The Intestinal Obstruction That Wasn’t

84 year old male – known to have chronic constipation, and on warfarin for atrial fibrillation – referred in by his GP for ‘inability to open bowels for 2 weeks’ – yes you read that right folks, T-W-O W-E-E-K-S! – ‘increasing abdominal distension and abdominal pain, along with decreased appetite and a possible mass in the pelvis/abdomen going above the umbilical area’.
The nurse triaging him came to me, asking for some pain relief for the patient ‘and an enema because that’s what he usually has for his constipation’ – I decided to go see the patient myself. I stepped into the cubicle and the gentleman seemed to be in some discomfort, but he kept saying that he was in an uncomfortable position/posture rather than anything else causing him discomfort. I introduced myself and asked him what had brought him to ED – he replied by telling me he had not opened his bowels for 2 weeks now, and though was still passing wind and had passed some today, he was drinking very little and felt nauseous and omitted a few times in the past 3 days. I asked him if he had been passing urine normally, and he reported that yes he was peeing fine, but that he was drinking so less due to the nausea that only small amounts were trickling when he needed to go. I took that statement at face value and moved on. He was lying in a trolley, awake but lethargic and completely oriented. His observations were all within normal limits except for a systolic BP of 89, and his GP notes reported a background of chronically low blood pressure. I examine him, of particular note is his visibly very distended tummy – which assort but distended, feels like gaseous distention from the percussion notes, and with tinkling infrequent bowel sounds – and is quite sore particularly in the lower half of the abdomen, and I can also palpate a mass in the lower part of the abdomen – the patient reports that’s been going on for atleast 3-5 days, possibly when the vomitting began as well. This seemed very much to me to be a classic case of intestinal obstruction – and the management plan is – do baseline bloods (already very kindly done by the triage nurse), get venous access (also done), start some fluids, abdominal X-rays, nasogastric tube and surgical referral, and also catheterise patient, to monitor intake and output.
I speak to my registrar who agrees with said plan of action and while I request the X-rays and take the patient down for it, the lab apparently calls back and my registrar takes the call – the patient’s urea is 44, and the creatinine is 469, last creatinine 3 weeks ago was 141 – so he is going into renal failure, if not there already. While I seemingly faff around with the surgical consult, my registrar gets an ultrasound machine, and I assume it is to rule out a AAA, so I walk into the cubicle with him. And he explains to me a great pearl of wisdom that clearly comes with experience but is such a simple thing that I am left berating myself for not thinking about it earlier. He told me that if someone comes in with such significant renal function decline so acutely, always think of and rule out an obstructive cause for this presentation before moving on to other more sinister things. He was doing an ultrasound to look for hydronephrosis or hydroureter, which is basically the dilated urine collection channels in the kidney downwards and the reason they are dilated is due to an obstruction further down the channel. And that is exactly what he found. The left kidney was moderately enlarged but the right kidney was massive and its ureter was like a fire hydrant pipe rather than the small thin tube – and the mass in the lower part of the abdomen, going from pelvis and extending up from the umbilical area? His urinary bladder!!! I was in shock – as my registrar then gave me the second pearl of wisdom: never believe anything you are told, do not take it for granted until you have objective evidence. The patient felt he was peeing less and less because he wasn’t drinking enough. Yet he was peeing less because the channels beyond his bladder were so narrowed and obstructed that they did not allow emptying of the bladder and it just kept filling up till it was a massive huge thing floating in his belly. I at once made arrangement to catheterise the patient, whereby 2000 ml (that’s 2 litres!!!) of dark brownish urine poured forth out of him.

He had been in urinary retention for the better part of 3-4 days, possibly due to an enlarged prostate that had just gotten worse, and his constipation (though being chronic) was either a factor of his massive bladder pressing on his rectum/colon and not allowing the contents to move ahead; or (a bit like the chicken and egg thing, of which came first?) he was constipated, which gave him some abdominal pain (expected) and that pain had the added effect of causing urinary retention – anyways, after passing the catheter and draining all that urine the patient felt quite comfortable, and the surgeons took him away to do their wonderful things.

