Sometimes it is the smallest things that make you the saddest

Ever notice how you can go on being an automaton, robotically engaging in work stuff, moving from one patient to the other, each one a statistic on your ever growing list of patients to see or having had seen – no interaction long enough to actually create a connection other than that of patient/doctor and you professionally enter and exit the cubicle and move on to the next job, next patient, or indeed next shift. And yet sometimes it does happen that something hits the mark, and there is a chink in the armour, the professionalism slips (not outwardly, but it surprises you that you feel something other than empathy towards the patient in front of you – you really look at the patient, not as just a patient but an actual human being with feelings, and thoughts start milling around your head – or your heart? – and you think of the patient’s feelings, their desires and weaknesses, the consequences of their actions – and you realise with a jolt that you are not an automaton, that you are, indeed, human.

I am usually a happy presence at work (if I may say so myself) but I was having a particularly ‘smiling-from-ear-to-ear’ day a few days back. A recent couple of professional achievements, along with being well rested from a full night’s sleep meant I was walking around with a bit more bounce in my step. I was working a late shift, but from the broad smile on my face you would have thought I was about to go home on a 2 week holiday! (I was not, but yes, I am a bit weird – I actually have fun at work!) – I was assigned to see paeds patients in ED, all the minors, majors, ENP ones etc – and I was going about my day when the consultant asked me to come out of Paeds for a bit and see the next adult patient, who was already at 3 hours (that much time had elapsed since she had come in to the hospital) – the brief note from triage nurse said that this was a young female between 25-35 years of age, who had come in with a self harm injury or injuries – she was categorised as a ‘yellow’ which meant there was no imminent threat to her life but she did warrant a thorough assessment.

Treatment/management of such cases is usually 2-pronged: one, manage the obvious injury or insult and treat the current presentation, and two (and more importantly) try to deal with and manage the longterm/shortterm psychological aspects of the presentation (not an ED thing but there are certainly specialist who are better equipped to deal with this and who very kindly assess and evaluate patients from that perspective after they have been treated from a physical ailment point of view. So anyway – I went in to see the patient – it had been mentioned in the notes that she was accompanied by her support worker – but the woman who stood up when I announced the name in the waiting area was alone. And she stood up at once and followed me into the cubicle to be assessed, along the way I introduced myself, and thanked her for her patience in waiting. She was extremely polite, and even offered me a smile, but she kept looking anywhere but at me directly. I asked her what had brought her to the ED that evening and she matter of factly stated that she was here because she had self-harmed. Again. She did not seem to be in any sort of pain, so I assumed (wrongly) that she had a superficial sort of wound that wouldn’t really require too much medical attention. I smiled at her and said something along the lines of ‘well, let’s see what we are dealing with here, and I will try to help you any way I can.” She exposed her left arm unto her shoulder, and I took off her temporary dressings from her upper arm (above her elbow) – while I was doing so, I kept making small talk, and registered the many, many scars from previous self harm attempts there before me were 4 very large, very long, and VERY gaping full thickness lacerations to her upper arm. In places where normally the skin/muscle sags a bit, it was really using the lacerated margins to gape quite widely. The patient had something like an hour left before they breached? NO WAY was I going to be able to administer local anaesthetic AND suture all 4 of these wounds in under an hour. Alone.

This patient completely threw me off my game. I have closed wounds in numerous ways, and in all sorts of weird and wonderful places – I have once years ago even raced my mentor consultant orthopaedic surgeon in bilateral knee replacements to see who closed up their respective knee first! – But this time was different. This patient was different. And the reason will become apparent up ahead.

I called my consultant because he may have been under the impression this was a quick ‘tape-wound-shut-refer-to-psych-move-on’ kind of situation – he stepped into the cubicle and hemmed and hawwed. I was silent throughout. This felt like an operating table scenario with a patient’s body cavity open up in front of me – The smell was exactly the same. Flesh. Blood. Sadness.

