Working while you’re drunk, wanker bosses, and painful insight. The (real) life of an ED Registrar.

wanker

One unanticipated effect of running this blog is that I’m occasionally contacted by ED Registrars who are doing it tough, who are asking for advice or just want a sounding board but for all sorts of good reasons don’t want to talk to their boss or anyone who works in their ED.  I have to say that all of these contacts thus far have come from people who are having normal, sane reactions to ridiculous circumstances, and one recent email in particular caught my attention. With the permission of the author, I’ve reproduced this below, (de-identified) in the hope that people thinking of signing up for ED training can get a look into what the next several years of their life may involve, and so that others who are experiencing similar working conditions can see that they’re not alone. This is a long post…

Here’s the email:

Having just finished a set of nights in the perpetually overcrowded, bed-blocked, 4 hour target ridden (name withheld) hospital ED, I came home this morning with an overwhelming feeling of despair – disillusioned with the state of Australia’s public hospitals, and wondering how much longer the current status can be maintained before a complete disaster.
 
I’d be grateful if you could read through my rant and whinging, and feedback with some advice/pointers on maintaining sanity within the ED maelstrom. Don’t get me wrong, I am well supported by the Staff Specialists here, most of whom understand just how overcrowded the department is, and how shit the nights are.  Again, senior nursing staff on nights are not passing on undue demands, and overall we are a unified team.  On that note I am very fortunate.
 
I came home this morning mentally and physically exhausted from 4 weekday nights.  Every night I have come in to an overflowing department, with >50% of the patients in the cubicles admitted and awaiting beds.  Patients waiting hours to be seen, ambulance crews holed up in the corridor, and chest pain patients waiting for beds.  The ED Specialist about to leave rings up the hospital exec begging for more beds to be opened…..”they can give us 4 – but there’ll be 10 over-census beds available in the morning”.  Well thank you very f+%^ing much, that’s going to help me when resus is full, and nothing moves.
 
As usual I am the senior reg on nights – apparently the most skilled at critical care amongst the night team (don’t laugh), but also responsible for patient flow, supervision, and fighting fires.  It actually takes me longer to fully work-up and admit a patient.  For every patient I see, I discuss/review at least 2 others, and get rudely interrupted by a sicker patient or worse and angry/agitated psych pt… and, well I’m not sure what else.  I seem to be constantly doing several tasks at once with frequent distractions, but never satisfactorily complete anything.
 
6 o’clock in the morning comes – time to review the department, the admitted and waiting patients.  Make sure there’s nothing I’ve missed in the admitted or waiting patients.  Complete care of my own patients, call the admitting teams, and make sure the juniors are finishing up and aiming to be out on time.  I used to start this at 7, but have since learnt that the sickest patients come in between  6 & 7.30, and admitted patients unexpectedly deteriorate around this time also.
 
8 o’clock comes – I do not have a handle on the department, but the sickest are stabilised.  Handover looks and sounds like shit, there are numerous unsorted patients. Yesterday I took great offence (quite unprofessionally) at the consultant’s desire to use the handover round as a teaching and nit-picking opportunity.  I admit there were a few unsorted patients; We had however managed to successfully resuscitate a bradycardic arrest (in an admitted patient) around 6-7 am.
 
I worry about how stressful I find night shifts, and how difficult I find it to maintain an overall situational awareness and control of the department.  Presuming I make it through fellowship exams, how on earth will I develop the skills to run a department?  How can I give patients the best care they deserve, will things get better?  How do I maintain my sanity?  Don’t get me wrong – I love Emergency Medicine.  I enjoy the clinical work, even more now than I did 12 months ago & am passionate about my career.  However in the current climate I find the Emergency Department a stressful & unsustainable workplace.    We are constantly fighting fires and waiting for the next disaster.  Hopefully it won’t be career ending.
 
I wonder what hospital execs and government policy makers would actually think if they spent a shift in the ED of a tertiary referral/ trauma hospital, rather than a quick walk through.  Does the care we currently provide pass the “friend of your parents” test?  Most certainly not.

As I said before I am well supported here, and hope to catch up with my DEMT/mentor next week (to discuss many things).  Any of your thoughts/ pointers/ advice would be appreciated (even if it’s stop whinging, we’re all in the same boat)!