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.)

Rat-Bite Fever

You really do learn something new everyday!

So today I had a patient – 4 year old male with a 24 hour history of abdominal pain which woke him up in the middle of the previous night (he kept crying and pointing to his tummy, saying ‘ouch’ over and over again), associated with 1 episode of vomiting, and this morning when he woke up he had a fever (40 degrees) and was off his food and drink – Mum took him to the doctors, who diagnosed him (provisionally, I guess) with tonsillitis and sent him home with oral antibiotics (phenoxymethylpenicillin) the child had as yet only had 1 dose od this antibiotic but Mum felt he was being very difficult to feed/keep fluids down so was concerned, child still had an ongoing fever of 39.4. There was no history of any rashes, no cough but had a sniffly nose the last couple of days. Wetting nappies as per usual (a sure sign he was taking in enough fluids) but no dirty nappies today (not unusual for this patient to go x2 days without pooing) Upon my review he was a bit upset, and seemed to be in discomfort, despite having had some sickly sweet paracetamol a while ago to counter the fever.

He had a background of some degree of developmental delay due to a disorder that I do not want to disclose here, for patient confidentiality so this story is untraceable back to them. There were no other comorbidities.

On examination, the child was sitting in Mum’s lap, crying but was settling down when soothed. ENT exam revealed a slightly hyperaemic throat with enlarged tonsils, no exudate or discharge. He kept sticking his tongue out and wincing when he swallowed – pointing towards the possibility of odynophagia or painful swallowing. May explain the ‘off food and drink’ as may be too painful for him to swallow. The mother was giving him regular round the clock calpol though, so difficult to say. Ears were wax-laden and I could not visualise a tympanic membrane in either. Chest was clear to auscultation, no heart murmurs or other weird sounds on listening to the chest. Tummy was nice and soft with no palpable masses and child did not appear to be in discomfort when tummy was examined. He was moving all four limbs, neck seemed soft and his observations (vitals – heart rate, capillary refill/BP, respiratory rate, oxygen saturation on room air – were all within normal limits; all except the temperature, which was still high despite the calpol. I prescribed some ibuprofen. There were no rashes (did I already say that? Yes, that was history, this is examination) – Moving on…

I asked mum if he had been unwell prior to the waking up with the ‘ouches’ in the abdomen? She reported he had spent the weekend with Dad, where he had been bitten by a rat (!!!) on the right index finger – sure enough, on examining, his right index finger had a blackened almost shiny minuscule raised bit – an unmistakeable bite mark, on the distal end of the finger. Surrounding area was a bit reddened and slightly inflamed looking. On movement of the finger, hand, wrist etc, he did not seem to be in a lot of discomfort, though he wasn’t exactly happy I was poking and prodding him so much. There were no palpable axillary etc lymph nodes either – but he was a bit warm to the touch still, and when the temperature was rechecked it was 40 again! We quickly started some antipyretic measures while I quickly listed the differentials in my mind. A) It seemed very likely that the tonsillitis was not bacterial (probably) as a sniffly nose and the acuity and high grade of the fever pointed towards a viral upper respiratory tract infection. It could still be a bacterial infection, though, so I wasn’t going to stop the antibiotics. B) I could potentially/probably send the patient home, as even though they did not seem to be drinking too much, they seemed to be weeing as per usual, according to their wet nappies frequency, with advice to sort of force fluids, along with some adequate antipyretic advice and analgesia advice, with followup in the GP surgery, and that if situation worsens or any of the red flag signs appears, to come to A&E instead. C) could it be an infection spread by the bite of the rat? This last bit I honestly did not know – I had heard and studied about (and mcqsed!) about cat scratch disease and dog bites and human bites and tick bites, but I had never in the course of my 5 year study or almost 10 years as a doctor come across a rat bite – my curiosity piqued. I did what everyone does when they are confused about something – I want to say something impressive like ‘I discussed it with my seniors etc etc’ but in reality I … googled it! (I discussed it with my seniors after that, though, who very kindly reviewed the patient, and discussed it with the paeds registrar and admitted this patient to the hospital – the rationale being they still had a fever despite significant attempts by Mum and A&E staff.) But my google search was very fruitful, and I present to you a few bits and pieces about RAT-BITE FEVER (yes, sounds very impressive and a little icky, and it is!): (this information is courtesy of the CDC website, which is probably the most reliable and authentic information out there as it is so aptly named the Centres for Disease Control and Prevention!)

