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What are we doing in EM?

12 Jun, 14 | by ibeardsell

Screenshot 2014-06-12 08.46.02It’s been a tough few months in UK Emergency Departments and has caused me recently to do a bit of thinking, as I knew I was losing a bit of my zeal and enthusiasm for our specialty. Yes, there’s the constant unrelenting pressure over targets and working under very trying circumstances with overcrowding and understaffing on an almost daily basis. It remains an enigma to me that for a lot of aspects of our work aviation is taken to be a shining example of how CRM should be done, yet a pilot would not take to the sky with 170% capacity and half the crew missing but we do, carrying on with a”Dunkirk spirit” to the best of our abilities.

So much appears to be put in our way, when trying to care for our patients.  We are drowning under the mass of bureaucracy and paperwork, it reduces time available for patient care. Common sense and practicality have gone out of the window, you can’t admit a patient to the short stay ward for a few hours without completing a host of paperwork required by outside agencies. Cannulation forms, an assessment of VTE risk, estimation of alcohol intake and smoking habit, consideration of hidden harm, a falls assessment, etc etc. A folder bulges with Standard Operating Procedures (SOPs), some about important clinical topics, but others seem appear to be bureaucratic ticks in boxes.  We even had to write an SOP  and subsequently approved in numerous places to allow a patient to sit on a chair in a clinical area rather than a trolley, but only after consulting the SOP on how to write SOPs!

Unlike colleagues in other specialties, where patients appear more grateful for their care, those attending the ED seem rather less so and referrals for inpatient admission are rarely greeted with thanks.  As much as we all try to persuade ourselves we don’t need external validation to feel valued I for one will openly admit I feel a whole lot better about myself and the job I do if just occasionally someone says thank you, well done or good job.

The final straw came when I did a brief online questionnaire which revealed I’m at very high risk of burnout. Whoa! I’ve only been an EM consultant for 6 years, part time at that. So the rethink began and I’ve come to the conclusion that what I personally, and I believe we as a speciality, need, as corny as it sounds, is  to get back to basics. To do the fundamentals really well as part of team working.

burnout

I’ve distilled this down to three areas: self; patients and environment. For myself I will try to always be a role model to others: to smile, think positively and value myself and others. My patients I will keep informed, take away their pain and encourage regular observations. The environment we work in should be professional, clean, tidy and quiet. Most importantly of all I will never forget that at the heart of all of this is care and compassion for our patients.

None of these are revolutionary requiring a policy or SOP, they are common sense, low cost, communication based basics that everyone, medical, nursing and support staff can fully participate in. So no-one can change my enthusiasm and zeal for the job except me, I’m trying to get the fundamentals spot on and encouraging others to do likewise, will you?

Dr Sarah Robinson

Consultant in Emergency Medicine

ROBINSONSarah

Spotlight Interview: DevelopingEM

14 Feb, 14 | by rradecki

image007Today, we virtually interview Lee Fineberg and Mark Newcombe, the hearts and brains behind DevelopingEM.  They are emergency physicians who have returned from Havana, Cuba, after the second edition of their conference concept providing resources and support to medical education in the developing world.

Tell us a little bit about visiting Cuba, a place that’s traditionally been closed off to many in the Western world.

Mark: Cuba is an absolutely fascinating country. A combination of Madrid and Moscow in the middle of the Caribbean.
Crumbling colonial buildings, 1950s American cars, revolutionary murals, rum and cigars, with an integrated multicultural population which makes Cuba an incredibly romantic place to visit.

Lee: Yes its certainly an amazing place. Scenically incredible as Mark says but also culturally impressive. With a rich history and a revolutionary ideology that continues to infuse through peoples’ values, it is a welcoming, fair and safe place for visitors. We were both certainly made to feel welcome by both medical and non-medical Cubanos.

What challenges did you witness in the delivery of medical care in Cuba?

Mark: As you probably know Cuba has a healthcare system that provides its citizens with healthcare indices equivalent to the United States. This healthcare is free for all Cubanos and is achieved despite a 50 year old economic embargo that prevents delivery of advanced pharmaceuticals and medical devices to Cuba.  We have called upon President Obama in an open letter to end this embargo, an immoral policy whose stated goal is to “bring about hunger, desperation and the overthrow of government”.

 

Jerry Hoffman in 2013

Jerry Hoffman in 2013

Lee: Yes, Cuba, despite having limited economic resources, has made health care a priority and as Mark has said, despite spending 1/25 the spending per capita of the USA on health, Cuba has approximately the same figures regarding overall life expectancy, as well as infant and maternal mortality. Cuba also has an impressive and largely unheralded program of international medical education, through the Latin American School Of Medicine (ELAM), and international medical aid. ELAM has been described as the largest medical school in the world with approximately 15,000 students from 50 countries. Cuba’s medical internationalism currently also sees 20,000 doctors working in multiple countries around the world.

Mark: So whilst there are challenges Cuba has an impressive national and international healthcare system that has many lessons for our own systems.