Right then, the consultant asked me to stitch the wounds up – I gave the wounds a good thorough clean with some saline and the patient did not flinch. She did however, apologise quite sincerely for wasting my time. I will not go into the details of why she thought she needed to do this today – absolutely no judgements to be passed here on that account. But I did assure her she was well within her rights to be there. I said I would go calculate the amount of local anaesthetic require and get it and get it all ready – and her polite demeanor stiffened up. She absolutely refused any local anesthetic. She said, and I quote: ‘ I am not here to waste any of your valuable resources. Please use them for someone who really deserves it – and anyway, I am not in pain and the stitching can’t hurt me more than I have done myself – also (and I was surprised that she knew this) the amount of local anaesthetic required would be a bit too much and wouldn’t be safe for me – and it would wear off by the time it was done being administered!” She was right on all counts – but I requested my consultant to give me an opinion, since she had me absolutely flummoxed. He agreed, no need for the anaesthesia – and that I would achieve better results with a skin stapler rather than suturing the wounds. I had never used skin staplers outside of an OR before, and never on a patient who was conscious and sitting up and talking to me and FEELING THE STAPLES GOING IN! I took a few deep breaths. Got the stuff ready. Took a few more deep breaths. And a few more. And dove in. I put in upwards of 45 or so staples (yes metallic pins sharp enough to stab through the superficial tissues of skin etc and pull them close to optimise wound healing) – did I mention the wounds were exceptionally gaping? Each staple gun comes with 30 or so staples – and I had to use a second one about halfway as well. Wow. My mind was already blown after the first 2-3 staples. But I went on putting more in. I did my best – and to her credit she did not flinch. There was silence. And that smell. And sometimes she would talk to me.

She kept thanking me, and apologising to me, and kept pushing her other hand through her hair as if berating herself mentally. She told me she had a masters degree in something (I forget what – my ears still start ringing everytime I think back to that cubicle) and we chatted about how I wanted to pursue another degree, maybe a masters of some sort and hadn’t quite decided what. She guided me about which staple to remove because it had been bent at an awkward angle due to how gaping the wound was initially, and so when I had ‘scaffolded’ it with staples next to it either side, I removed the offending staple and put another one in. Like I said, she didn’t flinch. At all. She kept that small polite smile in place, was very respectful and I learnt something new about myself that day. That this had gotten to me beyond what I can express here or anywhere. I had seen dead and dying people almost on a daily basis. People in pain, people vomiting with pain, people trying to process bad news or loss or a shock. I have been the villain in so many stories in peoples lives – the bringer or the news that someone they loved had passed away, or what the reports had shown or why we feel that further aggressive measures would be futile – But I had not been affected by those things as much as this calm young woman had affected me. What about her affected me? Nothing about her situation. It was sad, no doubt. But what really affected me was what I realised about myself: I judge people, I am cynical about them, about their diagnoses, about their mental health problems – I never fully appreciated that when someone comes in to hospital following an overdose or some deliberate attempt at self harm, I focus solely on the physical aspect of the case, and let someone else deal with the mental/psychological/psychiatric aspect of it. But this time, I was metaphorically chained to the situation I usually avoid and judge as a spectator – and I could not escape how normal this young woman appeared. She was well read, had a grace and calm in her manner that belied a good upbringing – yet she was obviously in this mental pain and it got so severe sometimes that like this day, the thought of cutting herself and so brutally was her only way to cope with it, and possibly caused her less pain that she was already in. And to be able to get sutures or staples without any anaesthesia on board – how remarkably strong a pain threshold would you have to bear that? Or that you were so used to it that this was all just commonplace occurrence to her. And this wasn’t even the worst part. The worst part was that this was neither the first time, nor (we both knew) the last time that she went down this route. I could help her physically, suture/staple everything – but did I actually do anything at all to really, truly help her?

So like I said – we are usually automatons, going about our daily drudgery – and then one day a patient really opens our eyes and makes us sit back – and question …absolutely everything we know and believe in and understand. Or don’t understand.

