Casualty phobia
Richard Beavington
describes a novel clinical
syndrome
I
want to talk about a clinical syndrome I have named “casualty
phobia”. It develops after a medical students first
exposure to a busy emergency department. I noticed it developing almost
insidiously. An attack starts to develop the night before I am on call,
manifesting as a feeling of dread. It gets worse as, the next day, I
walk slowly towards the emergency department, dressed in white coat,
with yellow book and copious blue crib sheets stuffed into my pocket.
Once I even walked round the long way to put off the moment when I
stepped into the firing
line.
Why
the dread? Maybe it is fear of being stretched too far, of
making a mistake or making a fool of myself
I hope that, perhaps today, therell be no
patients at all, or at least that the medical in-tray will be
empty. I walk through the double doors bracing myself for the
mayhem inside. Every cubicle is doubly occupied, and patients on
trolleys lie two deep along the thoroughfares. In the narrow corridor
outside, queues of patients are standing, sitting, and lying. A patient
is screaming for help, and another is gasping for breath. An ambulance
crew delivers another victim into the crush. Staff are extremely busy,
and the medical and surgical in-trays are overflowing with
patients notes. I once heard a nurse remark “Its
like a major incident every day here.” My natural instinct is to
run. To get away from this nightmare, and return to the nice, quiet,
safe library at the other end of the hospital. To bury myself in a
textbook and pretend this place doesnt
exist.
But I dont. The facade
of confidence remains intact, and I find our firms doctor,
slaving over a set of notes. He is obviously busy and looks tired, but
is pleased to see me—another hand to the decks. He tosses me a
set of notes, “See what you make of that one. And take bloods;
FBC, U and Es, glucose, trop T, amylase, and ask a nurse to do such and
such, and put a cannula in. Oh, and he doesnt have a bed so
youll have to find somewhere to clerk him.” The doctor
disappears into the melee as I struggle to remember the list of
instructions. And then begins the search for a friendly nurse who can
find me a side room for my patient. And having got a room I then need
to defend it from unfriendly nurses who burst in from time to time and
exclaim “Youre still here! How much longer are you
going to be?” Well, I clerk my patient, and hes a nice man
and was happy for me to talk to him, and things go well, and the doctor
is pleased with
me.
So why the dread? Maybe it is fear of being stretched
too far, of making a mistake or making a fool of myself. Perhaps it is
because I feel I am not in control, or possibly its the
responsibility of dealing with a real ill patient. I think it is also
the pressured environment and the busy and stressed people who work
there—many of them friendly, but enough fierce ones around to
keep you on your guard.
But the
funny thing is that after a while, it doesnt seem so bad. A bit
like jumping into a swimming pool that at first feels uncomfortably
cold but soon feels fine. You just get on with the job, and do as
youve been taught. And this is helped by the occasional word of
thanks or praise. A patient that thanks me for my time, or commends me
on my blood taking; “You obviously know what youre
doing.” Or those times when a doctor congratulates me on taking a
good history, or that time when the consultant commended me for my
clerking; “That was good. Very good. No, that was really very
good.” For a moment I was on top of the world. Gradually
confidence builds and skills are developed and, of course, the more one
is immersed the faster this happens. I take comfort from realising just
how good many of the junior doctors appear to be, and thinking that one
day Ill be like them!
So does
this mean that my casualty phobia has been cured? Oh no, not yet! Next
time Im on call it will come back, perhaps not so bad, but
Ill still feel it. But my wise and pragmatic clinical tutor (a
consultant general medic and a personal hero) tells me that everyone
has it, or should do, because as soon as you lose your apprehension you
risk becoming complacent and start to miss things and make mistakes.
After a while, he said to me, your steep learning curve flattens out
and if youre not careful it starts to drop. So a little casualty
phobia is perhaps a good thing.
Richard Beavington, third year medical student, St Georges Hospital Medical School, London
Email: pg004584@sghms.ac.uk
studentBMJ 2003;11:219-262 July ISSN 0966-6494
