Primary Survey July 2017

Last winter was a difficult Winter for Emergency Medicine (EM), ED and the staff who work within them. The unacceptable pressures that faced us have only partly gone away and many of us have probably not fully recovered. Stress levels were high, dissatisfaction wide spread, the patients kept coming, and few appeared to leave.

As the year rushes by and Winter can be seen on the not too distant horizon, this themed issue of the EMJ is timely and of significant relevance in focussing upon stress, psychological well-being and job satisfaction amongst a range of Emergency Department staff from both within this country and abroad. Four articles examine this subject and are supported by an excellent commentary from Liz Crowe and her colleagues.

 

Emergency medicine is a great career:

The first article is a qualitative narrative study interviewing a small number of Consultants from a variety of large EDs in Wales. The study was undertaken to deter- mine their views on both the positive and negative aspects of their jobs and to inform prospective trainees of the attractions of a career in EM. Reassuringly, and despite the pressures of the job, most Consultants were positive about EM, citing a range of factors to justify their opinions. Perhaps surprisingly, all were positive about a Consultants work-life balance, a view contrary to that held by both EM and non-EM trainees, a view that we need to promote to all students and trainees to consider EM as a viable career option.

 

EM consultant well being

The second paper by Fitzgerald et al is a further qualitative study, this time of a larger representative group of Consultants from the South West of England. The authors this time set out to determine the perceptions that EM Consultants have of their psychological health, factors that impact on this and how they attempted to cope with the pressures of being an EM Doctor. There is much within this paper of importance but for me the negative effect of external organisational issues on the well-being of EM Consultants stood out. This paper should be read by managers as well as Emergency Medics.

 

A view from abroad

Demonstrating that stress and job dissatisfaction are not unique to UK Emer- gency Departments, the paper by Jiang et al examines the rates of career satisfaction and burnout in a large group of ED nurses from China. In a questionnaire survey with an impressively high response rate, they showed that despite a relatively high percentage of nurses being satisfied with their jobs, there was a high level of burnout with worryingly, almost one in four nurses stating that they were likely to leave their job in the next year. While there may have been some cultural differences behind these findings, the study clearly showed again the relationship between the working environment and levels of stress and burnout.

 

It’s Not Us, It’s the Organisation

Finally, the systematic review by Basu et al from Sheffield brings together the existing literature on organisational issues that may negatively impact on the psychological well-being of ED staff, as well as adversely affecting their ability to care for their patients which ultimately results in burnout and early retirement. The authors decided to focus on organisational stressors rather than individual vulnerabilities as they felt that these were more likely to be amenable to change. The review found that, common to other specialties, high workload and work intensity as well as long hours negatively impacted on the staff’s psychological well-being and feelings of burnout. In addition, low levels of support from managers and non-ED colleagues, lack of professional recogni- tion and lack of educational opportunities were all important additional contributors not only to psychological well-being but also to compassion fatigue and the ability to care for our patients. While the authors found that studies examining interven- tions designed to alleviate organisational stress were lacking, the evidence presented provides an excellent base to develop interventions at an organisational level to support all ED staff, both in the short term and the long term.

 

The positive effect of GP’s reducing ED attendances

Undoubtedly one intervention that helps all ED staff is a reduction in the numbers of patients that are seen within an ED. An interesting study from the West Midlands examined the effect of a pre-hospital partnership between ambulance staff and GP’s. GP’s, according to pre-defined call criteria, either provided telephone advice and support to paramedics or attended patients at scene. Almost 10% of calls were able to be handled by GP’s with 80% of these patients not requiring subsequent transport to an ED. The sustainability of this project is supported by it continuing to function 4 years after its initiation.

 

Too hot, too quick

There appears to be increasing evidence that higher oxygen concentrations during resuscitative processes may lead to harm. This now appears to extend to the use of external exothermic warming devices used pre-dominantly in the pre-hospital setting. I must admit I wasn’t fully aware of these devices designed to externally warm patients, let alone being aware of the oxidative chemical reactions that are used to generate heat. In a neat mannequin study, designed to simulate the use of higher concentrations of inspired oxygen in an enclosed environment, the study by Brooks and Deakin clearly shows that the use of higher inspired oxygen concentrations not only accelerate the exothermic reactions used in the warming devices but result in excessively high temperatures that may lead to clinically significant burns.

 

Why Patients take the bus

Finally, a paper from Australia, examining the effect of a public health campaign on the use of Emergency Medical Services to transport patients with an Acute Coronary Syndrome to hospital. While the majority of patients with an ACS recalled seeing the campaign, disappointingly the campaign appeared to be unable to influence patients’ behaviour, with over 40% of patients using alternatives to EMS, believing them to be faster than waiting for an ambulance. The authors conclude that further efforts are necessary to inform the public of the medical benefits of EMS transport.

 

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Richard Parris