(Edit: The rest of the shift went by in a blur or a haze, I don’t know if it was all too fast or all too slow for me. I am I think back to my usual self now – albeit with one difference. I am maybe not so quick to judge – and maybe not so quick to dismiss mental anguish based upon my perception of the physical consequences of that mental anguish. I admit to not knowing enough – and hope I can change my practise in a way makes all of this worthwhile.)

FRCEM (Primary) – Done and dusted!

So I am happy to report that the results of the recent FRCEM (primary) exam were announced this evening – and I am proud (read ecstatic!) to share that I passed it! *takes a bow* (if you are interested in questions from the exam, read about that in a separate post here)

This is why I have been slightly out of the blogging scene for the past few weeks – prepping for the exam, juggling the ARCP for my first year of training and what has been very likely the hardest and longest and hottest summer stretch I have ever endured (and I am from Pakistan!) But I am back with the proverbial bang!

And I bring with it the novelty of experience.

It’s not a difficult exam per se – but it is an exam that requires commitment, and time and energy. Be ready to make that commitment. It’s a new exam, only started in Autumn 2016 I believe.

Back in the good old days when I was a (very) junior doctor back home in Pakistan, I had the luxury of having ‘many’ weeks off in lieu of exam prep – the job itself was intense but i had no other commitments; i.e training, portfolio, assessments, ARCP, etc. For this exam, I was working in your regular, run-of-the-mill A&E department in the UK, as a 1st year trainee. I decided to take the exam, decision was taken in January, I booked an online question database then, and I booked the exam in mid February, but I didn’t really get a good momentum going initially, and was still in 2 minds. Why? Because of the ARCP which is an assessment of all your competencies for a required year of training that you have managed to accumulate over the period of the past year, and a panel of judges basically sits and decides whether your performance (based on these signed competencies) is good enough to warrant your progression to the next stage/year of training. So this year was to be my first ever ARCP and coincidentally the exam fell on the exact same date as the ARCP, so in addition to the preparation of the exam, I had to focus on my assessments/requirements for ARCP – all to be juggled along side a full time job in the A&E as one of the juniors. It is doable folks.

So in bits and bobs I started my prep. I had that textbook of emergency medicine, but I must admit I never got beyond the first 5-7 pages of it! Doing the questions from the question bank is what helped me pass along with (as I said) youtube videos. I took a 4 month subscription for the FRCEM exam prep website – previously known as MCEM exam prep website. (‘tom-aye-to, tom-aah-to’). They have a good database of questions fortunately of the SBAQ type as well as the older true/false format. I have ready in many places that you could use any of the other websites/question banks as well.

On my days off, I aimed to do 50-100 question (see, I made you laugh there!) Who am I kidding, I barely got 30 done on a good day – these questions came with explanations, why this option is right, and why the others are wrong, along with a short description of the topic that the question deals with. I inevitably began making a habit of taking pictures of the explanations in my cellphone, and I went back to them again and again, for example before going to bed, or while waiting for my wife/son to wake up in the morning on my rare days off. I found this habit helpful, as you may not retain some of the information that you read, but if you go back and go through it again, or atleast if not all of it, then maybe just the major salient points, it is bound to stick to you.

On my days where I was working, I tried doing a few questions while at work, on my phone, between patient. That was a bad idea. Not only did I not have enough time to do even a single question justice – I also did not retain too much due to the lack of concentration in a busy A&E department. Ditched that idea fast. I did however vow not to waste any of the days I was working though, so after a busy shift, I used to come back, rest, recuperate or sleep (mostly slept) thanks to my wife who really upped her support game and banished me to a separate room in the house at all hours of day or night, waking or asleep – no diaper duty, no bath time no sleep time with the baby – just the books, fooding and my laptop. Where was I? Yes – days I was working, depending on what shift I had done, I still tried to get a good solid 3 plus hours of ‘mcqsing’ as I called it. On days that I was on morning shifts, I came home by 5 pm, straight to bed, slept for an hour and a half or 2 – woke up – tea/food/family time for an hour or 2 and then hitting the books (or laptop in this case) from 10 pm onwards up until 2-3 am – then 5+ hours of sleep and a repeat of this. Or on the afternoon shifts (2pm/4pm to 10 pm or midnight) similarly I used to come back home, freshen up, spend a minuscule amount of time with the family before they dropped off to sleep and then ‘mcqsed’ till the wee hours of morning, going to bed at 5 am or thereabouts, to wake up just in time for lunch and off to work. Night shifts were a bit more difficult, and I sort of gave up on trying to cram anything in my head during the 4-5 night stretch we have – the hangover like state I was in during the night shift stint was not really amenable for any further insult to the brain by forcing it to swallow any other bits of information/mcqs.