Does any of that sound familiar? Suffice to say, I can remember my nights as a senior Reg 5-6 years ago were exactly the same as this, so nothing has really changed. We’ve all been there, learned to cope with the hypocrisy and pressure of a training program that demands excellence and patients who expect no mistakes, whilst working in a system that is perfectly designed to prevent us from delivering excellent care, and exposes us to unchecked medico-legal and personal psychological risk.  Classic Catch-22 (which I suggested this Registrar read immediately, and you should to if you haven’t read it and you work in ED. Paperback here, Kindle here!)

So the description of the overcrowding and workload is nothing new.  However what this Registrar is experiencing as a result of this, is what’s referred to in psychiatry as “painful insight”.  It’s when someone comes out of their first psychotic episode, and slowly realises what’s just happened, and that their life trajectory has been irrevocably altered, and their terrible affliction is likely to recur, forever (incidentally this is a very high suicide risk time for these patients). In ED training, it refers to that point when you realise that the system’s f*#ked, no-one in authority cares what you think, and you are too far into your training to change paths.  Some people never gain this insight and bumble through blissfully unaware. They’re the lucky ones.

There is no solution to this, it’s part of the skin-thickening process of ED training. You need to come to terms with the consequences of what seemed like well-informed choices that led to you being here, suck it up, and focus on the good things, or what few positive things you may gain from it, because the bad things will never change, in fact they are simply and predictably getting worse.  It’s that or bail out, as some wise people I know have chosen to do. There’s no shame in choosing to walk away from this madness, and in fact, I have a lot of respect for people who make this choice. I sometimes wish I had.

A second point I’d like to comment on is use of morning handover as a time to “teach” and nit-pick the performance of the night team. This is a particular bug-bear of mine, and really boils my blood.  To any ED Consultant out there reading this who thinks that morning handover is for doing anything other than:
1) Making sure all of the patients are alive
2) Getting the night team home as quickly as possible
…then you need to have a good hard look at yourself.  At the end of a night shift, ED Registrars are working in a state that has been proven beyond any doubt to be the same as working when you’re drunk. If you don’t believe me, read this.  Most will not have had a piss, and likely nothing to eat or drink all night.  If you think for a second that this is a good time to “teach”, “give feedback”, nit-pick minutiae or reprimand mistakes, you are displaying a degree of ignorance, lack of insight, and lack of collegiate respect that will earn you a reputation as a first class wanker amongst your juniors. How do I know this? Because this is how Registrars describe people who do this, all the time to me.  Shut up, take the handover, and if you really have an issue with something they’ve done, write it down, and bring it up when they come back on deck, rested after their days off after nights. You will earn far more respect, and be far more likely to be listened to. And remember, duty of care is contractual. Once their shift is over, and they’ve handed over, they are not obliged to be there. So for God’s sake don’t bastardise your future consultant colleagues by making them hang around and finish menial jobs after a night shift.  Thankfully I haven’t seen an ED consultant make a Reg pickup another patient after morning handover for a while, (yes, this used to happen), and anyone who does this should be shot.

Lastly, for those of you who’ve bothered to read this far, I want you to have a good hard think, and if you can, tell me another profession that treats such well educated, loyal, hard working employees who choose to accept the level of risk ED Registrars accept on nights this poorly? Would you apply for a job with an airline who made trainee pilots get drunk, then get in the cockpit of an aircraft with twice as many passengers on board as it’s designed to carry, with half the engines working, with no food, toilet or rest breaks allowed for a 10 hour flight, whilst also having to supervise 2 or 3 other drunk, more junior pilots who are flying other planes, through a hurricane, whilst being constantly interrupted by phone calls, angry passengers and engine failures, and the only help available is from other drunk pilots who are only trained to fly different models of aircraft? Oh, and doing this with the  constant fear of being sued or possibly sacked if you make a mistake. And agree to do that every few weeks for 3 or 4 years whilst studying 20+ hours a week in your spare time for the last year?

So there you go, an inside look into the life of a senior ED Reg in the brave new world of KPI’s and overcrowding. Sound fun? Not really? Well, it’s a fair description of the real ED world, straight from the horses mouth.  For anyone who is experiencing real difficulty with ED work and training, there is help around. Talk to your DEMT, if you don’t trust them or can’t face them, talk to a colleague who you trust, your family/partner, your GP, the College or if you’re thinking bad thoughts or are getting ill from the stress of work, check out the Doctor’s Health Advisory Service  (in all states of Aus & NZ).  And of course you can always drop me a line at EDExam.

