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The weekend effect: Part 2 – a traumatic time!

29 Oct, 16 | by cgray

the-weekend-effectpart-2-a-traumatic-time

If you haven’t already, listen to Ellen Weber and Chris Moulton talk about the background to the weekend effect. Click HERE.

The UK Junior Doctors’ contract changes imposed by the government in order to shape their poorly defined ‘Seven Day NHS’ caused much debate and consternation surrounding the ‘weekend effect’, which seemed to be the main selling point for their demoralisation of a large proportion of the clinical workforce. Patients admitted over the weekend have been shown in several studies to fare worse than those admitted during the week (though indeed other studies suggest the opposite, or no difference at all!). The reasons for this are unknown however, and further research is being done to try to ascertain the cause of the ‘weekend effect’, whether particular patient groups are more at risk, and what, if anything, can be done to improve care. There is currently no evidence that doctor staffing levels are the cause and many feel that the effect simply reflects that patients who present over the weekend are, on average, more unwell. Other factors could include coding practice, or the availability of diagnostic resources at the weekend. However, all agree that if this effect truly exists, it’s important to establish why, as this will then determine whether it can be modified through changes to service provision or structure, in order to treat our patients better.

David Metcalfe and team from the University of Oxford are one group looking into this. Published on the EMJ website earlier this morning is their paper on the weekend effect in major trauma.

metcalfeabstract

The abstract is here, but as always we’d advise you read the full paper to draw your own conclusions.

Major trauma networks have been around for four and a half years now, with the most severely injured patients preferentially triaged to the major trauma centres (MTCs). Patients arriving at these hospitals are usually managed from the start by a consultant-led trauma team, whether it’s 10am on a Tuesday, or 3am on a Sunday. Access to imaging, diagnostics, surgeons, and emergency operating staff and space are also a necessity for these centres, and MTCs are rewarded under a best practice tariff (BPT) for meeting quality standards.

Who was studied?

49,070 major trauma patients (adult and paediatric) presenting to the 22 MTCs around the UK. The inclusion criteria were admission for at least 3 days, requirement for high-dependency care, or death following arrival at hospital. Data were gained from the Trauma Audit & Research Network (TARN) database from the time the BPT was introduced, and for each hospital only from after the period they were operational as an MTC. From this the authors hoped to gain more complete data, as this improved after the BPT was put in place.

The group also subdivided patients later according to injury severity score (ISS), and whether they presented during the day (0800 to 1700), night (1700 to 0800), weekday, or weekend (Saturday or Sunday).

What did they find?

If we took the total data collected by the team, and condensed all these patients down so that they all presented to major trauma centres in just one week, 327 patients per hour would have turned up during weekdays, 333 per hour on weekend days, 210 per hour on week nights, and 419 per hour on weekend nights. Of course, the reality is much less, as these data were spread out over the period of the study, but these numbers give a good indication of major trauma frequency across the week.

Major trauma occurs more frequently on the weekend, and the patient characteristics demonstrate that those presenting at night are generally younger, with a higher male:female ratio. Less patients were conveyed via air ambulance at night, likely as a result of flying restrictions at these times.

Aside from a shorter length of stay in patients admitted during weekend nights compared with weekend days, there were no significant differences in the primary outcomes of length of stay, mortality, risk-adjusted excess survival rates, or Glasgow outcome score when comparing groups.

The study found that patients presenting with major trauma at night were more likely to be transferred into a Major Trauma Centre at night, which likely reflects daytime availability of diagnostics and specialist input at trauma units. There was no difference when comparing weekday to weekend day, however. There were also no significant differences found in the ISS >15 subgroup in any of the outcomes.

They found no evidence of a ‘weekend effect’ in this major trauma population.

What conclusions can we draw?

This is a large population multicentre observational study, with good data completeness, clear inclusion criteria, and clear outcome measures. There are no significant findings when comparing various groups, and the outlined definitions of day vs night are consistent with normal rota patterns.

