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A look at Life as a Physician Associate in A&E

I've managed to get 2 amazing Physician Associates -Myya and Andy -who work/have worked in A&E to give you the inside scoop on Emergency Medicine. Read on to discover if A&E is the right place for you.

First up from Myya:

My day starts as I walk towards the staff entrance to A&E and look around to see how many ambulances are lined up outside. As I walk through the door, I gauge to see how many patients I can see in the department which usually gives me a good idea of what kind of day it’s going to be! It can vary from 1 or 2 to a full house.

I make my way to the department and find out from the Consultant team leader where they would like me to be, majors or minors, and make a start. The Majors area deals with generally systemically unwell patients such as those with an exacerbation of COPD or acute abdominal pain. Minors deals with more of the minor injuries such as broken ankles. Resuscitation (Resus) is where patients who are in a life threatening-condition and need closer monitoring are looked after. I don’t currently work in Resus, unless my patient is transferred there. I hope that with time, experience, further training, and if course confidence, I will be able to treat patients there also.

Each patient has a ‘Cas Card’ the front sheet of which will give you the patient details, the triage notes and a set of observations. Patients are triaged by the Triage nurse in order of priority using the Manchester Triage system. We see patients in order of urgency and then secondarily time order.

A&E wasn’t too scary for me to start on as a newly qualified PA as I was fortunate to spend a good chunk of student placement time in the department I now work in. As a student I spent my time learning and absorbing as much as possible. Now I am a functioning team member, I have to consider not only the patient, but keeping a good flow in the department by working efficiently and independently.

After my first day on placement in A&E, I knew I wanted to work in Emergency Medicine. It was fast paced, meant thinking on your feet, adapting to changing situations and all within a 4-hour time period. Perfect for me as I have a short concentration span, but I love solving problems. 4 hours goes faster in A&E than any other place on Earth, for the clinician anyway. The timer starts as soon as a patient walks through the door and by the time you actually see the patient they’re often at least 1 hour in, depending on how busy the department is. By the time I’m seeing the patient, particularly if has been a long wait, they can often be frustrated and tired. I’ve personally found that a good explanation of what the patient should expect to happen in the department, answering questions (admitting when you don’t know the answer!) and the offer of a cup of tea and a biscuit can help to ease many anxieties. Going out of your way for a patient may just make their hospital experience a little easier in a time of acute distress.

Over the past few months I’ve learnt how to start my clinical assessment as I walk into the cubicle or as I bring the patient in from the waiting room. You can often tell how unwell someone is by just observing them. Do they struggle to get up from the chair? Do they stop 3 times before you get to the cubicle because they're breathless? I’m by no means any kind of expert and everyday I learn a lot. I’ve learnt that emergency medicine is about recognising the acutely unwell patient who is, or could shortly be, in a life-threatening situation. I’ve learnt to go with my gut instinct.

A few weeks after starting I experienced this for the first time. I picked up the Cas card of a patient who’d come in feeling generally unwell after being on a cruise. I noted that her observations were fine, I thought she’d probably have picked up something viral from the ship. She was 75, so I knew I had to rule out anything serious that may present atypically. I drew back the curtain and she looked dreadful. She was moaning intermittently, staring into space with her mouth hung open. She looked dry, dehydrated and limp in the bed. She did not look as well as her observations suggested she would. She was able to answer my questions but every word seemed to exhaust her. Her daughter said, “you wouldn’t think she was driving around doing her shopping 2 weeks ago”.

Her VBG, and in fact all her bloods were wildly deranged. She had a serious urosepsis with a hyperkalaemia. It was an exam question come to life, but there was a real person in front of me. I couldn’t organise my thoughts, I knew what I needed to do but my brain was firing off in a million directions. But the best thing about working in A&E, especially as a newly qualified PA, is that there is always someone around to help. I’ve seen more and more patients like this and I’ve learnt from senior clinicians. They've shown me how to be calm, focused and prioritise tasks. I’m never panicking alone for long!

You can’t fix everything or work out exactly what is going on in 4 hours, but you can make a patient stable and give them any acute treatment they require. A&E is a busy place and I personally take the opinion that wherever help is needed, you help out. Whether that means wheeling a patient to X-ray yourself if no one is available or helping a colleague with a difficult cannula. Helping to keep the department moving and using your initiative to help out the team can be just as important as your patients.

