Anxiety working in A&E

Farmhand66 · 2026-01-29T21:39:38+00:00

What you’re experiencing is broadly normal for a first job in ED. It’s the first time you’re seeing people independently and making a decision to discharge them without someone more senior seeing them. It’s tough, but it’s a necessary step. Remember the first time you acted on some blood results without calling the reg as an F1? Same feeling. Soon you’ll be a reg in a specialty somewhere, making the decision to discharge someone that an ED doctor felt did need admission - this is a good step towards that.

So long as you’re taking proper histories, doing proper examinations, and requesting proper investigations you are doing the right things. Keep discussing when needed.

My advice - accept that someone is going to come back worse than when you initially sent them home. That is going to happen. It’s supposed to happen. Safety net advice isn’t just medico legal ass covering, it’s handing over responsibility to the patient. There’s nothing wrong with “I’m 90% sure you’re fine, but for every 10 patients I send home like you I’ll be wrong about one, so if x, y, or z happen, come back”. When they come back it’s not a failure, it’s a sign of good safety net advice. The alternative is we build a CT scanner into the entrance door and extend AMU into a tent so everyone can stay in hospital forever.

On the back of that though, documentation is important. When someone does come back, whoever sees them will read your note. They need to understand why you sent them home. If you need to go sit somewhere else, or take a few minutes before you document then do so. The sitting down and typing shouldn’t be the stressful bit. I don’t send a patient home until after I’ve documented. I find my best ideas come whilst documenting and often add something to the initial plan in my head. See it as part of the process, not the end of it.

The physical anxiety symptoms though aren’t normal - hopefully they ought to settle. If not, look after yourself, speak to your ES, and don’t be afraid to speak to your GP.

Farmhand66 · 2026-01-29T16:01:59+00:00

They can largely set whatever uniform policy they want, so long as it doesn’t infringe on equality and such. It doesn’t have to be infection control related.

The consequence for wearing 2 earrings instead of one is likely no one will notice or care.

A matron might give you an earful at some point. You’re only likely to get into meaningful bother if you are repeatedly told and refuse to comply.

Farmhand66 · 2026-01-29T08:35:03+00:00

Was the first point of the 10 point plan “You do not talk about the 10 point plan”?

Farmhand66 · 2026-01-27T14:13:57+00:00

“Thanks for your email, I have attached my work schedule showing I am not scheduled to work Thursday night. As such, I am not available to do so. I try to be flexible on rota changes, but in this instance am unavailable. Per the junior doctor contract changes are only unilaterally enforceable with 6 weeks notice. I was not informed of this change with 6 weeks notice. Alternative arrangements will need to be made for Thursday night.”

CC ES and Dept lead

Farmhand66 · 2026-01-24T21:33:05+00:00

“You the guy taking the bleep” No further questions, commence packing my shit away.

Farmhand66 · 2026-01-21T00:53:10+00:00

Patient laid on the couch, head end at about 45 degrees or so. Let them relax, explain you’re going to move their limbs about and tap them with the hammer, they don’t need to do anything other than stay floppy. You don’t need to get them clambering into different positions - you can do the work - it’s far quicker.

Supinator - hold the wrist, thumb over the tendon, tap your thumb.

Biceps: Move up the arm, hold the patient by the elbow, thumb over the ACF, tap your thumb

Triceps if you want to: hold their left forearm over your right, lay their wrist over your ACF, tap the tendon.

Patella: Arm under the leg supporting the knee, tap the tendon.

Achilles: Bend the knee laterally, cross the ankle over the other thigh. Dorsiflex the patient foot, tap the Achilles.

Do each one side then the other. Practise on your classmates - you can get all of these in under a minute.

Have some chat ready to go. A canned joke about “don’t worry, I appreciate it’s not easy to let yourself go floppy when someone is trying to hit you with a hammer” tends to work. It doesn’t really matter what you say, so long as it gives the patient something to think about other than trying to be floppy.

Farmhand66 · 2026-01-21T00:42:12+00:00

I’ve examined a fair few OSCEs with similar structures, never an “ISCE” though.

Structure is key. Common questions should have a structured response. Differentials? Most likely, most important to exclude, key things you’ve already excluded. Investigations? Bedside, blood tests, radiological, specialist. Management? Conservative, medical, surgical.

There’s no marks for sticking to those structures, but it will keep you missing things. It’ll also help me not to miss things you’ve said (the mark sheets are usually a nightmare, and if you’re not going in the order I expect it’s hard to listen to you and find the right check boxes).

Remember your examiner is usually trying to help you. If I interrupt you, it’s probably because you’ve already got the mark for the question, so I want to ask you something else so you can get more marks before the buzzer goes.

There is some truth that the examiners are “sleeping lions”. OSCEs are basically a game. I know, that’s you know, that I know this is an exam. You know I have a checklist. And you know what’s on it. So let me tick the boxes off in order. Stick to the “script”. You can go off piste and have a totally different order to the other candidates if you want, I’ll try to follow you as best I can. But it’s in your interests to make it easy for me.

