convey a sense of crisis – reiterate how important/imperative this measurement is.
rapid cycle

CARDIOLOGY – ACS
definition of ACS
reiteration of importance of history – onset and character
repeat ecg, compare with previous
do not delay treatment waiting for biomarkers in “cardiac-sounding” chest pain.
consider bedside imaging if hemodynamic instability
escalate appropriately, consider involvement of tertiary care
dissection a differential? CT aorta stat (discussion about d dimer as useful in this scenario – some people say a negative d dimer rules out a dissection – research shows that is not the case)
management – analgesia+dual antiplatelet therapy, GP2B3AI, antihypertensives (b blockers) ACEI. statin, REGARDLESS OFWHETHER AN INTERVENTION TAKES PLACE LATER ON OR NOT, GIVE THE MEDICAL TREATMENT. if already on aspirin, 300 or 225 of aspirin either way doesn’t matter, 600 of clopidogrel and 80 of tigacrelor (not to use if warfarinized – MAKE SURE INR IS THERAPEUTIC)
immediate management – angio +/- PCI (for STEMI within window, ongoing symptoms, cariogenic shock, for NSTEMI – hemodynamic instability, ongoing schema or shock, IF REFRACTORY TO INITIAL MEDICAL THERAPY)
high risk/labile/recurrent schema – urgent angio
all others get routine angio
12 hours stemi – def PPCI, greater than 12 hours – if symptoms, PPCI, greater than 48 hours – no PPCI.
<30 mins door in door out in non pic centers. <60 mins door to wire crossing in PCI centre. and LBBB/RBBB considered equally. no o2 if >90 sats on RA.
consider CPAP, IF DISTRESS. iv amiodarone for AF, Look for hyperglycaemic states, MRA if CF.

if unable to decide if LBBB is new or old, compare to previous but if none available to compare, look at the patient. vast majority are not acute, unless they’re in cariogenic shock.

 

DIARRHOEA
definition
types
causes
symptoms
may be a symptom of sepsis – does not mean primary focus is gastrointestinal- particularly in the elderly
rotavirus most common in children – vaccine now available, rotarix at 8 and 12 weeks, seasonal
COD – dehydration/acidosis
use dioralyte instead of pure water for replacement. diluted juice.
norovirus and c.difficile has to be reported.
electrolyte disturbances – hypo/hypernatremia, acidosis, acidosis, hypoklemia (3-3.5: oral replacement or 20/1000 ml saline over 2-3 hours; 2.5-3: 40/litre over 4-6 hours; <2.5 or with ecg changes at any low level such as prolonged QTC, flat t waves at risk of arrhythmia; <1.5 will be paralysed, muscular weakness, apneoic. ECG-CARDIAC MONITOR-CONSIDER RESUS
discussion about hyponatremia and its management

 

PALPITATIONS
multiple cases discussed and shown, along with rhythm strips, interactive 1 hour session with responses from the audience tailoring the talk. VERY interesting.

FRCEM Intermediate (SAQ) – “Revisiting the recent past (recalling the nightmare!)”

