So, what is it actually like to work in A&E?
A few words spring to mind. It’s different, varied, unpredictable on a small scale but often similar on a large. It is stressful and intermittently satisfying.
Tell me more.
There are a number of categories of A&E work – majors, minors and resus – each is quite different and has its own themes and typical presentations.
Resus: The apex of A&E care, with facilities unmatched anywhere in the hospital except intensive care. Complete with monitoring, diagnostics (X-ray, blood gas analysis) and interventional equipment (ventilators, defibrillators, IO line guns etc) for anything from taking blood to managing massive polytrauma, resus is only for the sickest patients – trauma, arrests, and patients who are peri-arrest. There is enough space to get ten people around a patient, hence the less-scary and patient-friendly name of ‘the big room’. As resus opens up its bays, staff are drawn away from other parts of A&E to take the strain and specialty teams may be called from all over the hospital to assist, depending on the emergency.
Majors: Chest pain, abdo pain, collapse ?cause, overdose. Come to majors and see the bread and butter of A&E! This is where I lurk most of the time, dealing with all ages and issues. The vast majority of patients admitted to hospital through A&E come through majors.
Minors: Got bumps, bruises, or broken arms/hands/wrists/ankles? Been bitten by your pet houndbeast or over-enthusiastically carved through your own fingers over Sunday roast? Minors is the place for you. Patients here usually take much less time to see and the vast majority go home with dressings, plaster casts, or man-up tablets. This section is usually manned by specialized nurses, and I will pop over if either a) their queue gets to over a couple of hours wait or b) all the majors patients have been seen.
How do you decide who to see first?
We have a box in A&E. Each and every patient who comes in gets an admission document printed, and they go in the box in order of urgency (as seen in triage!). When I’m finished seeing a patient, I pick up the next card in the box. It’s a little bit like Forrest Gump’s box of chocolates: you never know what you’re gonna get (it’s not all good). It takes about 45 minutes to 2 hours to see a majors patient, but because of all the delays (blood results, waiting for x-rays/CT scans etc) I will often have 2-3 patients on the go at once. Once I’ve figured out what’s going on with someone, I’ll start treatment as needed and either send them home or admit them under the relevant team. After they leave the department my involvement in their care generally ends. If I don’t know what’s going on with someone, I speak to the consultant, the probable correct admitting team, or I rule out all the dangerous stuff and send them to see their GP. Can’t solve everything in 4 hours, after all.
So you don’t find out what happens.
Sadly, often not. I also rarely find out whether my diagnoses were correct or not, despite following up as many patients as I can. I’ll often start my shift spending 5 minutes looking up scans etc of patients I saw previously to see if I was right or not, but if they’ve not had a scan or similar I may never know what happened. It makes learning difficult, because rarely finding out when you were wrong is not conducive to changing practice.
Do you enjoy it?
Ultimately, yes. I like the variety, I like the practical, hands-on stuff, I like the teamwork and I like the feeling that you have directly helped someone, yourself, today. There is an immediacy to the work which is quite different to the treatment of innumerable chronic incurable conditions so common on medicine. That being said, the rota is socially crushing, many presentations are underwhelming or repetitive, and there is a sense that you can’t win – the tide of patients continues regardless of the effort you sink in. Two of my F2 colleagues, both excellent doctors, are talking about leaving medicine after working in A&E.
I guess what the work is like depends on who you are. Do I like it enough to stay? I don’t know.
And yes, we have a red phone. It has its own distinctive trill to signify impending doom and busy-ness.