It is a bacterial infection, has two types of bacteria implicated in it: the spirilary (spirillum minus bacteria) type and the streptobacillary (caused by streptobacillus moniliformis) type. It is transmitted by either being bitten or scratched by infected rodents, or with regular handling of infected rodents even without being bitten, or due to ingestion of the pathogens in food/water that is laced with rat urine/feces. It is not contagious. Symptoms include invariably a combination of any or all of the following: fever, vomiting, headache, joint pains, muscle aches, headache, rash, ulcer at bite wound, swelling around the wound and swollen lymph nodes. Can we agree we are ticking off a lot of the boxes for rat-bite fever? Symptoms may begin within a few days of being bitten by a rodent, or may present a few weeks after the bite. Rash is usually maculopapular. There are certain people at risk – like if you have a rat fetish or handle them or keep them as pets or if your local rat population lives alongside your local human population. Penicillin is the treatment of choice – don’t ask me what it is when you are allergic to penicillin! Complications include meningitis, myocarditis, pneumonia and rarely death. *cue ominous music* Prevention is a) avoid rats! duh b)practise good hygiene c) do not put infected fingers into the mouth.

AND THIS IS WHERE IT ALL CLICKED FOR ME WITH REGARD TO THIS PATIENT – HE PROBABLY PUT HIS INFECTED RAT-BITTEN FINGER INTO HIS MOUTH – AND INGESTED SOME OF THE PATHOGENS – AND HE WAS CURRENTLY AN IDEAL CANDIDATE FOR TREATMENT FOR RAT BITE FEVER! Fortunately he was already on the treatment for it – the Paeds registrar concurred with our assessment and the patient was moved to the pads unit.

I reiterate: Learn something new everyday!

Exams – what to do, what not to do – and when to do?!

Having recently passed the FRCEM (Primary) – I have yet to decide what my next step is going to be. I start my second year of training in 4 weeks. I had initially planned on a practical approach to training requirements, such as trying to get atleast 1 exam (check!) and 1 course (ALS/ATLS/APLS) per year of training, and though I have not yet done another course (I did my ALS in 2015!) this year and ideally would like to do another course this year – I am getting more and more inclined towards taking the next part of the FRCEM, known as the intermediate part. I am wondering whether that would be a good idea. Everyone I encounter seems to think that is a good way to go. One of my consultants even feels the intermediate might be an easier exam to take than the primary, since it is clinical oriented and has to do with what you deal with on a day to day basis rather than the facts and figures of physiologyanatomymicrobiology and the other basic sciences. So it tends to be easier for someone who is working in an environment that gives them good amount of clinical exposure to day to day EM cases. Thoughts, anyone?

The whole examination schedule is a bit of a confusion at the moment – well, let’s face it, examinations are very confusing anyways, atleast for someone like me. So let me break it down for you, if you were as confused as i was – if you weren’t, good on you and you can move on!

