Indulgent navel gazing post on doing the job for a moderate length of time

4 Apr

In a fit of reflectionism (sic) on a damp and cold camping trip with the family (much more fun than it sounds…) I started thinking about how things have changed in my practice of medicine over the 14 years I’ve been doing it. Feel free to take this as the premature nostalgia it is and forgive me if he lapse into stories about how i walked 10 miles to work bare feet in the snow…

Gizmos

Bedside ultrasound must be the big one. I remember when the ED got a machine and I would spend ages after shift scanning my wrist and neck to see what I could find. I learned all my lines and procedures in the time before ultrasound was widely available. I’m glad I did as you would find it hard to learn them without ultrasound these days. My current ED has a very limited machine that isn’t always working and I still cope just fine without it but there are still some times when I would feel so much better if there were B lines of not, or avoid poking a poor patient 5 times for IV access

Drugs

LAT gel also didn’t seem to be around when I first started and now that it’s everywhere it makes dealing with wounds on kids so much easier. That and intranasal fentanyl with an atomiser. We had intranasal diamorphine when I started but the fentanyl is much easier to work with.

Starting people on anticoagulation seemed like it used to be a much bigger deal. Now with DOACs you can start it incredibly easily. This is in many ways a good thing. There are also some pit falls – the easier it is to do things the more people will do it and they have a tendency to forgo the thorough risk assessments one might do with a more complicated system. The pathways and protocols for starting anticoagulation are now common place and almost a daily occurrence (when 14 years ago they might have been admitted) however I think our procedures to ensure that we do this safely are still lagging a bit behind.

Stroke

This one is interesting. When I started we just admitted all strokes. Didn’t even order a scan in the ED. I remember finding stroke difficult and pretty sure I admitted someone with a rotator cuff tear as a stroke and someone else with a blood sugar of 1.5 whose stroke miraculously disappeared with sugar.

Then came thrombolysis which was nothing if not controversial amongst the EM community internationally. I wrote my own magnum opus on it when I was first learning how to critique papers. The train has already left the station despite our concerns about the quality of the evidence base. The same could be said of course for something I really love – PoCUS but of course we can all be quite selective about when the evidence suits us…

My experience of the implementation of lysis for stroke in Ireland has been very positive. There are not that many conditions that get a consultant to the bedside for an assessment that quickly. Whether or not you agree with the evidence acute stroke patients are getting a high level service. We can’t manage to do it for trauma yet…

I’ve had limited exposure to clot retrieval for stroke but what I have has been excellent – they are a truly tiny minority of strokes but the outcomes I’ve seen have been great (which fits with the consistently positive trial data).

Imaging

When I started getting a CT in the ED was a very uncommon experience. Even when you did this was pre-PACS so you got those lovely tapestry like printed out things. Now it would be a very odd shift if I didn’t order a CT.

There are (at least) two reasons I can see for this. Firstly we do a lot more work in the ED that would’ve been previously done as an inpatient. This seems like a good thing and I find it hard to find the downside. I think we’re reaching the end point of admission avoidance schemes though and the majority of people who need to come into hospital probably need to come into hospital. The only admission avoidance scheme that might work for us is an efficiently functioning out patient system and i think we’re a long way off that in Ireland.

The second reason is increased indications – CT is just such a good test for so many things. I remember doing all our own injections for IVPs for years. It was a pain in the bum and wasn’t really a very good test. We used to spend so much time debating over the nuances of the abdominal xray.  Now we just skip it and get the CT. Unstable trauma patients would never go to the CT but many places are now quite comfortable with deliberately scanning the unstable patient. 

Education

OK so if you’re reading this then you’re experiencing the change that I noticed. My initial experience of EM was limited to the Oxford Handbook and my local ED that I used to work as a cleaner in. The hospital was round the corner from the house I grew up in. I had no other experience to judge things from. In around 2006 as a junior there i discovered EMRAP on the iTunes store and through that discovered the abstracts. I’d started to feel that no one I worked with was quite as obsessive enthusiastic as I was about medicine. I wanted to go to the pub and talk about papers and odd clinical presentations (i still want to do this…) and then I discovered Life in the Fast Lane and twitter and it turns out all the compulsive obsessive geeks enthusiastic EM docs were there.

Some people experienced the growth of new media in education as a move from traditional media which they abandoned in favour of the interwebs. This was not my experience at all – in fact the more online material I consumed the more traditional journal articles I would read. I started buying actual paper textbooks of EM to give me more of the background to clinical presentations and conditions.

This stuff now takes up a lot of my time and for me has been a great protection against disillusionment, isolation and burnout (probably). Realising that I enjoy the job more and do better at it when I work less has also been part of this.

Posts like this one

When I first started the site (May 2011 I think), pretty much all my posts were rambling incoherent opinions like this one. I’ve always enjoyed writing like this (whether anyone read or not) and to be honest I’ve kind of missed it. The material on the site now is a lot more structured and probably more useful to more people than it used to be. And I’ve dedicated a lot of time to some substantial projects that I’m glad to have committed to. However these have all taken away from the mental space I’ve had for nonsense like this. But the nonsense matters – at least to me it does so hopefully you might some more posts like this in future. With more Simpsons GIFs too…

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