The first Wednesday of August in England is known by some observers of the NHS as ‘Black Wednesday’, the more cynical ones calling it the start of ‘the killing season’.

Recent studies show there are 6 – 8% more patient deaths in the first week of August than in the last week of July. Although at first glance this is scary, it does need careful and cautious interpretation as it does not demonstrate a causative link between junior doctor errors and patient deaths.

With over 6,000 junior doctors starting new posts, some of them for the first time, it is no surprise that this is a worrying time for hospital staff, hospital risk managers and the public. Coincidentally perhaps, ED attendances have fallen over recent years on this particular day; perhaps it reflects public awareness of this phenomenon.

The Academy of Medical Royal Colleges (AMRC) have called for action to be taken. Although attempts have already been made to reduce the number of serious untoward events, it is clear that general standards of patient care including length of hospital stay need improving during this critical period.

It does not take a rocket scientist to work out that a supervised induction period will lead to better overall preparation for junior doctors and should improve patient care. A ‘shadowing’ initiative, suggested by the AMRC, has been piloted by several UK trusts with some success. On paper it is an excellent initiative; in practice however, how practical is it in a fast-paced and time critical environment such as an emergency department where changeover day only serves to stretch the already overstretched staffing debt? How can we ensure appropriate senior doctor/consultant cover during this critical period?

Induction should focus on systems, communication, crew resource management and patient safety. Standard systems and protocols nationally will certainly be one solution, as well as placing junior doctors in hospitals where they have trained as medical students; local knowledge will help.

Staggering the changeover period is another option; the downside is that a five-day induction stretches resources and not all hospitals with have the infrastructure to manage this safely.

Patient care is an absolute priority at all times but especially so during this time; we need to continue to support and encourage our junior doctors who are often facing one of their most difficult and challenging times of their professional lives.

Janos P Baombe/Sivanthi Sivanadarajah

Here are  the highlights from this month’s issue…

Location, location, location

Five departments in the South West replied to a survey to see if they followed the CEM guidelines about having immediate availability of antidotes to a variety of poisoning agents.

The questions asked if they knew were the antidotes were, if not how to get hold of them, and how long it would take to get them.

Results are revealing and should lead the reader to repeat this work in their own department as a worthy exercise! Do you know where the dicobalt edetate or sodium thiosulphate is kept, or how to get hold of more stock?

Here are  the highlights from this month’s issue… 

Ophthalmoscopy in the Emergency Department

Ophthalmoscopy is a difficult but essential skill in the Emergency Department environment. In this short report, the panOptic ophthalmoscope was compared to traditional direct ophthalmoscopy in conditions comparable to those found in most EDs. While the newer instrument was preferred, the actual clinical utility of doctors using both was worryingly poor. See the performance of trainee emergency physicians for yourselves.

Perfect World or Dark World

Emergency Department crowding is a problem just about everywhere. In this paper, a discrete event simulation created models of the Emergency Unit to explore the effect of various changes to physical capacity and human resources. The relationship (in the model) between the physical resource requirements and the number of clinical decision makers is particularly noteworthy.

Alphabetical handover

Emergency Departments abound with clinical risk: high numbers of new, undifferentiated and unwell patients, multi-professional and multi-specialty staff in unfamiliar teams, time constraints and a high turnover to name but a few. Anything designed to reduce avoidable risk is to be welcomed. Our colleagues from Imperial College, London describe the development and implementation of a tool for ED shift handover that clearly works for them. The papers are worthy of close study.

Buscopan and/or Paracetamol in moderate abdominal pain

We all have hobby horses (or fixations!) and I have to admit that one of mine is a profound desire not to give patients with abdominal pain a dry mouth, blurred vision and a raised chance of urinary retention in addition to their presenting problems. I was delighted, therefore, to see the paper that randomised patients with acute abdominal pain into groups that received either oral paracetamol or intravenous hyoscine butylbromide alone or a combination of the two. To see what they found and to find out whether my fixation was justified or whether I need to eat my hat you’ll have to read the paper!

To CRP or not to CRP, that is the question

Santos and colleagues from Sao Paulo report on a problem that faces us all—the uncontrolled rise of the easily requested, expensive yet ultimately clinically unhelpful test, juts like this well known, non-specific marker of inflammation. Their initial assessment of the problem involved an audit of current practise together with a review of the evidence of clinical utility. The most interesting story they have to tell is, however, in terms of the intervention they designed to combat the problem. It is well worth getting this paper out and studying it, as the lessons are generalisable to many situations and settings.

They think it’s all over

It wasn’t just the athletes and the gamesmaker volunteers who had to prepare for the London 2012 Olympics—there was a considerable, hidden public health agenda too. Part of this was the development of an Emergency Department syndromic surveillance system to help monitor the nation’s health. As Elliot and collaborators report in their paper describing the early part of this work, such a system is both feasible and useful.

and finally…

In a short report Reed and others from Edinburgh, Scotland report on a possible role for troponin assay in patients with syncope. Well worth a read.

Kevin Mackway-Jones

In this short blog, Aruni Sen shares his thoughts on a retrospective study he conducted with some of his colleagues around a 24/7 senior clinician delivered emergency care and the reactions from the profession. 

