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I completed my medical school and background EM training from India (Christian Medical College, Vellore and Apollo Hospitals, Hyderabad) where I worked for 4 years. Following this, I devoted (with all my heart) about 1.5 years to do US Medical Licensing Exams. My stint towards an EM Residency in States did not work but it took me to places and it has been quite a journey. I then relocated to London, England to work as a Registrar (Non-Trainee) in A&E. This gave me an opportunity to better understand NHS, EM training pathways and more importantly the EM Mindsets in the United Kingdom. 

Currently, I am pursuing Higher Specialist Training in Emergency Medicine at South East Scotland Deanery where I have the honour and privilege of training under some of the most innovative brains in the field of Emergency Medicine. Over the past few years, I have realised that LEARNING and UNLEARNING (which can be challenging!) is equally important to deliver cutting edge care to our patients.And through this blog, I aspire to disseminate knowledge, assist trainees with exams and stay up to date with contemporary EM literature. I have always been an avid FOAMed supporter because FOAMed has always played an indispensable role during my training. 

Lakshay Chanana
ST4 EM Trainee 
Edinburgh, Scotland

Monday, April 16, 2018

Leading the shop floor - Unsolicited advices!

Night shifts tire out A&E doctors and lead to considerable amount of distress. Things can go worse due to lack of staffing, complicated patients (who always turn up during these hours), unfamiliar (or familiar) locum doctors around. Explicit details vary depending on the "local settings and culture of Emergency Medicine" but overall theme remains the same to manage a busy department overnight. By morning, we end up signing countless ECGs, ordering several medications (with minimal background info available) and listening to numerous SHO/F2 case presentations. Essentially, we walk on the very thin ice during night shifts and there are good chances of making errors. 

Is there a way to circumvent this or at least minimize this risk?
What can we do to manage flow better and avoid handing over an 8 hour waiting time?

1. Using checklists
  • Procedural Sedation Checklist
  • Resuscitation checklist 
  • Post Cardiac Arrest Care checklist
  • Reading a CXR checklist
  • ECG checklist 
  • Discharge Checklist

These can reduce cognitive overloading, save time and minimize errors, especially during the busy hours.

2. Listening to FY/SHOs presentations 
Take time and set rapport with your night team. Get a sense of their background, previous experiences and what rotations they have been through so far. Allocate tasks keeping this in your mind. Early on, try and see (at least eyeball) every patient that they are allocated and once you understand their clinical acumen, go with that. 

Being approachable with junior doctors is they key for patient safety. Ask them if they are concerned about anything in particular or if they want you to examine the patient. 

3. Documentation and Risk Management 
Diagnostic uncertainty is a part of Emergency Medicine. it is almost impossible to come with a definite diagnosis within a span of few hours. Sometimes, it takes weeks and months to reach a definitive diagnosis after several out-patient visits. Our job is to think about life threats. We work on the basis of probability and likelihood. Explain this to a patient. Most of them will appreciate and just need some reassurance. Prepared scripts can be useful here. For instance, discharging a low-risk chest pain. Document a clinical decision rule such as HEART score and tell them that:

Based on our evaluation today, your blood reports, and serial ECGs, your risk of heart disease is extremely low. I think your symptoms are likely due to acid reflux. I am going to prescribe some medications and discharge you. With aging, we all develop some degree of blockage in blood vessels around the heart and you may have that as well but this does not mean that you are having a heart attack. You need to follow up with you General Practitioner as an out-patient for further evaluation, see response to reflux medications and a for a definite diagnosis. However, if things change anytime i.e you feel unwell, sweaty, dizzy, short of breath or concerned about anything else then please come back to A&E and we will be happy to assess you again. We are here 24x7. 

Document this conversation briefly in the chart briefly under "Medical Decision Making". Your chart should depict your thought process and rationale behind your decisions. Use scoring systems like Wells, PERC, HEART to manage risk. Occasionally, you will see a patient who asks for a 100% definite diagnosis. Ask about their concerns and set expectations as soon as you see them. If you are sending someone home who looks clinically very well but with a unclear diagnosis, safety net them and arrange further follow up as an out-patient. 

Documentation: It is best to finish documentation/clerking as you go rather than carrying a bunch of charts with you to finish after the morning handover. After the handover, you would want to leave the ED ASAP and this will certainly compromise the quality of your notes. Write explicit and legible notes. 