WHAT IT USED TO BE
It used to be a membership exam, which entailed 3 parts and got you a ‘Membership by examination’ of the Royal College of Emergency Medicine, UK (which used to be just the College of Emergency Medicine until about 2014 when it was given the status of a Royal college, in essence converting the MCEM into the MRCEM) – the first part was the written, true or false patterned exam. It dealt with all the basic sciences (physiologyanatomymicrobiology), and the format was 50 questions with 4 parts each (so in essence 200 questions) each with a true/false answer. This was followed by a 2nd part, the MCEM B which was a clinical knowledge exam, also written. And then came the MCEM C, the practical or “multiple stations of interaction, examination, history taking, counselling etc” exam. Pass all three and you gained the membership of the RCEM. This was the prerequisite for someone training, or interested in training, in emergency medicine needed to pass before being considered for a higher training post (the ST4 onwards stint in a ST1-6 training program). After entering ST4, and before the end of ST6 you were required to sit for the FRCEM (used to by the FCEM) exams which were the Fellowship of the RCEM exams – pass the 5 parts of that (yes FIVE! hideous, I know!) and you can move on to a consultant post – a specialist in the field of emergency medicine.

WHAT IT IS NOW:
They are now in somewhat of a transition period. They are starting to phase out the MCEM/MRCEM exams as a requirement for trainees in the UK at least – after 2018 I believe it won’t be a requirement at all. They have now coalesced the MRCEM and the FRCEM exams into one single entity, called the FRCEM exams, which entails three parts. The first part is the basic sciences bit, the equivalent of the MRCEM A, and is called the FRCEM (primary) – *please click here to get to the post about my experience with this exam*   followed by the FRCEM (intermediate), which as I understand consists currently of 1 part, the written clinical oriented short answer questions exam but as of a few months later (autumn 2017) there will be a ‘part 2 of the part 2’ a second component of the Intermediate exam. This bit, called the Situational Judgement Paper or the SJP for short (and for convenience!) is more of a management type exam that is once again a written exam like the SAQ. But I have no idea what else it entails; more on that in a later post! But as it stands right now, the FRCEM intermediate is just the clinical written exam.

I am yet to figure out what is the counterpart of the MRCEM C, the practical bit of the previous set of exams, in this new-fangled exam scenario. I have been told however that you can take the part C exam of the MRCEM and if you are able to do that before August 2018, then you have 2 pluses: you are exempt the SJP (which means its the counterpart of the MRCEM C?) and you get an official membership degree, the MRCEM, in addition to the FRCEM degree when you complete it.

The third and final part of the FRCEM exams is the FRCEM (final) which is basically what the original FCEM exam used to be – with a slightly different format/ and 1 or 2 parts either exchanged to something else or dropped completely from the list.

As I understand, you need the FRCEM  primary and intermediate before you can be considered eligible to progress from ST3 to ST4 as an EM trainee. The rest you can complete thereafter. You have 6 attempts at each part, previous attempts at their counterparts do not count – so if you have attempted and failed the MCEM A, those failed attempts won’t count when you attempt the FRCEM primary, it will be a clean slate that you start off with. If you fail a 6th time, and can explain away the reason for failing as a genuine distraction/trigger for failing – the college does consider and may allow you to take the exam a 7th time but that is to their discretion and is dealt with on a case by case basis. You are also allowed an extension of 6 months of your rotation, from ST3 – to allow you to pass the exam and move to the 4th year of training.

Non-trainees or doctors not working in the UK can still choose to obtain the MRCEM by examination, and take parts A, B and C of the MRCEM; it carries weightage in India, Pakistan, Sri lanka (not sure) and UAE/Dubai/Middle East. If you are in a UK based training program in emergency medicine you automatically become a member of the RCEM by association – so the MRCEM is now technically obsolete. It is still a good exam to have on board, a great feather in the cap.

I am just beginning my journey in the EM training field so my experience with the rest of these exams is minimal. I will update this post as and when I prepare/take the other exams, and/or find out more knowledge/updates about the various parts/schedules/content. Or it may be in a later post, the link of which I would put up here. Till then, I sincerely hope I have not confused you further!

EM interview – my experience

So a lot of you have asked about my interview experience – I had it last year and it was my first major interview experience in the UK. I applied for the ACCS-EM post, run through training. My interview was last year, and the details are a bit sketchy, but I am putting them up here in case someone is curious about what it actually entails.

It was done in two batches on the day of interview, there was a morning batch and an afternoon batch, and I believe this was;t the only day of interviews. Mine was part of the morning batch.