I also youtubed a lot of videos – specially anatomy ones, and one or two for physiology and microbiology. There are a lot of good ones out there. I focussed on upper and lower limb anatomy the most, along with the plexuses. You can just search for them under ‘anatomy, mcem or mrcem’.

My strategy towards the middle/end of my prep was to focus mostly on the maximum yield subjects – broadly anatomy and physiology which carried the most weightage in the actual exam, with 60 questions from each subject (out of a total of 180 questions!) Followed by significant input from microbiology/pharmacology/pathology. I used to do 3 sets of 20 questions in a row – the first set being anatomy, second physiology and the 3rd annoys the others, but I kept the first two sets the same, due to its weightage. Anatomy threw me, as it was basically learning a new something I had learnt almost 13-14 years back in the early medical school years! I think it was safe to say I had forgotten most of it, despite having a refresher course during my stint at the USMLE exams. But I digress. I found the following topics high yield, and got an inkling from my various forays into the question banks that these were important enough to be tested and warranted more attention (or repetitive attention) from my end.


– Upper limb (muscles -attachments and function, nerves, bones, blood vessels) -Lower limb (Same as above) – brachial plexus – abdominal wall layers – blood supply of the heart – borders of the heart – contents of spermatic cord/inguinal canal – Sacral plexus – Optic nerve lesions – cranial nerve basics – triangles of the neck – foramina of the skull and their contents – diaphragmatic openings – Facial nerve – spinal cord lesions based on presentation – stuff going on at T4 level – brain blood supply


Lung volumes – cardiac cycle – hormones (renin, angiotensin, mineralocorticoid, cortisol, adrenal medulla, pancreas, PTH, calcitonin, Vit D and its metabolytes) – renal physiology – 


Vaccination program – Drugs that induce/inhibit cytochrome p450 – broad microbiology – allergic/hypersensitivity reaction types – types/examples of vaccines – immunoglobulin types – 

I also attended a course arranged very kindly by our deanery for candidates interested in the FRCEM primary. It was purported to be a tough exam, as the previous attempt had had a passing percentage of 43 percent. Yes, only 43 % of the candidates who appeared for the previous attempt passed. We gulped down our fears, and while the course gave us a broad idea of what wee needed to be doing (which was a lot!) it served no greater purpose than to tell us that we were not alone in being scared and that everyone seemed to be equally stumped by their performance in the questions – slightly reassured by the fact that during practise mcq sessions, when the consultants tried to solve the questions they were mostly unable to. Slightly reassuring, and mostly horrifying, as how were we supposed to pass the exam?! Yikes. What threw most people was that the exam format had been changed – from the previous true or false format, to the  Single Best Answer Question or SBAQ format. All options in a given question may be correct in different ways, but select the answer which is most appropriate according to the stem. Which basically translates to “guess what the examiner was thinking when he/she made this question” – so no pressure!

By the last few weeks, I was about to pull my hair out – the amount of mcps I was doing wasn’t too much, and I didn’t seem to be ding all that well if you calculated the number of questions I was getting right – overall a 52-55 percent of correct answers. Abysmal. I did not let that disappoint me, however, knowing full well that practicing questions was the way to go in such an exam format.

