Day 3 in A&E

The last day of my short placement in A&E was a very mixed day. On the one hand, I got to properly clerk a patient for the first time on my own and suggest a diagnosis. On the other, I was bollocked for not informing the consultant that technically I was a first year and therefore shouldn’t really be left on my own like that.

It started like the previous day had, on the CDU at 7am. Unlike the day before however, A&E had been busy during the night. This meant that the CDU was busy this morning. My consultant was also off, having been called into A&E at 1am to deal with the high patient volume and three neutropaenic patients being admitted with severe respiratory infections. One neutropaenic patient in a night is bad luck. Three in the space of 2 hours in a small district hospital is unheard of. Neutropaenic patients are patients who, for whatever reason (chemotherapy or immunosuppression usually) have very low or no circulating neutrophils – a huge part of your immune system – and are therefore unable to fight infections themselves. This means that if they pick up an infection they can get very ill, very quickly and their prognosis without rapid treatment is very poor.

As my consultant was recovering some well-earned sleep, the other on-call consultant agreed to take me and Katie (other medic that I’ve mentioned) on for the day. Sadly, he seemed to assume that we were final year students and looked a little bit concerned when we weren’t able to answer some of the questions. This is where the bollocking originated from.

By the end of the CDU round (most of whom were fairly simple) I think we had managed to convince our new consultant that we were competent as we managed to answer most of his questions (only really struggling with treatment questions) fairly quickly. He then took us through to majors, went to the folder box and pulled the first one off the top of the pile, looked at it and handed it to me.

” Cubicle 6. 32 year old female, abdominal pain. You have 10 minutes, I want a diagnosis.”

I’m pretty sure that what I felt when he handed me that folder is the same feeling that I will get when eventually (hopefully anyway) Alex tells me she is pregnant. Overwhelming pride and excitement tinged with  ball-numbing fear. Potentially this womans life was in my hands.

“Yes sir.” I said, taking the folder confidently and walking to the cubicle. Before I pulled the curtain back I took two seconds to compose myself and to straighten my stethoscope around my neck.

I moved the curtain back and walked in, careful to close it behind me as I knew I was going to have to do an examination.

“Hello Doctor”

That stopped me in my tracks. I think this was the first time that someone had called me Doctor. Damn. I’d have to correct her.

“Sorry, I’m only a student, my name is Oscar”

“Ah, I thought you looked a little too young to be a doctor.” Well, there went my ego. I’d been carefully cultivating some stubble to avoid this very occurrence. The sad thing is, at 23 I am actually old enough to be a doctor.

I went through the usual spiel of introducing myself and asking permission, which she was very happy to give. I went through my mental checklist.

The patient looked in obvious distress, huddled in the foetal position, taking frequent gulps of the gas and air. She also already had an IV line delivering fluids. Her friend was also sat there holding her hand, looking very concerned.

I started to ask my questions and quite quickly built a rapport with the patient. I was smashing this. A differential diagnosis started to form in my head; although with hindsight, a monkey with a weeks medical school could have reached my conclusion. The woman had gallstones. It was obvious from the history. We were told in a clinical skills lecture that a correct diagnosis can be reached from the history alone in 90% of cases. This was one of those. However I still had to do an examination, and for that I needed to offer a chaperone. the patient seemed really confused as to why I would need a chaperone, but declined the offer, saying that I “didn’t look like a rapist or a pervert or anything like that”. I decided to take that as a compliment.

After exposing the patient adequately (none of this nipples to knees bullshit that some of the textbooks preach) I did an abdominal exam, careful to leave the area that was causing the patient pain until last.  This was the first abdo exam I’d performed on a real patient. Obviously we’d done loads on each other in our practical sessions in uni, but it is different when you’re actually doing it on a patient. At the end of the exam I had to do something that every medical student fears (not a PR). I had to hurt the patient.

In order to confirm my suspicion of an inflamed gallbladder (cholecystitis) – probably caused by gallstones (cholelithiasis)- I had to do a “Murphys test”. This involves placing the flat of your hand along the lower border of the ribs on the right hand side and asking the patient to take a deep breath in.

She nearly hit the roof. Positive Murphy’s sign. Inflamed gallbladder. Win.

I apologised for having to cause her pain, explained what I thought it was and that I was going to go and talk to the consultant about referring her to the surgeons so they could decide the best course of action.

I walked out, head held high and feeling on top of the world. I had diagnosed a patient, on my own, unsupervised. I walked over to the consultant who was having a conversation with Dave the staff nurse (see day 2 for a description of Dave) and gesturing towards me. The consultant turned.

“You are a first year?!”

“Yes..well..technically”

“We do not have first years in majors. Tell me what you think you were doing with that woman in there.”

So I explained that I thought she had gallstones from the history and the examination.

He was not happy.

“Follow me, I will show you how to take a history and examine a patient.”

He went into cubicle 6.

“Hello Oscar, hello Dr, do I have gallstones th..?”

He cut her off, explaining that he was going to have to repeat everything I’d done. He did. In a very curt and abrupt manner. Not giving the patient any time to answer questions properly and made her stop taking the gas and air whereas I had allowed her to use it whilst I asked the question – following the latest evidence that analgesia actually improves the accuracy of diagnosis from examinations. He must have missed that memo.

He did everything that I did, asked the same questions and performed the same examination in the same order (more or less). After the second positive Murphys sign (although this time she jumped a lot sooner as she knew what was coming) he reached the same conclusion as me, and without a word to the patient, turned on  his heels and walked out and proceeded to bollock me in front of the rest of the staff. I thought this was kinda unprofessional. Especially as I’d reached the same conclusion as him.

This is when something rather unexpected happened. The curtain of cubicle 6 was pulled back and the patient (obviously in a lot of pain) walked over, despite the insistence of 2 nurses that she get back into her bed. She then proceeded (in front of the rest of the A&E staff) to inform the consultant that I had done everything that he had done, in a much more gentle and friendly manner and that he could learn a lot from his students.

Deathly silence ensued as the patient stumbled back to her bed.

I took the hint that this was the time for me to leave. So I did, without saying a word. (I like to think I looked quite cool-like the bigger man walking away. In reality I probably looked like I was running for my life).

I understand that there has to be limits on patient exposure, especially at this stage of my training. Realistically I should not have been sent in there on my own to diagnose a patient whose folder said little more than abdominal pain as she could have had any number of life threatening conditions. However, in this case she didn’t and I got it right, so I think a well done before the bollocking for not explaining the extent of my knowledge would not have been amiss.

As I only had half a day left of my placement, I decided to avoid majors and spent the rest of the day working in minors (where the nurses are less friendly, but also less likely to throttle me). It was fun, but nowhere near the same level of adrenaline as when I saw that patient.

Whenever I have doubts about medical school, I think I just need to think of that moment and everything will be alright again.

Sorry that’s a really long post. Didn’t think I could miss much out though.

My consultant, minus the megaphone. He didn’t need it.