Category Archives: ED Management

Studying for FCM (Fellow of Corridor Medicine) at St.Emlyn’s

St.Emlyn's waiting room-1

(Ed – there are two parts to this post. The slightly tongue in cheek beginning and a more serious endpiece that addresses the very real and very dangerous issues of ED overcrowding. If you’re interested in the useful stuff then skip to the end)

 

Why have we created the FCM?

Emergency physicians are renowned for embracing new ideas, new concepts and new techniques to benefit our patients and departments. In recent years we have seen the development of resuscitationists, paediatric emergency medicine, ambulatory emergency medicine, geriatric emergency medicine and prehospital care. Many of these subspecialities have generated sub speciality accreditation and fellowships to recognise the additional skills, knowledge and training gained by thos studying in those areas.

In a similar vein The University of Virchester has teamed up with the College of Virtual Emergency Medicine to develop an approved training program in Corridor Emergency Medicine.

This new course and exam is based on the need to care for patients in non-traditional ED settings when all cubicles are full, the resus room is at 150% capacity and where in the past it was considered that there was ‘nowhere to see the patients’. This lack of ED capacity led to a number of clinical incidents and deaths where patients waiting for admission to the ED, or awaiting transfer out of the hospital were left unattended in Corridor space.

Like many subspecialities in EM the drive to develop Corridor medicine has been led by innovators and enthusiasts who have chosen (Ed – forced you mean) into taking medical care to the patient in whatever thoroughfare they may reside.

 

Curriculum

A detailed curriculum is available from the College. The main areas of study include

Exam

  • Log book
    • Candidates will present a log book of reflective reviews based on their experiences of ED overcrowding and corridor medicine. A minimum of 20 episodes including at least 20 serious harms to patients should be included.
  • Written
    • MCQ
    • Short answer questions on legal, clinical and management topics.
  • Practical
    • Choosing which of the 8 patients who require resus care in the 4 available beds are most likely to survive.
    • Assessing patients for serious illness injury whilst fully clothed, sat in a wheelchair and without recent observations.

Certificate

Successful candidates will be awarded the Fellowship of Corridor Medicine. The awards ceremony will be held by the bins at the back of the Albert Hall in London on Saturday 14th. Sadly Cirque de Soleil are using the Albert Hall that day, so we have moved the ceremony to an alternative location. As FCMs the location does not matter. It will surely be just as good.

Established clinicians with past experience, credibility and evidence of performance in corridor medicine can apply for fellowship through the presentation of a CV and a log book detailing their strategies and reflections on the practice of the speciality.

You can download a blank version of the certificate hereFCM certificate

 

 

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Prof. S. Cared-Tofail

University of Virchester

 

The serious bit.

Top 10 tips for managing the overcrowded department.

Many of not all UK EDs are facing periods of severe overcrowding this winter. This places a huge strain on resources, and by resources we mean people. Some of the most challenging times I have had in the ED are not when deciding to do the thoracotomy or the USS procedure, it’s when the capacity for safe treatment of patients has been overwhelmed and as a senior clinician I have to make invidious decisions about who goes where, when and how quickly they get seen. Let’s consider a situation that a UK ED consultant may face when arriving for an evening shift.

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Scenario

Your department has 4 resus beds, 18 cubicles in majors, 10 cubicles in minors.

You arrive to find 6 patients in the 4-bedded resus. Two are ventilated. 4 are in beds, 2 others are in the middle of the room attached to portable monitoring (one in fast AF, another with chest pain and an ischaemic ECG). None is fit to be transferred out of resus. All cubicles in majors and minors are occupied by patients waiting to be assessed or who are waiting for in-patient admission. There are 6 ambulance crews waiting on the corridor to off load patients. As you walk past a crew asks you to see their patient who they think is drunk. His GCS is only 11 and they are starting to get a bit worried.

