VICDOC Winter 2022 - Magazine - Page 77
And so policy appropriately prevents me
from exercising any discretion about when
to respond to out-of-range observations. It
is an interesting juxtaposition, though, that
I have no policy impediment in choosing
how to respond from a wide range of
options. If I decided that bed 1 needed
IV hydralazine, bed 6 isoprenaline and
bed 5 an insulin infusion, it would be the
discretion and experience of my nursing
and pharmacy colleagues – rather than
absolute policy – that would prevent me
executing those ill-advised plans.
Waxing philosophical and exploring
hyperbolic hypotheticals do not help
with my dilemma, though – what to
do about my patient’s blood pressure.
If I do nothing and suggest the day team
review the regular antihypertensives,
I or my overnight colleague will assuredly
be paged again when the blood pressure
remains elevated in the evening (and
again in the morning, and again…).
If I prescribe a stat oral antihypertensive,
I can pat myself on the back for a job
well done, while ignoring the piercing
disappointment my medical school
tutors would surely feel for prescribing
an unnecessary medication to
“chase a number”.
In the last issue of VICDOC,
I discussed developing confidence as an
intern in prescribing common medications.
Now I must develop experience in deciding
when to intervene, and when not to.
For my stable patients on ward cover,
it perhaps usually matters little. But
one month later I am in the emergency
department, my patients are sicker and more
undifferentiated, and my supervision is
more indirect. The patient I fluid bolus may
turn out to have heart failure and develop
pulmonary oedema. The patient I am too
quick to request a D-dimer for may end
up with a whopping dose of radiation they
didn’t actually need. I discuss my cases with
my seniors, but I am acutely aware there is
much I do not know that I do not know.
Much of my learning in the emergency
department has been about developing
comfort with uncertainty. My medical
school exams did not admit uncertainty.
Every multiple-choice question had a
single best answer. Every patient with
an abdominal complaint had either an
unambiguous benign diagnosis, or a clear
need for emergency theatre. Rarely was
safety-netting of an unlikely but possible
differential required. Rarely was a CT
abdomen required to clarify diagnosis.
Though I navigate increasing
independence, my registrars and
consultants are supportive, and I do not
make these decisions alone. I discuss with
my seniors about when serious differentials
are made sufficiently unlikely to enable safe
discharge, and conversely, when sufficient
uncertainty exists to warrant additional
investigation. The purpose of my training
is to develop my knowledge, skills and
experience, so that when I do come to
make these management decisions on my
own, they will be safe and appropriate.
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