The major trauma network is intended to provide well-staffed and resourced hospitals with senior specialists available 24/7 in order to provide severely injured patients with expedient access to necessary investigations and treatment, facilitating the best possible outcome. Whilst there is no evidence of a ‘weekend effect’ in patients presenting to MTCs, this does not mean that it does not exist elsewhere. If a difference had been found, however, this would suggest that staffing and resourcing in the hospital make little difference and that there are other forces at work.

Further work is needed on other populations, but it is reassuring that, unlike data from the US that trauma patients admitted at night are more likely to die, a large scale study of the UK major trauma centres has shown equivalent outcomes throughout the 24/7 hours of operation. It’s a fantastic achievement and one that all those working in centres across the country should be proud of.

vb

Chris
@cgraydoc

 

If you haven’t been keeping up with the recent body of evidence surrounding the ‘weekend effect’, the Vice-President of the Royal College of Emergency Medicine, Chris Moulton, has provided a fantastic commentary to the Metcalfe paper. He’s also managed to give us a history lesson on the origins of the weekend at the same time. It makes for great reading.

Why do Emergency Medicine?

21 Dec, 15 | by scarley

Great work from colleagues in Edinburgh.

Why would you do EM? Learn more by visiting their website at http://www.edinburghemergencymedicine.com/ and join the #EDvolution.

vb

S

Primary survey Highlights from the January 2015 issue. Mary Dawood, Editor

16 Jan, 15 | by scarley

EMJ_100x100

A mask tells us more than a face (Editor’s choice)
As ED clinicians we often pride ourselves on recognising the sickest patients by how they look, this skill is tacit and one that is the result of experience and longevity in emergency care. Our psychiatric colleagues have long accumulated significant research into disturbances in affect recognition in patients with mental illness, so I was intrigued to read in this issue a study by Kline and colleagues from the US which explored the variability of facial expression in patients with serious cardio pulmonary disease in emergency care settings. They found that patients with serious cardio pulmonary disease lacked facial expression variability and surprise affect. They suggest that stimulus evoked facial expressions in ED patients with cardiopulmonary symptoms may be a useful component of gestalt pre-test probability assessment. So, there may be some substance in one of the many satirical remarks made by Oscar Wilde that “A mask tells us more than a face” though I doubt his context was clinical.

It’s not the age that matters
Accurately measuring weight in children presenting to the ED is essential and particularly crucial in resuscitation situations where interventions and drug dosages are calculated by weight. The APLS formula, 2× (age+4) has been widely used in western ED’s, but as obesity in our young people is becoming more common and children are taller than previous generations , this formula may fall short in terms of accuracy and patient safety. An alternative formula (3×age)+7 by Luscombe and Owens (LO) has been suggested as more accurate than the APLS formula. Skrobo and Kelleher in Cork University Hospital Ireland undertook a retrospective study of 3155 children aged 1–15 years comparing both formulas to identify which one best approximates weight in Irish children presenting to the ED. They conclude that the LO is a safe and more accurate age based estimation over a large age range. Maybe it’s time to review our practice but do read this paper and weigh up your own thoughts, no pun intended!

Not all suffering is pain
Pain is the commonest reason patients attend the ED. Our sometimes lack of appreciation and subsequent under-treatment of pain is often a source of distress and dissatisfaction which can result in uncharacteristic behaviour. However not all suffering is pain and we may find ourselves wanting when the cause of distress is emotional rather than physical. This issue features a prospective cohort study by Body and colleagues in Oxford which sought to describe the burden of suffering in the ED. Of the 125 patients included in the study many reported emotional distress particularly anxiety as well as physical symptoms. Indeed only 37 patients reported that pain was causing their suffering. It should not come as any surprise that being seen, information, reassurance, explanation, care by friendly staff and closure were the key themes reported as relieving suffering. This approach just represents best practice but in the mounting pressures of ED’s worldwide it is all too easy to lose sight of the person and their need for compassion and understanding. Dismissing emotional suffering as perhaps someone else’s problem is detrimental to our patients and ultimately ourselves. Do read this paper; it is a timely and salutary reminder of what we should be about, why we do the job we do and what patients expect of us. There is also a podcast with the Editor in Chief and the author. Find this online alongside this issue.

