General Interview - ED Flashcards
Why ED?
-Since my first F2 placement in ED. Continued to work as a JCF for the last 18 months (ongoing)
-Variety; problem-solving; practical skills; team working
- Variety - paeds, obs/gyn, gerries, medicine, surgery, trauma -> no other specialty is as varied
- Problem-solving - love the challenge of making a diagnosis. First person to see a patient and formulate a plan. Free time enjoy puzzles (chess / cryptics) - aligns with me
- Practical skills - hands on; enjoy + am good at. Logbook: FIB, joint manipulations; US access, chest drains; Arterial / central lines, LPs, POCUS (course, monthly club)
– having looked at ACCS curriculum, have a base set of practical skills very well suited - in conclusion; love the work in ED and well suited to my skillset. Look to pursue dual CCT in ICM.
Why you?
Many strengths towards work as EM clinician - great feedback from seniors in current EM JCF role. Eg of inspiring consultant, leading trauma call - amazing, just the sort of doctor i want to be
Communication/teamworking skills; problem solver - diagnostician; quick learner - good practical skills
TEAMWORK - teamwork / rapport / comms - developed in rugby, continue to
PROBLEM-SOLVING - love diagnosis, problem-solving – eg head injury –> brugadas. Helps make diagnosis, think broadly & open-minded.
LEARNER - pick up skills, love hands on nature of the work - logbook, very proud of - US, FIBs, joint manips. Expand this repertoire in training.
Great experiences so far in EM - med student, F2, JCF in major trauma; very committed - attended courses & teaching - BASICS / EM L1 US / ALS; also keen on developing non-clinical work - QIP (EPAU), teaching med students / simulation; would look to make this part of my role as a consultant. Recognise the challenges, but well aware of these and love the specialty.
Many skills required, i have an excellent baseline to start training and really make the most of a career in EM.
Time you were unable to deliver good care?
(S) Acute medicine, big hospital, 2 arrest teams, changing bleeps, unclear (piece of paper on wall in office). Time went to arrest, full team not present. Ended up utilising other doctors present on the ward, but patient ultimately died
(T) Unsafe, uncertainty amongst juniors about who should attend.
(A) Datixed the incident. Decided I wanted to improve this. Surveyed doctors - showed clear misunderstanding. Made a simple intervention - putting stickers on all the bleeps of AIM / GIM.
(R) Re-survey - massive improvement. Anecdotally at arrests - better attendance, better outcomes.
Commended by my clinical supervisor
Reflection - happy with this improvement. Preventing further mistakes. Acute care is area i am particularly passionate about.
Time you made a mistake?
(S) Miscommunication with nursing colleague led to medication error. Busy resus, pt w/ CAP, i asked nurse to give abx / ivi. misheard - gave neb
(T) Fix mistake, patient safety, prevent further
(A) reassessed patient, ensured no harm, ensured prescribed medications given
(R) Discussed with the nurse, miscommunication due to rushing, busy dept, noisy. Could have been improved by clearer closed loop comms.
Changed my practice - always take time + use closed loop - subsequently prevented medication errors in another scenario.
Datixed + discussed at M&M - changed departmental practice - electronic prescription required before administration of drugs. - further layer of safety
Time your communication has positively impacted a patient?
Communication something I really enjoy about EM, discussions with patients. Working as part of a big team.
(S) drunk lady, wound ?stabbed, very rude/aggressive
(T) safety, vulnerable patient, ?assault/abuse,
(A) i was very patient, non-judgemental, empathetic, listened. Allowed her to go out and smoke. As i sutured the wound, she opened up, talked about abusive relationship and wanting help
(Result) - referred to DV services, given help she needed
(Reflection) - commended by SpR who could hear on my communication and empathy.
- taking time to listen
- would have been easy to dismiss patient and not find out about this - could have come to harm
Leadership?
(S) Patient with incarc periumbilical hernia.
(T) Needed prompt investigations, treatments, referral for emergency surgery
(A) Led the team around me:
- CSW - bloods/cannula
- Nurse - analgesia, abx, ivi
- Escalate to CIC
- D/W Radiology for CT
- D/W Gen Surg for review
(Res) - patient went to scan + was in theatre within hours of review
(Ref) -
What do you know about ACCS curriculum?
ACCS curriculum hugely exciting, really attracts me to ED application.
