You don't need to be signed in to read BMJ Blogs, but you can register here to receive updates about other BMJ products and services via our site.

Primary Survey: November 2016.

22 Oct, 16 | by scarley

primary

Richard Body, Associate Editor

The Manchester derby for paediatric early warning scores

There is clearly a need for a validated physiological early warning score for specific use in the paediatric emergency department (PED). In this issue, Cotterill et al compare two paediatric early warning scores developed in Manchester: the Royal Manchester Children’s Hospital Early Warning System (ManCHEWS) and a modified version, the Pennine Acute Trust Paediatric Observation Priority Score (PAT-POPS). The modified score incorporates the original physiological scoring system but also takes account of the nurse’s judgement and specific elements of a patient’s background. This Manchester derby was a close call: but will the marginally superior accuracy of PAT-POPS for predicting hospital admission ultimately win over the simplicity of ManCHEWS?

Future emergency care: the (citizen’s) jury has spoken

In Queensland, Australia, Scuffham et al took an extremely interesting approach to patient and public involvement. They convened a citizen’s jury to deliberate on matters relating to the delivery of emergency care. The jury’s verdict is intriguing and highly relevant to the future of Emergency Medicine. The participants were clearly amenable to alternative models of emergency healthcare delivery including care provided by allied health professionals and decisions not to transport patients to hospital from the pre-hospital environment.

What is ‘productivity’?

If you sometimes feel that measuring productivity in the Emergency Department has the potential to create a dehumanized production line (and even if you don’t), this month’s paper by Moffatt et al is a ‘must read’. In a series of semi-structured interviews with healthcare practitioners working in an Emergency Department, this team explores their feelings about the notion of ‘productivity’. The findings are heartening and are sure to kindle a warm feeling in the heart of any emergency physician. Hopefully this important work will lead to greater recognition of the need to retain compassion in our practice, promote an appropriate balance between ‘care’ and ‘efficiency’ and avoid the “sausage factory” mentality, to quote one of the participants.

A SuPAR new biomarker of serious illness?

In Emergency Medicine we are becoming accustomed to the use of biomarkers that may lack specificity for any one particular condition, but that provide important prognostic information. Lactate could be considered one such biomarker, and its interpretation has become an important skill for emergency physicians. This may suggest that we are at the dawn of a new era for biomarkers. Our traditional ‘binary thinking’ about diagnostics, whereby tests can simply tell us whether a patient does or does not have a particular disease, is beginning to seem crude and outdated. In this issue, Rasmussen et al measured SuPAR at the time of admission to an Acute Medical Unit in a cohort of over 4,000 patients. SuPAR was shown to predict mortality and the need for hospital re-admission even after adjustment for confounders. The findings are impressive, and this work must lead on to further research to identify how this interesting non-specific biomarker can be used to guide real life healthcare decisions.

Health inequality and the global importance of emergency care

We know surprisingly little about the relationship between emergency care provision and the impact of emergent conditions on health, internationally. Of course, emergency physicians might expect that failure to provide adequate emergency care would lead to greater mortality and morbidity from such conditions. In this issue, Chang et al quantify this problem. In an analysis from 40 countries, they found that all fifteen of the major global causes of mortality and morbidity can present emergently, and identified that insufficient access to emergency care is clearly associated with higher mortality and morbidity. This makes sobering reading as a demonstration of global health inequality, and highlights the pressing need to develop Emergency Medicine internationally.

vb

Rick Body

@richardbody

Should More Emergency Physicians be ‘Piloting British Airways’? The Musings of a Trainee: EMJ

22 Aug, 16 | by rlloyd

musings

Emergency physicians (EPs) routinely manage the sick, undifferentiated patients in whom life-saving interventions need to be executed rapidly. Our Royal College defines emergency medicine as ‘the specialty in which time is critical.’

In severe illness or injury, ‘A’ comes first. Securing a definitive airway is the gateway to the rest of critical care; without one, our sickest patients will usually be carried out of the resuscitation room in body bag. For this reason, emergency airway management must lie within the skillset of the emergency physician.

Rapid sequence induction (RSI) and tracheal intubation are, appropriately, considered core skills for EM trainees in the UK. The second year of ‘Acute Common Care Stem’ (ACCS) core training – the route to advanced EM training – consists of six-month rotations through anaesthesia and intensive care, allowing for ample exposure to critical illness, and development of advanced airway skills.

