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Knowing when you are out of your depth

I stood over my four-month-old patient, syringe of morphine in hand, concerned parent looking on, anxious nurse gently restraining the child. That’s when it hit me – I was completely out of my depth.

As an F2 in paediatric surgery, I was on-call when a baby was transferred to us with suspected intussusception. It was difficult to reduce and the bowel could only be partially decompressed. Over time the baby was given a large dose of IV morphine, which was in excess of the recommended guidelines. Between us, we made the decision to allow the swelling in the bowel to subside and then attempt to reduce it again a few hours later.

That afternoon, both the on-call consultant and registrar were tied up. The other registrars were also in theatre or busy clinics. The radiologist had rearranged the ultrasound waiting list for our patient and the pressure was on to make sure that she was ready. It dawned on me that I was the only doctor available to administer the IV morphine, even though the hospital’s guidelines state that this is the responsibility of the paediatric surgical registrar.

My consultant saw I was in a difficult situation but told me if the procedure went ahead and was successful, it would save the patient from invasive surgery. “Now remember”, he said, “she has had a lot of morphine, so be cautious. Don’t worry though, everything will be fine.”

I have to admit I wasn’t really comfortable but I did what I could to prepare. I read the guidelines; double checked the morphine dose in the BNF; drew up a naloxone dose (just in case) and, finally, checked that we had resuscitation equipment to hand. It wasn’t until I got started that I realised just how under-prepared I was.

The child was crying louder and louder as I gave her morphine, slowly approaching the maximum dose. Should I give more? How much was safe? As an F2, did I really have enough experience to judge this?

Finally, feeling weighed down by my lead apron, I realised that should the worst happen and the patient’s bowel perforate, I didn’t have a large-bore cannula to decompress her abdomen. Also, if the bowel perforated or the procedure failed, they would need to go to theatre immediately for a laparotomy. It was surely beyond my competency level to be making such important decisions. How had I let myself get into this situation? I wasn’t just out of my depth, I was drowning.

Thankfully, my registrar arrived moments later. It was clear that the reduction wasn’t going to work, so the patient was taken to theatre where the intussusception was reduced at laparotomy and the child made a full recovery.

Afterwards, what frustrated me the most was that I had taken on this responsibility even though I felt uncomfortable. As junior doctors we are eager to work hard, be enthusiastic and of course, to impress. We don’t want to admit we can’t do something. However, we have to recognise our limitations, be able to discuss them, and ultimately, not expose our patients to risks.

So, if you feel out of your depth:

1. Put patient safety first – you may feel pressured into doing a task, but consider the risks to your patient.

2. Voice your concerns – your seniors may not realise that you are unfamiliar with certain roles.

3. Ask the experts – talk to those who are familiar with the task.

4. Further your training – ask to be properly trained in how to do the task. This shows that you are keen to improve and take on new responsibilities.

Dr Jo Pointon writes for the Medical Protection Society about her experiences as an F2 in paediatric surgery.

To read the full article, please see the latest edition of New Doctor.

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2 Responses to “Knowing when you are out of your depth”

  1. Tom Goodfellow says:

    Remember being an “expert” allows you to be wrong – with authority!

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