Was it a fall? Did the patient black out? Can I explain how the patient ended up with that deformed wrist? ‘I was feeling dizzy’ he said…. Is it stroke … perhaps vertigo … could it be a heart block or just a simple vagal episode?
Can I safely discharge my patient after this ‘funny’ episode? These were the questions that annoyed me the most when I would see a patient triaged with ‘MECHANICAL’ fall or ‘Collapse ?cause’ .
All this on my mind, I spoke to my mentors at the Emergency Department at St James’s Hospital in Dublin. They came up with this amazing idea of Fellowship in ‘Emergency Medicine Syncope and Related disorders’ in collaboration with Falls and Syncope Unit at St James’s Hospital.
Stratifying patients presenting with unexplained falls and syncope can be very challenging. The older these patients are, the more complex their pathophysiology is. The majority of the time these are the most complex multimorbid patients in the emergency department. That does not mean that these patients need admission. We know that older adults tend to have worse outcomes with hospital admissions. We also know that any intervention that can avoid an admission is always a life saver in geriatrics. With that in mind I embarked on this fellowship.
This fellowship provided me with an opportunity to work as a ‘Senior Clinician / Fellow’ with Emergency Department Falls and Syncope (ED-FASS) consultants, both in the Emergency Department and, in the Falls, and Syncope Unit (FASU) with Professor Rose Anne Kenny, Head of Department of Gerontology, and FASU.
This fellowship has trained me in the comprehensive specialist assessment of patients presenting with the various types of syncope. I have also learnt to review high-risk medications including polypharmacy and deprescribing techniques, sophisticated cardiovascular testing including the use and interpretation of data using Tilt testing, Finepress and Carotid Sinus Massage. I was also trained on the indications, procedural techniques, and interpretation of Implantable Loop Recorders.
This fellowship has provided me the opportunity of improving my research portfolio. I am currently involved in novel research crossing over both in emergency medicine and syncope related disorders. There is a strong track record of interdisciplinary research and development between the Emergency Department at St James’s Hospital and the Falls and Syncope Unit (FASU) in St James’s with numerous high-quality original publications and contribution to ESC guidelines.
At the end of my fellowship year, I have completed certification in syncope and related disorders from Mercers Institute of Successful Ageing. This fellowship has also opened the door for me to work as a ‘Syncope Physician’ along with being an ‘Emergency Physician with Special Interest in Geriatrics’. Adding them both together, I feel it is a great mix of skill set for any emergency department.
The biggest perk of this fellowship was being able to work with my consultant colleagues in Emergency Medicine as a very senior trainee. I got to learn how to effectively work as a Consultant in Emergency Medicine. A consultant in Emergency Medicine is not just a clinician but also a teacher, an administrator, a patient safety champion, a compassionate colleague, and the guardian of the front door of any hospital. While these skills will take ages to learn, I certainly got a head start.
This all might not sound as exciting as intubating on the back of a helicopter. However, deprescribing an older adult while improving their orthostatic intolerance, reducing their risk of falls / delirium, and improving their overall quality of life is very satisfying. For all the adrenaline addicts, looking at the heart slowing down into a block while doing CSM on a 60 year or inducing a 15 second asystolic pause on a tilt table in a 23-year-old does give you an adrenaline rush
Add this all up with paucity of weekend work and night shifts on my roster as a Fellow, as Don Vito Corleone said, ‘I am going to make him an offer he can’t refuse’. This is a fellowship opportunity for any EM trainee too hard to say no to.