A PA in A&E
Wednesday 31st July 2019
Myya Mystry (PA-R)
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.