- Posted by James Lawler
- On 21/01/2019
In my first week as a doctor I was working in a small-ish emergency department. I saw one of those patients where everything goes wrong. She was an older lady from a non-English speaking background with dementia. She had come in complaining of some pain and pointing to her epigastric area. She was the next patient to see, so I brought her to a bed, but attempting to take a history was fruitless due to the language and cognitive issues. She had come in alone and she wasn’t keen on letting me examine her. Her observations were stable so I went to a computer to read some of her history. I knew from medical school that I needed to be careful about a patient with epigastric pain.
She was a frequent presenter to the emergency department. She always had a similar presentation, but her ECGs were normal, her troponins never rose, and she would be sent home once the pain was settled. But then I found that seven months ago, she had presented with the same symptoms but that time she had had a NSTEMI. I spoke to the only registrar in the department for some advice. He suggested I take some bloods and that he would come and give me a hand when he was free.
I failed to insert a cannula because I was a nervous intern in his first week and my patient didn’t seem to like the look of me or my needle. She was getting agitated, actually. I’d asked the nursing staff to get an ECG but my patient was refusing this, too. I tried my best to calm her, calm myself, and get the cannula in.
Suddenly the registrar turned up, “This patient looks sick. What’s her oxygen sats?”
I looked up. He was right – I’d been focusing on that cannula and hadn’t been looking at the patient as a whole. She was quite agitated and just looked unwell.
“Um, they were 96% when she came in, but she refused to wear the sats probe.”
My registrar was already checking, “Ok, her sats are 89% now – let’s give her some oxygen and move her to the resus bay.”
The rest of the night was a blur. I had to get the registrar to do that cannula – he did it, then suggested I get an arterial blood gas, but I missed that too. My patient was having a NSTEMI with a troponin of two-thousand-and-something, and her chest x-ray showed she had pulmonary oedema as well. She quickly ended up on BiPAP. The registrar asked me to do another ABG, but of course I missed that as well. I felt ashamed and embarrassed having to ask him to do a simple task for me the third time in a row.
The registrar asked me to call the consultant because this patient needed an advanced medical plan and to go to the high dependency unit but I made a mess of this too – there just seemed to be so much going on that I couldn’t summarise what was happening accurately. I couldn’t answer his questions – he just seemed confused talking to me. He politely asked if he could speak to the registrar, so I handed over the phone.
I felt worthless. The registrar was doing all of the work for this patient, and I felt like a ball-and-chain attached to his ankle. Throughout all of it, he was taking questions from other juniors, and, briefly, to other patients who were becoming irate at not being seen quickly enough. He asked me to document what had happened and sorted out another patient.
I took a moment to appreciate how good this registrar was. As the most senior doctor in the department he was dealing with my patient, other patients, and taking questions from other junior doctors. He was frequently interrupted by other patients and their families, irate at how long they were waiting, and quickly apologising and reassuring them. He finished speaking to the consultant, outlined the plan for my patient and left me to document what had happened.
Pretty soon it was time for handover. I felt worthless, like dead weight, and I couldn’t wait to be out of the emergency department. But as we were leaving, the registrar took me aside.
“Hey, how are you feeling after all of that?”
“Ah… I just feel like a mess. I was useless tonight.”
I mumbled that I was sorry.
“Hey, there’s no need to feel that way. You did great tonight. I was much worse than you in my first week. You actually did the most important thing – you got my attention about this patient early on, which is why I came and had a look. Grab your bag – let’s head out together.”
It occurred to me that I knew exactly what the registrar was doing. He was debriefing with me, because he knew this is important for people who are part of a stressful situation. I had read and heard about how important it was.
But I had no idea it would feel so good. I suddenly had a sense that I mattered again. This registrar, who cared for all of the patients in his department, was giving me his time and attention to make sure I was in a good place. I didn’t believe for a second that I’d been “great” that night, or that he was ever worse than I had been as an intern, but he made me feel like I was important, and I was part of the team.