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“R*silience” is a dirty word.

The world breaks everyone, and afterward, some are strong at the broken places. (Ernest Hemingway).

Now no sane person ever said that training in EM is easy.  No one ever said that you won’t see people at the extremes of suffering, and heights of pain.  These moments will affect you, and they will change you, now that’s part of life, and seeing it at it’s most extreme limits is one of the privileges and burdens of being an EM doc.

We have no control over what comes through our door (or flow out of our departments).  Sometimes there will be no end in sight, you’ll be tired, you’ll have 2 or 3 or 5 things on the go and worried you aren’t doing any of them particularly well.  You will feel like you cannot cope.

That is okay.  That happens to everyone.  It is normal.  It shows a degree of insight, and situational awareness which is good, and should be encouraged.

There will be shifts where you cry.  That is also okay.  It happens to everyone.  It shows that despite the NHS’s best efforts you are still, in fact, a human being.

Resilience in the context of your training is a word that someone who doesn’t know you uses when he or she means to say “I know it’s shit but you just need to cope”.  So when some people talk about resilience training I worry they want to teach you to suck it up.  It’s an excuse for poor workplace design and management.  It suggests that your management team have given up on making the lives of their employees easier.  In which case they need to go on the frickin’ course, not you.

Examine your own working day:-  You arrive, see patients, have lunch, see some more patients and go home.  There is no scheduled time for you to do audit, CPD, attend courses, or even usually do your bloody mandatory trust induction.  Annual leave is a fight.  Study leave is a rare privilege.

Even the most single minded surgeon is not operating for 10 hours straight day in and day out .  Their day is broken up with up with clinics, admin, ward rounds, and MDTs.  Remember you are in a training job.  Clearly the majority of your time should be on the shop floor, but it is insane to think that it should be 100%.

When people talk about resilience training,   I see a secondary agenda in which the trainee is being somehow chastised for not coping with an inhumane working environment.   It is essentially rationalising institutional bullying.  I’m not using hyperbole here,  someone is effectively telling you it’s your fault, where you are likely under-appreciated, unsupported, and over-worked, they are saying  you weren’t strong enough.  The truly resilient response to such a stimulus is to give them the finger.

Now, there are some very good bits and pieces out there on resilience, I think training in resilience is probably useful if you are going to a battlefield, or work for Médecins Sans Frontières, but for christ’s sake if you need to use techniques picked up from people working during a humanitarian crisis to manage a normal working day or night in a British hospital THERE IS SOMETHING FUNDAMENTALLY WRONG WITH YOUR WORKPLACE.

A few months ago I had two consecutive resus patients die.  I then needed to tell their families that their loved one had died back to back. I felt like the angel of death, and it was emotionally exhausting.   It affected my confidence, I certainly didn’t want another resus case, and it took me a little time to process what happened (after a period of alcohol fueled reflection with some colleagues).  That is okay.   That shows that this ED Registrar still has his some vestige of soul left .  I think there are probably different ways of being resilient, but that most of the ways we describe it are in terms of a masochistic ability to block out human suffering.  I dont think that that is healthy for us, or good for our patients.

Emergency medicine especially needs a variety of different types of people working in it to work.  We need the methodical, as well as the gutsy, we need the blunt as well as the touchy-feely, so to assume that they’ll all be able to cope with the same pressures in the same way is madness.

I also worry that people can be too resilient .  If you keep on being told that there is nothing you can do to change your environment and all of the changes have to be internalised to adapt to the environment you find yourself in then maybe you’ll tolerate poor conditions for too long, or fail to do things like report failures in safety or quality that really should be reported.  You might also fail to see or act to help people who don’t have the same hardened carapace that you do.  Not to mention the obvious effect on your ability to develop rapport with your team and your patients.

So if someone suggests you go on resilience training as part of your ED training;

Think hard.  Be resilient.  Tell them to get bent.

What to do when it’s all going wrong around you….

It’s winter.  Every ED in the country is getting progressively more crowded, and people are packed into corridors waiting for wards.  There’s nowhere to see new patients, there’s patients getting their second or third dose of antibiotics in cubicles.  There are no beds in the hospital.  The wait to be seen is 3 hours 52 minutes, there are lots of people in suits you don’t recognize (hint; they are managers) crowded around arguing with the ED consultant who looks like they’re deciding whether to break down and cry or haul off and punch someone.

Here are some tips and tricks to remaining sane, and getting stuff done in a department that’s a bomb site.

First off accept these three truths:

  1. This is not your fault. This is not even the fault of the ED, the ambulance service, or the people you are going to look after.
  2. It is rubbish for everyone at work, but it is worse for your patients. Crowded ED’s are more dangerous than uncrowded EDs.
  3. Breaches do not matter. Patient care matters.