-Professional knowledge, skills, values
(F2 - ITU, EM, AM - absolutely loved)
4 rotations (EM, AM, anaes, ICM)
- Clinical learning outcomes encompassing domains of good clinical practice including practical skills
– already completed many of these, look forward to improving competency
- Generic learning outcomes - education, quality improvement – pillars of clinical governance, already involved in
- Have a good skill set to make the most of the training programme
Following 2 years - 1 further year of ED before entering HST; I also really enjoyed ITU rotation of F2 + attended BASICS, would look to dual train w/ ICM.
Challenges facing training?
- Stretched resources - money, time, educators
- Increasingly busy ED department, necessary to prioritise patient care - means more limited scope for education - CBDs, DOPS, attending departmental teaching etc
- eportfolio - lots to sign off, i have been keeping a logbook so this is part of my day to day practice
- exams - important to balance work-life to be resilient, intend to do MRCEM asap and work towards it prior to ct1
- rotation to new departments - excite for new challenge
Challenges facing EM?
Unprecedentedly busy time in EM, increasing pressures over the last few years.
*Number of attendances
*Exit-block & overcrowding
– patients waiting for inpatient beds leads to bed block, delay in reviews, poorer outcomes (400,000 / yr waiting 24hrs in dept)
– also this has huge effect on staff - moral injury, burnout, wellbeing
- older population, more comorbid
- Read on RCEM - #resuscitate EM manifesto
– Needs urgent action
Where do you see yourself in 10 years?
Variety of directions can take role as EM consultant: Trauma, education, hospital management, QI, paediatrics, Sim, medical examiners, research etc.
- Dual train ICU / PHEM
– ACCS 3 years, enter higher training for ICM ST3 / ED ST
- MRCEM 1’, sba, osce + FRCEM; + FICM exams
- Completed ACCS and higher training, in early career as consultant.
– Particular areas of interest = ICU, POCUS, education
- personally: house renovations, ?family
Problem solving made a difference to patient care?
(S) Young man presented with head injury. He was brought by his friend did not want to come, very dismissive
(T) Assessment of head injury
(A) thorough history, he had collapsed on walking with no prodromal symptoms. Had happened several times. Further tests - LSBP, ECG -> showed Brugada syndrome
(R) Interesting case, keeping broad open mind in assessment.
Would have been easy to pigeonhole patient into minor head injury not requiring CT.
But problem solving skills meant I recognised abnormality, investigated and diagnosed with rare cardiac condition - patient admitted, further tests, was d/c with ICD
Worked well under pressure? Managed competing interests?
(S) AMU; arrest bleep + deteriorating patient; take shift
- (T) blood tests and imaging to chase; reviewed a deteriorating septic patient; arrest bleep went off
- (A) patient safety priority. Lady i’d just reviewed needed fluids & escalation of abx; arrest to attend
- (R) Ensured treatments prescribed for deteriorating pt; nurse aware; had my bleep no.
– Went to arrest, day team + medical SpR present, explained situation and was allowed to return to my unwell lady
- Patient safety is priority. Organise tasks in order of clinical need. Sick patient/arrest clearly top of list. Utilising MDT around me; CSWs, nursing staff; other junior doctors; peers.
How do you deal with stress?
- Being a doctor carries with it a deal of stress - different types (busyness/overworked, emotional, cumulative fatigue). Each dealt with differently
- High workload, deal with by being organised, efficient and working as a team. Recognise own limitations. Take breaks
- Emotional stress - challenging patients, seeing death etc. I am calm, levelheaded - received good feedback on this from seniors
- Cumulative - hobbies outside of work; music, reading, seeing friends; sports - rugby / CF; used to juggling competing pressures and organising my time. Helps me switch off. Also recently started meditating which I’ve noticed a real benefit
- Conclusion: many ways to deal with stress. Find I am often able to remain calm in challenging situations
Differing clinical opinion from colleague? How did you deal with it?
- Middle aged lady with syncope, diarrhoea, menorrhagia – long history of all these problems
What are human factors? How do they impact care of patients?
– Broadly speaking, human factors refer to a range of environmental, organisational and individual characteristics which could influence our performance at work. In the healthcare setting, these factors could affect or impact the safety of the care we deliver to patients.
– Examples of some personal factors which commonly influence people to make mistakes/errors are stress, loss of situational awareness, distraction, fatigue, lack of teamwork, communication etc. Do not forget that simple environmental factors such as computers not working, having to complete multiple paper forms for a single request, different labels that look alike, or a lack of appropriate equipment in clinical areas also have a significant effect