There are currently 90 patients in the department and a 3 hour wait for patients to be seen at both ends of the department. A glance at the computer screen suggests that (roughly) there are 30 patients waiting to be seen in minors, there are 10 patients waiting to be seen in Majors (plus the 6 on the Corridor). There are 15 patients waiting to be triaged. There are 25 patients waiting for in patient admission. You have one consultant, 10 junior doctors and 2 ENPs. Every cubicle is full with a patient on a trolley.

You are the only consultant on duty in the ED, the day shift consultant hands over and leaves looking exhausted and in no fit state to do a few extra hours. What are you going to do?

 

What can you do?

1.  Be Strategic

  • It is easy to get sucked into the care of individual patients when the department gets busy. So many people need help at these times and you can quickly fall into the trap of losing oversight of the unit. When it gets busy, take a step back and assess the entire department, not jus the patient you are looking after.
  • Make an assessment of the current situation. How risky is it? Is this a temporary situation or is the overcrowding likely to persist.
  • On some of my busiest days I see few patients. Busy days require strong departmental leadership.

2. Talk: Communicate up, down and sideways.

  • Talk to your senior management directly and tell them what you want them to do. Don’t just moan. Give them actions. Duty managers are often unfamiliar with the ED. Help them by giving suggestions as to what you want them to do.
  • Talk down to your team (the multiprofessional team) empathise, understand and explain what the situation is and how they can help.
  • Talk to your colleagues in the ambulance service to understand their current and predicted demand. Can they deflect patients to other hospitals? What’s the workload like in other centres (they will know).
  • Talk to your in patient colleagues. Again tell them how they can help. Be as specific as you can.
  • Get your shop floor management team together regularly (hourly) to discuss what can and cannot be done.
  • Walk the shop floor. Talk to all the staff. Gather information.

3. Be positive

  • Your attitude, your behaviour and your words will be heard by all. If you adopt a passive, pathetic or hopeless position then so will your staff. Great shop floor leadership sometimes means putting on a persona that can support and motivate others, no matter what you feel inside.
  • Challenge (gently) other senior figures who publicly catastrophise the situation. Ask them what they can do to support their juniors, and how you can help them.

4. Allocate a corridor doc.

  • If ambulances are waiting to offload then allocate a competent doc to speak to all patients and waiting crews. Task them to make an assessment of who gets the next bed. Tell them to alert you if they have concerns.
  • Task them to make a rapid assessment of priority and then to report back to you and the triage nurse.

5. Get inpatient teams to review their patients in the ED.

  • Some patients wait for admission in the ED for up to 16 hours in the UK. A decision of need to admit at 1 hour may have changed by the 15th hour. Some specialities are reluctant to review patients in the ED. Encourage them to be less reluctant.

6. Report the overcrowding

  • Unless the overcrowding issues are shared across an organisation nothing will happen. We risk spending too much time firefighting the acute event without making plans for the future in a sustainable fashion. Whilst it can often seem pointless to fill in incident reports about overcrowding (it happens so often) it is a mechanism for making senior figures in the trust take note.
  • Report individual patient harms
  • Report overcrowding in general (let’s face it, overcrowding kills).
  • Tomorrow – look at the trust risk register. Does overcrowding feature on it. If not, why not.

7.  Use non traditional space

  • If you are told that there is nowhere to see patients be pragmatic, think about what urgent clinical assessments can be made in different areas and prioritise. Try and ensure your patient’s dignity and confidentiality.
  • In a crisis any space can and may be used. See patients wherever they can be safely reviewed.

8. Be honest with patients.

  • Apologise for the delays.
  • Apologise for the circumstances they find themselves in (no-one wants to be on a corridor for 4 hours)
  • Tell them about delays when they first arrive and (where appropriate) suggest alternative health care providers.

9. Look after your staff

  • No-one goes to work wanting to do a bad job. All our staff want to deliver great care, but that cannot be done in an overcrowded ED. Overcrowded EDs deliver poor clinical care and an awful patient experience. Inability to deliver care to the level that we would wish is probably the biggest stressor for our teams. Recognise this. Thank them, be nice, look after them. If you recognise your colleagues becoming unwell as a result of pressures in the ED help and guide them to whatever support they need.

