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!