The philosophy we strive for in the care we offer in the Emergency Department at Wrexham Hospital is that every patient, if needed, deserves to be seen by a consultant regardless of time of day; if a consultant emergency physician is needed at 9am then the need is no different at 2am. This view is ridiculed by many of our consultant colleagues in the United Kingdom; a throw away comment that we are ‘working like a glorified registrar all our life’ is cynical, insults both registrars and consultants and often comes from those who are not clinically active in hours – never mind out of hours.

We reject this cynicism; our working pattern now includes night shifts and we did so because of the risk to patients left to the care of junior doctors at night; instead of expecting the middle grade doctors to work an unsustainable number of night shifts, the consultants decided to share the burden.

Do consultants make a difference by delivering care at any time of day? The answer is unclear during the day (as there are many consultants, middle grades and juniors working) but at night (a consultant or middle grade doctor with a junior) it is more straightforward.

Our recent paper in the EMJ reports what we found – that a consultant is more efficient and does the job better than others. This should be no surprise to anyone; after all a registrar trains to improve as a clinician, and so if a consultant does not outperform a trainee we need to go back to the drawing board and ask what it is all about.

The benefits that we reported are quantitative; our next step is identifying the cost savings that a consultant service offers compared to that by juniors. A harder thing to measure accurately and in a reproducible way however, is the quality of care given, namely rapid decisions, focused investigations, admission avoidance and comprehensive counselling to name a few. We are not sure how to show this on paper.

One certainty that cannot be argued against is that our desire for respect from other specialties is unrealistic while we allow the bulk of service delivery to come from juniors. The hospital is not blind. For those of our colleagues who accuse us of committing self-destruction in writing this paper (like turkeys voting for Christmas) we must ask the question what our patients will think if they hear these negative comments.

We can only wonder…

Aruni Sen

ED attendances are increasing at a phenomenal rate worldwide. This, along with staff shortages has resulted in an ever-growing mob of exhausted and dissatisfied staff members. Exhaustion can result in worsening patient care and even lead to serious medical errors.

The European Working Time Directive (EWTD) have succeeded in capping average weekly hours, but 13-hour night shifts and a week of night shifts amounting to some 80-90 hours are not quite a thing of the past yet. To the great despair of their staff, many EDs have found ways around it…

The EWTD has also failed to cap the intensity of work and the proportion of antisocial hours worked. Is there anyone out there who actually gets all his or her mandatory breaks?

We are now a fully-fledged 24-hour service where in some instances nights are actually busier than day shifts.

We need to find a good balance between working sensible hours and continuing to achieve adequate training. The surgical specialties have long been denouncing the negative impact that reduced hours have had on their training.

How many of us have not ever felt slightly edgy when we have been tired or hungry or both and have allowed a colleague… or worse still a patient to sneak a glimpse of the inner Hyde character. This does nothing for patient compliance and satisfaction.

Being exhausted can, not only dampen motivation, but can also lead to poor attitudes to work and learning. Overworked doctors become lazy learners. It also breeds a “them and us” attitude.  ”If they give me nothing I will give them nothing in return- why should I do anything over and above the bare minimum expected of me?” In all work settings we know that a bad attitude can spread amongst staff like wild fire, which can escalate to full work place revolution, even amongst those you could have previously banked upon.

What about the dire effects on our health?

The aviation and driving industries have already recognised the dangers of exhausted staff on safety and performance and have imposed sensible mandatory breaks. http://blogs.bmj.com/emj/2012/05/16/crew-resource-management-in-the-ed/

In medicine however, we rarely practice what we preach, often eating convenience foods, finding little or no time for exercise and walking around in a haze of stress and sleep deprivation.

On a personal level, burnout can lead to depression and contribute to substance misuse and broken relationships at home, not to mention strained relationships at work.

The most common reason for rejecting a career in EM is a poor work-life balance. The answer to staff shortages is not to pile more work on the already over-worked. Worldwide staff shortages within ED are going to be a long-term problem unless we urgently seek to remedy these problems.

EM is a vibrant, challenging and growing specialty, but sadly its workforce will not be for much longer, so by balancing hours as well as training, please let’s make it an attractive career option again!

Sivanthi Sivanadarajah/Janos P Baombe

The brave new world of major trauma centres (MTCs) is here; most Emergency Departments (EDs) are planning for them, be it reassurance (and relief?) for smaller ones as trauma patients are whisked off to the local MTC, or the increased workload for the new MTCs as ambulances head to their doors.

Changes of this nature mean a change in team dynamics; the increased work for MTCs means there will be a focus on the trauma team – a varied group of staff that meets in moments of intense pressure to deliver advanced care to the sickest patients the hospital will see.

Are we a different animal from other professions that find themselves in comparable situations? If not, why do these other professions (e.g. nuclear plant workers, fire and rescue personnel and airline cockpit crew) continuously practice, simulate, brief and debrief incidents whereas trauma teams rarely, if ever, do?

Crew Resource Management (CRM) is creeping into clinical practice and, despite the cynicism of skeptics, it is having a positive impact. The ability of individuals to work as part of a team, and for that team to then work as an efficient single entity in a reliable and reproducible way, must be the goal of ED teams and CRM offers simple and logical ways to support this.