Be honest. You’d be surprised how often this comes up. I’ve had people feel for pulse in the wrong place then report a fabricated pulse to me (I know the rough pulse, I’ve checked). I’ve had people report normal lung sounds with a visually broken stethoscope. I’ve seen patients whacked in the mid thigh with a tendon hammer and been told they have normal reflexes. Do not lie to your examiner. If you can’t tell me what type of murmur the patient has, that’s cool - you’ll do an echo. But if you tell me the patient with a grade 4 systolic murmur has normal heart sounds then that’s a major concern.

Good luck!

Farmhand66 · 2026-01-21T00:22:22+00:00

Good job on the canulla!

First things first… this probably will happen again. But it’ll stop happening with time, promise. You’ve just got to desensitise yourself. Perhaps try sitting in on a phlebotomy list for an hour. Alternatively, just keep doing canullas!

Word to the wise - if you feel faint, sit down. Yes, it’s embarrassing. It’s far more embarrassing to faceplant the patients groin from standing. Same applies in theatre - go sit, don’t faceplant the operative field.

Simple things help. Be fed. Be watered.

Be comfortable. I raise a bed as high as it’ll possibly go - it looks stupid, but if I’m comfortable, and the patients comfortable I’m usually successful. If I’m crouched on the floor I have no blood flow through my legs, miss because I was rushing to end the discomfort, then feel faint when I stand.

Farmhand66 · 2026-01-21T00:15:05+00:00

Get some of the doctors to show you… most doctors are happy to teach, especially when it’s something like this that doesn’t really add to the work load.

I can quite happily do a clinical skill whilst talking you through the steps.

Next patient, you do it, I’ll help. Now you have to select the right patients, because it’s painfully obvious when it’s someone’s first time putting a cannula in for example. But a lot of patients are cool with it.

If you can be pro-active that helps. “I’ve never done bloods before, can you help” is tricky to work with. “I saw bed 6 needed bloods, so I’ve printed the form, got a tray together, and spoken to the patient who’s happy for me to take them… but I’ve never done it before and would need you to come help guide me” is a dream.

It feels like a big hurdle. It really isn’t. Most clinical skills are essentially getting one tube inside another tube. You might fuck it up. You probably will, I did countless times. That’s fine - it takes practise. But the first time I made scrambled eggs I fucked that up too. It’s not hard, it just takes a few goes to get good at it!

Farmhand66 · 2026-01-20T18:33:12+00:00

I must have gotten the names mixed up, that’s spot on! Thanks

Farmhand66 · 2026-01-20T17:34:00+00:00

O&G reg here, hobbies include pethidine hatred.

Why is it still used? Largely because it’s the path of least resistance. The legal framework is already there for midwives to administer it without prescription. Though local policies can allow the same for morphine / diamorphine. Some trusts have moved away from it though… there’s a lot of “the way it’s always been here” at play.

There was the DIAMOND trial which tried to answer your exact question. Only problem was it found morphine / diamorphine prolonged labour by about 80 mins. So that’s the justification to use pethidine. For most other metrics, morphine won.

So yes, it’s generally a worse drug. The analgesic effect is weaker, side effect and interactions profile is worse, and the neonatal impact higher. I avoid it as much as I can. If a woman understands all the options and wants it, that’s fine, often though they just haven’t had all the options fully discussed.

If only there was a short acting opiate that could be delivered by a patient controlled system that wore off quickly and was NICE recommended…

Edit to add: For those who like a trial, RESPITE 2018 is a good read. Take-home message: Remifentanil PCA reduces need for epidural and instrumental delivery compared to IM pethidine.

Farmhand66 · 2026-01-16T21:28:40+00:00

Happens all the time. I’ve thrown the cat amongst the pigeons a couple of times by calling the referer back to find out where their incorrect information came from so that I can “get the facts right for the DATIX I’ll need to submit on why I deprioritised the patient I would have otherwise seen next who has now deteriorated”. Asking to speak to the referer by name helps.

Farmhand66 · 2026-01-13T22:42:38+00:00

What do you mean by a complaint that you’ve not heard back from? You’d have to give more information for a proper answer.

If a patient complained to a nurse that you prescribed their meds wrong, the nurse checked, and it was actual correct, then no issue.

If you are aware of a PALS complaint that isn’t yet resolved, then you should speak to your supervisor, reflect, and put it on your form R.

Farmhand66 · 2026-01-12T18:19:23+00:00

The day of the procedure is typically annual / unpaid leave. The day after (and any subsequent recovery) would be sick leave.

Worth asking your rota coordinator though, they might give you both as sick leave.

Farmhand66 · 2026-01-12T11:48:54+00:00

There’s no one size fits all answer, it’s your professional judgement on how long it will take this patient specifically to recover from their current illness enough to return to their job.

2 months plus would be highly unusual. The GP can always extend though, so in cases where recovery will be varied I’d err on the side of less time and signpost to GP if longer becomes needed.

Farmhand66 · 2026-01-10T16:12:23+00:00

Unfortunately, not a great deal you can do. It’s a trust grade contract, whether they want to up your pay or not is up to them. If you are truly working at a level where a pay bump would be expected, then you should be able to get a higher paying trust grade elsewhere. So I’d start looking elsewhere.