10. Look after yourself

  • As a senior clinician you’re expected to be able to suck up all the pain, the risk, the danger and yet still lead with a positive attitude that supports everyone else. This is tough and I know of many casualties. If you think you need help ask for it before it’s too late.

 

Final thoughts.

When the team reviewed this article we did wonder whether it sounds negative as we still love emergency medicine and we love our jobs. However, when the times are tough we recognise that the ED can be a challenging place with the potential to harm both staff and patients. The Faculty of Corridor Medicine is clearly a spoof and is used here as a vehicle to help us engage with the problem, but to also to think beyond helplessness in the face of difficulty such that we can do the best that we can.

Despite the pressures there is much we can do to help our patients, friends, colleagues and staff. Do the best that you can. Good luck and as the RAMC motto In Arduis Fidelis states, be Faithful in Adversity.

Please share your top tips for managing the ED overcrowding problem? Share them in the comments below.

Good luck and best wishes.

Before you go don’t forget to subscribe to the podcast using this link. You can also subscribe to the blog using the link on the right side of this page.

Show Me The Money: Coding at St.Emlyn’s

coding stemylns podcast

Have you ever wondered how it is that your hospital gets paid for the work you do? Perhaps you think that this isn’t relevant to you? Well, in this podcast we discuss how hospitals in England are remunerated for the patients they see in there EDs and why we, as clinicians, should do everything we can to ensure the clinical coding recording the details of the patient’s visit is correct.

Hospitals in England are paid on a “payment by results” basis. In essence, the more you do for a patient the more they are paid (up to a maximum of £237). This is done via “HRG4” codes that add together investigations and treatment, to give a code that equates to how much that episode is worth, with eleven different codes available.

HRG Code Table

It’s important to remember that the hospital is paid this fee for any patient who attends the ED whether they are admitted or discharged (there is a further set of complicated codes to work out cost for inpatient hospital stays).

This data isn’t just used for costing purposes, but also regularly quoted when looking at patients who attend for whom “nothing is done” in the group VB11Z, so accuracy is vital and we hope this podcast will help encourage you to take just a little extra time to ensure your data entry and discharge information is as complete as possible.

 

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Iain

 

 

Addendum: The post has received a lot of interest, most notably from Cliff Mann himself who reminds us that the college has put tariffs and payment systems as a very high priority.

Don’t forget the CEM10

D__websites_Medicine_collemergencymed2014_Upload_documentz_CEM7878-10 priorities for resolving the A&E crisis (External v8 04 11 2013)

Q&A with a Virologist: Ebola in the ED at St.Emlyn’s

EbolaThis week Sarah Payne from the North East of England joins St.Emlyn’s. Sarah is no stranger to blogging and is a keen #FOAMed advocate as her bio below clearly shows.

Specialty trainee in Emergency Medicine in the Northern region, currently out of program as a Simulation Teaching Fellow across the Newcastle Hospitals trust and Associate Clinical Lecturer at Newcastle University while studying for MClinEd. Interested in #FOAMed and medical education, particularly simulation and reflective learning. I also tweet on behalf of @NEsimulation, @NEFOAMed and @TASME_Northern. Outside of work my life revolves around being a taxi driver for my kids. Advocate of women in medicine in general and EM in particular.

In addition Sarah is rather conveniently married to a virologist. With Ebola in the headlines she shares her family’s knowledge about this devastating illness…..

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2014-05-24 06.51.19
Sarah Payne

Last year I sat at the Northern Emergency Medicine trainees’ conference and listened to Professor Richard Bellamy, one of our local Infectious Disease Consultants, talk about imported infections.

As he talked about Ebola and other viral haemorrhagic fevers I found myself thinking that this was interesting but ultimately a bit of waste of my time…I mean seriously… Ebola? In the UK? Never going to happen.