Best evidence or clinical acumen (Readers’choice)
As demands for emergency care and acuity of patients presenting continues to rise globally, ED clinicians are increasingly faced with making decisions to discharge patients from high acuity areas of the ED. Patient safety and well being should govern any decision to discharge a patient but many cases are complex and weigh heavily on clinicians making such decisions. Calder and colleagues in Canada conducted a real time survey of experienced ED physicians to determine how they perceive their discharge decisions and the impact on adverse events. The authors concluded that ED physicians in their study most often relied on clinical acumen rather than evidence based guidelines and that neither approach was associated with adverse events. They recommend further research which focuses on decision support solutions and feedback interventions.

The greater good
Pulmonary embolism (PE) is a leading cause of death in pregnancy and the post partum period and a devastating event for mother and baby. When accurately diagnosed and treated the risk of an adverse outcome is low. In this paper Goodacre and colleagues explore the options for imaging and discuss the evidence for using clinical features and biomarkers for the selection of women for imaging. Their review of the literature suggests that the harm of investigation with diagnostic imaging may outweigh the benefits but that clinical predictors could be used to identify women at higher risk who could be appropriate for imaging. They also state the need for further research around clinical predictors and particularly the use of D-dimer at a pregnancy—specific threshold.

Pearls of wisdom
There is little doubt that the emergency department is a quite unique environment that offers abundant opportunities for learning. Seizing and exploiting these opportunities is not always as straightforward as we would like it to be. The constant pressure to manage multiple patients and make decisions to refer, admit or discharge against the backdrop of a ticking clock often mitigates against the teachable moment however genuine our desire or commitment to teaching is. It’s easy to feel impatient and exasperated by the seemingly slow pace of some learners when you are trying to maintain safety in a crowded department. On the plus side, however, learning in such an environment can instill a sense of urgency, something that cannot be learnt from a textbook. Nonetheless teaching and learning is integral to all our roles and so it was refreshing to read in this issue “Top 10 ideas to improve bedside teaching in a busy emergency department” by Green & Chen from California. We have probably all used some or all of these methods to teach in different circumstances but the authors imaginative use of a framework, of ‘mnemonics’ and easy to remember names such as “Aunt Minnie” and “Snapps” is amusing and lighthearted. In reading this paper, you may just find that pearl of wisdom for the next teachable moment.

 

Mary Dawood

The view from the F2…..

14 Jan, 15 | by scarley

The view from the F2

As an aspiring emergency physician I have been keeping a close eye on the latest media frenzy regarding the NHS crisis. My own feeling is that from working in the NHS over the Christmas and New Year period is that the hospitals are considerably busier than this time last year.

Headlines such as ”hospital declares ‘major incident’ in NHS A&E crisis”1 have become common place and mutterings from GPs, consultants and juniors alike are saying the NHS is at breaking point.

Is it clear that the A&E departments across the country are facing an unprecedented number of admissions than ever. It is worrying that the strains demonstrated by hospitals declaring themselves as ‘major incidents’ could indicate the demise of the NHS , unable to cope with the extra demand.

Why is this? I wish to explore this topic and discuss some of what I believe to be the most crucial contributing factors to this NHS crisis.

I have asked myself, my colleagues and scoured the reports on this ‘ NHS crisis’. Why has there been such a high demand on the NHS this winter? What can I or my colleagues do to alleviate this?

The following are some of contributing factors which I believe have placed the NHS under more strain than ever. I have also discussed action plans that we as physicians could implement to try to alleviate some of these pressures.

