Has anybody seen my comfort zone?
Thoughts on the 7th IBTPHEM National Induction course 2020 (http://www.ibtphem.org.uk) by Dr Hilary Thornton (PHEM Clinical Fellow)
As everybody knows, Emergency Medicine is the best job in the world. Given that it encompasses the entirety of medicine, it expands as we progress, allowing depth of knowledge to meet with breadth and making us better at what we do. The Emergency Department is our dwelling place (how many of us are completely incapable of directing anyone to anywhere else in the hospital because we never venture out?) and our comfortable place. Over time we forget the discomfort that really ought to be evident on the faces of our speciality colleagues as they visit our domain, noisy, unfamiliar and scary, where staff are seemingly unfazed by the oddest of situations and the humour has a unique quality. Moving to a new department brings challenges, but we quickly settle in to the same craft in a different place.
All in all, it has been a while since I left my comfort zone. I had a suspicion that I might be about to step outside it as I drove out of Wales and across the whole of England to get to Lincoln, knowing that the week ahead would be filled with sim sessions, for which I have publicly professed a deep dislike in the past. I would be joining four of my middle grade colleagues from Bangor who are also doing the PHEM clinical fellowship. We had been enticed with phrases such as ‘adult playground’ and ‘it’s great fun’ and there was the promise of a nice hotel and plenty of caffeine.
Attending the course was a massive privilege for us, since we are not PHEM trainees. Most of the participants are right at the beginning of their official training posts, whereas we were there to learn and experience, but perhaps without the added pressure.
Day one felt nice. We sat at socially distanced tables (thanks to Covid-19) in the hotel and had a variety of talks, including on CRM (or how the team forms and is affected by a variety of influences). and the massive importance of looking after ourselves and each other.
Day two took us outside. The training ground is used by the Lincolnshire Fire Service and the first things you notice are the tall metal training tower and a partially overturned train on a stretch of track, plus an aeroplane standing on the grass. We were put into teams, and learnt about how the ‘flash team’ that we frequently form in the ED when there is a trauma call, where nobody really knows anybody else or what they can or should do adds another layer of complexity outside the hospital. The team, just like the risk assessment, is dynamic, with people coming and going. We are usually not the first members of the team, and have a need to slot into the situation without causing chaos. Nor can we take our usual role of standing with arms folded, taking everything in and assimilating it all into a workable plan. We still need to do this (except the arm folding bit) but at the same time as being hands on, because there are not enough people to do otherwise. We were exposed to situations such as road hazards, cardiac arrest in a dark and difficult to access room (the moment when I realised that I need to buy a torch), a patient surrounded by drug paraphernalia, falling bricks on a building site and how to lose a team member to an irrespirable atmosphere (doubly unfortunate when you discover that they took your only radio with them!). The day was exhausting and frankly terrifying, but each scenario was followed by a surprisingly encouraging feedback session from the faculty, who somehow managed to turn even the most stupid of decisions into a positive learning point.
Day three brought new learning and new challenges, with the learning curve continuing its almost vertical slope. The theme was road incidents, from cars in various odd positions to patients in lorries and multiple casualty situations. Again, learning focussed on safety, but also on the lack of absolutes. By the time we reach the middle grade level in Emergency Medicine, we have often internalised the subtleties and the art of what we do, differentiating patients by some kind of sixth sense built on years of experience and learning (Gestalt, perhaps). We also have all the time in the world (well, four hours) to deal with what we find and as much help as we need. In these scenarios, we found ourselves having to make quick decisions based on limited information, declaring that a patient was big sick and needed to be out of that car right now, regardless of how we get them out, and on the flip side, regardless of what other damage we might cause whilst doing it.
Day four turned up the heat, fairly literally. The temperature was soaring towards 30degrees, we were outside and wearing flight suits plus varying degrees of additional PPE. The theme was on difficult environments, and a lot of the learning was about where not to go. Once you have crawled through spaces in a collapsed building that do not look big enough to fit a person through, or climbed to the top of the fire tower on a ladder, you fully realise why attempting to deliver any quality of medical care in these situations is probably futile. Add in house fires and lorries dripping unknown chemicals onto the van beneath and you become very appreciative of teams such as the Fire Service and HART. There was a subtle shift in the assessment of risk towards how much risk we are willing to take rather than whether we are willing to take a risk. Learning points aside, this day was really good fun, and it is always useful to find out that you do not have claustrophobia or acrophobia!
Day five was another hot day, and by now we were beginning to be glad of the requirement to wear masks on the bus to and from the hotel as we donned the same flightsuits every day. The theme was on critical, lifesaving procedures, and the difficult decisions required to undertake them. The procedures themselves, such as thoracotomy and resuscitative hysterotomy, are not unfamiliar to ED trainees (front of neck access in a bariatric patient and amputation maybe more so), but the situations are – what if your thoracotomy patient is inside a night club, dark and with music blaring? What if the pregnant lady in arrest is in a car? What if, rather unexpectedly, someone is shooting at you?
Day six somehow, remarkably, took us even further out of our comfort zones (which had already become a little dot in the distance). Most of the focus was on transfer and moving patients, perhaps a realm more comfortable for the anaesthetists, particularly when the patient is sedated and ventilated. But what if the patient is up a hill? Or the ambulance does an emergency stop? Or the patient arrests? Or the patient in the back of the ambulance is unsettled and violent? Maybe the patient is underneath a train, or perhaps you cannot even see the patient and are giving advice over the phone? Spoiler alert: uncomfortable and bad things happen! The main things we picked up here were really the importance of thinking about every single thing that is likely to go wrong and being prepared for it, whether that be having equipment ready or having another plan to get out of somewhere.
Day seven came surprisingly quickly and provided a mixture of simulated and real chaos in the form of a major incident. There were still elements that were fun, such as clambering through disorienting train carriages at weird angles and some almost Oscar-winning acting performances by some of the delegates who were playing patients. All of the learning so far needed to be brought into play, alongside new skills such as rapid triage and avoiding being distracted by screaming people. Most of the discomfort from the day came from not really knowing what was going on anywhere else, and eventually it dawned that this was sort of the point. In contrast to the previous days, when we were in control (well, allegedly) of the situation, here we were following instructions given by people who had an overview, and needed to focus on doing our own part well. The improved communication by radio that we had been working on all week was pretty soon demolished in the noise and busyness, and we needed to come up with new ways of updating people. An unexpected element was how difficult it is to count in these situations, whether it be keeping a tally of how many of what kind of patient are where, or whether you may or may not have accidentally left one of your team members inside a carriage which is now on fire…
I think we would all agree that this is the best course we have ever attended. I hope to be able to retain and use even a fraction of what we learnt, and I believe that it will make me a better ED doctor, let alone a better pre-hospital one. PHEM is almost a levelling up of emergency medicine – you have to be good at the basics of what you do (in fact, better than good), and then you are ready to have an infinite number of challenges, decisions and impossible situations thrown at you. My comfort zone has widened somewhat, even though I was undeniably happy to return to scrubs and the usual ED chaos. If we do not challenge ourselves, we do not grow, and that would be a waste.
Caption: What participating in the course feels like, a pictorial description (photo credit Hilary Thornton)
Caption: The Bangor PHEM Clinical Fellows on the course (photo credit Hilary Thornton)
(photo credit Gareth Evans)
(photo credit Gareth Evans)
*A massive thank you from all at YGED to the IBTPHEM course organisers and team. Our Clinical Fellows all agreed it was an excellent course and a steep learning curve!