What do you think of ED night shifts? Are the work conditions reasonable? What are the good things you focus on to help you get through? Leave a comment below.

 

PS: I have had ongoing communication since this email that assures me this Reg is doing fine and coping well with the insanity of this job.

 

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7 Responses to Working while you’re drunk, wanker bosses, and painful insight. The (real) life of an ED Registrar.

  1. Andrew Tagg May 12, 2013 at 1:36 pm #

    Night shifts can be truly awful. I have also experienced the heartsink of coming on at 10 in the evening to find 20 plus patients waiting to be seen with no beds to see any of them in. There are certain fundamental flaws in the system that we are never going to be able to fix.

    I agree that the absolute worst thing a boss can do, after you have survived the night, is nitpick or get you to stay behind and sort things. In one ED I have worked in that was the norm so you would never want to pick up patients half an hour before the end of the night shift (unless you really had to) but in another it was fine to hand over an unsorted patient. Just ordering some bloods or a CT and charting some analgesia was required and the morning shift would be starting with a bit more information. The bad nights were always made better by the morning consultants just acknowledging the job we had dome and saying “Thank you”. I always respond better to a pat on the back.

    And as registrars on the evening shift we can help too. We can make sure patients are actually sorted before they are handed over, or at least make sure the night team don’t have to go and review every resident’s handovers because you have already looked at them.

    Nobody wants to pick up a patient when they get to their last hour but if the four of you that are going home at 10 each pick up one fast track patient then it is a huge work load off of us working the night. Working in Team Nightshift shouldn’t be a ‘them and us’ scenario with the day workers.

  2. ObGyn May 12, 2013 at 9:10 pm #

    Hi Andy,
    A recent episode of registrar harassment at morning handover led me to forward your blog to my junior colleagues on the nights roster. One of my colleagues was verbally bullied (I don’t use the term lightly) over the management of 2 women, whom he had asked the overnight boss about. He had done nothing wrong. He asked for advice and done what he thought was appropriate.

    The obstetric morning handover is very intense. There are at least 40 people in the room. All eyes are on the registrar who has to justify every action during the night. Obstetrics is easy in retrospect as there is an unambiguous result (live baby with normal gases vs sick baby / sick mother). It is much harder in real time.

    The stakes are really high. Everyone expects a perfect outcome. There are no shortage of critical “normal birthers” to undermine the decisions for caesarean section or instrumental delivery.

    People forget that shit happens. And although rare, when shit happens the fallout is forever. I had a baby die during my third year as a registrar. I was exonerated by admin, senior docs, even the HCCC but still had to deal with the mother periodically calling the hospital to speak with the evil bitch that killed her baby. The midwife involved no longer works on delivery suite. It wasn’t even my management – it was the evening team’s plan. I was just the monkey when the shit hit the fan.

    So we are forever shaped as clinicians by our experiences. Today I was accused of arrogance on twitter when I said that doctors are different. Our nursing colleague couldn’t understand it. We don’t get an opportunity to down tools at the end of the shift. Sometimes we aren’t allowed to. Sometimes we choose not to. Actually we never do – we carry the patients around with us, the bad outcomes like armour. It gets heavy sometimes.

    Your analogy of the drunk pilot flying an overloaded plane with junior drunk pilots, through a hurricane, with engine failures, no food or water or rest is brilliant. I always joked that if my creatinine was normal at the end of training was normal, then I won!

    Thank you.

    I think the only way to improve things is to acknowledge that we are all on the yellow brick road – some are still with the wicked witch of the west, some at oz, but all on the same road. We need to be kind to our juniors. We need to be available to them.
    There’s no way to describe to the public, or the nurses for that matter, what it is to be the pilot of that plane. But we know to each other.

  3. Kathryn Woolfield May 12, 2013 at 10:40 pm #

    Hi Andy, thanks for an awesome post!

    I’m sure this post resonates with so many Emergency and other specialty registrars who have the privilege of working and supervising night shifts.

    It is absolutely my all time favourite airline industry – medicine analogy. Because it highlights why we can’t function perfectly and get everything right all the time.