I used up all of my 2 weeks of annual leave and 3 out of 5 days of study leave for this exam, which brought me to just about 20 days of uninterrupted preparation (coupled with MANY visits to the department for ARCP related issues). That I feel was the single best thing in way of preparation – the time off was focussed, and I wasn’t tired from running around – preparation is mentally exhausting as it is, coupled with the physical exhaustion of day-to-day ED life – it takes a toll. All I did was sleep, eat and study. Lather, rinse, repeat.

But I will reiterate here what I have said before as well – you can never do enough questions as practise – just keep doing as much as you can, every waking minute make sure you are doing questions. Whether its 5 or 50 questions, make sure you stay consistent and do not get laid-back and forget to do questions – keep doing them, whether right or wrong, as long as you are also focusing on the explanations of those questions, its a learning experience.

Advice about the exam itself: Time management – 180 questions, 3 hours. The way I did it was divided it into 3 parts, so I needed to have completed 60 questions in 1 hour, and preferably even faster than that, since I needed to allow some time at the end to go back and tackle the more difficult or confusing questions. Keep track of time as well – if you seem to initially be on track, keep checking the clock every 10-15 minutes and make sure you are on track. If you feel you need to think more than 20 seconds for an answer and are still unable to do so, then mark the question and move on, return to it later. Do not waste minutes on a single question, causing a delay and jeapardising multiple other questions. Read the stem carefully – often we do not read the ‘except’ ‘all’ which’ ‘most appropriate’ next step’ gold standard’ ‘not included’ bits of the stem and inadvertently end up selecting the wrong option. In case of long stems, read the last bit/question and the skim over the rest of the stem, to gauge what they are looking for. If you don’t know the answer, go through the options by the process of elimination. Eliminate the blatantly wrong options. Think about the rest, if possible eliminate another 1 or 2 till you are left with one. If you read the stem and know the answer, look for that in the options, if you see it, select that. Always attempt all questions, no use leaving a question blank and lose an opportunity of a lucky guess. Feel free to draw, make flowcharts, write things down in the margins of the question paper if it helps you remember, calculate, reach a conclusion (I remember I drew the whole optic nerve/tract/radiation diagram to help me diagnose where a lesion was based on the hemianopia referred to in the question paper!) The questions may be easier than your practise question bank – don’t worry!

And I had the support of good friends. I don’t know, there is something about prepping for an exam (or anything in life for that matter!) and knowing that there is someone else going through the exact same thing as I am – it creates an interestingly unique bond. I had 2 such colleagues and friends, and I am pleased (and incredibly proud) that they have passed as well. We used to work together in the same ED department back home in Pakistan, and are now in different parts of the UK pursuing careers in emergency medicine. Onwards and upwards!

An interesting lump, courtesy of Warfarin – a dilemma in clinical management

59 Year old female came in to ED due to a painful lump that she had noticed overnight in the right side of her abdomen, associated with pain in the right half of her abdomen, back and upper part of her hip. This was the vague and slightly confusing history on the card as I went to review her. She was a very pleasant lady, who walked into the cubicle without assistance, no support required – and clearly no hip pain?

She reported she had had a cough x 6 weeks – not continuous, but had had a chest infection initially, and was still recovering from that about 3 weeks back when she began to have productive cough and fevers again – and had to complete a second lot of antibiotics, the last of which finished yesterday. She still had bouts of cough though, even though it had improved considerably – one of which had happened last night just as she was going to bed. She couldn’t sleep all night due to the continuous coughing, but this wasn’t the reason why she was here that morning. She woke up in the morning feeling quite sore in her upper abdomen, and put that down to her constant coughing. She tried to ignore it, and took some paracetamol, but as she tried to dress herself, she felt that she required help with undressing and dressing, which was a concern. To top it off, she also noticed in the shower that morning that she had a palpable tender lump under her ribs, in the upper part of her abdomen on the right side. This concerned her enough to come to the hospital. Oh, and she was on warfarin – that lovely blood thinning medication that’s given for clots in the lungs or in the legs, or if you have a heart rhythm disturbance that makes you prone to throw clots to your brain – for recurrent PEs (clots on the lung) and her last INR was 2.6 (a test to see if the warfarin is doing what it is supposed to be doing, and whether it was doing more or less than it was supposed to be doing – recommended range for her condition was between 2.5-3.5)