  1. picture of a bruised foot. fallen off horse, foot stuck in stirrup and dragged upside down. now unable to weight bear. bruising evident on medial dorsal area and lateral plantar area of involved foot. what is the mechanism of injury? what is the injury?
  2. patient with small stab wound to epigastrium. X-ray (picture shown) shows air under diaphragm on right side. what is the finding on X-ray and what does it signify? what is the management plan for this condition? how will you investigate/comfirm diagnosis next?
  3. image of bilateral knees of a middle aged patient. presented with sudden swelling and painful left knee, which is shown as slightly swollen. cause? treatment/management?
  4. paeds patient, infant, barking cough every time they cough. sniffling viral like symptoms …diagnosis? management?
  5. anaesthetic machine shown with knobs for respiratory rate and tidal volume adjustment, rest rate set at 8/min. scenario given of patient with head injury, aside from other measures, what will you do to ventilator settings to help, and how will it help.
  6. picture of pneumothorax (right sided) shown. what are the 2 abnormalities in the radiograph? (i could only see the pneumothorax) management questions about where to insert the seldinger, and what common complication can happen and how will you avoid it (what measures will you take to ensure it doesn’t happen)
  7. elbow posterior dislocation image shown. how will you manage in ED (explain/summarise maneuver) and what nerve tends to be damaged and what will you look for on neurological examination. what x 2 steps will you do after reduction
  8. image of posterior dislocation of shoulder shown. radiological sign?
  9. young child, accidental ingestion of paracetamol syrup. asymptomatic. previous history of similar episode last year. what steps will you take? when will blood need to be drawn?
  10. wife presents to ED with injuries sustained from beating by husband. has minor children but are not currently living at home with her or husband and have not witnessed abuse. she self discharges and does not want to press charges. what steps do you need to take
  11. image of open mouth, what is the malampatti scoring?
  12. young male, fallen from 30 foot height, complaining of back pain. otherwise normal examination. what is the first reasonable investigation?
  13. head injury patient, subdural hematoma. gcs 13/15 initially, on revaluation, drops gcs to 10/15, what will be your next step in management? how will you proceed? if they initially are ventilating well, and then drop sats, how will you proceed further?
  14. transferring patient who is intubated and ventilated suddenly notice significant drop in sats, blood pressure OK, what is likely cause, how will you manage/proceed?
  15. sudden onset painful testicular swelling in young male – likely cause? management? what time frame? if not this, then what is the next likely cause
  16. young girl – dizziness and fainting spells. biochemistry shows hypoglycemia, borderline raised potassium, borderline low sodium. diagnosis? what investigation will you do?
  17. renal failure patient, sudden worsening. ecg shown, hyper acute t waves seen. diagnosis? management? mechanism of action of 1 drug that you will prescribe
  18. pregnancy 3rd trimester. abdominal trauma. abdominal pain, hypotension, diagnosis? management?
  19. middle aged female, found with suicide note and empty pill packets. low gcs. blood gas shows alkalosis, low co2, high bicarb. likely drug?
  20. paeds with sob, not eating, generally unwell but appears well, playing with toys, interacting, low sats but other jobs all normal no fever. cxr shown (normal looking?) ? diagnosis?
  21. elderly patient, hip fracture, fascia iliac block administered for pain relief. sudden dizziness, followed by cardiac arrest. cause? how will you manage? (dose and name of drug)
  22. how will you immobilize/pull femur on child with fracture femur? analgesia options?
  23. image of facial trauma during RTC – airway concerns? how will you manage complications/difficulty? what will you advise your colleagues to do or not do
  24. post vomiting, chest pain, car shown, findings? (subcutaneous emphysema)what 2 causes can be attributed to this condition? how will you investigate further to find out which cause this is
  25. ecg shown ? LBBB?
  26. ecg shown – VT – conscious patient with palpitations. shocks given x 3 not reverted, how will you manage further.
  27. epipen administered. what total dose in MG of adrenaline administered in single dose?
  28. seizure activity in epileptic patient, already on phenytoin. status epilepticus. diazemols/lorazepam 1 dose given. allergic to valproate. what is the next 2nd line drug to give?
  29. patient on warfarin, routine blood tests high INR of 8-9 no bleeding, recent antibiotics. what possible antibiotics would have been used? first step in management?
  30. female child from african country, returning from trip, feeling unwell, crying, not interacting. c/o ado pain etc. no fever, all obs normal. nurse noticed bloody discharge on underpants. likely diagnosis? who will you inform? how will you manage?
  31. hip pain, limping child, non traumatic? X-rays shown. what view is it? what is the diagnosis? what are x 2 common causes of hip pain without trauma in paediatric age group?
  32. renal colic clinical picture. analgesic of choice? investigation to confirm? complications?
  33. paracetamol overdose patient. what x2 investigations will you perform?
  34. elderly patient present with a fall. what bedside investigation can you do to rule out dehydration
  35. patient with ascites, fever, abdo pain. diagnosis? where will you put needle in for ascitic tap?
  36. patient with red eye shown (image) presents with sudden onset headache, vomiting. diagnosis? management? what topical drug will you administer in ED?
  37. elderly patient, agitated, needs cannula. what will you give to the patient? what will you tell the helping nurse to do?
  38. patient with chest pain. ecg shows inferior MI.
  39. IVDU. c/o back pain. tender lumbar region. diagnosis? investigation?
  40. question about intraosseous access
  41. young male with rectal bleeding and diarrhoea travelling from african/middle eastern country. cause? give non infectious/non inflammatory cause
  42. scenario is patient has ingested amyl nitrate. picture of patient’s wound site with swab on – showing bleeding, blood is ?darker color than usual? identify what the abnormality is, and how will you treat it
  43. high BMI (50) patient, unconscious/collapsed – what factors affect her airway and what makes it a difficult airway for her – what manoeuvres will you do to improve/mange these factors
  44. do not remember the question but size of cannula given and rate or time 1 litre of saline gets completely given through it

