Anaesthetics – what I have learnt so far…

  • your ODP is your best friend and most of the time your saviour – treat them right.
  • there are literally a hundred ways to skin a cat. And more to come up with a plan for anaesthetic for any given patient. All are right and some may be wrong – try to sift though and pick and choose and delete and save – and come up with your own brand of magic
  • always be on time for a theater list – or 30-45 minutes early! Pre-op assessments are part of your learning and an integral part of why we do what we do when we give a patient a particular anaesthetic.
  • make sure you attend most if not all teaching/training days arranged by the deanery – they’re VERY particular about attendance
  • know your doses – sux, roc, propofol, local anaesthetics, etc. You may be called upon at the most surprising of moments to decide a drug amount (for example the surgeon may yell out during the procedure how much local anaesthetic he can infiltrate in his rectus sheath block and you may need to do your maths to give them the answer. Bring your A-game)
  • get ready to be surprised at how chilled and laid-back everyone and everything is. When I first entered the department I expected everyone to be on their toes, pumped full of adrenaline, dancing around critical patients who were losing their airways and fighting fires along the way – while this is essentially what happens, things aren’t quite as dramatic
  • get ready for a VERY steep earning curve. Very steep. Very. With a capital S (for steep)
  • There are 4 times more consultants in anaesthetics than emergency medicine. Even more than that. 6 weeks into my anaesthetics rotation and I still haven’t worked with or met all of them. And only 4 times have I worked with someone I have worked with already.
  • Anaesthetics is not about intubating everyone. In my first month, I had observed 58 surgical procedures – only 7 of which were intubated. The rest were mostly LMAs/iGels.
  • The best talent to have/learn is not how to intubate; How to ventilate, bag-mask is more important.
  • You will really get good at cannulation. All sorts of difficult, easy, wriggly, invisible, stubborn veins – you will put a cannula in to all sorts. And then some.
  • Will continue to update these as the time comes. Feel free to watch this space.

To X-ray or not to X-ray – that is the question, but what is the answer?

Guidelines and protocols are in place for a reason. Based on years and years of experience and collated data and individual opinions of specialists etc, these guidelines are set up to aid the budding EM physician. They are not absolute though, as I learnt the hard way (a most unenjoyable way to learn!)

56 year old female, otherwise fit and well, comes in to ED one fine morning around 7am. I was part of the night team, counting the minutes down to when the day team will arrive and I will be able to go home. I was asked by the registrar to see this patient who had turned up to be assessed in the first assessment bay; she was at that time the only patient waiting to be seen (a rare occurrence in ED). I went into the makeshift cubicle (which basically meant drew the curtains around myself and the patient’s bed) introduced myself and asked her what brought her to ED that morning. She reported she had an ongoing pain in her left ankle, that she had been to her GP for. Twice. When I asked her when it first began, I was quite disappointed to find out this had been going on for a few weeks (3 I think she said!) She had been to her GP who had told her on two separate occasions that this seemed like soft tissue injury, and she was advised pain killers. She came in today because she felt she was not improving. She was into hiking and jogging and was a very fit 60 year old. The concern for her was she was unable to pursue her rigorous exercise routines due to this pain. She denied any direct trauma to the affected limb, and reported no swelling or bruising. No previous history of any joint problems (no prior medical history, actually!) and she examined very well: no bony tenderness to medial or lateral malleolus (the inner and outer parts of the ankle); she was able to put weight on it, as evidenced by the fact that she had walked into the department of her own accord without any support (and without a limp!); she had full range of motion except some difficulty in everting her foot, which reproduced the pain. There were no wounds or bruises or swellings, and full power and normal reflexes ended my examination, along with palpable pulses, good capillary refill distally and no neurological deficit. I advised her to continue taking pain relief and to seek a physiotherapist because she may have injured her muscles or a tendon/ligament and may require some specific exercises. She then suggested I x-ray it, and I explained to her why I thought it didn’t warrant an x-ray. She seemed a little less convinced but did not argue, and I sent her home. I documented everything, and thought that was the end of that.

I was called by one of my consultants a few days or weeks later, informing me that I had had a letter of complaint against me. It transpired that eventually when the pain had not gotten better over the next 10 days, despite having been seen by physiotherapy as well, the patient went private and got an x-ray done, which revealed (or so I am told) a stress fracture of the distal end of the fibula! A stress fracture! Of the fibula! The fibula is one of two long bones forming the lower part of your leg. I had never actually in my not-so-many-years of experience heard of a stress fracture involving the fibula.

My consultant was very supportive about it. She had gone through my documentation, and was quite satisfied with the plan I had made for the patient based on my assessment at that time. She agreed that based on that assessment there was no indication for the x-ray. But she taught me a few things about stress fractures that I did not know; that they are more common in the metatarsals than in the fibular end, but that in view of her age, I should have considered the possibility that she might have been osteoporotic and would be prone to fractures without any significant trauma, a detail that I had failed to factor in in my assessment of her. The experience taught me so much about how I need to remain humble in this profession that I decided to do a reflective note on it at the time and added it to my portfolio.

What have I learnt? I have a lower threshold for stress fractures in older patients, despite having no findings on examination/history suggestive of bony injury. I intend to read up on stress fractures and increase my knowledge base on the topic (and maybe blog about it in a later post!). I still intend to continue fully taking a history and doing a proper detailed examination of a patient, and then using my clinical judgement in order to decide on a plan of management for a patient.

You never know when your well-intentioned actions may be the wrong way to go, regardless of whether or not they work for the other hundreds of similar cases. So never get cocky, never get complacent, always be humble, and always, always DOCUMENT!

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.