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Out of my depth

Many new doctors are pushed to the limits of their competence – if you feel out of your depth speak up Out-of-my-depthbefore it’s too late, says Dr Jo Pointon

As I stood over my four-month-old patient, syringe of morphine in hand, concerned parent looking on, I wondered how it had come to this. My consultant’s parting words echoed in my head, “Everything will be fine”. I threw a reassuring smile at Mum, eyeing the door behind her wishing my registrar would burst through it. With an anxious voice, the nurse, who was gently restraining the child, announced: “Doctor, I think this baby needs more sedation”. It hit me – I was completely out of my depth.

Talk to a group of junior doctors and most will have a story about how they found themselves in over their heads. They may have felt pressured, for a variety of reasons, into taking on unfamiliar roles or tasks. But what can a junior doctor do if they feel they are being asked to work beyond their competency level?

“Everything will be fine”

I found myself in this position as an F2 in paediatric surgery. I was working within a friendly, enthusiastic team and always felt well supported. While I was on-call, a four-month-old baby was transferred to us with suspected intussusception. She was immediately transferred to ultrasound, where the consultant paediatric radiologist would attempt radiological reduction. My registrar would give IV morphine for analgesia (not sedation), which was in accordance with the hospital’s guidelines for intussusception.

What can a junior doctor do if they feel they are being asked to work beyond their competency level?
The intussusception proved difficult to reduce. After a prolonged period, the bowel could only be partially decompressed. By this time, the baby had received a large dose of IV morphine, in excess of the recommended guidelines. She was closely monitored and her condition was stable. The decision was made to allow some time for the swelling in the bowel to subside and attempt further reduction a few hours later.

That afternoon, both the on-call consultant and registrar were tied up in emergency theatre. The other registrars were also in theatre or busy clinics. The radiologist had rearranged a full ultrasound list to accommodate our patient and the pressure was on to ensure that she was ready. It quickly became apparent that I would be the only doctor available to administer the IV morphine. The hospital’s guidelines specified that this should be the responsibility of the paediatric surgical registrar.

I spoke to my consultant in theatre, who recognised that I was being put in a difficult situation. He explained, however, that if the procedure could go ahead and was successful, it would save our young patient from invasive surgery and the registrar would join me as soon as possible. “Now remember”, he said, “she has had a lot of morphine, so be cautious. Don’t worry though, everything will be fine.”

Prepare for the worst, hope for the best

I was not completely comfortable with the task ahead of me. I did have some experience, albeit F1 experience, of using IV morphine in anaesthetics, but not in this age group. In the limited time available, I did what I could to prepare. I printed the hospital’s guidelines for intussusceptions; checked and double checked the morphine dose in the BNF; drew up an appropriate dose of naloxone (just in case) and, finally, checked that we had all the necessary resuscitation equipment to hand.
How had I let myself get into this situation? Not only was I out of my depth, I was drowning

It was not until the procedure was underway that I realised just how underprepared I was.

Firstly, the child appeared to be very uncomfortable, crying louder and louder as the air enema distended her bowel. I had expected some crying of course, given that she was being held down in an unfamiliar environment, but was she in pain? I had, as instructed, given morphine cautiously, slowly approaching the maximum dose. But should I give more? How much was safe, given that only a few hours previously she had received double the dose for her body weight? As an F2, did I really have the appropriate experience to judge this safely?

Secondly, the nurse’s request for “sedation” made it apparent that I had not properly explained to her, or to the mother, that the morphine was for analgesia, not for sedation. Again, I felt under pressure to give more morphine, but did not feel it was safe, knowing how much she had already received. I had already given her close to the maximum dose and was unhappy to give any more and risk respiratory depression.

Finally, feeling weighed down by my lead apron, I realised that should the worst happen and the patient’s bowel perforate, a recognised complication, I did not have a large-bore cannula to decompress her abdomen. In addition, should the bowel perforate or the procedure fail, my patient would need to go to theatre immediately for a laparotomy. It was surely beyond my competency level to be making such important decisions for this child. How had I let myself get into this situation? Not only was I out of my depth, I was drowning.

Finally, feeling weighed down by my lead apron, I realised that should the worst happen and the patient’s bowel perforate, a recognised complication, I did not have a large-bore cannula to decompress her abdomen. In addition, should the bowel perforate or the procedure fail, my patient would need to go to theatre immediately for a laparotomy. It was surely beyond my competency level to be making such important decisions for this child. How had I let myself get into this situation? Not only was I out of my depth, I was drowning.

A lesson learnt

Thankfully, my registrar arrived moments later. Unfortunately, it became clear that the reduction was not going to work, but my registrar was able to arrange for our patient to go straight to theatre, where our consultant would be waiting. She was in the anaesthetic room within five minutes. The intussusception was fully reduced at laparotomy and the patient made an excellent recovery.

As good doctors we need to be able to recognise our own limitations, have the confidence to discuss them and, ultimately, not expose our patients to unnecessary risks
Afterwards, what frustrated me most was that I took on this responsibility despite feeling uncomfortable about it. I think that as junior doctors we are eager to work hard; to be enthusiastic, diligent and thorough in how we care for our patients. Of course we also want to impress. It can at times be difficult to admit that we are unable to do something, especially if we feel our seniors expect more of us. Equally, however, as good doctors we need to be able to recognise our own limitations, have the confidence to discuss them and, ultimately, not expose our patients to unnecessary risks.

Advice for junior doctors

Although the guidelines used here specify a safe dose of morphine, it is important to remember that all patients vary. When in theatre, paediatric anaesthetists do exceed these doses, titrating according to the patient’s physiological response and their stress response to surgery.

However, anaesthetists also have the skills to manage respiratory depression and the knowledge to gauge when a patient will breathe spontaneously on extubation and when postoperative ventilation will be required. The margin between these two states in an infant is much smaller than in an older child or adult.

In situations like this, where there are concerns regarding deviation from the guidelines, it would be advisable to contact one of the paediatric anaesthetists or paediatric pain nurses for their support.

If you feel out of your depth:

  • Put patient safety first – Despite the pressures you might feel to perform a task, always consider the risks involved for your patient
  • Voice your concerns – Your seniors may not have appreciated that you are unfamiliar with certain roles
  • Ask the experts – Seek advice from those most familiar with the task at hand, such as seniors in other specialties or specialist nurse practitioners
  • Further your training – Ask to be properly instructed in how to perform the task required. This shows that you are keen to improve your practice and take on new responsibilities.
Dr Pointon was an F2 working in paediatric surgery in the East new Midlands. Thank you to Dr Hannah King, consultant paediatric anaesthetist, for her contribution and advice.