Addressing some of unique challenges faced in the Emergency Centre: practical guide

As I reflect on some of the challenges we face in the Emergency Centre, I want to write this short piece to ensure that people know they are not alone, to highlight the challenges, but more importantly, to give you room to dream and seek solutions for these problems, and hopefully point you in the right direction to begin advocating for these challenges.

Long Hours and Shift Work

As a medical student and intern, we were introduced very early on to long shift hours, as we essentially worked the same hours as most medical officers and interns, all while having to return to our university residence to study for upcoming tests and exams. It was gruelling, but it was part of the grooming process for what was to come. Even at that point, it was not unusual to feel drained and hopeless, but my personal hope was always that one day I would become a “real” doctor and that life would be much better. Little did I know that emergency medicine was my destiny.

The long hours and shift work are not something I have gotten used to, to this day, but I have found ways to manage it after rotating through several emergency centers. Here is a list of things you can consider discussing with your department to see if they could work for you:

1. Play Around with Scheduling to Suit Individuals with Different Needs

   1. Consider having 3 shifts per day on weekdays and 2 shifts on weekends.

      1. Practical: 08h00 - 15h00; 15h00 - 22h00; 22h00 - 08h00.

      2. Advantages: This allows individuals to have days to do their admin or spend time with family for breakfast, etc., and to come in later in the afternoon or evening. It provides those who prefer night shifts with a good amount of sleep during the day, while still allowing time for life activities before work.

      3. Disadvantages: You need a robust workforce to achieve this, which is not always feasible in our limited settings. However, you can adjust the level of seniority between the different shifts and pair junior staff with senior staff to fill the gaps in numbers.

2. Pair Up Teams

   1. Practical: Emergency Centers experience a high turnover of staff, especially in training or university hospitals. Creating 4-6 different teams with the same team leader (senior medical officer) allows for consistency in the delivery of excellent care, regardless of changing team dynamics.

   2. Advantages: This structure helps recognize the seniority of team members, empowering them and giving them room to grow in their leadership skills. They will be your eyes on the floor when you are not around and help you identify who may need extra time in teaching, guidance, or support. The team should be encouraged to have social days together, as this strengthens their teamwork and fosters reliance on each other, even in the pressures of the emergency center.

   3. Disadvantages: Not having a compassionate or empathetic team leader can create challenges and lead to team discord. This can be managed by the emergency physician/consultant or head of the department taking an active role in nurturing the team leaders, as they reflect the culture that the emergency centre is trying to establish. Hopefully one of patient centredness, teamwork, evidence based care, ubuntu and caring for each other.

Overcrowding and Access Block

If you’ve ever worked in an extremely busy unit — I mean really busy, where the same people you saw in the queue when you started your shift the previous night are still lined up on a bench with a hospital blanket and have not yet been seen — there is a sense of guilt that arises from feeling like you haven’t done enough. However, you eventually reach a point of despondency when you feel that you have given your all but can’t do any more. The same food you so passionately packed for your lunch box remains untouched and will probably be the same food you bring back for your evening shift, as you’re just going home to sleep.

Take comfort in the fact that this is not just a personal issue. It is a holistic systemic problem that has been discussed in numerous articles, yet there is no single solution. It is unfortunate that this message is not communicated to the juniors on the floor who continually strive to “clear the queues.” The emergency medicine setting is a revolving door, and unless the inside gets cleared, the patients will keep coming.

Practical Tips for You as an Individual:

1. Prepare yourself mentally for each shift before it starts. Meditation and prayer have always been helpful for me, allowing me to leave everything in God’s hands and to feel content with what I have done. It lifts a large burden off my shoulders and enables me to accept my limitations while still striving to give my absolute best, regardless of how limited that may be. This also helps you avoid being too hard on yourself, especially when the consultant comes in the morning after you worked tirelessly to “clear the queues” yet offers no acknowledgment of your hard work. Even worse, you might be asked why there is still one folder or one patient not seen.

2. Completely dissociate yourself from each shift. This means that whatever happened during your shift stays there. The beauty of emergency medicine is that you never receive that phone call, “Doctor, the patient you admitted is deteriorating.” If there was an amazing patient encounter that you want to remember, definitely use that as fuel to keep you purpose filled. However, any negative encounters should be viewed only in terms of the learning points you can take from the incident. Everything else (including others trying to project their negative emotions onto you) should be left at the trash can at the entrance of the emergency centre as you leave your shift. True dat.

Difficult Referrals

In emergency medicine, we unfortunately cannot avoid difficult conversations with challenging colleagues, particularly from certain disciplines that view emergency medicine as their interns and expect us to complete all tasks for patients before they are referred to the wards, minimizing their workload. I want to clarify that it is always a pleasure to package a patient well to reduce further delays in their care. However, when you have attempted to reduce a fracture twice and the referring othopaedic doctor on call suggests to attempt another reduction and send her the images while they are at home - is unreasonable, especially when the emergency center is full of patients still to be seen.

Let’s look at practical tips to overcome some of these challenges:

1. Discussions need to occur between the heads of departments to establish a clear understanding of what needs to be done for certain patients before they are referred to their departments, and this needs to be communicated to all doctors on the floor to ensure everyone is on the same page. For instance, if a patient needs to remain in the emergency centre’s resuscitation room until they are fully out of DKA — due to a lack of space in high care or the wards not having the monitoring capacity to safely manage patients on insulin infusions — that is a compromise that can be reached with the stakeholders.

2. Communicating your needs to the referring doctor is essential. When referring to a specialty, always start with the problem, what you’ve done, and what you need them to do. This summary facilitates an easier conversation and transition of care. Take a few minutes to prepare your pitch before calling, as this allows you to be more composed and enables you to think through your problem statement, helping you to identify points you might have missed otherwise.

I know there are many more challenges we face; this is just the tip of the iceberg to start the conversation. I would love to hear the tips and tricks you are using in your units, departments, or casualty so that we can learn from each other.