 

  1. Ageing population: Medical advances have allowed an extended life expectancy for our population. 30 years ago a myocardial infarction carried a mortality rate of over 40%, now with advances such as PCI, time limits of 60mins from onset of chest pain to catheter table , cardiac rehabilitation & medications the mortality rates have significantly improved. This has consequences for the health service in other ways – people are living longer in the community with now more chronic illness. Our population is also living for longer , there are over ten million adults aged over 65 years living in the UK currently and this is projected to increase by an additional 5.5 million in twenty years time.2 We are now experiencing the conse of this situation with more patients with chronic illnesses unable to cope in the community and requiring hospital admission.
  2. Four hour target in the A&E department – The government and media have publicised the 4 hour target in the Emergency department. This is a potentially lucrative enticement to a patient who cannot get an immediate appointment from their GP in that they can be seen / investigate / treated / admitted or discharged within 4 hours from the emergency department. Should this target be abolished? – there does not appear to be much evidence that it improves healthcare and it seems that it in fact has created additional waiting / clinical assessment unit type wards in the hospital. If the targets were dropped and patients were seen purely on clinical need, perhaps not so urgent / acutely unwell patients would attend and instead try and attend their GP.
  3. GP out of hour’s service access – Since the GP contract changed in 2004, it has placed an extra strain on access of healthcare ‘out of hours’. Patients often think that after 6pm there are no GP services available and therefore present directly to the emergency department as they know its open 24/7. Some patients are unaware that a GP out of hour’s services exist. Is there an opportunity to educate patients in the community about accessing healthcare out-of-hours?
  4. NHS budget – in the financial climate, austere measures have been placed upon all public services. The NHS has also been affected by this. The NHS budget has been frozen for around 5 years, more productivity has been demanded from it and as the population has risen demand upon it has increased. The NHS is paid for by the taxpayer, and it is difficult to ask more from the taxpayer to contribute to the NHS. This calls into question privatisation of the NHS (I do apologise if this word causes offence to anyone reading). Should some fees be introduced to the NHS? e.g. fines for those who continually fail to attend appointments , recurrent drunks in the ED , a small fee for calling upon ambulance services and attending the ED?? Imposing fees could have major consequences. It is known that those who are in the lowest socio economic state have the poorest health. If fees were placed would we be neglecting those who could not afford a small payment towards their health? What do we do if patients refuse to pay? Do we set litigation against them? Would fee for service environment result in a more litigious society?
  5. Societal attitudes to illness and health – With the advent of social media , constant and instant information is available from Twitter , Facebook and Google. Society has become more risk averse. People are generally unwilling to accept any health risks (and why should they accept risk?). Therefore attending the hospital /emergency department whereby health can be assessed quickly with bloods & imaging and quick decisions can be made is now an expectation. It is not uncommon to hear colleagues complain that more patients are attending the emergency department for non emergency ailments such as simple coughs and sore throats. I don’t think there is any solution to this rather than acceptance of society’s shift in their health beliefs and health seeking behaviours. Perhaps its time we roll with this change and consider making healthcare more accessible to people’s lifestyles e.g. running more evening clinics in general practice when people can attend after work.

 

Rant over, I feel like a weight has been lifted off me however the gravidity of this situation is bearing down on the NHS and it appears to be unravelling before our eyes (maybe I am being a tad dramatic here but it is a pressing issue all the same).

I realise that this is a complex issue that will require time, money and patient education. What can we do as physicians? What can I do as a budding emergency medicine doctor? I suppose for now its patient education. Information empowers our patients and perhaps the next time we encounter a patient in the emergency room who you felt may have benefited from a visit to their general practitioner rather than the emergency room, inform them of this. There is no need to chastise patients but pointing out the resources available such as walk-in centres and out of hours GP services towards the end of the consultation may be worthwhile.

So from a foundation doctors perspective the above factor are what I belief are contributing to the current crisis however , what do you think? Are there other factors I have not considered? Does anyone have any remedies for this NHS ailment?

Yours comments and opinions are greatly appreciated.

Thanks for reading.

Aine Keating

 

References:

  1. BBC news article Nick Triggle (06/01/2015). A&E waiting is worst for a decade. UK
  2. Government document. (2007). Ageing population. Available: http://www.parliament.uk/documents/commons/lib/research/key_issues/Key-Issues-The-ageing-population2007.pdf. Last accessed 06/01/15.

