How Not To Deal With Heart Block

I write about my triumphs, and so it’s only fair that I also tell you about my disasters.

The nice people at the GMC and the sadist who dreamt up NHS ePortfolio would call it reflective practice, although I expect I’ll swear more in this than I might if I were writing it for my educational supervisor.

As part of Preparation for Practice, I spent a day this week at one of the acute care training facilities where they have plastic people who can talk. The basic idea is that a room is set up to emulate a hospital ward or a medical receiving unit, complete with everything that would usually be found in such a room, a phone that goes through to two people behind a one-way screen, and a SimMan who can sweat and shout and, as we discovered to our collective horror, vomit. Acting as the FY1, assisted by a nursing student who would be acting as a staff nurse, we were each to run an acute care scenario. We could call for help in the same way that we would in real life. We had all recently been on an ILS course and so we were promised that at no point during the day would we be expected to deal with a cardiac arrest. The place is also full of cameras and microphones, so that the six or seven people who aren’t involved in a given scenario can watch from the next room.

The other times I’ve done this sort of thing have been in exam situations. The main difference between an exam and real life (and, therefore, between an exam and a simulation) is that, generally, in OSCEs, it isn’t in real time. For example, in my last final, I had a patient who was having an asthma attack. “I need venous access,” I’d say to the examiner, and she would instantly tell me that I had venous access. “I’d like to get a blood gas,” I’d say, and, after a short delay, someone would hand me a set of results. In an OSCE, acute care scenarios are usually set up in a way that allows for a protocol to be rattled through — and has to be set up that way, really, on account of time constraints. I hadn’t had to worry about getting venous access or doing the blood gas, and I hadn’t had to give so much as a passing  thought to the simple but suddenly incredibly time-consuming tasks like getting a Kardex or finding someone who knows where the ALS drug box lives. And, oh, how relieved am I that this, the first time I’ve really needed to think about those things, was in the safety of a simulation and not actually during my first medical on-call.

It was really shit.

It was a really valuable learning experience, but it was, you know, really shit.

I arrive in A&E to see a woman who had collapsed while out shopping with her husband. I am met by a senior nurse who informs me that the department is very busy and that my patient has been got onto a trolley and started on an oxygen mask but has otherwise been left. I have a staff nurse who starts getting her obs, and someone has kindly got for me a list of her usual medications. I start talking to her, and determine fairly quickly that I’m not going to get much of a history. For one thing, she thinks we’re in Asda. However, she is talking and so she has a patent airway. The nurse has got a monitor turned on and I can see that her oxygen saturations are down in her boots, so I turn the oxygen mask up to 15 litres — cursing as I do so the people who think that everyone over the age of 45 is a CO2 retainer until proven otherwise.  I ask the nurse if she has the other obs yet. And I think that’s where it all fell apart. I remember everything that happened next, but not exactly which order it happened in. I know that I was interrupted by a senior nurse who wanted me to clear the bay because other patients were waiting. I know that I got another FY1 in to get IV access. I know that the nurse told me the other obs and that I misheard them or heard what I was expecting to hear, and I ended up thinking that she was hypotensive with a tachycardia rather than hypotensive with a really profound bradycardia.

I know that I was being watched by my colleagues, who had the obs on a second screen and had realised that they weren’t what I thought they were and were by this time trying to get me to look up at the monitor through sheer force of will.

The patient, through all of this, was steadily becoming less and less responsive. I panicked and disappeared into my own head, which is not the way to be an effective team leader. If I had said, out loud, while I was assessing circulation, that the patient was tachycardic, the nursing student would, I hope, have realised that I’d made some sort of mistake somewhere and at least repeated the heart rate. If I had said, out loud, “oh, my God, the world is ending, help,” which was the thing I was chanting to myself at that point, she might have suggested that I call someone else or the FY1 who was cannulating might have realised that I was actually floundering so badly I could have been an extra in The Little Mermaid. I needed, ultimately, to make a phone call to my FY2 and said, “I have someone down here who is really sick. I don’t know why and I don’t know what to do.” And I did, in the end. And then I called the cardiology reg. And then I put out a periarrest call. My educational supervisor, when I told her about this, said that in real life I’d have asked for help more quickly than I did, and I think that that is probably true. It didn’t matter that I couldn’t remember how to treat heart block. It mattered that I freaked out and, instead of falling back on ABCDE, I fell back on the time-honoured response of metaphorically curling up into the foetal position and squeaking helplessly.

I could have dealt better with any of the other scenarios than I did with that one. There are areas of knowledge that I’m confident in, and, unless it’s the kind of cardiac arrhythmia that I can fix with CPR, cardiac arrhythmias is not one of them. Although, after a half hour with the Oxford Handbook of Clinical Medicine and a chat with a couple of people, I now know how to treat heart block. Of course, there were things besides my wobbly knowledge base that made it difficult, like being asked to clear a patient out of a bed while the patient was busy becoming unconscious, but that is the kind of thing that I need to get used to dealing with. (“I was trying to be polite,” I said, protestingly, to the tutor who had been acting as the interrupting nurse. “Don’t,” she said.) But although I might have acquitted myself better if I’d had to assess a septic patient, I wouldn’t have learned nearly as much as I did from dealing very badly with something that I didn’t know much about. I think this might have been what I meant when I wrote on Sunday about maybe needing, now, to be thrown to the wolves.

But like I said, only if I can have my FY2s bleep number tattooed somewhere before I get thrown to them.

It was a hideous experience. It was admittedly a great deal less so than it would have been if this were a real patient, but, nevertheless, it was shit. And sometimes there is nothing to do about that but to acknowledge that it was really shit, to have friends who understand that it was really shit and are able to offer their own stories in commiseration, and to find value in the parts that were valuable and to take from it the lessons that can be taken. And, when you’ve done all that, to move on.



  1. Since you’re typically a decisive and quick-moving person, I suspect this may have been like being trapped inside of a Hieronymus Bosch portrayal of hell. Well – I suspect this is the scenario that many medical students fear, and now you’ve gone and blundered around and had to be extricated by others, now The (Nearly) Worst Has Happened. You will learn to be more rude and pushy and advocate solely for your patient, and not strong-arm interrupting nurses with the best of them.

    Next year at this time, re-read this post. You’ll be amazed by what you have to add. ☺

    1. A Hieronymous Bosch portrayal of hell was exactly what it felt like. One where I couldn’t find the ladder to get out.

      You will be amused to hear that I was dwelling on all this on Tuesday night when I became aware that The GPs In The Back Row were musing on how serene I am, which is not a character attribute that I usually associate with myself and certainly not this week.

  2. “and not strong-arm interrupting nurses with the best of them.”
    — Oh, dear, innate politeness strikes again. DO strong arm some nurses, and ask pointed questions. Practice raising a sardonic eyebrow. These things will take you quite far.

  3. I suspect a lot of this was a transitional thing. Changing from being a medical student, who is pretty much lower than the worms, and being examined, and trying to find solutions all on their own, who cannot turn to the examiner and say : ‘Please help me I don’t know what to do next’ and who is bossed by nurses, to being a doctor, who can call the shots, and who needs to focus on the patient in a different way.

    1. Perhaps. I was relieved to learn today when talking to other people who got that patient on a different day, that mostly everyone else panicked just as badly as I did.

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