28 Aug 2020
Having documented his transition from student to new graduate in Grad Expectations, then offered readers an honest and open account of his experiences and mistakes as an intern in Practice Makes Perfect, regular Vet Times contributor Dave Beeston embarks on his latest column sharing the next step on his career path as an emergency and critical care resident.
David Beeston
Job Title
The majority of Dave’s time will be split evenly between shifts in the emergency room and shifts in the ICU. Image © Kzenon / Adobe Stock
I feel as if I’m stood at the base of Mount Everest, looking on the challenge ahead of me with a true sense of excitement and nervous butterflies.
Having finished my rotating internship at the RVC, I am spending a few weeks off in preparation for starting my residency in emergency and critical care (ECC).
Starting this residency has been a goal of mine since I was a final-year student at the RVC (talk about being institutionalised) and I’m still in shock that I’ve been given the opportunity to spend three years immersed in an intense clinical training programme.
But what is a residency? What is the speciality of ECC? I’m sure many of you are familiar with the more well-established specialities in the UK:
…the list goes on.
The field of ECC is a comparatively newer speciality, despite being much more established in North America. I thought it would be a good idea to go through what the next three years are going to entail, why I’ve made the decision to embark on this epic task and what my end goal of the residency is.
We’ve all been veterinary students at some point, so you’ve probably noticed that a hierarchy of qualifications exist throughout the university clinical environment.
Lecturers are typically experts in their field and most commonly are “board-certified” and “recognised specialists”. The RCVS states that a recognised specialist must have achieved a postgraduate qualification to at least diploma level, and contributed to his or her speciality both nationally and internationally – for example, by participating in further research or teaching.
Diplomas are awarded following periods of intensive training (typically four years, including a rotating internship) and a set of board exams in a specific area of veterinary medicine, ranging from anaesthesia and analgesia to zoological medicine. These diplomas are awarded by individual colleges within the American Board of Veterinary Specialties or European Board of Veterinary Specialisation.
So, how do we get there? Well, you have to complete the intensive training first. A residency is designed to cram in a huge caseload specific to your chosen discipline, allow you to be involved in research and publishing in the literature, and develop your knowledge and critical thinking skills.
At the end of the residency you sit exams that assess you on your knowledge of your chosen field, including anywhere from three to five years of literature in various journals, both veterinary and human.
Residencies certainly aren’t for everyone. They present numerous challenges and pretty much require you to put your life on hold to pursue a specific goal for three to four years.
Residency programmes often include longer working hours and a pay sacrifice when compared to general practice; unfortunately, this means they aren’t accessible for many people. Alternative routes to specialisation are available, but they’re certainly not common and often present even further challenges to overcome.
I’m a firm believer that each of us in this profession is on a spectrum of knowing a little about a lot and knowing a lot about a little. One isn’t better than the other, they just have different challenges.
Already I can feel some of my skills from general practice fading away, and I definitely miss a lot of aspects of general practice. I miss having my own regular clients, my team at Leonard Brothers Veterinary Centre and being able to do a bit of everything – from abdominal ultrasound, to soft tissue surgery, to dentistry. But I’m ready to move on and start narrowing my areas of interest.
Say the words emergency and critical care, and I’m sure many people will instantly think of night and weekend work, but it’s much more than that. While my residency does contain a lot (and I mean a lot) of nights, twilight shifts and weekends, I will also work during the day in our ICU or emergency room (ER).
I am going to be completing a residency to undertake specialisation into the American College of Veterinary Emergency and Critical Care (ACVECC), with the option to apply for the European College of Veterinary Emergency and Critical Care (ECVECC) once I finish. The residency requires me to complete 72 weeks of ECC work under the direct supervision of an ACVECC/ECVECC diplomat and “out-rotations”, including:
There’s not a lot of time for much else, but we also have to cram in independent study weeks, research projects, CPD, 200 hours of seminars (including regular journal clubs) and teaching of veterinary professionals.
So how do you have a life outside of all of this? Truth be told, it’s something I’m going to have to really work at. I think things will get easier as I get more comfortable with the complexity of cases, and the required regular reading for weekly exam preparation and journal clubs, but it’s going to take a while – maybe I’ll be organised enough in my third year…
Although I have lots of out-rotations to complete, the majority of my time will be split evenly between shifts in the ER and shifts in the ICU.
I love our ER. Although it can get a little crowded and busy, it is a dedicated space to allow appropriate triage and stabilisation of a wide variety of referral cases, as well as hosting our first opinion out-of-hours service that is run by the hard‑working interns.
We have an incredible caseload that encompasses medical, surgical, neurological and ophthalmological cases, and varies from day to day. As with any emergency work, the pace of the shift is dependent on the cases coming in. We take emergency telephone calls from referring vets 24/7 and provide advice on urgent cases where we can.
The ICU is where the sickest of the sick patients end up. We operate an “open” ICU, meaning patients from other services are able to be housed in ICU, while the ECC residents and faculty provide advice where necessary.
We also have our own ECC patients – these typically are patients that aren’t stable enough to leave the room for prolonged periods of time, and require intensive monitoring of their haemodynamic, respiratory, neurological and nutritional status. We provide intensive care and complex procedures such as mechanical ventilation, dialysis and plasmapheresis.
The ICU is primarily run by a fantastic group of nurses who I’ve mentioned previously in my Practice Makes Perfect series, and I look forward to them showing me the ropes – and keeping me on the straight and narrow – as I progress over the next few years.
I’m getting flashbacks to my residency interview…
In human medicine, ECC is typically split into intensivists (of which there are many subspecialities) and emergency doctors, but we get to do it all. I am really glad we haven’t specialised further and separated the two disciplines.
I love the pace and variety of the ER. My job is primarily to stabilise and start initial diagnostics before transferring to other services within the hospital.
Although I miss the formal follow-up of cases, I do keep tabs on the interesting ones as they continue their stay with the other services. This allows me to reflect on my initial approach, while taking on the advice and expertise of my fellow colleagues who have their own areas of expertise.
Patients arrive to us at varying levels of stability – some have urgent fractures that need fixing without any other systemic compromise; others may be septic, and require rapid investigation and stabilisation of their haemodynamic status. We get to see it all, and I can’t imagine a time where I’ll be bored of the variety.
Then we get on to the critical care component of the residency. I think my friends and colleagues will attest to the fact that I’m a bit of a perfectionist… I love getting back to the physiology, and tweaking things here and there, waiting for the patient to show me where to go next.
Critical care is about using the patients’ physiology and working through internal checklists for each of the body systems to give them the best chance of healing. Obviously, the job involves a lot of patients that unfortunately won’t make it. By definition, if they’re under my care in the ICU, they’re probably quite sick – but my aim is to make patients comfortable and to put quality of life above all.
Ultimately, I plan on spending the rest of my career in ECC. The residency will open up a huge array of opportunities and I can’t wait to see where I am in three years’ time.
If you have a question or want to discuss a topic from ECC Endeavours, please feel free to drop me an email at [email protected] and I will try to get back to you ASAP.
Until next time, take care.