ECT – the conflict within

DISCLAIMER 1 – EXTRA-LONG POST. You have been warned.
DISCLAIMER 2 – More importantly – this is in no way supposed to be a ‘for’ or ‘against’ type of post regarding any particular therapy/treatment – it is just my opinion and my own feelings about this experience which was very new to me. Bear with me, before rushing to judgement or conclusion – and if you already have formed an opinion without prior knowledge/experience then please stop reading further!)

For those of you who do not know, I have recently started my 6 month rotation in Anesthesia as part of my emergency medicine training, and it has introduced me to a whole new weird and wonderful world that is equal parts unexpected and fun and slightly scary but mostly awesome. But more about that later. Today (and for the past few days) I have been wrestling with some inner demons (wow, that’s not melodramatic at all!) about a recent experience and the ensuing internal conflict broiling inside me. I will try to explain things in my usual way, which is to take you on that journey with me.

So the day usually starts at 7:30 AM, and the rota tells you it’s a different theater every morning – I checked the night before and all it said was that I was assigned to a particular consultant to shadow (read badger/annoy for the rest of the day!) and that we were supposed to be in the “ECT” area (theater?) in a completely different building from the one I had been going to for operations/procedures requiring anaesthetics in the past week. My first thought was ECT? It can’t be electroconvulsive therapy? That’s not still being done in this day and age? But I texted one of my friends in the same rotation as I am, and he said this area was in the building that houses the maternity block, and I thought it was probably some sort of gynaecological/obstetric procedure requiring anaesthesia which is why I am being assigned to this and I am sure I thought of ECV – external cephalic version! I reassured myself and went to bed, woke up the next day bright and early and headed to whatever this amazing day heralded. It was not amazing. Atleast, not initially.

ECT, as it turned out, did mean electroconvulsive therapy – a treatment for drug-resistant psychiatric conditions (please excuse the rough/non-medical language) – and I found out that what I was assigned to today was in fact the ECT suite, a separate entity from the rest of the hospital- where I was shown around while I was waiting for the consultant. There was a procedure room, with anaesthetic stuff and an OT table, and a separate recovery area. There were 4 nurses, a head nurse, 2 health care assistants and 1 psychiatrist/consultant – aside from my anaesthetics consultant and absolute-novice-baby me! The whole area was very peaceful and calm, and the staff were very friendly and spoke in calm, reassuring voices even when they asked me if I would like a cup of tea. I felt myself calm down a bit (I was nervous because A- I had no idea what to expect and B- I HAD NO IDEA WHAT TO EXPECT!)

There were 4 patients on the list for today. 3 of them (the first 2 and the last one) were regulars, here for their 7th, 3rd and 11th treatments, so they did not need pre-assessments doing from an anaesthetics point of view – just a confirmation of their consent for the current procedure (consent did not mean a blanket consent for all treatments, you could consent to the first treatment and revoke consent at any later treatment session, if you were deemed to have capacity. All 4 patients today had capacity) The 4th one had completed 12 sessions of the ECT previously and that usually meant their treatment was over. But their doctor had assessed them and had thought that despite the improvement the patient could benefit from further sessions, and so they had to give another detailed informed consent – because initially they had consented to the 12 sessions, and this was adding on to what they had initially consented for. But I digress – there was just so much to take in and learn that I do not want to miss out on any of the details/finer points that I came across.