Fast forward a year, and we’re facing just that reality. My home turf ED (Newcastle) was the site for one of the Ebola resilience simulations last weekend, and the Infectious Diseases (ID) department is preparing to take cases once the capacity of the Royal Free is exceeded.

Thanks to some very extensive planning and preparation by the ED and ID teams the weekend simulation exercise went swimmingly, but it’s genuinely scary stuff. Particularly so in my household, as I’m married to a Infectious Diseases/Virology doc who works at the same trust. I’ve spent a fair amount of time quizzing him about it over the past few days, and thought it might be useful and interesting information for other ED docs.

Q: What’s the scale of the problem?

A: There are predicted to be tens of thousands of cases in West Africa over the next few months. In contrast, the prediction for the UK is a single figure number of cases. The UK has capacity for 26 beds over the 4 sites of the Royal Free, Newcastle, Sheffield and Liverpool.

 

Q: So are we all overreacting?

A: No. Definitely not.The problems in Spain and Dallas tell us that we need to take this very seriously indeed. Given the potential for even small amounts of air traffic from West Africa and an incubation period of up to 21 days, it is inevitable that we will see some imported cases in the UK. It is clear that these will put health care workers at significant risk unless protocols are rigidly adhered to.

 

Q: How infective is Ebola?

A: The things that are in our favour is that it isn’t infectious by the respiratory route and there isn’t a presymptomatic infectious period. Transmission is by direct contact with bodily fluids only. However, all bodily fluids, including sweat, are potentially infectious, and the infectious dose (amount of pathogen required to cause infection) is very low.

 

Q: So I could catch Ebola from touching a surface that an infected patient had sweated on?

A: That’s a bit dramatic and the honest answer is that we don’t know at the minute. Contaminated surfaces are certainly a risk for infection but this is likely to be predominantly surfaces contaminated with blood or vomit. We don’t know for sure how infectious, for example, a door handle contaminated by sweat might be – if at all.

 

Q: How do you kill Ebola in the environment?

A: It’s sensitive to standard disinfectants such as bleach based products.

 

Q: I noticed in the practice run that the stuff the ED team was wearing looked different from the ID team… What’s that about? Are we at lower risk?

A: The Public Health England (PHE) guidance for managing a high possibility case is double gloves, disposable gown or suit, apron over gown, eye protection and FFP3 respirator (mask). In addition, the CEM guidance advises overshoes as well. EDs should be stocking this kit for suspected cases. The risk of contamination increases progressively as the patient deteriorates, particularly if they develop haemorrhagic complications, so additional measures are needed when nursing a patient for a longer period and that’s why the inpatient team may use different kit depending on how the patient is nursed, for example whether the patient is contained in a trexler tent or not.

 

Q: My concern is people who don’t know they’ve got Ebola – for example those unknowingly in contact with a case who just present with fever. Is this a likely scenario?

A: Over the next few months the most likely scenario is of someone recently returned from West Africa (especially Sierra Leone given the strong links with the UK) developing symptoms shortly after they return. I’d anticipate that this person would recognise themselves to be at risk, be worried and seek healthcare promptly and if they are triaged either via telephone or in the ED, mechanisms should be robust enough to pick up this travel history. The situation of someone becoming infected by person to person transmission within the UK is unlikely because of the very low chance that an index case would go unrecognised in the UK health system. In the event of any case in the UK the relevant Public Health body would activate extremely extensive contact tracing.

However,, PHE guidance would change if the epidemiological risks shifted significantly. Also, as a general principle of any febrile returned traveller it is good practice to consider the need for PPE, and to seek advice early. Also remember that universal precautions make a huge difference, particularly in early cases.

 

Q: So what do you look out for?

A: It’s difficult. The initial symptoms are non specific and flu-like with fever or a history of fever. The disease then typically progresses through diarrhoea and vomiting to haemorrhagic manifestations such as easy bruising. By that point they’re likely to be pretty ill. At the minute the key is the travel history and fever.

 

Q: So what do I do as an ED doctor if I have a patient with fever and a travel history from west Africa?

