Never a dull moment

IT IS fair to say that no two days are the same in emergency medicine. In the space of just one memorable nightshift as part of the emergency department team, I had to manage an acute exacerbation of asthma, status epilepticus, a road traffic collision with haemorrhaging scalp laceration, congestive cardiac failure and cardiac arrest then, just before handover, a paediatric seizure. This was in addition to a string of other minor injuries including the intoxicated patient who thought it would be a good idea to put their fingers into the food processor at 3am.

Medicine is a career that offers something for everyone. From the nuances of autoantibodies in the rheumatology clinic to practical skills in the operating theatre, career options abound for medical graduates. Deciding on a specialty is rarely easy but for me the choice was obvious.

One of the reasons I applied to medicine in the first place was as a response to the question – ‘if someone collapsed in the street in front of me, would I know what to do?’ Fortunately I’ve never been in this position but now, thanks to my training in emergency medicine, I can answer ‘yes’.

A satisfying buzz

Throughout medical school and the foundation programme I found myself interested in the acute care aspect of treating patients, having had a number of acute foundation jobs including trauma and orthopaedics, general medicine, surgical admissions and emergency medicine. The satisfaction of diagnosing, stabilising and treating unwell patients was what gave me a buzz during the early part of my training and prompted a further desire to specialise in emergency medicine.

Emergency medicine (EM) is defined by the International Federation for Emergency Medicine as: “A field of practice based on the knowledge and skills required for the prevention, diagnosis and management of acute and urgent aspects of illness and injury affecting patients of all age groups with a full spectrum of undifferentiated physical and behavioural disorders. It further encompasses an understanding of the development of pre-hospital and in-hospital emergency medical systems and the skills necessary for this development.”

What most attracted me to EM during my foundation placement was the variety. The job was fast paced, and I could quickly apply theory learned in the lecture room in the resuscitation room.

EM involves all aspects of medicine: adults and paediatrics, acute medical and surgical emergencies, major trauma and resuscitation, psychiatry, minor injuries, orthopaedics and of course general practice. This diverse spectrum of presentations captured my interest and, as the saying goes, “there is never a dull moment”.

I enjoy the challenges of treating an unselected group of emergency patients and being the first point of contact that they have with the NHS. Using my diagnostic skills and implementing management plans are what make each day satisfying. Of course it’s not all serious illnesses that present to the emergency department. Some memorable cases from my time in EM include a pole dancer who fell off the pole and landed on her neck (fortunately no major injuries) and learning about the art of parcour, or free running, from a 12-year-old child with a thumb injury.

The variety of patient groups also interests me. On any given day I could be listening to war time stories from elderly patients, or hearing the intricate details of children’s TV programmes like Peppa Pig in paediatric A&E. Working with sick and injured children can be difficult. Thinking of novel approaches to provide distraction from procedures and seeing the ‘brave face’ stickers proudly worn makes this another rewarding aspect to EM.

“Doing” medicine

EM also offers the chance to perform many practical skills and procedures, including the suturing and plastering of musculoskeletal injuries, interpretation of ECGs, defibrillation, chest drain insertion and airway management. I enjoy the “doing” aspect of medicine – being able to intervene in a patient’s life and have an impact on them, their families and their medical conditions.

EM gives me a sense of job satisfaction in this respect, allowing me to see, treat and send home or alternatively diagnose, begin treatment and refer to definitive care. Since beginning specialist training the number of procedures has also increased with opportunities for FAST scanning in trauma, airway management and line insertion.

As a foundation doctor, what attracted me most to EM was seeing the acute and critically ill in the resuscitation room. I valued being part of the team involved in the care of these patients when they were most in need of a doctor and I wanted to gain the necessary skills and knowledge to look after them. A career in EM seemed the most logical way of achieving this, by becoming a true generalist in every sense of the word. When the poly-trauma arrives, your training kicks in allowing you to begin assessing, intervening and then reviewing your treatments looking for instantaneous improvement in physiological parameters.

My time as a foundation doctor in the emergency department opened my eyes to the challenges involved in being an EM physician – dealing with major incidents and multiple poly-trauma patients or tackling aggressive and disturbed behaviour, as well as managing families who have suffered an unexpected or traumatic death.

After deciding on EM as a career I embarked on the specialty training application process. In the UK, emergency medicine training involves joining the Acute Common Care Stem (ACCS) programme. It is structured in six monthly blocks comprising of emergency medicine, acute medicine, anaesthetics and intensive care followed by a year in your chosen specialty, in my case EM. This broadbased acute training allows further refinement of the skills required for managing acute and critically unwell patients.

Other challenges

In daily emergency practice, you must also be prepared for the many ethical and medicolegal issues that arise, including child protection and the documenting of assault injuries to be later presented in court, or trying to assess capacity for refusing treatment in the confused and agitated patient you think has diabetic ketoacidosis. The rota can also be challenging in that a large proportion of work is out of hours and weekends; however, the days off during the week help offset this.

No two days are ever the same in the emergency department and that is part of the attraction. From myocardial infarctions to major mountain trauma, airway compromise to the extremely chatty intoxicated head injury, low blood pressures to high blood sugars – EM physicians are experts in dealing with variety. You never know what the next ambulance is going to bring in.

While some doctors relish the long-term follow up of patients this is limited in emergency department patients. Sometimes you never find out what happened to the patient with chest pain you started on the acute coronary syndrome pathway and are left wondering ”was the diagnosis right?” ”Did they get angiography?”

But on the plus side there are few ward rounds, it seldom requires the holding of pagers and most of your work is done in one department with a team of nurses and doctors. The teamwork involved in managing a major trauma reminds you again why you do your job – for the benefit of that patient lying in front of you in the resuscitation room – with all members of the multidisciplinary team pulling together, doing their best.

Medicine offers a host of interesting and rewarding career options and you should choose one which stimulates and challenges you. That certainly holds true for emergency medicine where variety really is the spice of life.

Further information

• College of Emergency Medicine www.collemergencymed.ac.uk
• More information on the ACCS

Dr Craig Brown is a CT2 in emergency medicine at Aberdeen Royal Infirmary