So anyway – while we waited for the first patient to turn up, my consultant took pity on the incredulous expression that I had on my face (this was without me realising it) and explained a few things to me, and looked up a very good paper for me to read about ECT. He broke down what we needed to do here, which basically entailed: introducing ourselves; confirming patient details; confirming no changes to medical/pre-assessment history had taken place in the last week since last treatment; putting a cannula in; hooking them up to some monitoring (continuous ECG trace, pulse oximeter, blood pressure, an initial temperature reading) and also hooking them to an EEG machine which is basically just like an ECG of the brain – mapping the electrical activity of the brain; administering the induction agent (usually propofol) and/or a sedative, and supporting the patients breathing before, during and after the procedure till the anaesthetic wears off.  ECT is basically electric current that is run via two ports/electrodes placed at both temples while the patient is unconscious. The current causes your neutrons to fire in a way to cause a generalised toniclonic seizure, and your brain activity is mapped continuously to make sure it has worked, and that the seizure lasts a certain length of time (usually greater than 10 seconds but on average about 30seconds in duration). It is essentially equivalent to being ‘under’ for a surgical procedure, just like you don’t feel the surgeons scalpel or drill, you do not feel the actual shock. Your heart rate and oxygen levels and blood pressure and all that jazz is continuously monitored and in the event of any fluctuations, it is handled by the team of extremely qualified individuals in attendance, as it would be in any surgical procedure. But the actual procedure was what caused me to be so incredulous. Why, you may ask? I will explain, but first let me take you through the first patient’s treatment.

This was a 50-something female, with a history of depression, and she had become so depressed that she had stopped eating and drinking, and none of the medication or combinations of medications had seemed to work on her. I had all this information from her history sheet, and chatting with the consultant psychiatrist made it clear that this was sort of a last resort. She had become anorexic to the point that she didn’t really have the strength to lift up her head from where she lay in bed, to take a sip of water. She was initially medically rehabilitated, her caloric intake monitored and her strength returned, and while she had become medically fit, her depression was still strong. She began this prescribed treatment, and today was coming in for her 7th session. She had been almost a complete mute prior to the first treatment, and was markedly different today. She walked in to the room unsupported (I thought she would atleast be in a wheelchair). She made eye contact with all of us. She smiled at me when I said good morning, and replied shyly that it was indeed a good morning. As they hooked her up to the various monitors she looked around with that smile her face, and gave adequate responses to the questions and requests from the staff members, such as May I put these ECG stickers on you?, and can I put a cannula into the back of your hand? We walked her through the procedure, put her under and after she had drifted off to sleep and we were monitoring her airway and breathing, we put a rubber/foam type thing between her teeth so she wouldn’t end up biting her tongue or lips, and then they placed those electrodes on her temples and …I don’t know what I expected, probably that the patients arms would flail around and her legs would jerk up off the table and it would all be very violent and gruesome. It was certainly difficult to see, but nothing quite as dramatic as that. She just straightened out a bit, feet became a bit rigid and there was a generalise trembling, followed by some twitching. The continuous EEG trace showed she had had a seizure that lasted 34 seconds, and while she became tachycardiac during it, she settled down almost at once after the seizure ended. She began breathing spontaneously after a few minutes and was taken to recovery as she regained consciousness. And now for the crux of this post – the reason why I was so conflicted.

All my life, or at least the last 10 years when I have been a doctor (15 if you count medical school) I have been working with the idea that we need to minimize seizures and we work very hard to figure why someone may have had their first fit, to try and prevent it from happening again, and I have been involved in extensively counselling and reassuring family and patients and parents of toddlers etc on the subject – so the ‘inducing’ of a seizure as a treatment was a bit of a shock – no pun intended! I knew the patient came to no harm from the immediate procedure, the electric current and the anaesthesia, and they actually did not feel anything, much like any surgical procedure (with the added benefit of amnesia as a known side effect of propofol!) and much more importantly, the patients reportedly feel better and they don’t have memory of it etc etc. But having never actually witnessed it before, I had quite mixed feelings about it because it conflicted with my mindset of ‘how to manage a seizing patient’ – as opposed to this current situation – once again, no pun intended! The conflict I speak about is not of the “ohmygod I do not agree with this practise how dare they?!” type of reflection, and I apologise if it sounded that way. Rather it is more of a “everything I feel inherently about this situation is basically not true!” and I had to actively try and work towards not panicking when I saw this patient seize. And the one after that. And the one after that. It didn’t get any easier, and I didn’t get used to it and it really bothered me. I didn’t know what really was most bothersome for me. Was it the fact that I pride myself in being completely professional and see all sorts of unexpected medical scenarios and presentations as an emergency medicine trainee with the calm and focussed approach that is taught and cultivated in my specialty, but that in my almost 6 or so years of emergency medicine experience, I have never been this affected by any procedure or situation? In other words, was it the procedure that had bothered me, or my own reaction to it?

