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Chris Hani Baragwanath Hospital only hospital in Soweto largest in Sub Saharan Africa South AfricaInsightful story: Memoirs Of An Intern

 

Hosh panics on his first night shift during his Trauma elective when compressing a wound doesn’t arrest patient bleeding

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Rosh lay in his bed, reading what his son had written about his unforgettable learning experiences in the World's third biggest hospital, Chris Hani Baragwanath, in South Africa:

On my first night shift during my elective in trauma, I saw a 28-year-old man who had been assaulted on his head with a glass bottle. He was alert, but in pain and very anxious.

To try to relieve his anxiety, I permitted his wife and mother to stay with us in the assessment cubicle.

The man’s head was bandaged in multiple layers and the bandage was soaked in blood. I unwrapped the bandage and uncovered a cut temporal artery. It was bleeding from the wound site. I applied pressure, but the bleeding continued.

The cubicle looked like a set from a scary movie. The man was crying in pain. His blood was sprayed around everywhere. His family looked horrified. His mother was screaming at me that he was going to die. I felt I had to do something, but had no idea what.

I asked him to hold the bandage to his head and apply compression while I got him some help. Leaving them there, I rushed to the resuscitation area, but had to wait very long for a doctor to become available. This was not a situation I felt adequately prepared for.

I had panicked when compressing his wound hadn’t arrested his bleeding. I felt personally responsible for controlling it and his pain, and relieving the family’s anxiety, but I had never been in an acute situation like this before which I had had to solely manage.

My nerves were in overdrive, my heart racing. My breathing was fast and shallow. I was sweating. My hands felt heavy, my mind confused.

Not knowing how to stop his bleeding, hearing him crying out in pain and seeing his family suffer had compounded my own anxiety.

I felt like I had mental tunnel vision. My thoughts were fixated on worrying about what was going to happen to him and whether people would hold me responsible for that, rather than on what else I could have done to help in the situation. Regardless of whether others felt similarly or not, I certainly felt incompetent and therefore, ashamed of myself.

This experience made me reflect on how to better manage such situations in future. It would have been more helpful had I asked for nursing assistance early, given the patient appropriate analgesia early, warned them all of the potential unsightliness of his injury while reassuring them of his non-life threatening situation, considered crowd control measures, prioritized adequate compression over his fear of pain, managed his pain expectations while doing so, concurrently treated loss of blood volume by fluid replacement, and anticipated further medical management (like gathering equipment to place hemostatic sutures).

Uncertainty in acute settings and inadequate preparation or knowledge can cause panic, shut down the mind and make it hard to see good potential management options within the scope of practice.

I have also thought about how my own personal biases influenced my experience. In my upbringing, the importance of knowledge has always been stressed. Competence comes from knowledge, practise and preparation.

As I had none of these in my new environment, I had felt ashamed, not knowing what to do. Also, I am a person who learns best by doing, and likes learning practically or ‘on the job’.

So, I had overlooked the importance of being orientated to the hospital, hospital processes and basic management principles in a new specialty - in a hospital and country I had never been to before.

In future, I will aspire to do these before rushing into clinical practice (e.g., learn how to quickly access guidance for acute settings like the RMO Handbook when senior colleagues are difficult to contact).

It is inevitable that I will face other situations of uncertainty that I will have to manage as my responsibilities grow. Situations will arise when I may feel underprepared, perhaps even incompetent again, but I have learnt to accept that learning is a lifelong process. Experience continues to teach, long after one is finished with the books.

I have realized that it is best to focus on the situation and not its consequences, to better manage it and to critically self-reflect on the scenario later and seek guidance, if needed, to improve competence, confidence and efficiency.

Feelings of shame arise when one knows what is appropriate but fails to do it. They can pull one down in the vortex of self-pity and worthlessness, or inspire one to pursue excellence and rise to the challenge. I consciously choose to do the latter.

Mindfulness of my thoughts, emotions and actions will continue to help me not only prevent future mental meltdowns but consistently improve my craft, competence and confidence.

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