(I will upload a separate post about portfolio requirements, here I am just sharing my interview experience.)

It had four stations. Presentation – Ethical scenario/clinical scenario – portfolio station – General Management etc

Each station had 2 emergency medicine consultants giving feedback, so in all 8 consultants to give you a score.

My first station – and possibly my worst one! – was the presentation station. This is where they give you a topic for presentation, the topic can be anything, it has to remotely be related to the medical field, it doesn’t have to be something clinical. You get the topic when you reach the station, after which they give you a few minutes to prepare (3 or 5 minutes, I don’t remember the exact amount of time) They take you into a separate room, you are provided with different coloured markers/pens, sheets of paper on a stand and the topic at hand. My topic was ‘Should the UK adopt a policy of implied consent for organ donation after death?’ I thought about what it meant, because it doesn’t really come to you straightaway does it, the meaning of the statement? I assumed (probably rightly) that it meant should the UK adopt a policy of implied consent where the wishes of the deceased had not been known, in cases of sudden or unexpected death, and utilise their organs without actually having their prior consent. I decided I stood against this notion, and I went ahead to try and make a presentation around it. Now here is where I hit a snag – I can say if the answer is yes or no, but to make a 5 or 7 minute presentation around it? What do I do? So I started by outlining what I wanted to speak about, first minute of introduction to what organ donation actually was, which organs could be transplanted and used by other individuals, etc. Then I tackled the actual controversial topic: yes or no. I said no, and then I gave my reasons: Patients ultimately should have a right of deciding what happens to them or their bodies, and in cases where they can not or have not expressed their wishes then their next of kin or legal guardian or court appointed person has to make the decision for them. But someone has to MAKE the decision for this to happen, it shouldn’t automatically happen, you have to take into account the deceased person’s wishes, their family’s wishes, their religious or cultural factors influencing their decisions. I think I babbled on for a while, and ultimately petered to a stop. The two consultants present in the room smiled at me. I thought that was it. But no. They had questions! The first one was pleasant, smiling – and asked me a question I do not remember even. I don’t think I knew the answer to that question but I bravely said I could look up the information if you like and come back to you with that information, but that I honestly did not know. She backed down. The second consultant, boy was he getting into a state! I realised now they were playing good cop bad cop. He questioned my opinion, asked me three times (yes, three times!) how I felt it was appropriate to let organs go to waste when the dead people couldn’t utilise them and why would I not want these to be put to good use. I kept calm and reiterated my initial stance, he even banged his hand on the table to express his displeasure at my answer. I stood my ground (what could I do, I did not want to portray one opinion from the beginning of the presentation and then back down and go for the complete opposite opinion!) He then finally smiled at me and said your time is up, you may proceed to the next station. I was shaking in my suit but I felt it could have gone worse. Atleast I got to say what I felt and wanted to say, eh?

