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I stood in the emergency department resus department waiting on the arrival of a middle-aged man who was having a myocardial infarction. That day heart attacks were like buses; nothing for hours and then just as the evening shift started two arrived at once. We had to split our teams accordingly.
My patient arrived red-faced and drenched in sweat. A quick glance told me he was somewhere between conscious and not, he snored and a red plastic airway hung precariously out of his mouth. I estimated his BMI at more than 50.
So this will be my first emergency intubation in resus, I thought, as I looked at him and took a slow deep breath in.
‘We need to get this patient to the catheter lab, are you happy with his airway?’
I wasn’t, so I prepped for an intubation and thanked the Gods that there was such a thing as a resus ODP. A senior colleague was with a patient behind the next curtain, I told him my plan, I knew where he was. A pre-hospital trauma consultant was another cubicle away.
I looked down at my patient as he lay on the trolley; yes he was huge and red and gasping, but he was breathing for himself. I would soon put a stop to that. Please God let me see the cords.
Just as I began to adjust the trolley, I looked up and saw another emergency medicine consultant. I hadn’t seen him since I’d rotated through as an FY2, but he remembered my name. ‘How are you?’, he asked.
We talked about my plans A and B and without suggesting he had anything but complete faith in me he asked if I would rather he left me to get on with it, or stood quietly behind my left shoulder. I chose the latter.
We pulled the curtain around and I sent my patient to sleep. I waited the seconds that seemed like hours for paralysis to set in and he stopped breathing. I lifted the laryngoscope and pulled up and then up with more force, and there they were; the cords.
The bougie went in, followed by the tube and it was done. The consultant had only said two things during the procedure, just quietly enough so I could hear him, ‘this is going really well’ and ‘you’re doing great’.
I think I must have looked at that consultant like he was the most wonderful man in the whole world. Help comes in lots of different forms and even when you know you have ample skilled seniors just a moment away, sometimes what you need is that person on your shoulder just telling you that they know you can do it.
He probably did the same for tens of other trainees that week, but it meant all the difference to me.
What were your best (and worst) learning experiences on the wards? Use the comments section below
By the Secret Doctor
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If you have a good view of the cords, there is no need for a bougie, just put the tube in. However I'm aware that this is the teaching in emergency dept. Bougies can cause injury.
He passed me last week on my way into the hospital. It was his energy laden walk which I recognised as he shot past. Shyness and a fear of not being recognised after 22 years, prevented me from rushing up to him to say "thank you ". He was one of the registrars on rotation in the ward, I was a new highly sensitive House Officer with the added complication of having graduated abroad.
I always felt totally supported , he never questioned why he was bleeped but only what ( which made get as much information as possible before bleeping), never made me feel any question was stupid (which made me learn more), he was creative when things went wrong (once using an Echo machine to do an abdominal ultrasound in an emergency) , always explaining everything as he went along . Like the Secret Doctor's story above, he told me I could put a line in and stood patiently ...then said "thank you for your help" when I succeeded... I left clinical medicine 20 years ago , but thought about that registrar often.
He gave me confidence and support and although being exceptionally bright and competent, was one of the most modest I have known. I did think , like the story above that he has probably helped hundreds of trainees since , but I hope they have all had the opportunity to say thank you and do you realise how much good effect you have on people because you are not only supporting juniors , but also teaching them how to be good seniors
Great to hear you had such a great mentor - even after you'd "moved on". This consultant is surely one of those who make the NHS great. What an inspiration to us all.
My greatest teachers (and I have had many!) have been more about how they teach than what they teach. Calm authority and compassion to patients, staff and relatives and an ordered, clear and logical approach mean more than a whole textbook of knowledge - and make the textbook easier to digest too. No NICE guidance, referral pathway or e-learning could achieve this in the same way. It takes the personal touch to impart confidence like this and to allow learning from failure. This is what we need to strive to hang on to in the NHS and it takes time and energy to achieve.
thank you I needed to read something positive. We all need role models.
We all need great role models. One of mine was Peter S an endocrinologist and superb generalist in Leeds. From him I learnt in the 1980s that giving an expert opinion is not about asking for a dozen more tests. It is about assessing the patient and information and giving the very likely diagnosis. Rarely were more than a couple of tests required, rarely was the differential more than two options. I carried this approach with gratitude through my consultant life. David Bullimore (retired)