How is emergency care supported – or neglected – in their healthcare system?

Lee: Cuba has a different model of critical care delivery than the Anglo-American model we are used to. The core of the health care system in Cuba has revolved around the community based polyclinic with more advanced investigation and management occurring in specialty based hospitals. Critical care has been delivered primarily from an intensive care setting.Final Logo-01

Mark: Yes, emergency departments have increasingly become integrated into both the polyclinic and hospital setting with the realization that unwell patients can present to either setting. The bulk of critical care continues however to be centred in the intensive care. Whilst a different system, it works well within the Cuban setting.

Many folks may not have heard enough about DevelopingEM. In a nutshell, what’s your core mission?

Lee: DevelopingEM is a new direction in medical education, combining cutting edge training in critical care medicine, with a focus on providing a meaningful contribution to medical professionals in developing regions through an inclusive and philanthropic approach.

Mark: We’re a not-for-profit conference organising agency specialising in providing a practical clinical approach to the delivery of emergency medicine and critical care education to senior practitioners in the fields of emergency medicine, intensive and critical care medicine, anaesthetics, and prehospital and retrieval medicine.

 

Lee Fineberg

Lee Fineberg

Lee: With short, sharp, polished presentations focusing on evidence based best practice we hope to provide a clinically relevant educational experience aimed at the senior critical care practitioner.

Mark: Yes, in fact this year we’re looking at 20 minute, 20 slide presentations, more audience participation, panel discussions and demonstrative scenarios.

Lee: As with the past two conferences in Sydney and Havana, the core topics will include adult critical care medicine, pediatric critical care medicine, and trauma medicine, with optional sessions covering the Brazilian experience of emergency medicine, global health and emergency medicine, prehospital medicine and ultrasonography.

Mark: As well as the education provided during the conference we also aim to follow up on our efforts in Cuba and the Caribbean by hosting satellite workshops in the region and also donating computer workstations preloaded with FOAMed resources to centres in the region

Lee: Yes, in 2013 we hosted an ultrasound course in St Lucia performed by the Ultrasound Podcast guys, and also an ATLS course in the Bahamas.

Mark: And we provided 4 Mac mini based computer workstations for health centres in the region. These were preloaded with EM courses and resources. We’re hoping to repeat the effort in Brazil.

Lee: As Mark mentioned earlier, central to the philosophy of our concept is the not-for-profit model. We have avoided industry sponsorship in order to prevent content conflict of interest.

Mark: Yes, conference registration fees and donations alone will be used to fund the ongoing costs of the annual conference and utilised to subsidise the attendance of regional delegates, the establishment of future conferences, and ongoing continuing education projects.

Lee: This model has been a successful financial model for the last two conferences with costs covered and enough credit to cover start up costs of the subsequent conference.

Mark: Our annual conference this year will be held in Salvador da Bahia, Brazil between September 8th and 12th and, as with our model in Cuba, DevelopingEM is forging ties with local Brazilian critical care specialists and organizations in order to secure Brazilian involvement in both attending and presenting at the conference.

Lee: As well as Central America and the Caribbean, and South America, DevelopingEM hopes to take its educational concept to Sub Saharan Africa and South East Asia. Possible conference settings to follow Salvador include Gaborone in Botswana and Siem Reap in Cambodia.

What inspired you to initiate this program?

Lee: Primarily the inspiration grew from a desire for us to share in the experiences of our colleagues working in under resourced regions around the globe.

Mark: Yes, we’ve met some truly inspiring people doing incredible work around the world. Unfortunately, they often have a very limited ability to attend international meetings and interact with multi national

Joe Lex in 2013

Joe Lex in 2013

critical care colleagues.

Lee: So I guess within a conference format we hoped to introduce our delegates and faculty to amazing clinicians from developing regions so that we can learn from each other.

Mark: And I think in Cuba we really were able to achieve this goal, and hopefully we’ll be able to repeat the process in Brazil.

How can interested folks support the initiative or become involved?

Mark: Registrations are the key for DevelopingEM. Without our delegates the whole concept doesn’t work. So we’d encourage everyone to take a look at the evolving program on our website and if it appeals join us in Salvador.

Lee: They can find us online, on Facebook, on Twitter, and on Instagram and spread the word to their colleagues. Not only will we be advertising the conference through these sources but also hosting an educational blog based around the presentations from Havana.

Mark: Even if your readers can’t make it to Brazil there will be options for virtual registration and delegate sponsorship to allow anyone to contribute.

 

vb

 

Ryan Radecki

@emlitofnote

Ryan Radecki

Ryan Radecki

 

Reasons to be cheerful 1.2.3 with Iain Beardsell

16 Jan, 14 | by scarley

There are many reasons to be cheerful in emergency medicine….

The almost constant talk in the media of a “Crisis in A&E” (sic) has made me contemplate why I’m not always dreading work or considering other employment options.  Daily news headlines are a constant reminder of the difficulties we face on a day to day basis and the problems the specialty is having in recruiting doctors in training into its ranks and made contemplate why it was I chose to be an Emergency Physician (EP).

