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. ┬áBefore 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.