Ten Tips

  1. See patients as you normally would. If they need bloods, they need bloods, if they need CT’s, Xrays, and they haven’t been done, get them ordered, get them done.
  2. Don’t try to cut corners or speed up, that way you’ll make mistakes, miss things or end up having to go back and go things again.
  3. Write your notes while with the patient.
  4. If you need to admit someone write a plan that’ll last longer than 4 hours. Make sure more fluid, more antibiotics are prescribed.  Keep a sticker or their name on a cheat sheet, and go back and check on them at 6 hours. You might even be able to discharge them if you’ve had them long enough.
  5. If your patient is well enough to be on a corridor after you’ve seen them, move them out to the corridor yourself. Explain why.
  6. It is okay to apologise for the wait. It is okay to apologise that people cannot get toileted, cleaned, rolled, and fed as they need to be.  It’s not good enough and it’s okay to acknowledge that.  Most patients and families will see everyone is working flat out.
  7. TAKE YOUR BREAK. If you don’t I’ll find you, and I’ll KILL YOU.
  8. Be kind to the receiving teams, the medical team especially will be absolutely swamped.
  9. Ask for advice early. Come up with a plan, by all means but don’t try and cope, find the Reg or consultant and get them to check it with you.  They might streamline things for you.
  10. Communicate with your nurses. Help them if you can.  Commodes, getting patients comfortable, mixing IV’s, putting up fluids.

 

Good luck.

CT1: Getting the assessments.

the incredibly rare anaphylaxis CMP1 pokeman
the incredibly rare anaphylaxis CMP1 pokeman

To win ACCS CT1 you need to collect assessments.  Think of it like pokeman go, and hunt in the long grass where the things you need might be.  Sometimes this means being in resus, other times it’s about keeping one ear open to whats going on in triage.  If you have a friendly ED reg or consultant on and you let them know you are looking for ‘X’ you might be more likely to find it.

Now many deaneries will be organising a welcome event for you, often that is sometime in September, to give you guys time to bed in.  You do not have time to wait for this.

There is a lot to do, and realistically you have 9 months to do it in, as ARCPs happen in June, two months before the end of your placement, and in some deaneries your portfolio is locked in May.

Most deaneries split your requirement over AM and EM, but anecdotally I hear that most people find getting the requisite number of assessments in AM difficult and catch up in EM.  This is difficult if you do EM first (so try to get ahead).

A lot of people aimlessly gather assessments as the year progresses with no real sense of focus.  Prioritise collecting assessments you need, ‘extra’ assessments are fine, but there is no real point in having 4 DOPS for primary survey.  So to be smart about what you need you need to know what the deanery ARCP panel will want.

By the end of CT1 you will need:

  • 4 assessments for the ‘major presentations’ (2 summative ones in ED, 2 from AM).
  • 20 assessments for CAPS (5 specific ones as summative in ED).
  • 18 CAPS covered in any other way (elearning, assessments, reflection).
  • 10 DOPS (4 specific in ED, another 6 are anything you can find).

That is a minimum of 34 assessments in effectively 9 months, or just under one every week.  Does that feel manageable to you?  Well I think it’s a big ask.

 

How do you do this?

  • Know the curriculum
  • Know your deaneries ARCP checklist
wall
A ‘serial killer wall’ can help match what you have with the curriculum, and allow you to see where your gaps are…

First off get to know the list of CMP and CAPS.  If you come across someone with that ‘problem’ keep a sticker or the patient’s details.  Use it for CBDs.  Make appointments in consultant’s non clinical time to do CBDs.

If a consultant offers to do a mini-cex.  Get them to fill in the eform or paper form right there and then.

Portfolio time is best spent little and often (spend 10-20 minutes a week on your eportfolio will save you lots of heartache come June).

Do a ‘elearning/reflection’ a week and you’ll be fine.  Wait till the end and you will be screwed.  Reflections do not have to be War and Peace.  Sometimes a 50-100 words is all you need.  You deanery must provide you with teaching.  If you write a short reflection on each lecture you get you can link that to a CAP.

LINK items to common competencies and core curriculum items as you go.  As soon as an assessment is done.  Link and forget.  You need to demonstrate ‘level 2 competence’ in 50% of the common competencies by the end of CT1.  This is really an exercise in wording your reflections correctly.  To do this well you need to know what ‘level 2 competent’ is for each domain.  That means you need to know the curriculum document (which is here).

EM people, here’s the list (the requirements for AM trainees and anaesthetic trainees seem to fluctuate).

2 x CMP 1 – 6  Summative mini-cex, or Cbd from a consultant.

  • CMP1 Anaphylaxis
  • CMP2 Cardio-respiratory arrest (or current ALS certification)
  • CMP3 Major Trauma
  • CMP4 Septic patient
  • CMP5 Shocked patient
  • CMP6 Unconscious patient

Summative assessments from a consultant for these (mini-cex or cbd)

  • CAP1 Abdominal Pain
  • CAP6 Breathlessness
  • CAP7 Chest Pain
  • CAP18 Head Injury
  • CAP30 Mental Health

Formative assessments, 5 covering any other CAP, these can be from a HST, and incorporate ACAT and other tools.