 

 

 

The Role of IO in Trauma: A #FOAMed Debate

11 Oct, 14 | by rradecki

The Emergency Medicine Journal recently published a review of intraosseous access experience from the Royal Army Medical Corps. This review documents 1,014 IO devices and 5,124 infusions of blood products, medications, and fluids. There were no major complications, and the rate of minor complications was extraordinarily low – the most frequent being device failure, occurring approximately 1% of the time.

But, what is the role of intraosseous access in trauma?

Who is Dr. Brohi, you may ask? Just the head of the LondonTIER, Professor of Trauma Sciences in the Blizard Institute, Barts and the London School of Medicine & Dentistry, and Consultant Trauma & Vascular Surgeon at Barts Health NHS Trust. Someone whose opinion is worth a listen. If you have any doubts, watch him speak at SMACC GOLD.

To say his comment spurred a rivulet of FOAM would be an understatement. To see the entire thread of responses and branching conversations, start here and don’t stop scrolling. But, a few of the highlights:

What do you think?  Do you agree – the IO is, as used by the Royal Army Medical Corps (RAMC), a temporary tool prior to definitive access in a trauma center?  Or, do you find utility, even in the setting of a fully capable trauma resuscitation?

Why do we call it ‘Teaching’?

4 Aug, 14 | by scarley

A Reflection on Teaching and Learning Culture in UK Emergency Medicine

 

One of the things that most amuses my school teacher friends is my insistence on referring to postgraduate educational opportunities as ‘teaching sessions’, e.g. ’I’ve got regional teaching this afternoon’. I’m not alone here in referring to ‘teaching’ – it’s common amongst doctors and medical students alike.

And an all too commonly heard moan for doctors, (I’ve done it myself, many times), is that they aren’t getting enough ‘teaching.’ At the recent College of Emergency Medicine and British Medical Association joint seminar held as part of the Emergency Medicine Trainees Association 2014 conference a recurring theme was a perceived need for more shop-floor teaching.

This is all anecdotal of course, but there is very little evidence out there regarding trainees views on this topic. The GMC National Training Survey[i] is a good place to start, but when you look at the actual questions and how the scores are calculated, it becomes clear that a score of 70-ish for local teaching (which it has been steadily since 2012) means very little, being calculated as it is from a combination of questions like ‘How many hours a week do you receive local specialty specific training?’ (What does this mean? Shop floor supervision? Small group seminars?), and ‘Who carries out local specialty specific training?’ (Senior doctors scores highly here but is that a true marker of quality? Does being a Consultant automatically make you an excellent teacher?) We are also asked to rate the quality of our teaching sessions, but against what standard? In summary, this survey is not an especially valid way of evaluating the quality of a teaching programme.

What do we actually mean when we say ‘teaching’? As postgraduate learners, we have a wealth of opportunities available to us, from organised lecture programmes and seminars, to shop-floor supervision to simulation courses.

Calling these varied learning opportunities ‘teaching’ turns them into passive activities and implies the spoon feeding of facts and transfer of knowledge direct from our teachers to our brains. It absolves us of our responsibility as learners to make the most of them.

The complaint of ‘not enough teaching’ is generally used to refer to shop floor learning, where a trainee is directly supervised doing something by a senior, (for example leading a team or performing a procedure), hence the regular comparisons with the one-to-one training that junior anaesthetists receive. That juniors in emergency medicine have senior supervision available for absolutely every single patient that they see seems to pass us by. That senior anaesthetic trainees practice independently for much of the time without constant one-to-one supervision also seems to escape us.

In actual fact, we do receive a significant amount of this kind of teaching. In the departments I have worked in, there has been consultant presence on the shop-floor for the vast majority of time in-hours. My current department has consultants on the floor for 16 hours a day. Supervision is therefore available to me for the vast majority of my working hours. Are we counting those ‘Can I just ask you about?’ and ‘What do you think of this?’ as being ‘teaching’?