I knew at a relatively early age that I wanted to study medicine at University. I don’t remember it being a conscious decision; it was simply what I was going to do. Chronic illness in close family members meant I had been visiting hospitals since I was young and there was something about it that I liked. Combined with an aptitude for the sciences and general expectation that high achievers either did medicine or law and my destiny was almost out of my hands.

It wasn’t until seven years later, after A levels and medical school had been safely negotiated, that I faced another choice about what branch of medicine I would pursue. The truth is, I’d probably decided this all those years before, in, what we then called, “third year” at school and was determined by what I’ve always believed is the essence of being a doctor – saving lives.

Emergency Medicine is Medicine. Anything and everything is our business, which makes the speciality endlessly satisfying. I will never know it all and I learn something new everyday. I see people at their most vulnerable , I take away their pain, allay their fears, and yes, very occasionally, save a person’s life.

Now, that’s all well and good, but how do we ensure that young doctors can see just what it is that we do and not be put off from applying for training posts in EM.  Undoubtedly, there is a danger of us starting to believe our own publicity, although I am by no means play down in any way the challenges we face. Medical students and junior doctors need early exposure to EM in well functioning, and most importantly, happy EDs. Training forms only a fraction of a medical career – the majority is spent as a consultant and we need to make sure that we are excellent role models to whom our junior colleagues can aspire. Disenfranchised, unhappy consultants will never inspire others to follow in their path.

Emergency Physicians are, by the nature of our job, “cup half empty” type people. We spend our working days fearing the worst case scenario and often can see the world as a bleak, unforgiving place. We need to change our outlook on how we view our work. I believe we have the most rewarding job that medicine has to offer. With appropriate job planning a decent worklife balance is not just a dream, but an achievable reality.  Yes, we work more “out of hours” than some of our medical colleagues, but this can provide opportunities unavailable to others. Prehospital and Sports medicine, medical journalism, management, teaching and training are all ideally suited to us. It is no coincidence that EPs across the world are leaders in online education and social media. These portfolio careers provide balance to the stresses of our ED clinical work.

We should remember that the grass is not always greener. As a speciality we may be receiving a lot of media attention, but our colleagues, both in hospital and primary care, are also having a tough time. Spend a day with an on call medical registrar and this becomes all too obvious. An ED shopfloor can often be a negative place to be – complaints about why doctors aren’t answering their bleep, or worse, answering their bleep with negativity and unhelpfulness. This usually just reflects other stresses they are feeling and we need to remember it isn’t personal. An offer of support and understanding to them often yields great results, both for the doctor-doctor relationship, but most importantly for the patient. Amongst the clipboards and pressure we have to try to make our EDs a happy place to be.

We have a job with endless variety and never-ending job satisfaction. An arbitrary government target has seemingly sought to destroy our specialty, but we need to move beyond that and remember what a privilege it is to do what we do. I believe our cup is, indeed, half full, and with judicious planning and appropriate support can be overflowing.

bw

Iain Beardsell

Consultant in Emergency Medicine

Associate Social Media editor EMJ

Health Education England outlines recruitment drive to UK Emergency Medicine.

18 Dec, 13 | by scarley

UK readers will be fully aware of the staffing difficulties currently faced by UK emergency medicine. Arguably the difficulties are so severe that our international readers will also be aware, since many of them trained in the UK before moving abroad to achieve a better work/life balance.Screen Shot 2013-12-18 at 18.25.30

This is not the time or place to review why UK Emergency medicine finds itself  in trouble, but in my opinion demand has simply outstripped the resource that the UK emergency physician provides with a cycle of underfilled posts leading to a progressively more dissatisfied workforce. Many departments are held together with a mixture of locums, non-specialists and overtime. This is not a sustainable solution to the pressures of emergency care and progress must be made. This will not be easy as EM faces the twin difficulties of both recruitment (most notably at middle grade level) and retention for all grades of staff.

This week we may have seen the first part of the jigsaw appear. Health Education England has published its first workforce plan for Emergency Medicine. You can download the full report here. This joint report addresses the issues around recruitment and workforce expansion.

There is a clear recognition that the speciality needs to expand with an initial increase of 125 new training posts in 2014 (75 at ACCS and 50 at ST4*). More trainees and medical students will be exposed to EM during their training and alternative routes into EM are to be developed with the possibility of dual accreditation and/or credentialing in EM by other professional groups.

The HEE report goes some way to outline how the issues of workforce expansion and recruitment will be addressed in the next 3 years. It is less explicit in its consideration of workforce retention. Increasing pay is ruled out as an option and other options such as the alteration to working practices for older consultants are unclear and arguably aspirational. This may be because such changes to working consultant working practice are not within the remit of HEE. However, unless retention is addressed with as much energy and resources as recruitment I fear the crisis will remain.

vb

Simon Carley

Associate Editor EMJ

@EMManchester

 

 

* ST – Specialist Trainee

* ACCS – Acute Common Care Stem

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