A few positive notes/observations from the day –
*Any patient who can consent because they are deemed to have capacity will be asked for their explicit consent for the treatment, and they will be given the full information regarding it. Out of the 4 patients scheduled for the day, the 3rd one who was coming in for her 13th treatment (having completed 12 previous ones and deemed to still be in requirement of a few further sessions) came in and then declined to give consent for the next one. And, even though she had consented for 12 sessions and had had them, AND she had the capacity to refuse at any time, we respected her decision and she went home. We didn’t just strap her down like a bunch of frankenstein-y mad doctors while cackling in high pitched laughter to administer jolts of voltage against her will – though I will be the first to admit this is what I thought when I first found out I was in the ECT suite, that this was my unfortunate concept of ECT, based on nothing but my (very vivid, it turns out) imagination.
*Also, it has been around since 1938 – there is tons of research on this topic and while it is all shrouded in controversy mostly due to preconceived notions and ideas, there is no denying the absolute faith people have in this treatment.
*The sons of the first patient who’s treatment I detailed earlier were sat outside in the relatives’ room and while the patient was being wheeled to recovery, I went and asked them how they felt the treatment was affecting their mum. They both agreed there was a distinct difference in Mum, that she had begun enjoying her meals – looking forward to what was on the menu for the day,  offering to go to the park with the grandchildren and making plans for one of the sons’ wedding that was supposed to be an out of country type thing. This was in stark contrast to her being in the throes of progressively worsening depression since their father had passed away a few years ago.
*They don’t just administer this treatment without trying anything else.
*It is not like touching a live wire; you don’t feel anything – you aren’t zapped like a Tom&Jerry cartoon situation. In fact, the voltage is so low that I was surprised that while the current was being administered, one of the nurses had their hands on the patient’s chin as a reinforcing/reassuring measure. They were clearly not feeling the effects of a transmitted significant voltage, unlike in a cardiac arrest situation if you administer an electrical shock, you have to be clear and not touching any part of the patient’s body lest you get a shock as well. It is all very professional and clean and protocol-oriented.
*There are a lot of good people working very hard to make the experience as comfortable and easy for the patient as possible.

At some point I will probably do some research into the subject. It has certainly piqued my interest – but I am ashamed to admit I won’t be looking forward to the next time I get assigned to this area, and I dread looking at the rota announcing when I am going to go there next. And at some point I may actually grow to appreciate the whole process. And look beyond the obvious conflict. But today is not that day. Sigh.

It’s not just about the exams and the competences – COURSES!

Here is a list of courses and additional skills that I would recommend (I am trying to tick off these on my own personal checklist so this is not an official list, rather my own opinion):

ALS – Definitely a requirement to even be considered eligible for a training post – a basic course to attend for any training or non training doctor – certification lends you 4 years, and then needs to be recertified

APLS or EPLS – whether or not you’re paediatrically inclined – the paediatric life support courses, or their european counterparts are a good feather to add to your cap

ATLS – the advanced trauma life support – need I say more?

Ultrasound levels 1&2 – good thing to begin this early on in your training, what with everything being scanned for these days even vascular access – its a good thing to have ticked off earlier in your career so you can begin the arduous process of getting signed off for it which may take a while

Attend conferences – the RCEM provides a lot of guidelines, and then there are always foreign conferences like SMACC (Social Media and Critical Care) – be very open to the exchange of ideas, you never know which interaction might be a teaching moment or lead to one – and change your practise.

Look at out of program opportunities or secondments that either support your career growth in your own field or cater to your own personal growth and add to your skill set in addition to your training pathway. See if your deanery or your local hospital has any sponsored programs, maybe an additional masters program or other academic or teaching opportunity, a mentorship course or a volunteer ALS/BLS instructor or even a nominated teaching go-to person for medical students rotating in your specialty. It adds to your CV, makes you a better candidate for the future and just rounds you off that much better. (My deanery offers a few postgraduate degrees in stuff like entrepreneurship and leadership skills – I am seriously considering the option to apply to be considered for such an opportunity!)