Covering another 10 CAP by any method you like (teaching, elearning, reflection, or other assessments).

You need 4 specific DOPs too.  Airway, Reduction of fracture, Wound management, Trauma primary survey, AND one other.

In AM you need:

2  CMPs from a consultant (some deaneries want formative, others summative so CHECK).

10 CMPs covered by Formative assessments (using mini-cex,cbd or ACAT)

9 CMPs covered by reflection, elearning, audit, assessments, teaching

5 DOPS

So by May June in 2018 you need to have an item/assessment/certificate/reflection in each of the CMP bits of your portfolio (there are 38).  You will also need to cross reference and re-link those bits that are relevant to the general curriculum, as at least 50% of them will need to be covered.

Now many deaneries will provide their own checklists which will give you an idea of exactly what they want you to achieve by the end of the year.  Find your deaneries checklist, pin it to the wall somewhere at home.  Use it to plan.

Now there are arguments about whether this entire exercise is educationally valid, or has any kind of useful patient safety component in weeding out the bad doctors.  I’ll be talking a bit about that later in the year.  In the mean time you just need to get started.  If you start covering things as I’ve said in the above post you’ll be in a much stronger position come your ARCP, and you will feel a lot less stressed about passing.

Below you’ll find a list of ARCP checklists I’ve found for the LETBs/Deaneries in the uk.  Any mistakes, or if you find a checklist I can’t find please get in touch and I’ll add it.

Good luck!

ACCS: Induction

Right.  You are about to start CT1, either in acute medicine or EM.

You are undoubtedly going to have to fill out about 20 forms, and go to a hospital induction during which you’ll be told about diversity and fire procedures, but you won’t get access to the blood reporting system, PACs or a computer log on.  All that is going to do is p*ss you off, and it will not help you in any measurable way.  If you want to make progress do this…

Do these in week 1:

  1.  Find out the identity of your educational supervisor, and clinical supervisor.  Schedule a meeting with both of them.
  2. Gain access to eportfolio for EM.  This requires you to send £90 to Royal College of Emergency Medicine.  Yes it’s extortion.  No it’s not fair.  Just do it.
  3. Find out what heap of assessments you will need to provide at the end of the year, your deanery should publish a checklist of what they want.  If they don’t use the version from here, (I’ll be going into more detail soon).
  4. Start keeping a list/book of interesting cases.  In that book write down a list of all clinical problems you need to cover.
  5. Write a development plan, the following things should be in it, there is no reason why you can use the same development plan for your ES and CS.
    1. Courses
      1. Life support courses, do them, get instructor potential for them.
      2. USS level 1
      3. USS vascular access
    2. Vague stuff
      1. Improve management of emergencies
      2. Improve team working and communication skills
      3. Develop history taking and examination skills
      4. Develop bedside and formal teaching skills
    3. Stuff related to training in ED
      1. Sit MCEM part 1, or A, or whatever the hell its going to be called.  Aim to do the first bit.
      2. You need to do an audit.  Just because.

At the first meeting do the following.  This is your checklist.

  1.  Make sure you know what your ES/CS is expecting from you at work.
  2. Bring food/coffee to that meeting
  3. Get an assessment while you are there.  Bring a case.  Anything.
  4. Get your ES or CS to help you decide on a topic to audit
  5. Get any A/L and S/L forms signed for the next 6 months.
  6. Set the date for another meeting in 4 weeks time.
    1. This is so you can check progress, come with a tranche of further assessments AND discuss your audit.

The Rota.

You ideally need to meet your CS and ES after you’ve got a handle on the rota.  The rota will be horrible.  Every ED rota is horrible.  I am sorry.  So sorry.  It get’s better the more senior you become. I promise.

  1. Take EVERY second of annual leave you are entitled to.
    1. Yes, even odd days here and there where you have nothing planned.
    2. TAKE. EVERY. SECOND.
  2. CHECK what you are entitled to in terms of bank holiday lieu days.  ED rotas often ignore them, but sometimes don’t give you days in lieu for working them.  So check.
  3. Book things to look forward to.  As complex as holidays, as simple as meeting someone for a coffee.  Make these a priority OVER audit, OVER portfolio, OVER revision.
  4. Your training is a marathon, it is not a sprint, it’s okay to stay late occasionally if stuff is going on that will benefit you, but make sure you leave on time, the majority of the time.  Giving the trust or the department an extra 2 or 3 hours a shift is not on.  This means being present at handover on time, and handing stuff over (my wife will roll her eyes at this point as I am very very bad at this, however I recognise it’s important).
  5. Giving handovers mean you have to have happy to receive handovers as well, so accept them with a (sometimes fake) smile.