A: Well, hopefully you’re not reading this with a patient like that in your department!

All EPs should know where the PPE is, how to don PPE and more importantly how to remove it correctly. You also need to know which is the designated holding room in your ED. In terms of PPE training, different trusts are probably at different stages, but it’s reasonable to think it should be happening across the country over the coming weeks. It can take up to 15 minutes to put on your PPE and you should have someone check it before you go into the room. It’s also unpleasant to wear; although it can be worn for up to 3 hours at a time, in reality it’s very uncomfortable and difficult to tolerate for more than an hour or so. Taking PPE off is also something that needs to be carefully done and practised as the items need to be removed in a specific order to prevent contamination.

The patient should be immediately isolated and someone will need to suit up and assess the patient to make a risk assessment before liaising with your local Virology/Microbiology or Infectious Diseases consultant. Local arrangements will differ and it’s important that you know what they are. You will be expected to take routine bloods and malaria films in the ED unless your hospital can immediately divert to an ID bed. The College of Emergency Medicine has produced an excellent flow chart which you can download and display in your ED.

 

Q: What happens to the bloods? They must be pretty high risk for the lab.

A: Most routine analyses are run on large automated machines. The risk of transmission from these is considered very small due to the large volume of dilution involved, therefore initial samples can be run on normal automated analysers. The lab staff should be made aware as there are implications for sample handling and waste disposal. It’s up to the ED consultant to decide what tests should constitute essential investigations but I’d think as a baseline you’d be sending your standard ED sick patient package plus malaria investigations. Remember it’s more likely that this patient has something other than Ebola.

Your local infection Consultant will then arrange transfer of samples to Porton Down to test specifically for Ebola. Bear in mind that the patient may well remain in the ED until that test is performed, and this could be up to 12 hours.

 

Q: Are there any treatments for Ebola?

A: Not specifically. There are a couple of experimental drugs which may be tested in the field over the next few months but they’ve been very much rushed out and it remains to be seen whether they will be effective. The mainstay of treatment is supportive care.

 

Q: If you’re caring for a patient with suspected Ebola and you get blood on yourself, what do you do?

A: You mean other than panic?! (Don’t do that!) You’d need to liberally wash the area first of all, and then inform your national Public Health Body (Public Health England, Public Health Wales, HSC Public Health Agency in Northern Ireland,  Health Protection Scotland, or the Health Protection Surveillance Centre in Ireland) . You’d  be subject to active monitoring for the next 21 days,

 

Q: What does that mean? Would you be quarantined?

A: You’d have to take your temperature twice a day and phone it to the relevant public health body. Quarantine arrangements are unclear at present and will be decided on a case-by-case basis. Staff who’ve managed an Ebola patient with no recognised breach in PPE should undertake passive monitoring i.e. self monitor for symptoms for 21 days. That might change in the light of the Spanish and Texan cases.

 

Q: Do you think there is a risk that people will become blasé about it?

A: I’d hope not, with a mortality rate of over 50%. We need to take this seriously. Everyone should read advice for the UK in addition to the relevant local advice. Some of the information produced by Public Health England is relevant to the whole of the UK but if you live in other parts of the UK or in Ireland be aware of your national public health body too.

PHE & Dept of Health Guidance – click here

England – click here

Scotland – click here

Wales – click here

Northern Ireland – click here

Ireland – click here

2014-05-24 06.51.19Brendan Payne

 

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Sarah Payne & Brendan Payne

 

Further reading:

  1. UK Ebola guidance from College of Emergency Medicine
  2. Ebola Special at FOAMCast (US guidance): Blog & Podcast
  3. NEJM Ebola information
  4. Lancet Ebola information
  5. Ebola Editorial by US ED Resident Jeremy Faust at Slate

 

For the Record: Can Patients Record Clinical Consultations?

RECORD

Somewhere in the ITV archives is television footage of me, on my first day in the PED as an ST3 doctor, assessing a child with a scald in resus.