    Doing nights is like going into battle. We just want to make it to the end and with as few injuries as possible. They are awful, but can be very rewarding.

    Your suggestions are spot on.
    I would add:
    – Get lots of sleep
    – Take a water bottle to sip in between resus
    – Debrief when you need to.

  4. Amit Maini May 13, 2013 at 2:50 am #

    That email sounds so familiar to me. The morning handover dissection over the night’s events, the stinging critique, and “helpful” advice of senior colleagues, who have forgotten what it is like to do nights, or did nights in a different, far less busy era, without the pressures of arbitrary KPIs. Shame on them.

    It’s even worse than this though. There are regs out there working in departments that are now publishing weekly individual KPIs, with regular “performance reviews” if quotas are not met, or KPIs are breached. Indeed, some trainees are even staying well beyond their shift finishing times (unpaid of course), just to see their obligatory ten per shift, in order to avoid such reviews. This is thoroughly unprofessional behaviour, and in my opinion constitutes workplace bullying.

    Anyone complicit with this sort of behaviour should seriously take a long hard look at themselves.

  5. Andrew Perry May 24, 2013 at 3:30 pm #

    Cynical but so true. One thing I am never going to forget when I make it through to being a boss is to go through morning handovers with the mindset that as long as the night staff kept the patients alive and the department ticking over they have done their job. I have no problem with the night staff saying at handover – “I need some fresh eyes and brain matter to look at this patient again – I have done all the preliminary investigations but can’t put it all together.” And definitely agree with Kathryn Woolfield’s tips. My one other tip is to regularly stay in touch with your fellow ED doctors throughout the night, not so much about their patients which we already do, but how they are going in terms of having breaks and seeing if they need a hand with either a patient or the area of the department they are responsible for e.g. minors or resus.

  6. Seb October 16, 2013 at 1:49 am #

    Great to read the above blog. It is something I have always felt strongly about that we work in a very unhealthy environment and yet we are expected to deliver advice on health and wellness and do procedures to help people get better. As mentioned earlier we work in a concrete bunker with little natural lighting, behaving like drunk pilots in the middle of the night and are called upon to deliver optimum health and wellness decisions. If the public are not aware and the lawyers aren’t suing us then surely we should stand up for our patients and try to change this environment. I believe that the emergency unit, as the first point of call, should be some of the most top heavy with staff( both doctors and nurses) and not just ICU. Also why don’t we do something about the shifts rotation. Lets work punchy short shifts of 6 hours. Also lets have fresh doctors/ staff come on shift at 3 or 4 AM for example. That is, they can sleep till 2 or 3 AM and then come to relieve the early night team. If we are so keen to improve health care delivery then surely we need to make more of a stink about this. Shouldn’t we make our work environment healthier for ourselves and hence by default will be better for our patients.

  7. NS October 23, 2013 at 6:30 pm #

    Hi Andy
    Great topic of discussion and wanted to share a few thoughts that might help some of the registrars reading.
    Having only recently become a fellow of the college I very clearly remember the exact sentiments of the trainee who wrote the email.
    I was lucky enough to have a group of very supportive consultants guide me through my training but of course there is always that one boss who you dreaded giving morning handover to. To my surprise in my department this happened to be the most junior consultant at the time.
    Years later some of their comments still echo in my head…. about a stable patient that the previous evening shift consultant had given permission to keep in the department for an investigation in the morning .. which I had completely forgotten after multiple resuses and a chaotic night….. I was told I had ..” completely failed in making the right disposition decision”…

    On the flip side I have had fantastic bosses who actually come to the floor 20 mins before the handover and help out with finalising the morning pre handover tasks and ask about difficulties overnight/ problems that they would like addressed etc and personally thank the night team after the handover.

    I used to find that I was also extremely sensitive after nightshifts and often wouldn’t have the emotional strength to respond to the criticism in the mornings and would just keep quiet in fear of getting tearful. I used to see this a major weakness of mine but over the years I learnt to except that this is a very normal response to the extreme stress and the added hunger/ thirst and tiredness we go through as night in charge registrar. This realisation actually helped me to be more assertive and take charge at the morning handover.

    As a junior consultant now taking morning handover I aim to finish the handover as soon as possible and get the team out of the department as soon as possible and make sure I thank them.

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