Patient info leaflets and discharge advice: If you think they are going home, hand over specific discharge leaflets to them beforehand. Tell them to have a glance through them and ask any questions. This keeps them busy and helps to understand their ailment better. Moreover, you are medicolegally safer since you hand over written red fags to them specifying when to return to ED.

4. Triage led blood sets (for minors) - to expedite decision making
  • Young Chest Pain 
  • Pleuritic Chest Pain 
  • CP with risk factors
  • Abdo pain female
  • Abdo pain male 
  • Shortness of Breath 
  • Needle Stick Injury
  • Febrile Illness
  • Fever in Traveller 

Triage led to blood tests based on chief complaints improves the flow but these should be interpreted carefully. Sending troponins for every 20yo with CP will lead to nowhere and may lead to unnecessary further testing. I advocate that tests such as d-dimer and hs-troponin should only be ordered after discussion with a consultant or any senior physician whenever possible. Both these tests are very non-specific but if used judiciously, they can be very useful. Routine second troponins lead to unnecessary long waits and prolong the length of stay. False positive d-dimers subject patients to the unnecessary risk of anticoagulation and follow up. 

Avoid "just to be sure" type of investigations. Do not start hunting for problems in a well-looking 90-year-old. Follow guidelines for imaging and deviate only if you feel strongly about something. If a blood test is not going to alter your management, then don't do it. Check out RCEM guidelines on redundant activities here. 

5. Situational Awareness and communication
While running the show as a registrar (equivalent to final year resident in the US), do less and allocate more. Having a good sense of what is going around with patients seen by junior doctors is crucial. Anticipate further care needs of every patient. For instance, eyeballing patients on arrival and organizing imaging such as X Rays and Head Scans can save a lot of time. Ask yourself:
  • What can you do for this patient in ED?
  • Who is well and who is sick? 
  • Who needs admission and who can be discharged?
Seasoned clinicians almost always decide to admit v/s discharge after 2-3 minute conversation with a patient, occasionally just after eyeballing a patient! Verbalise a clear plan to junior doctors and if possible, write it on the chart. 

Keep a track of co-morbidities and social issues (carers, living alone, frail elderly demented, homeless, domestic violence) before discharging patients. Think twice before discharging an elderly during twilight hours. On a 10 hour shift, I typically spend just about 1 hour with patients and rest of my time goes in getting things done - requesting scans, discussion with Radiology and inpatient teams, adding blood tests, calling labs, difficult cannulas, and most-importantly documentation. When running the shop floor, it is important to delegate as much as you can. 
  • IV Cannulation - Ask the nursing staff to keep the USG machine and equipment ready
  • Joint reduction - Ask FY/SHO to prep everything - hook them to monitor and keep sedation drugs ready 
  • FAST/AAA Scan - Move the patient to a room and keep the USG machine jelled  
  • Wound Repair - Procedure nurse to prepare equipment 
If you are leading the department, then your time is precious. Everyone will be out there looking for you (nurses, junior docs, angry patients, in-patient teams, difficult referrals) and don't involve yourself in something time-taking procedures. 

I work in an enormous ED and it can take me up to 2 minutes to walk from one end to the other. Having a list of phone numbers of HDU, Minors, Resus, Assessment areas can be immensely useful. You can then just call and liaise with nurses rather than physically going to each of these areas. 

Communicate with nurses : Nurses are the backbone of your team and if they stand by your side, things go very smooth. Know them by their names and let them know that you are running the shop floor before you begin your shift. Assign them tasks like putting back slabs, getting medications quickly, patients who need monitoring and frequent observations. 

6. Calling for help
Knowing our limitations is crucial and we must know what we exactly want a specialist to do when we call for a consult. Whether it is ITU, Anesthetics, Trauma team - the theme remains the same. Whenever possible, know their names and with time set a rapport with them. Developing negotiation skills while conversing with a specialist is a skill that we all must learn. 

7. Safeguarding and other clerical work 
On a busy shift, the last thing we want is a doctor held up in sorting out safeguarding and social issues for a patient. Undoubtedly, these tasks are important our job should be to raise concerns about them. FIlling 6 page long referral forms and sending e-mails to a group of people can be very time-consuming and this can seriously halt the flow of the department. I strongly believe that these tasks would be best done by a clerk (non-medical) as this does not require a medical degree. 

If you have anymore thoughts on this, then please feel free to comment and share your wisdom.

Posted by:

     Lakshay Chanana
     Speciality Doctor
     Northwick Park Hospital
     Department of Emergency Medicine


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