By the time I got to my third shift in the emergency department, I thought I had gotten into a comfortable rhythm.
I would find a registrar who had lots of patients to see, offering to see some of those patients for them. After finding the patients and bringing them to an examination room, the standard routine would begin, a rigmarole which consisted of asking about what brought those patients to hospital and inspecting for any important signs on a physical examination. The end result of this would be a short summary of the patient prepared in my head, delivered to one of the junior doctors and documented in the emergency department’s electronic records system.
With a fair number of these done in the days before, my competence felt like it was growing – I felt confident and comfortable doing histories and examinations, although speed was an issue. At this point, each patient would take me nearly 20 minutes to see. Nonetheless, the variety of patients I managed to speak to in the previous 2 shifts refined how I gathered information from patients – a variety of pre-planned yes-or-no questions proved useful in ruling out specific causes (e.g. did this happen because of an infection, a problem with the patient’s vasculature, etc) early on, so I could start trimming down my list of possible diagnoses.
The start of this shift wasn’t unlike the last few. I was clerking patients for a junior doctor and had just come back to present the most recent patient to him.
“Alright, so what would you do next? You’ve said she has a yearlong history of palpitations and some recent chest pain, with no abnormal bloods or ECGs.”
“I think doing a 24-hour ECG (halter) might be merited.”
Pfoooooot.
I turned around to see one of the consultants blowing a raspberry.
“Wrong,” he says, getting up, explaining that the role of the emergency department is to rule out pertinent negatives (like heart attacks or traumatic lung injuries), not to investigate things like this.
“We refer them to their GPs and let them handle it. There are patients in far worse states who we need to dedicate our time to.”
“But given that she does have these palpitations somewhat regularly, shouldn’t we still organise the halter?” I regretted these words as soon as they were out of my mouth, realising that an ED referral would probably trigger a GP organised halter test. To use a military metaphor, consultants are the officers, the junior doctors are the sergeants, and the medical students are the newly enlisted recruits. What I had just done was akin to a recruit questioning an officer, and I had just provoked the wrath of the officer in question.
I saw a kind of sadistic glint in the eyes of the consultant, who reiterated his point, but now tacked on something else.
“Right, I want you to get this patient, Sandra Dumas, take a history and examine her. You have 9 minutes, starting now. Better get a move on!”
Foolishly, I replied confidently, “done,” while screaming internally, desperately trying to figure out how to compress everything he asked of me into 9 minutes. Even in exam settings (which we only had once before!), we have 10 minutes for a history and 10 minutes for an examination, never 9 minutes for both of them together.
I strolled away, trying to project an air of confidence, but the second I was out of his eyesight, I ran towards the waiting room and shouted out for Sandra Dumas, actively trying to avoid a nervous crack in my voice.
Sandra looks rather bored, sitting in a wheelchair with her adult daughter by her side. Her head perks up as she hears her name called, and looks up inquisitively at this person approaching her, someone who is far from an actual doctor.
I introduce myself to both of them and bring them into a side room, explaining that one of the doctors has asked me to see her. You could tell that she had used the long waiting time to think about what she wanted to say – she was incredibly systematic and organised in explaining how she had a fall 6 months ago which broke her pelvis in 3 places. She mentioned that an orthopaedic rod had to be put in to stabilise it and that some pain in the front of her hips began a few days ago.
Sandra looked down at me with fear and a tinge of exasperation as I examined her hips and legs, revealing that her surgeon had said that this sort of pain might begin if the rod slipped out.
Both her angst and anger that this might be happening were palpable in the consult room, and I was at a loss for what to say. I stood up, slightly panicked. What could I say? I was an underqualified medical student, who couldn’t really tell her with absolute certainty what was going on. This was someone who wanted to know right away why she was in pain and how it could be fixed – these were two questions I wished I could answer, but was all too aware that I didn’t know the answers.
“I’m not sure what is going on here, but the good news is that there is no shortage of people in here who will be able to tell what’s going on. The doctor who I’ll be bringing around is one of those people. The important thing is that you’ve come in here today to be seen by those who will know how to handle this situation.”
She smiles as I think about how cringy this soliloquy would have sounded to any observer.
Smiling back, I strip off my gloves and let her know that I’ll be bringing the consultant around. Once I know they can’t see me anymore, I race back to the consultant. “I’ve clerked her,” I announce, a little out of breath. He spins around, an eyebrow raised. “Really?” He queries. “Present her.”
In an excessively verbose way, I try summarising everything she’s told me. He nods at the pertinent parts of the story, particularly about how the rod could have potentially become displaced, and when I finish, he says “let’s go see her.”
We headed back to the consult room, where the consultant took the lead immediately. He introduced himself and was able to use an enviable charm which quite clearly put Sandra at ease. Summarising to the patient what I told him, he then began a more focused history, asking about specific changes to her walking to begin with. I couldn’t help but be awed by the slickness with which he was able to gather information, without being pushy or rude, but instead, with an air of grace and most importantly, kindness.
“My student and I are going to discuss your case and we’ll be back soon, just sit tight.” He announced, turning on his heel and beckoning for me to follow.
“What do you want to do next?” he asks, as we walk back towards the hub of computers around which a mass of doctors are huddled.
“X-ray her pelvis, get a full set of bloods to establish a baseline, possibly group and save if we think she might need surgery soon?”
“Not bad, I agree, let’s put it on the system,” says the consultant as he sits down at a computer, rapidly keying in orders for those tests. I thank him and start walking off to join the registrar I was originally working with, but without turning around, he says, “No, you’re sticking with me tonight. You’ve got a new patient to see,” gesturing at a new name on his screen.
“Grab him and do a full history and exam, this time you have 10 minutes,” he smirks, the first time I’ve seen him break into anything resembling a smile up until that point.
And so the night went on…
The Science Codex 