When I examined her there appeared to be no bruising to the area in question, and her abdomen was soft, though there was definitely a palpable tender firm swelling in the right upper quadrant, sort of jutting out of the lateral aspect of her liver – my thoughts immediately went to a spontaneous hepatoma/bleed into her liver because of her being on the warfarin – I quickly ticked off in my mind a checklist of things that would signify severe ongoing bleeding internally, like pulse and blood pressure (both within normal ranges for her) and she appeared nice and ‘hemoglobin-y’ – adequately perfused! I decided to request a quick ECG (which was normal sinus rhythm) and did some baseline bloods on her including a clotting screen (to check her haemoglobin and INR today – both were normal, though a slightly raised white cell count and CRP) as well as a chest x-ray (I felt there were two reasons for this: 1) cough for 6 weeks gradually worsening, warranted radiographic evidence and 2) in someone presenting with tenderness of right upper quadrant, it is very relevant to be thinking about problems with the lower part of the lung above, rather than just focussing on the abdominal complaint – she may well have a pneumonia sitting in her right lung base, causing pain in her right upper quadrant! In this case, however there was nothing nasty on the chest x-ray on the right, though you could argue the left lung base looked slightly more hazy than I would have liked; at any rate, she needed treatment for an LRTI)

I spoke to my consultant, who quickly magicked an ultrasound machine within the ED and did what is called a ‘FAST’ scan, an ultrasound to quickly rule out free fluid within the abdominal cavity, usually done for patients of abdominal trauma to look for bleeding, etc. The scan was negative for free fluid within the abdominal cavity (we both breathed sighs of relief!), however we did find what seemed to be a collection of blood within the abdominal wall in the area of pain – she seemed to have bled into her abdominal wall, probably due to the coughing, which caused a tear within the muscle wall, and due to her being on the warfarin, caused her to bleed internally but contained within the wall of the abdomen – causing her presentation of a tender painful lump in her abdomen. Mystery solved. Now to the management of said mystery.

The dilemma we faced was this: We couldn’t stop her Warfarin due to the indication for which she was taking it in the first place – it could prove fatal if she had a clot on the lungs again. We couldn’t just leave her bleeding on the warfarin and do nothing. We needed to treat her cough as well, because even if it wasn’t life-threatening at this point, if she went on coughing, who knew how much worse this bleeding might get? And we had limited treatment options for her cough-slash-chest-infection, because many drugs including some antibiotics interfere with the action of warfarin, and the patient was allergic to penicillin (of course, we wouldn’t want this to be too easy!)

So we requested a formal ultrasound from the radiology department – much more detailed than our very ‘FAST’ scan. They agreed with our preliminary findings, with the very valuable additional information that there seemed to be no evidence of ongoing bleeding – the hematoma was contained and was not likely to worsen. Her INR was within the limits appropriate for her, maybe slightly on the higher side, so we decided to advise her to skip the next dose of her warfarin, and to liaise with the anticoagulant monitoring service to monitor her INR in the next few days to make sure it was still within the prescribed limits for her. We sent a sample of her sputum for culture and sensitivity, and based on the haziness in the left lung base and the raised inflammatory markers (CRP and white cells) we decided to start her on some antibiotics – she was allergic to penicillin, and so the next best option was clarithromycin which unfortunately interacted with warfarin so we couldn’t go down that route; we decided on doxycycline being the best line of treatment for her. We explained to her any of the red flag signs, if she experienced any concerning symptoms, to come straight back for review. We advised some analgesia, and some cough medication as well, and the patient was very happy to go home. Fingers crossed, she has neither returned nor have I heard of any problems coming to light following her ED visit.