Second station was the ethical/clinical scenario station – 2 consultants, one scenario each, but they were sat at the same table so both could give an assessment of both answers. First case was the ethical case: You are asked to see a 50 year old male in rests who comes in clutching his chest in apparent chest pain – he speaks no english and you do not speak his language. He is accompanied by his 11 year old (or 14 year old, I don’t remember the actual age) daughter who speaks both languages fluently. How do you proceed? Now having worked in the ED in the UK, I knew that it was frowned upon to use relatives/friends as interpreters, and it was preferred to use professional interpreters that the hospital may provide, or a service called ‘language line’ which you ring up and ask for whichever language professional interpreter to be put through, and you basically use him/her as the middleman as you take the history and examine the patient, all the while communicating by phone. Not the most practical solution, but one that appeases examiners, as it did this time. They were quite happy with my answer, I told them ideally I would like to use a professional interpreter, language line etc. But since this is potentially an emergency and I am aware of the time it may take to arrange an interpreter, I would atleast like to ask for patient’s known history and whether he was allergic to anything, and atleast begin the process of giving painkillers and start my assessment with his consent via his daughter. I also used the phrase ‘will ask seniors to advise me on this situation as well’ which always sits well with examiners, especially for the more junior posts. They do not want you to be a hero, they want you to be safe and utilise appropriate senior help whenever you feel the situation entails. The interviewer then asked me if there was any other avenue I could utilise for this purpose, and I remembered once having had to use one of our staff members, a registered nurse, as an interpreter. I mentioned that, which was seemingly the right answer, as they moved on to the next question: what do you think would be the problems that you may face if you do end up using the daughter as an interpreter? I mentioned she is not a professional, I won’t have any guarantee that what she is relayed to the patient an what the patient is relaying to her is not literally lost in translation. I also mentioned there would be aspects of the history that she may not be aware of, such as his medications or some malignancy that he has kept from her. She may also be very frightened and seeing her father in pain or unwell may cause her to be very distressed, and would make her even more distressed if I used her in this situation. The buzzer went off at this point and so I was asked to move on to the next examiner (sitting in the same room). The second scenario was a clinical case, the interviewer showed me an ECG – asked me to identify it (it was an SVT – atleast, I thought it was!) which I did, and then she went on to ask me how I would go about managing the patient, I kept giving her options but I felt she was probing further, and then it clicked: ask for senior help or specialist advice, which I mentioned and she let me off the hook. I stepped into a 3rd encounter:

Third station – portfolio station: Once again, two interviewers, who already had access to my portfolio (they asked us to submit our physical portfolios at the start of the interview outside the portfolio station, and before our turn came for the actual portfolio station they had already gone through the broader aspects of each portfolio). Now here I must add there were candidates who had come in with huge binders of information, one candidate had three such folders and about 7 rolls of what seemed like very large maps but were very likely poster presentations of various researches and audits he had undertaken – these served to really really unnerve candidates like me who had the thinnest portfolio! Anyway, I went in, they asked expected questions, that sounded more like mere confirmation of information I had already provided (twice- first time when I wrote it all down in my application, and second time when I handed them the portfolio with all the hard copy evidence) – still they had questions like: So you have done an ALS course, no others, correct? Yes. And you have no other degrees other than your primary medical qualification? Yes. And I see you have some feedback from medical students that you have taught. Yes. Is there any other evidence of teaching? No (because if I had, wouldn’t I have submitted it before already?!) and this went on. We discussed some bits about my CV. Some bits about my prior experience (Tell me about this 6 month volunteer post you did back in the USA, or So I see you have some experience in Oncology? Tell me more.) So just basically a general chat to gain an idea about who I am and what I have done and how I have turned into this person sitting in front of them, applying for a training post in emergency medicine, how did I get here, what roads have I travelled.

Lastly – the Fourth station – I don’t know what this station is called but they asked sort of direct and indirect abstract questions vaguely related to the practise of emergency medicine. They asked me if I knew what the term exit block meant. I didn’t, so they explained that an exit block means that patients are coming in to the emergency department, but they are not coming out of it, probably due to a shortage of beds for the admitted patients, so that the system isn’t moving forwards, and there is a jam, or a  literal block. They then asked me how I would deal with this phenomenon.  I thought about it and replied to the tune of ‘make sure it’s still a safe department, make sure everyone has adequate pain relief, comfort measures, next antibiotic doses and regular medications prescribed, if they have been waiting a while, maybe get them a more comfortable bed instead of the trolley, try to offer them something to eat if it is clinically warranted, and a cup of tea or coffee would go a long way, along with a sincere apology about the wait and an explanation that all efforts are being made to make sure things progress. There was another question which I forget, but it was once again more abstract not directly clinical medicine but more management, I think it was along the lines of if you see a colleague is drunk or intoxicated, how would you proceed (I am not sure, I may be remembering some other time this question was asked of me) but anyway, you get the gist of it.

That was it.
I went home. Or rather I went to the train station, and took 3 connecting trains back home, slept for 3 hours and went to work on a night shift. I thought I hadn’t done too well, and anyway, it was my first interview for a training post.

It was also my last. At least for the next 6 years!