The swan is a bird of grace and beauty, gliding seemingly without effort, as it meanders towards its journey’s end. Of course, below the water’s glass-framed gaze, these swan’s legs are constant in their furious and frantic fight against the currents to achieve such a goal. Accident and Emergency (A&E) Departments are like the ‘reverse swan’; furious and frantic on the surface, exposed for patients and the public to see, and for the media to scrutinise, while underneath it all, there is in fact an established, dynamic, and deliberate pathway. A pathway designed to direct the patient towards the best possible targeted care.
Approaching the end of a four month gruelling, yet unbelievably positive and rewarding, rotation working in a busy London-based A&E Department as a junior doctor, I wanted to share a panoramic view of my experiences. As such I will, if you don’t truly, quietly and politely - but very deliberately - side-step the politics of A&E Departments that has dominated headlines over this winter; for as a junior doctor, I am in the infancy of my vocation and will leave politics to those much wiser for now, much preferring instead to focus on the job in front of me.
First stepping foot onto my A&E Department, known lovingly amongst many A&E staff as the ‘shop floor’, was an unflinching assault on the senses. My ears detected every buzzer, alarm and machine known to civilisation pinging a full 360 degrees around me, and voices with tones spanning a spectrum of happy to furious fill the department. The public address system is a constant tune of requests and demands for doctors to review patients, or present themselves to seniors for discussions regarding patient management plans.
Visually, I drink in a scene of patients, nurses, doctors, and all manner of allied healthcare professionals moving in what appears directionless yet impassioned manner. It appears chaotic and scary, and I wonder how on earth I will survive. Of course, with hindsight, having just made that statement as a doctor, it makes me appreciate a lot more how much scarier it must be for the patient for whom A&E is often an attendance of necessity rather than choice.
Today, as I write this I have six shifts left as an A&E doctor. In total I have completed 74 shifts, mainly at evening and night, averaging 10 hours each, and worked every other weekend for four months. The mixed sounds and sights no longer concern me; not because of complacency, but because now - through repeated daily exposure - I understand that every one of them has an explanation, a purpose and a plan attached. And of course too, these people aren’t directionless but rather moving very purposefully with clear destinations in mind and actions to be completed. I state this sanguinely because since that first day I walked onto the shop floor, I have been one of them.
A&E Departments truly are a unique microclimate with an intense diversity that, perhaps, you do not see in many other areas of hospital life. After-all, at any one time, this A&E Department is populated with staff, patients, ambulance crews, police guarding patients under arrest (that’s a daily event), social workers, and children (who occasionally drift out of the more colourfully decorated paediatric A&E Department).
In the past four months, having seen just over six hundred patients myself, I am now assured that no A&E Department healthcare team member will be without their share of unique moments or patients that will fail to fade from memory.
My experiences have unequivocally been on a rollercoaster spectrum, from The Heartwarming: treating a 94 year old couple in the same A&E Department bay where both claim the other one had fallen over first - but refused to leave each other; The Bizarre: pulling, what I am pretty certain was a cocaine stash, out of a patient’s ear at 3am - who then ran off; The Unexpected: finding the teenage patient in the A&E Department bed with her boyfriend and having to give them a telling off; The Heart-thumping: drilling a two-inch needle through the shin bone of an injecting drug user who we could not find a usable vein on, and was about to go into cardiac arrest; and, The Heartbreaking: seeing a patient in the resuscitation room tragically and unexpectedly die despite resuscitation efforts and then having to inform their large family in the adjacent relatives room.
That heartbreak is something that echoes across all hospitals around the world. In an era of social media, those moments have even been captured, such as in the US last week, when a doctor was pictured grieving for a patient. Moving on from these tragic moments is often insurmountably difficult, and in the few instances I have had to do it in my 18 months as a qualified doctor, I am all too aware of the false smile I wear for the next patient – my mind still firmly gripped the tragic events just passed.
Like the relatives of the dead who rely on each other to grieve and process such heartache, the healthcare professionals involved rely on loved ones and team members to debrief, acknowledge and accept what are clearly very difficult times. Ultimately we all cope in different ways.
The professional development gained from working in any A&E Department is immeasurable, but I doubt that any amount of theory could prepare healthcare professionals for its intensity, speed, ferocity and pressure that it, at times, can unrelentingly deliver. Having been shouted out, antagonised to the point where I am chewing my own lip-off just to hold my tongue, been cried inconsolably on by grieving relatives, or treated with such unpalatable distain because I refused to give into a patient’s unsafe and ridiculous demands, I cannot but reflect on the person I am as well.
I do not hide the fact that I have gone home angry, frustrated, or crying on my cycle home at 3am because of self-criticism and inadequacy, patient criticism, or simply the traumatic events of the shift. All those involved in healthcare, perhaps more so those in A&E Departments, may have experienced times like these. What I have realised though, is that for all those negative experiences, there have been other times when patients have thanked me, made that joke in the early hours of a Sunday morning that lifted all our spirits, and even given me an Easter egg to say thank you (which admittedly, was then eaten at 4am). However, as we all know and perhaps begrudgingly appreciate, we learn and develop best when we are stretched. I would be lesser without these experiences both professionally and personally.
I've managed not to mention four hour targets…but this is just a snapshot of A&E Department life from the perspective of a junior doctor working within a much larger A&E team; a team of people with whom I am incredibly proud to even be associated with - from the paramedics to the porters. But the most important team-member in the A&E Department is the patient – you, me, my family, yours.
When someone is taken from the comforts and safety of their home (not forgetting those who don’t even have a home), and they are converted to a patient, they are cast into this chaotic environment which they have little control over. This is scary, intimidating and lonely. I cannot change how the system makes them feel, but at the very least, I can do my part to put them at ease if they happen to be my next patient.