This served as a learning experience for me – coming to a diagnosis in this case when the presentation was completely different from what was actually going on, and then connecting all the dots in the history (warfarin, chronic cough) and the physical examination (presence of a tender palpable lump in the absence of trauma) and ultimately finding out the mystery of the sudden lump, and then reaching a management plan that should have been so easy and straightforward, but really wasn’t due to the patient’s unique situation.

Pearls of Wisdom – what I have learnt, the hard way

  • NEVER request a chest x-ray JUST to rule out rib fractures. It won’t change your management, unless the patient is short of breath or there are concerns for a pneumothorax, then request a chest x-ray to rule out PNEUMOTHORAX – but I repeat, NEVER for a rib fracture. If you put those words in the request form, that may well be the one (and only) time a radiologist will leave their dark dungeons and come out into the light, TO HUNT YOU DOWN AND KILL YOU.
  • ALWAYS have a chaperone present, or atleast offer the patient one, in cases of intimate examinations (PR, breast, pelvic and/or genitalia). Document – name of chaperone, or when the patient declines having a chaperone present, make sure to state that in the notes clearly. A chaperone is for your protection, and not for the patient’s only.
  • NEVER request x-rays for (suspected) broken toes. If it looks and sounds and feels like it is fractured, it probably is.  Before you x-ray it (which you should never do!) you will neighbour strap the affected toe to the next toe, sort of to act as a splint and reduce the pain. THAT is the management for a fractured toe. If you request an x-ray (once again, something you should never do!) you will find that it is indeed fractured, and then proceed to tell the patient that yes, it is indeed fractured but I have already buddy-taped (another name for neighbour strapping) your toe and the x-ray doesn’t really change my management. I will now run away because the radiologist is probably going to kill me now.
  • Always reduce an ankle fracture BEFORE x-raying. If it’s clinically requiring it, you won’t change the management by wasting time with x-rays; you don’t want the patient to lose their blood supply or stretch out their nerve to point of no return while they’re waiting in the x-ray department, do you?
  • NEVER discharge someone from the department on behalf of someone who has given advice over the telephone. They need to physically see the patient and make a judgement. You can ask for advice, but active management issues, and discharge from hospital on someone’s advice, doesn’t stick in a court of law. If they didn’t come down and document they saw the patient and THEN recommended this and that, then IT DID NOT HAPPEN. They will backtrack faster that a patient on furosemide will need a wee. Well, probably faster than that!
  • ANYONE presenting with abdominal pain, or loin pain, or back pain, above the age of 40-45, PLEASE CONSIDER AAA. It is never a good idea to miss anything, but it is a scary-ass thing to miss a AAA when you have been sitting on it for 3 hours.
  • LISTEN to your gut feeling.
  • Ask for advice BEFORE sending the patient home. No shame in asking for an opinion or running it by someone more experienced. But no forgiving the thing you missed that your ego didn’t allow you to question or ask someone for advice.
  • ALWAYS x-ray pelvis in elderly patients presenting with a fall, I have seen patients walking in to the department with a slight limp, found to have impacted femoral neck fractures. Specially patients with dementia or learning difficulties or any sort of cognitive impairment.
  • Be that extra bit more thorough in patient with cognitive impairment of any sort, delirium etc, they are the ones with hidden signs/symptoms that they sometimes can not express in usual ways of communication. Not every patient who is in pain will tell you (or will be able to tell you) that they are in pain. They may be agitated, or fidgety, or moaning, or distressed, or literally crying out every 2 seconds “Help me!” yet when you ask them what they require help with, they wouldn’t be able to tell you. Pay extra heed to them and be very, VERY vary of what you may miss in these cases.
  • Whenever doing bloods/putting a cannula in, always make sure you have a trolley near by or at least a comfortable chair in a private cubicle – patients have a tendency to faint/go vasovagal on you at the touch of the needle, you don’t want them to be flailing around while you have a cannula/needle in them.