As well as this, the College of Emergency Medicine has an exhaustive list of workplace based assessments that we are all required to complete. They are near universally despised, yet they represent direct hands on supervision opportunities, or to put it another way; ‘teaching’. Why then do we hate these assessments? Rather than seeing them as irritating tick box forms, can we reframe them as empowering us to request direct training and feedback on our performance?

And what exactly do we want ‘teaching’ on/about? If you’re a surgeon, then understandably you want to spend lots of time performing surgery, learning the craft of each procedure. If you’re a gastroenterologist, then the hours spent as a general medical registrar probably seem less relevant to your career compared to the endoscopy lists and clinics. This just doesn’t apply in emergency medicine. As an EM doctor, every single patient that we see on every single shift is a potential learning opportunity. We cannot just see the critically ill – our speciality is far broader than this. We need to be happy with the bread and butter of our specialty, not just the jam. Head injuries, elderly patients with falls, acute confusion, intoxicated patients both drugs and alcohol, febrile children, vague chest pain, dizziness, non-specific abdominal pain, deliberate self-harm, red eyes…It’s all on our curriculum and forms the vast majority of our workload[ii],[iii].

As senior emergency medicine doctors, we do not need to be directly supervised seeing these patients, but we should not dismiss them as non-learning or pure service provision events. There is no substitute for seeing large volumes of real patients and building up a bank of experience. Experience is what tells you that the ‘drunk’ patient with confusion has a subdural haematoma, or that the ‘back pain’ is an abdominal aortic aneurysm beginning to rupture (but experience is not everything – see below!) And sending a patient home reassured, happy and without what they thought came for (scan, antibiotics, xray) is as much an art as running a really slick arrest call.

Also on our curriculum are a whole range of managerial and leadership skills. Whether we like it or not, managing patient flow, supervising juniors and maintaining an overview of the department will form part of our job as ED Consultants. While we might prefer to be in resus seeing that interesting trauma, learning how to run the floor is essential, and can only be learned through practice. Maybe it’s not such a bad thing to be asked to run the show while the boss is in resus doing the fun stuff sometimes? It all depends on whether you see doing that as a key part of your role and important for you to practice or not.

And practice is the key word here. ‘Practicing’ medicine is what we are licensed to do. We cannot learn our craft solely through our computer screens, high fidelity simulators or textbooks. It is widely believed that to become expert in something, approximately 10 years of practice is required[iv]. Yet many people play sports or musical instruments for years without achieving mastery. Experience alone is not enough:

‘You have not had thirty years’ experience, Mrs Grindle-Jones,’ he says witheringly. ‘You have had one year’s experience 30 times.'[v]

Deliberate practice is required in order to become expert[vi]. Deliberate practice means thinking about what we are doing with each and every patient. It’s about seeking out feedback, following up cases, reading around. About thinking ‘Next time, I’ll do that a bit differently’. The responsibility for this lies with us. Our teachers are there to assist us in this process, not to do it for us.

I believe it is time for us to take control of our own learning. Complaining that we’re not getting enough ‘teaching’ isn’t good enough. We are surrounded by learning opportunities and it is up to us to make the most of them. What do you think?

 

 

Sarah Payne

Newcastle

 

 

[i] GMC National Training Survey, General Medical Council; 2014

http://www.gmc-uk.org/education/national_summary_reports.asp (accessed 30/7/14)

[ii] The Older Person in the Accident and Emergency Department, British Geriatrics Society; 2008

[iii] Health and Social Care Information Centre, Focus on Accident and Emergency, UK Government Statistical Service; 2013

[iv] Ericsson, KA. The Road to Excellence, Lawrence Erlbaum Associates;1996:10

[v] Carr, JL. The Harpole Report, Quince Tree Press ; 1972: 128

[vi] Ericsson, KA. The Road to Excellence, Lawrence Erlbaum Associates;1996: 21, 33

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

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