Intern woes

~"Never go home wondering if you did the right thing." - many old consultants and cute registrars~

For reasons unknown, I had the unfortunate luck to start my first days as practising doctor doing nights in emergency. "That's a bit tough." - the medical registrar, surgical registrar and ED registrar said to me in passing the first night. There are a few things that are different during the night. There are only four doctors (including myself), no consultant overnight - only a senior registrar and bad things usually happen at night. The more senior doctors are responsible for the critical patients and this keeps them very busy and therefore there is less supervision for me and less time to discuss issues.

The consequence? - grappling with one's own doubts and inexperience and dealing with the knowledge that the admitting officer is relying on your history and examination before providing the clinical support in the decision making.

Another busy night in emergency. The box has ten patients waiting - many of whom have waited over four hours and a quick look at the TV screen shows more patients waiting in a queue to be registered. There are hardly any free beds. The pressure to push patients up into the wards is mounting. Internal discussions continue between ED staff and admitting registrars about discharging and admitting patients while blood results and imaging remain pending - the lack of beds within wards slowing down the patient flow in and out of the department.

8 hours through the shift with not even a five minute break I knew I desperately needed and running between my patients and doing little tasks that only the intern would be stuck with -

"Hey can you do me a favour - I'm going home now, I just can't write up a drug chart after 15 hours of work, here's my patient's meds, can you write up the chart for me? Thanks." said a consultant.

"Mun, it's been so busy I've haven't had the time to document anything for most of my patients. Can you come with me and I'll tell you about this patient, I've reviewed her and she's ok to go home. This is what happened.....Can you write up some quick notes for her and type the discharge letter for me, my hands are really tied and my patients are very critical. Thanks."

My head was feeling very heavy and I could feel my stress levels hitting the downward slope on the the stress-performance curve.

This while I'm running through my assessments and planning the next steps of management and writing up drugs for nurses that somehow always interrupt me whenever I'm about to deliberate. These interruptions are moments that are fraught with anxiety and represent the struggle between the gone days of medical student and now doctor. Surely another 2.5mg of morphine should be ok. I don't think I have to spend the next 10 minutes looking for my registrar who is probably juggling eight patients to ask him whether it's ok for me to prescribe some pain medication. It's time to stop being a baby doctor. Time to toughen up and be decisive.

An hour to handover and I pick up a patient who had been waiting six hours after being involved in a vehicle accident.

After examining him from head to toe, I sought the help of a registrar to decide on how much imaging was required. His reply, "Look I'm not very familiar with trauma stuff - just x-ray whatever part you are concerned about."

10 minutes to handover, the morning registrar arrives and finds me and offers to take over my patients for me. I was instantly relieved knowing that I would not have to stay much longer and proceeded to give him the details. "And you've cleared the C-spine?" "Yeah, his C-spine wasn't tender at all, no focal neurological signs, neck movements ok and he walked in and was sitting on the chair when I came in." We moved on without a single more thought on the patient.

I went home and went straight into deep slumber. After 5 hours of sleep, I woke up with the NEXUS criteria in my head. No cervical tenderness, no altered conscious state, no focal neurological signs, not intoxicated and oh shit - presence of distracting injuries. Shit shit shit. Shit shit shit as I stepped into the shower, still very groggy and running through everything in my head. Instinct told me that he was allright and that he didn't need imaging of his C-spine. The only imaging I did were for his feet and wrist that were clearly tender and swollen.

The words came haunting back, "never go home wondering if you did the right thing." I knew that if I didn't resolve this, I would spend the next four days off worrying whether my patient might became a quadraplegic. I knew that the doctor I handed him over was more experienced and if he was concerned that he would do the imaging. But he was relying on my assessment. And during my assessment, I was sure that his C-spine was ok. But now, the the doubts of an amateur were sinking in.

I called switch, knocking myself mentally on the head for not even knowing the direct number to my department and traced down the doctor I had handed over the patient to, anxious that it was near the end of his shift and he might not be around anymore. Please, please let him be there or else I will have to speak to the AO and that would just be horrifying. Part of me was dreading his answer, afraid that I would get into major trouble and that I would have to come in and call the patient and convince him to present again. "Oh by the way can you come in so that we can get an X-ray of your cervical spine just to make sure everything's ok?"

I got through to the registrar and relayed my concerns instantly. "I'm sure his C-spine is ok but I just realised that he had injuries elsewhere - the multiple abrasions and probably the fracture in the foot. I'm not sure if this constitutes as a distracting injury or not using the NEXUS criteria. And I was just wondering if we should have imaged his C-spine. "

The registrar chuckled. "Don't worry, he looked completely fine. He doesn't need a C-spine."

Relief flooded me. "Sorry for bothering you, I was just worrying about it and I just wanted to make sure I did the right thing." Again he chuckled and reassured me, "It's ok, he's fine. But it's good that you called anyway." He was clearly amused.

And that my dear friends was when I learnt something about myself. Previously I trusted myself that I would be assertive when needed. I never really knew if when the situation arose, that I would have the guts to do so knowing that I may get into trouble and in the process be owning up to a huge mistake and causing harm to a patient. Maybe I worry too much but I think that's ok as long as the patient stays alive during my watch.

And more importantly, I learnt that 5 minute breaks should always be taken.