How to be EPIC

September 14, 2017 Medicine Comments (0) 1184

Let it never be said that we resist change. We, the consultants in my ED, have been reinvented. Previously our title was Duty Officer, which had a pleasantly communist, scratchy grey-overalled sound to it, but now we are the EPIC. An imperious title, in my opinion. This stands for Emergency Physician In Charge. Here’s where the duplicity begins.

I’m hardly in charge of my own brain, so feigning tight command of the beast of the Emergency Department is a bit of a stretch.  

But still, I turn up for shifts. At least I dress appropriately. I wear scrubs which make me look like a scrawny Police Officer but without the fun stuff hanging from my belt.

I carry THE phone. Yes, the one that has the broken ice-cream truck ring tone that peals out horribly during the depths of sombre conversations; the phone that conveys endless information bytes about patients who may, or may not, pass through our doors, or otherwise random requests or facts upon which I am allegedly supposed to act. With this, though, I am firmly in charge. I don’t answer it. That’s the limit of my in-chargeness, I think.

The days vary, like all good days in the vortex of Mount Doom. Let’s take one.

I start it by thinking about coffee, which is then rudely interrupted by waves of patient chaos. Busloads of them and their relentless pathology. By nine I am wondering whether I am coming down with some rare form of illness, perhaps vasculitis, or takotsubo cardiomyopathy, but it turns out I just want coffee.

I am supposed to be at, or possibly in, a huddle. I don’t know what a huddle is. I find out it is a meeting with people who are pivotal in managing patient flow, who will tell me exactly the number of beds we don’t have. Some people will get told off. I don’t get told off, because I don’t know such meetings are being held. And I don’t answer my phone.

Next the bat phone goes off. This is good, because this is what we train for. The registrars go head to head, fighting to answer the phone, because whoever answers it gets to run the code. A registrar is injured in the elbowing melee. They need to go lie down in resus. As I am puerile I announce the incoming code over the tannoy like an airhostess. No one is amused.

The code is a patient with crashing sepsis. Because I am so epic, I am not allowed to touch the patient. I look longingly at the patient’s veins, and imagine slipping a central line into the subclavian to a round of applause, using only landmarks and the fairy dust of a clinician who has been around for so long that they have a sixth sense where these structures are, like a Baggins in the Shire. This does not happen. The registrar slides the CVC in with exquisite skill, brandishing the ultrasound probe like nun-chucks. He does not need applause.

By now my need for coffee has become sentient, and is talking loudly in my head and causing hallucinations. I decide I will have to drink the hospital brew.  Sadly, our hospital cafeteria has insisted that the coffees need to be reproducible, so they have replaced the baristas with an automated grinder. I am not joking here. Something about benchmarks and KPIs. For coffee. At this point it doesn’t matter. I am prepared to drink anything, and don’t judge the drink for its dystopia.

I am ready, then, for the next patient (keeping in mind that I am so epic I know exactly what’s going on with every single one of the rest of the 45 patients in the Emergency Department – what their plans, vital signs, and backstories are, as well as the reasons for them breaching some weird militarily-enforced time-target. How do I know? Well that is the secret of being epic). The next patient is a trauma, a rather bloody and moderately deconstructed victim of speed and inattention. This time, I get to watch a registrar running the trauma, who is doing something called a work-place based assessment. This seems to be a mechanism designed purely so someone as garrulous as me is forced to shut their mouth and watch a trainee perform. In this way I can constructively educate and assess the registrar at the same time. My hands are so itchy to get in there and be involved in the intimacy of patient care they could be weeping in my pockets. The registrar does a fabulous job, and I have only interrupted her about eighteen times. The patient does fine.

I’ve had enough. I want to see a patient myself. I sneak into a cubicle and stealthily close the curtain, where I begin to take a history from a fabulous old man who has been waiting (patiently) for 3 hours to be seen, who is telling me where he fought in the war. But now I am hauled away to a meeting, because I wasn’t smart enough not to answer the phone. I am in trouble. They ask me why it’s taking so long to see the little man who fought in the war. I would like to make a witty joke about the irony of this, but the people with clipboards don’t look in the mood for a joke.

Basically the day continues like this. Sometime after lunch I feel I would very much like a nap. I look plaintively at the distressed relative’s room, and wonder if I could jigger the lock so I could have forty winks, but the phone rings again.

I am surprised by the variety of requests that come through on the EPIC phone. Mostly my job is to try and concoct an answer without getting too cross. Often the answer will end up being of little use to anyone, but I have learnt to phrase things just right so nobody knows that until well after they’ve rung off. A resident calls in sick. This is bad, because it now leaves the number of residents to staff the evening shift as a negative integer. We are suffering from junior staff cachexia at the moment. Everything has been downgraded. For political reasons our hospital has been repurposed and rebranded. Where we used to be the state’s top dog, we are now the punchy little sibling. Things may well change, and it is likely they will. Working here for decades has made it clear that the health ride consists of the dizzy peaks of the rollercoaster interspersed with the gut dropping lows, complete with arms flailing and eyes squeezed shut (or that could just be me). I am immensely proud to work amongst a team that has hung in there, undistracted for the most part by the flighty decisions made by health bureaucrats. The professionalism and commitment of my brethren to patient care has never wavered.