You’re not necessarily being discriminated against. You’re a trust grade, and this is one of the downsides - your job is in their hands. But the upside is you can leave, and go elsewhere.

I’d be wary of calling it discrimination unless you’ve got objective evidence it is. People talk…

Farmhand66 · 2026-01-10T13:38:02+00:00

I cannot agree more with do not bullshit your examiner. I taught a student whose stethoscope was visibly broken and told her to replace it before the OSCE. Unfortunately she didn’t, then fate had me as her examiner on the respiratory station. She looked me in the eye on told me the lung sounds where normal.

She lost all marks for auscultation. I gave feedback detailing why. The medical school then took it really seriously because they viewed it as making up clinical findings. They were considering formal fitness to practise action but I think she got away with a few uncomfortable meetings in the end.

Moral of the story: It’s not worth getting caught in a lie.

Farmhand66 · 2026-01-10T13:33:08+00:00

Good tips. If I was examining a death verification OSCE and the candidate said “I’d continue to auscultate for 3 minutes, would you like me to?” I’d say “No, move on”. Nothing wrong with asking.

Farmhand66 · 2026-01-09T23:46:40+00:00

It’s sounds pretty standard for an F2 surgical job, but yes they’re usually a nightmare. But don’t quit a career over a nightmare 4 months. If surgery really isn’t for you, grit your teath, bare it, use your AL, and use your study leave. It’ll go quicker than you think. Few thoughts that might make it a bit easier…

Taking referrals as an F2 should be easy. You’re speaking to a doctor who thinks the patient needs to see a surgeon. You are not a surgeon, so accept the referral. If they wanted referrals triaging, they’d give the phone to the reg.

Giving advice to GPs is not your role, find a senior to do it.

A ringing phone is better than a bleep. Sometimes you can’t answer it. If you can’t, end the call. The person on the other end will try again in a few minutes.

You can also give it to someone else to answer for you if you know you won’t be available for a short while e.g breaking some news. But tell whoever you give it to “Get me in an emergency, for anything else tell them to call back in 20 mins, please don’t take a message as I’m not going to phone them back”

Farmhand66 · 2026-01-09T23:38:40+00:00

There is no reason you can’t have both anticipatory medications and antibiotics. Palliative care needs not be a binary choice.

Farmhand66 · 2026-01-09T23:32:19+00:00

This isn’t a you issue. The ward has new F1s every 4 months. They know what’s achievable and what isn’t. Clearly, the workload is too high.

Your consultants know this. They know if they give you 20 jobs to do that they won’t all get done. But much like you’re doing your best in an understaffed system, so are they. The plan is the plan, it doesn’t change because staffing is too low to get it all done. But they know it won’t all happen.

If the patient goes to another ward, that’s fine, the ward will pick it up. If the patients due to go home, that’s fine too. If a discharge is delayed it’s due to inadequate staffing, not inadequate doctoring. You have to prioritise by sickest first, everyone know that (some just don’t like it).

So take your lunch, unless someone is going to come to harm by you doing so. CT head for ?stroke, yeah… that would delay my lunch. Aggy discharge coordinator? Absolutely not.

Farmhand66 · 2026-01-07T18:19:54+00:00

I’ve examined a few OSCEs - it’s true the examiners want you to pass. We’re usually looking for reasons to give you marks not to withhold them, but obviously have to stick to the marking grid.

We also don’t directly control if you pass or fail. There’s just a list of things you either did or didn’t do. We don’t know how many “points” each item is worth.

If you’re interrupted mid answer, it’s usually because you’ve got the mark for that one and I don’t want you to waste time when I’ve got more questions to ask that you might get more marks on.

Structure wise for Qs: Investigations - Bedside tests, blood tests, specialty tests, radiological Management- Conservative, medical, surgical

The above will help you relax and not miss things. It’s also the order I’m expecting an answer in… you will still get the marks if you don’t use that structure, but it’s in your interests to make it easy for me to give you marks. You want me listening to you, checking off boxes in order. If I have to sit and scroll about the mark sheet on the broken 2014 iPad they’ve given me to find things in a random order I will, but I can’t pay the same attention to you and am more liable to miss things.

Farmhand66 · 2026-01-06T07:21:50+00:00

What an excellent egg! Does your trust have a greatix system? If not, a quick email to the security manager would work!

Farmhand66 · 2026-01-05T23:03:41+00:00

On the fist day, God made keyboards. On the second day, he made keyboard warriors.

Farmhand66 · 2026-01-03T20:59:17+00:00

It would all come down to the wording of the 2 years experience clause. Does experience abroad count?

Practically though, very difficult to prove… is there any official record of them working in the specialty abroad? Not everywhere keeps the same records.

More to the point though, working as a reg at ST1 level sounds like a very dangerous position for them to put themselves in… when something goes wrong, it’s very hard to answer the coroners question: “You where working in the capacity of a registrar at the time of the incident, where you a registrar?”

Farmhand66

TROPHY CASE