I recently spent 3 days working in A&E. I say working, what that actually translates to is I spent three days getting in the way of the doctors and nurses that were doing some actual work. I had been looking forward to this for about a month, ever since I found out that I’d got this placement. You see, emergency medicine is the specialty I want to do. I want to spend ridiculous hours doing ridiculous shifts because it is the sharp end of the stick. It is where everything happens. There is never a dull day in A&E.
For anyone that’s ever watched the Channel 4 show “24 hours in A&E” you will know that a lot of stuff goes on. While that is set in a massive London trauma centre and I was working in a small district hospital, it is different only in the volume of serious trauma cases we receive. We get the same number of heart attacks, broken legs and stubbed toes as the rest of the hospitals, we just have a smaller staff and ward to deal with them.
I was shadowing a consultant who spent a lot of time in minors (the area in A&E where most people go – for broken arms and things like that). The term “minors” is misleading, especially for the people there (as I know from experience) the last thing you think your dislocated shoulder is, is minor. “Minors” just refers to the fact that they aren’t “majors”, these are the people who are in a bad way. These are the chest pain, head trauma and acute asthma attack patients. If you’re (legitimately) brought in by ambulance, the chances are that you will end up in majors. I say legitimately brought in by ambulance as while I was there a woman was brought in by ambulance wanting a pregnancy test and the morning after pill. Why the ambulance dispatcher sent an ambulance, I have no idea, but she arrived, spent 4 hours waiting to be seen to be told to go to Boots. (Other sellers of pregnancy tests and MAP are available).
In minors I saw a lot of sprained wrists and ankles, a couple of broken arms and one dislocated shoulder. I was only on minors for about 3 hours as my consultant decided that I wasn’t going to learn anything taking a history and “clerking” patients with minor ailments. So I moved to majors. It. Was. Awesome.
As it was quite busy (Monday is apparently the busiest day of the week for the ED) I was pretty much left to my own devices while the staff actually did important things. This meant that I saw patients on my own. While this may sound a little concerning, after less than a year of medical training, I think I learned more in the 2 hours I was on my own than I had in all of my previous clinical training.
I was asked to go and take a history from a teenage girl who had come in complaining of chest pain. It was suggested to me by a more senior medical student there that the chances are the girl would have nothing wrong with her, but it would be a good chance to get back into taking histories.
They could not have been more wrong.
The patient, who I will call Jess (not her real name) had suffered from a very rare heart condition as a child. To understand just how cool this case was I need to give you an anatomy lesson.
Your heart has 4 chambers, each with a different function. The right hand side of your heart is responsible for receiving the deoxygenated blood from the rest of your body (into the right atrium) and then sending it to the lungs via the right ventricle and the pulmonary artery to receive more oxygen. It goes from the lungs to the left atrium and then into the left ventricle. Your left ventricle is the main pump of the heart and forces the oxygenated blood out of the heart at high pressures through the aorta. All this pumping requires a lot of energy and oxygen, which is supplied via the coronary arteries, which branch off from the aorta immediately after it leaves the heart.
Okay. In Jess’s case as a child her left coronary artery (which supplies mostly the left ventricle) came off from the pulmonary artery (which carries mostly deoxygenated blood towards the lungs). This is a condition known as ALCAPA (Anomalous Left Coronary Artery from Pulmonary Artery) and has a 100% mortality rate if it is not corrected early in life. Sufferers are also prone to sudden cardiac death. This means that a sudden attack of chest pain is bad news for Jess and she was right to come into the hospital.
She was sent to the local children’s hospital for a scan and for treatment by the paediatric cardiologist, who said that her chances were very good and that there was probably little to worry about.
I guess that this story has a moral.. not to judge a book by its cover. The more senior medical student would have been able to take a history and write-up a pretty awesome case if they hadn’t decided that there was nothing wrong with the girl based only on her age.
I spent the rest of the day taking histories from other patients in Majors. I saw two angina cases, a pregnant woman who had a suspected pulmonary embolism (she was fine) and a cyclist who had been knocked off his bike and had a concussion.
More to come on the rest of my time in A&E.