And then, just like that, the day ends. My shift trying to keep the lid on the bubbling pot of entropy is done. I hand over the phone. Someone else gets the chance to be epic. And I’m sure they will be.

This post originally appeared on Life in the Fast Lane.

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Saving Lives, One On-line Module at a Time

September 14, 2017 Medicine Comments (0) 632

I’m not sure how we ever used to manage multi-traumas. We must have been frightfully underprepared. Back in the days before mandatory training we relied, rather guilelessly, on experience, a suite of knowledge from texts and journals and M & M meetings, the good-will of a team, and the wisdom of our trauma specialists. A precarious position, you’ll agree. And an area where you were never entirely clear whether you, and what you did, were good enough.

Now, thankfully, we, as employees, are standardised – acceptably and holistically checked off. Benchmarked and compliant and up to date with our mandatory on-line modules. This is good. Most aspects of emergency medicine are chaotic and messy enough as it is, seriously in need of a good digital check-list groom, let alone considering trauma, that most unpredictable of diseases. Trauma is another grade of disarray altogether. Anarchy held together by skin.

The beauty of on-line modules is the certainty. And the reproducibility. It is beyond edifying to know that the person working next to me is signed off as competent in accountable decision making, and I know they can safely handle a patient over a certain weight-grade. I can be confident the web spaces of their fingers are flawlessly washed and germ-free, and that they have practiced a variety of safety stances in the case of impending violence. They are, in the eyes of our executive, trained.

Although this does bring us back to the consummate violence – the type manifest by our major trauma patients. These patients are so damned disordered. Internally dishevelled. Disobedient. Take your eye off them for a second and they’re setting off fireworks somewhere in their innards, right where you didn’t expect. So we don’t. Take our eye off them.

Trauma is the ultimate team sport, best played with the slickest and most integrated, respectful team, peopled by the most experienced team members possible, running the shebang from the moment of the traumatic event somewhere in the giddy light-filled outdoors, sliding through the corridors of ED, then off to their various destinations; the end string of the maze chosen efficiently by leaders with a beady eye on the patient’s belligerent biology. But these people, these team members, seriously worry me. I have a growing suspicion that not all of them are up to date with their mandatory training. They seem to embrace uncertainty. Are comfortable with it. Are able to work within it and make quick, dancing decisions based on all sorts of unmeasurable factors. This simply will not do.

No. The tremendous sequel to the staggering increase in administrative staff over the past decade has been the glorification of the black and white. Nowhere is this demonstrated better than in the increasing production of mandatory on-line modules, and the reliance on these as a tool for signing off hospital staff as being compliant and competent. Time well spent, I can hear you all cry. What better way to prove that you are proficient in managing complex patients than by spending precious hours taking quizzes on terabytes of information about the muster points for a fire in the café? I know I’m not alone when my heart leaps a little with joy if I make a single error on the quiz, thus allowing me to return the start of the information package. Who wouldn’t rather read how to operate the hover mattress than a discussion of the nuances of trauma induced coagulopathy? Let us all learn to play chopsticks, not Chopin. No gaming or glazing while doing these tests, that’s for sure.

But, you say (rightly calling out my unseemly sarcasm), you have trauma meetings, missed injury reviews, audits and registries, discussions with colleagues and debriefs, to ensure you’re at your most capable. Yes we do (and thank the deities for these). Mostly, however, these are voluntary, certainly for the individuals within this vast swirling system. No. The only thing the institution expects of us is printed off, signed off, grinning compliance with the mandatory on-line education. And these are not the only digital incursions we must fill out, sitting lachrymose over our congealed coffee. The Working With Children Check (otherwise known as a ‘tax’) (a biennial, utterly baffling piece of bureaucracy that requires an ACTUAL visit to a post office), on-line credentialling at hospitals we have worked in for years if we want to even sneeze inside, and just when one’s hair is ready to be torn from its roots at the internal agony, an online mandatory training module for resilience and mindfulness (not yet at my institution – the irony bar has not yet swung so low).

It sometimes feels like a war. Us versus them. Complexity versus simplicity. Unmeasurable versus yardsticks. Commonsense versus the absurd. It shouldn’t be. Our goals should be aligned, we clinicians and non-clinicians – to provide the best patient and community care, approached sensibly, with respect enough that neither party should waste time on activities which do not contribute to either. We should not both be drowning in madness, in either the thick, or the administering of it. We await the return journey of the pendulum. In the meantime, it’s back to the mostly, unquantifiable mayhem.


This post originally appeared on Life in the Fast Lane.

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