Outside the entrance to the Emergency Department, NUH
Long hours on the feet. Uncertain mealtimes and toilet breaks. Harried staff at breaking point and abusive patients who think nothing of assaulting those trying to care for them. It’s all in a long day’s work – pre-Covid-19 days, that is. So spare a thought for A/Prof Peter Manning, Emeritus Consultant, Department of Emergency Medicine and Vice-Chairman, Medical Board, National University Hospital. He explains why this is not a job for the faint of heart.
“I’ll get you, you !@#$%^&*()!!!”
This sentence, yelled at me by one of our regular drunkards during one Saturday night shift, formed his parting comment before he left the Emergency Department in the company of two police officers. In his eyes, my egregious act was to not give him Milo and biscuits as per our departmental policy for not feeding drunk, abusive or otherwise disruptive patients.
One is always happy to rid the department of such drunk patients. However, they represent a medico-legal minefield and must be assessed for underlying life-and limb-threatening conditions before they are allowed or encouraged to leave.
They are often more abusive towards our nursing and desk staff and the doctor has to be ready to step in to intervene on behalf of our colleagues.
Emergency Medicine poses constant challenges — dealing with sick people and their families, making a host of clinical decisions in a crowded space with multiple distractions, and, with finite resources.
AProf Peter Manning in consultation with Dr Crystal Soh
OVERWORKED, UNDERAPPRECIATED, UNPREDICTABLE
A study in the United States of America by the American College of Emergency Physicians a few years ago observed a typically busy Emergency Department and noted that the average emergency physician was distracted by a colleague or an event every 18 seconds. We certainly are an over-stretched and, sorry to say under-rated discipline.
Emergency Medicine (EM) is unpredictable; one simply does not know what will come through the door in the next few seconds: 5% controlled panic and 95 % relative ‘boredom’ is an expression often used to describe our working lives – a constant battle between the excitement of the discipline and the ‘boredom’.
Being able to manage and thrive under this challenge intellectually is one of the key features of an emergency physician (EP). This unpredictability, the fast pace, the opportunity to work as part of a close-knit multidisciplinary team aligns with the satisfaction that our interventions can make a huge difference to patients during their worst (and occasionally final) moments of their lives. To counter that, some EPs bemoan the fact that we can only REALLY help perhaps 20% of our patients. The rest could have attended a GP’s office or polyclinic for the same result and at much less cost.
SUCCESS BREEDS MORE SUCCESS
Emergency departments (EDs) should be for emergency conditions. However, the public go to EDs for everything, probably because it is convenient (just like one-stop shopping), and, they know they cannot be turned away without being screened first. In short, EM has become a victim of its own success.
Unfortunately, this success is sometimes taken advantage of by doctors – if there is a problem that they cannot solve, send the patient to the ED and let them sort it out. In a way we have become a place of last resort for any number of issues and problems.
I alluded earlier to the type of verbal abuse shown towards us. Other challenges less obvious to our colleagues in other disciplines include self-care during shifts (do I have time for a meal/restroom break?), and, standing or walking for long periods. Perhaps most disturbing is the constant threat of physical violence from patients and/or their families.
I have been punched or kicked twice by patients in the last five years. Police reports were made in both cases, resulting in one expatriate assailant being warned severely of his immigration status at Immigration and Checkpoints Authority, while the other was sentenced to 10 months in jail (apparently he had ‘priors’ in terms of such activities.)
So, how does this type of working environment affect the typical Emergency Physician?
This results in often negative retrospective reviews by our colleagues in other disciplines who simply do not understand that under our working conditions, it is extremely difficult to make a perfect diagnosis or disposition. I quote Abraham Lincoln….“Don’t criticise them; they are just what we would be under similar circumstances”…unfortunately, too many of our colleagues expect perfection of us.
THE EMERGENCY PHYSICIAN’S PLIGHT
Increasingly, EM literature describes burn-out experienced by increasing numbers of EPs. It is my experience that burn-out is more likely to occur in the younger EPs rather than those of us who are longer in the tooth. This reflects, I think, a difference in generational expectations towards work-life balance. The alacrity with which staff ‘take MC’ often leaves us with a skeleton crew to cover a busy shift.
With all the distractions and stressors, it has been concluded that EPs are especially prone to cognitive errors. Metacognition has entered our lexicon in the recent past and describes a process whereby a person ponders their own thinking. Pat Gorskey, MD, a professor of EM has described metacognition as the best strategy to prevent diagnostic errors and cognitive biases.
Our job is a humbling one. You come on shift one day and one of your colleagues cautiously asks… “Do you remember the patient you sent home yesterday?” Nothing good ever comes of a conversation that starts with those words. This is when your body proves to you that you have an autonomic nervous system – you feel lightheaded and break out into a cold sweat.
This sums up the plight of an EP very well – most of our patients go home; but do any of them take home with them a mistake on our part?
In recent years, the issue of reflection has entered EM education. This involves taking the time to play out in one’s mind the many difficult clinical scenarios that can present. This could be a case that most EPs will never see or perform in their lives, for example, a surgical airway. However uncommon the scenario may be, the EP must know how to perform it. This is an example of prospective use of reflection.
Reflection can also be retrospective following a difficult case where the EP considers how they might have done better and use this reflection to plan for the next time they are in a similar situation.
Reflection can also be departmental, taking the form of Morbidity & Mortality conferences. These are held monthly and are well-attended by both senior and junior doctors. Again, challenging cases are presented to identify areas where we might improve our practice, both individual and departmental, for the future.
Contrary to what some readers might expect, many EPs have long careers, often exceeding 30 years. Yet we keep turning up on a weekly basis for more punishment.
I am not sure what that says about us. Are we ultra-dedicated or are we just big on pain?
Reviewing a patient’s scan