The principle behind CRM is good communication and decision-making. Clinicians’ decisions are often opinions based on personal experience and the immediate information available at the bedside. In the early stages of trauma management accurate information is limited, and to some extent decisions are educated guesses. Better quality background information reduces the degree of guesswork and this can be gained through open communication. http://podcasts.bmj.com/emj/2012/03/21/crew-resource-management-with-nick-crombie/

A team leader who briefs the team and introduces its members to each other before the patient arrives opens communication streams and allows team members to input to decision-making. The same team leader who then stands back, maintains situational awareness, observes the team at work, watches and listens, conscious of the ticking clock above the trolley will quietly allow the team to perform their individual specialist roles whilst ensuring that care is swift and targeted.

The role of CRM in aviation is illustrated by two events. When a twin engine British Midland 737 crashed near East Midlands Airport in 1989 killing 47 passengers there were significant failings in communication and decision making after a single engine malfunction led to the healthy engine being shut down before landing. In contrast, when a twin engine US Airways Airbus 320 landed in the New York Hudson River in 2009 following a bird strike and total power loss and with no deaths, there was a near perfect allocation of tasks, communications, decision making and activation of pre-briefed emergency drills.

The different outcomes in these two situations were in some considerable part due to CRM.

Why should teamwork in healthcare not be to the same standard?

Nick Crombie

THE MEDICAL MATRIX: WHICH DOOR IS OUT?

Do you remember that really irritating patient that came to ED at 3AM with a five-month history of neck pain, saying that the web told her that she might have a subarachnoid bleed? You probably thought – who the hell are you to self-diagnose – I am the doctor, not you!

The rapid propagation of the web means that the public is better informed about health issues than ever before. Some patients are now self-anointed experts and have made the questioning of decisions and diagnosis an art form.

Self-diagnosis is as easy as a keyboard click, with easily accessible search engines and online medical dictionaries. You can now bypass the ED or your GP; you can even self prescribe medication from dodgy websites offering anything from protein shakes to sexual performance enhancers.

Even if a website is robust and the information from a professional medical database, how reliable is it? Can laypeople understand the jargon and reach sensible conclusions? Or do they only believe what they want to believe when they find a site that tells them what they want to read?

Patients also seek information about their doctors online. They know who misdiagnosed a child with flu but who later died from meningococcal septicaemia last year, as it was on the web.

Professionals have also benefited from this digital revolution. We can now easily access the latest research and evidence and share it with our colleagues. It lets us learn remotely, especially useful for people working in remote areas or in developing countries.

How do we balance the current philosophy of empowering patients to make their own decisions without returning to an archaic hierarchical one-way communication and paternalistic style when they come to us spouting nonsensical rubbish?

How do we ensure Data Protection and patient confidentiality?

How do we respond to patients who try to befriend us on Facebook or Twitter?

Will the web bring more problems than solutions? Are we mature enough to use it safely?

Will too much information make us all sick?

Janos P Baombe/Sivanthi Sivanadarajah

Ars Moriendi (“The Art of Dying”) is the name of two Latin texts from the Middle Age – the time of the Black Death. They give advice on a good death. They told readers what to expect, and prescribed prayers, actions, and attitudes to achieve a “good death” and salvation.

The belief that death is the enemy is deeply ingrained in our culture, just as the concept of withholding or withdrawing treatment is taboo in the medical profession. This latter position derives from the Hippocratic Oath – “I will use treatment to help the sick according to my ability and judgment, but I will never use it to injure or wrong them.” Despite comments in mainstream media this viewpoint is not universally supported in the profession…

How should we manage death in ED? Is our duty to the patient, the family or both?

Traditionally our focus is on prompt resuscitation and life support, while investigations and diagnosis continue in parallel. As additional information becomes available we then think about survivable and non-survivable disease. Where is the best place to withdraw/withhold treatment – ED, ICU or a ward? Every day emergency physicians face these moral, ethical and legal challenges, regardless of the country or culture we work in. http://podcasts.bmj.com/emj/2011/05/03/a-propos-du-retrait-de-soins-therapeutiques/

Are we killing patients by stopping support or letting them die with dignity? Is this euthanasia or just a peaceful death? There is such a thing as dignity in death.  Japanese Samurai covered their face with their kimono whilst committing hara-kiri – the ultimate dignity.

Life sustaining measures buy time, allowing relatives and friends to say goodbye and last rites to be completed, important components of grieving.

Doctors are comfortable starting a new treatment, much less so when stopping an existing one. For many, removing life support is like killing the patient.

The patient with non-survivable disease does not need to be diagnosed “brain stem dead” in ICU before withdrawing treatment to make us feel better. Moving a patient to ICU for this, if it is not in the best interests of the patient or the family is wrong; we should manage these deaths in ED.

We should focus on making the patient comfortable, provide staff to support the patient and family during life support withdrawal and provide the right environment for it to occur in.

Dying is indeed a natural process…

Dr Sivanthi Sivanadarajah/Janos P Baombe

Edited by Geoff Hughes