I knew before I started my six month PEM rotation that the crew weren’t quite finished their filming commitments but at no point had I considered that, as the 8am starting doctor, I would find myself with a camera in my face explaining the importance of first aid for burns before I’d even acquired a set of scrubs. The stress of the situation was matched when the episode aired on national television some months later. The narrator was good enough to point out that although it was my first day, I had a lot of experience dealing with children and burns.

I remember my non-medical family being very excited about my upcoming television appearance. I also remember being terrified. Why? Because no-one needs to know that they look like a total idiot doing the thing that they do all day, every day.

Later the same month I was captured by the same crew trying to put small-sized gloves (my hands are medium-sized but for practical reasons at the time – boom mic, small cubicle, distance to hand towels, proximity of box of small gloves) over my wet hands. Thankfully this incident was edited out.

 

There is a phenomenon whereby people do strange and unexpected things under scrutiny; I’m sure those of you who examine in OSCEs at all levels of training have many wonderful and entertaining stories. There are things we do under the pressure of being watched which we ourselves struggle to understand. I hope that regular OSCEs and increasing comfort with the practice of high-fidelity simulation will go some way towards reducing the associated anxieties and normalise our behaviour in these circumstances.

But what about when the recording is being done by a patient?

Let’s imagine a scenario. You call the next patient from the waiting room into the cubicle, introduce yourself and ask how you can help. The patient whips out an iPad and sets it up on the desk.

“You don’t mind if I record this, do you?”

 

[DDET What is your immediate reaction?]

Like me, you may feel the immediate OSCE gut-squeeze: IT’S A TRAP!

The patient is trying to catch me out! And besides, they can’t record the consultation, because of patient confidentiality… or something… Or can they? [/DDET]

[DDET Can patients record the consultation?]

This is a relatively new problem but one which we may start to see occurring more regularly in clinical practice as smart phones and portable devices are ever more commonplace.

The short answer is yes: the patient can record the consultation and it is certainly not unlawful (in the UK) for the patient to do so. In recognition of the fact that this issue may arise in practice the Medical Protection Society produced some great advice in 2012 which you can read here. In summary:

It is polite to ask permission before recording someone; if the patient asks and you feel uncomfortable, you can request that the patient does not record the consultation.

If you ask the patient not to record and they do not comply, you have a duty of care and you should be wary of refusing to see/treat the patient on the basis of their recording.

Ultimately if you are behaving professionally there is nothing to fear: recordings help patients to recall complex information (we know that we are useless at remembering most of what we are told) and provide a more accurate log of events than our often scanty medical records. It is advisable to request a copy of the recording to supplement the patient’s notes. [/DDET]

[DDET What if the patient is recording covertly?]

When the recording takes place covertly – that is, without your knowledge – the biggest risk is harm to the trust between you as the clinician and your patient. Otherwise all of the principles above apply; the data being recorded is the patient’s own (although the recording may include your face and voice you will usually not be sharing any data about yourself) and so it is exempt from data protection principles as long as it is for their personal use as this guide from the Medical Defence Union explains.

The data belongs to the patient and they are entitled to do what they want with it – include posting it on the internet. [/DDET]

[DDET Can relatives record the consultation?]

This is more complicated and relies on the patient’s consent. If the patient is unable to consent (for example, unconscious) then the answer is no. The patient should be aware that the data being recorded is theirs and as such they may wish to ensure that the device being used is also theirs.

When the patient is legally a child, guidance is greyer. Parents are routinely copied into correspondence about their children and there is some common ground here. If it is the young person who wishes to make the recording it is a good idea to recognise that as an excellent opportunity to involve them in their care. In any circumstances where the recording is not being undertaken by the patient themselves, a quick chat about stewardship of digital recordings might be pertinent. [/DDET]

[DDET Is the recording something to be worried about?]

No. Behave professionally and be polite and courteous towards your patients and there is nothing to fear from being recorded. However uncomfortable we might feel there is no legal basis for the trust in a doctor-patient relationship but there is legal basis for the handling of patient data.