Exam prep courses – no shame in that, in the ever-changing exam scenario for the training program, it can’t hurt to be well-informed and look at guidance options – my deanery regularly arranges examination preparatory guidance courses. Consider joining!

European Board of Emergency Medicine exams – consider applying for these and taking them – the first part is something you get eligible for if you have 3 years of emergency medicine experience that someone can vouch for for non training people – for trainees it is after the successful completion of 3rd year of their training. Something to definitely consider as adding to the many feathers in your cap.

Simulation days – very informative and you learn so much, not just from doing it yourself, but from how others do it and how there may be a range of approaches and you can look at what works for you!

Last shift as an ST1 – bittersweet to say the least

So for ACCS we have 6 monthly rotations for the first 2 years, and tomorrow I go for my last shift as part of my A&E rotation (yay, yes I made it to the end!) AND  it will be my last ever shift as a year 1 trainee (or ST1) – even more yay!

This year has been wonderful – I got to know the slightly different other side of the coin as an acute medicine doctor the first 6 months of this year, and got to see firsthand what happens when you refer a patient to the medical specialty: what they look for, how they assess them, what investigations do they do and what is there mindset – and I learnt there were things I could do while the patient was in ED as my patient, and I could tweak certain things and maybe request something that would help the acute medicine department deal with the patient and make an informed and safe decision about their medical care – and maybe stop them from being admitted in the first place! This last bit was especially a unique experience, trying to sort out a patient with the 4 hour time pressure, but sometimes you picked up a patient that usually would be referred to the medical specialty, but if you had the time in ED you could potentially start a treatment that may actually make them better before their 4 hours were up and you could end up sending them home rather than in-hospital – like for a second troponin or someone who is slightly tachycardia with a fever, treat them and re-evaluate, obviously if they still warrant it, get them admitted but if they improve and can continue treatment at home, then let them go into their own familiar surroundings (sometimes the best option for patients with dementia and other cognitive impairment) – and the it doesn’t go unappreciated by the medical team!

The next 6 months were truly wonderful – learning experience from the get go – and since emergency medicine is my chose poison, my specialty of interest, I really was looking forward to it – and it did not disappoint. I learnt so many new things, and not just about the medical bit of it, but about myself as well. I gained confidence. I passed an exam (again, yay!). I realised I was interested in paediatrics, with a possible PEM (paediatric emergency medicine) fellowship consideration seriously for the future). I realised it wasn’t JUST about the resus patients, the cardiac events and the rest pains and the low-GCS and the stabbed-in-the-groin and the 3 passenger trauma call  – those were the interesting and the adrenaline pumping stuff you think of when you think emergency medicine. But I also realised that on a day to day basis you may not even see any of those heart-pumping sort of cases, and may have to deal with accidental overdoses and dental pains (!!!) and minor injuries (oh how I loved the minor injuries – really loved learning there!) and the beautifully vague C?C or ‘Collapse query cause’ and an amazing amount of geriatric and elderly care cases. And I realised I had chosen the right field. Because you don’t just treat the stuff of legend – crack open a chest or put a tube into the chest or restore alignment of a broken or dislocated bone, but you also end up (mostly) sorting out the more mundane cases and they teach you patience and empathy and make you also realise that these cases are also equally important: passing a catheter may be considered a legendary feat by the patient who comes in with 15 hours of urinary retention, or the wrist brace you put on an elderly patient with a sprain may make a world of difference to an elderly patient who has been unable to sleep due to the pain. It is the sorting of these cases which some may consider to be ‘boring’ or ‘brander’ or ‘not exciting’ that is truly the bread and butter of the ED physician.

And now I stand at the cusp of transitioning from year 1 to year 2 – going onwards to a 6 month rotation in aesthetics followed by ITU for 6 months. Am I excited? Yes. Am I nervous? You bet! Why excited, you ask? because: new things to learn and do that I have never known/done before. Why nervous? Because…exactly the same reason! But I am certainly looking forward to airway skills and critical care assessment, and gaining more confidence by adding to my skills – I hope its not too steep of a learning curve! Onwards and upwards, eh?

(Also – no weekends or nights for the first three months in aesthetics, and Friday half day –  somebody pinch me! I might just die of excitement at the prospect of that routine after the A&E rota! So yeah, joy!)