I have found Emergency Medicine to be rewarding and exciting. I haven’t had a boring day yet and you can never guess how the day is going to go. There’s still lots of skills I want to learn and every day I feel more inspired to better my knowledge and clinical skills. I’ve found it be a great place to start my career as I’ve really reinforced and built on what I learnt as a student. I use a lot of my knowledge every day and my confidence carries on increasing.

It’s not for everyone but I’d definitely recommend having some Emergency experience as a student or qualified PA, as most of the patients you will see in secondary care will have been seen first in A&E. It is a great privilege to be able to start someone on what will hopefully be the right track to recovery and perhaps even save their life.

Now from Andy:

First off, let me introduce myself: I'm a University of Manchester Physician Associate graduate who is currently undertaking my consolidation year at a Trust in Cheshire in a one-year rotational post. My year started off in a four-month block in the emergency department (ED), I then moved to acute medicine (where I'm half way through my four-month block) and I will finally finish in an acute surgical specialty. After the consolidation year, I plan on applying for a position in the emergency department with a specialist interest in trauma and cardiology. I have been asked by @notadoctoruk to give you all a glimpse into my rotation in the emergency department. I will give you some insight into my work-life: the highs, the lows and what I learnt from being on the front door of the hospital. Before starting in ED, I was anxious from the media, students and healthcare professionals painting the picture of 'It's awful, you'll drown in drunks, you can't move anyone due to no beds being available'. I'm not going to lie, there was fear on the initial morning, but I was welcomed by the consultants, the nurses were incredibly helpful and the junior doctors took me under their wing. Sometimes it is busy, it feels like you're being submerged by the amount you are being asked to do. All the cubicles are full, there is only one consultant, two other juniors and you're four nurses short. But every patient knows I care about them. They know their plan of care, that I will comfort them when they need it and that we're going through this together. The staff in ED also look after their own and support each. After a bad trauma call, we debrief and make sure everyone knows what they did well and give each other two minutes to regroup before going back out onto the floor. Every day is different and your family and non-medical friends don't/can't believe what you go through each day. It normally starts with a handover at 0800 from the night team and then the Medical Team Leader will tell you which sub-department (majors/minors/paeds) you're going in. Then it's either follow up on jobs from the night or pick a 'cas' card from the 'to be seen slot' and the day kicks off. My job varies from reviewing ECGs, assessing critically ill patients, liaising with the Registrars, Consultants and other specialities to admit patients into hospital. Clinical skills wise I've performed numerous cannulas, ABGs, venepuncture, relocating wondering shoulders, femoral stabs, suturing head wounds and performing ALS. It’s all in a day’s work. It’s fast paced and exciting. You see a variety of presentations every time you pick up a patient from obs & gynae to paediatrics, to being pulled into resus to deal with a critically ill patient. It's not for the faint heated and is often described as 'marmite' as most people either love the pressure or hate it

In ED the highs are high and lows can be bottoming. I have experienced patients dying in front of me and having to inform family members that unfortunately we were not successful. I've had patients complain that we aren't doing a good enough job or they have been waiting for too long. It is stressful and can feel like you only have five minutes to do certain tasks. But the majority of patients understand that you're there for them. They know if they're not being seen straight away its normally a good sign that they aren't critically ill and will be seen soon.

When you're on ED, enjoy it - the front of the hospital is where everything is saved or lost.

Here are some useful tips:

  • A-E Approach is a life saver (literally)

  • You will be expected to work hard so take your breaks!

  • The nurses and the healthcare assistants are your friends and can always help you

  • Be patient with your patients, particularly the patients you don’t like – make sure they are investigated properly

  • Learn to suture before you arrive

  • Learn how to put in nasal packs

  • Always explain what you are doing to the patients and their family – hospitals are scary

  • The Oxford handbook of Emergency Medicine and Raby’s Accident & Emergency Radiology: A Survival Guide are worth owning

  • All women of childbearing age are pregnant until a pregnancy test says they are not

  • NICE guidelines for head injuries and when to do a CT head – Read them!

  • Don’t miss the second fracture when the first one jumped out at you from the x-ray

  • Don’t avoid Resus – skills learned there are vital for your future career

  • And don’t ever forget the glucose!

  • A smile and a cup of tea or coffee will bring a smile to any face.

  • Make sure you know the name of the nursing staff, they'll save you more times than you can thank.

Hopefully you've now got a better idea of what to expect from placement/working in A&E!

As always if you like what you're reading feel free to leave a comment or share on social media.

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