It may be worth exploring why the patient wants to record the consultation as this may expose particular concerns you can then address.

In some circumstances, recordings made without your consent may be admissable as evidence in court but if this occurs then the defence will be entitled to both a copy of the recording and a transcript prior to the court date so that both parties can confirm that the interaction constitutes an accurate (and unedited) record.

In this recent ADC editorial (not FOAM), Ian Wacogne explores the relationship between patient consultations and the digital age. He quite rightly advises that we should not ignore the issues that the availability of technology – and of medical opinions – bring to us:

We cannot put our fingers in our ears and chant ‘la la la la’, hoping that this will go away.

[/DDET]

And of course, this is very different from the circumstances in which doctors record consultations with patients – there is GMC advice on that here. This post is based on UK law and may be different in other parts of the world.

Not Just History Repeating. St.Emlyn’s

Starting-3Our journey through life is peppered with “firsts”. From unrecollectable first words, to the first day at school, to our first kiss and beyond; these unique experiences stay with us and influence us forever.

Even with advancing years there are still many firsts to experience, both personally and professionally and I recently had one in the latter category. For the last few years I have been doing training shifts as part of our local prehospital team on the Air Ambulance. I came to this rather late in my career, so despite my senior status in the ED went back to being a trainee in a very foreign environment. Critically ill patients were no longer arriving to see me in a brightly lit resus room lying on a trolley at a convenient height for assessment, but instead were trapped in cars on rainswept country lanes.

After a long period of training and assessment I was finally ready for my sign off day; a consultant still with me, but assessing me and to offer assistance only if I really, really needed it. I had to be able to do it on my own.

DSCN7750
They look younger every year….

The sign off day progressed without alarm or major incident, until we got a call to a RTC with two casualties, both with major injuries and requiring urgent airway intervention. Arriving at scene, the team had to divide and I took the lead for one of the patients – a middle aged man with a severe head injury, probable facial and limb fractures and hypotension, whilst my senior colleague looked after the critically injured child. I’d prepared for this moment for weeks and even when not on shift had practised what needed to be done, both in simulation and mental drills. I’m a confident trauma team leader in the resus room and my EM training had included long stints in anaesthesia and intensive care, but this was still very different. Very new. My first.

All went fine and the patient’s airway was safely secured, prehospital blood transfusion commenced and he was transferred without incident to the Major Trauma Centre. I tried to appear cool – like this was something I do every day, but really I felt a mixture of relief, exhilaration and anxiety. Had I done everything right? Had I given him the best treatment I could? When it cane down to it, was I up to it?

This week Emergency Departments across the UK will be full of doctors who will be feeling exactly as I did on that day. In an alien environment, trying to do their best, but surrounded by firsts – the first patient with chest pain, the first sprained ankle, the first unexpected death. For those of us for whom the ED is a second home it is easy to forget how intimidating a place it can be. This group of doctors will be the twentieth I have worked with since becoming a consultant and I will give them (almost) the same talk about syncope I have given all of the others. For me it is just a case of history repeating, but for them every new encounter is a first. Each case they assess will present new challenges and it would be all too easy for me to forget and get exasperated at how long it takes them to tell me the history or become frustrated at explaining why they don’t have to always wait for the blood results to make a decision about the patient’s care.

Every time I can feel myself rushing one of these doctors (who, let us not forget, are some of the brightest of their generation) I’ll think back to that day as I waited for the induction agent to take effect as the sun beat down and the paramedic team looked on expectantly, and how that “first” felt for me.

Our patients will keep coming to see us, targets will still have to be hit and the pressure that we are so familiar with will continue, but we mustn’t forget that for some of those working with us this is very new, hopefully exhilarating, probably exhausting and just a little overwhelming. And this twenty first group of doctors deserve all of the attention, care and understanding I gave the first.

vb

Iain

You might also want to watch this excellent video from the Short Sharp Scratch team who interviewed foundation docs on their experiences as junior docs.