Despite this, frustratingly, EM-led RSI is a contentious issue in the UK. In 2010, Benger and Hopkinson published a survey in the EMJ that examined the practice of ED RSI across the UK over a 2-week period (1). It revealed that anaesthetists carried out the procedure a whopping 80% of the time (actual percentage likely to be even higher as only particularly ‘airway-keen’ EDs contributed). This starkly contrasts with Australasia and the US, where EM-led RSI is standard of care, with anaesthesia backup made available if difficulty is predicted.

Silo-culture and tribalism remain prominent in UK EDs in 2016, with anaesthetists usually assuming full ‘pilot duties’ when it comes to the airway. However, the landscape is changing, particularly in prominent teaching hospitals – in large part due to a new generation of EPs who’ve completed ACCS.

Additionally, there is some solid literature that suggests EM-led RSI is safe and effective, as long as practiced within a supportive system. Let’s have a look.

Stevenson et al, 2007 (2)

This EMJ publication is a single-centre prospective observational study which investigated the nature of ED RSI practice at a district general hospital in Scotland (Crosshouse Hospital, Kilmarnock) over 3 years. Data was collected via a questionnaire filled out by the intubating doctor immediately after the procedure. The authors were most interested in who was performing the procedure, and whether a specialty was implicated in airway-related complications (categories: desaturation, hypotension, aspiration, oesophageal intubation, cardiac arrest). In short, they wanted to know EPs were worthy of wielding laryngoscopes.

Over the 40-month period, 199 ED RSIs were performed. EPs carried out 44% of these – far higher numbers than contributing departments to Benger and Hopkinson’s survey (published 3 years later). Anaesthetists achieved superior laryngoscopic views and higher rates of first pass success (91% versus 82%) but promisingly, there was an identical overall success rate (97%), and almost identical complication rates.

The crucial detail from this paper is that the department had high instances of senior presence from both specialties during ED RSI. This suggests a supportive training environment, and a collaborative approach to emergency management. Ongoing inter-specialty synergy has probably further propagated safe EM-led RSI in this department in the years since the paper was published.

Kerslake et al, 2015 (3)

A more recent publication which supports EPs at the head-end is this paper from Resuscitation. Similarly, it is a single-centre prospective observational study, where 12 years of ‘ED Intubation Registry’ data was analysed.

Interestingly, this hospital (the Royal Infirmary of Edinburgh – a large, urban teaching hospital) has a protocol dictating that a senior anaesthetist is contacted to supervise all ‘drug-assisted intubations’ (invariably RSI). The anaesthetist only steps in if added expertise is required due to a predicted/encountered difficult case.

78% of 3738 tracheal intubations were performed by EPs – unprecedented numbers in the UK. EPs were found to achieve similar laryngoscopic views, but lower first pass success over the whole 13 year period. In order to reflect modern practice, the authors performed a subgroup analysis on intubations performed since 2007, which demonstrated improved EP performance – first pass success matched the anaesthetists (88% versus 87% respectively). This is probably a reflection of ACCS training being introduced relatively recently.

This paper demonstrates indisputably excellent numbers, and is further evidence that appropriately trained EPs, when part of a collaborative system, are fully competent airway practitioners. By formally protocolising dual specialty involvement with ED RSI, rapid progress has clearly been made at this institution.

National Audit Project 4, 2011 (4)

nap4

NAP4 was a very high profile publication from the Royal College of Anaesthetists which captured detailed reports of major complications from airway management across the UK over 1 year. Reports included cases from the ED and ICU as well as the anaesthetic environment. NAP4 has been widely discussed around the world because the lessons from it have been so valuable for all airway practitioners.

A headline finding from NAP4 was that out-of-theatre airway management is associated with a significantly higher complication rate than the anaesthetic room (at least one in four major airway complications occurred in the ED/ICU). Furthermore, these complications were far more likely to be fatal.

Close inspection of the paper revealed some eye-opening analysis with regards to events in the ED: Many complications were avoidable, and could be attributable to the visiting (often junior) anaesthetist being unfamiliar with the environment.

Analysis of the ED-based events included mention of:

  • Communication breakdown in the resus team.
  • Lack of team-based contingency planning (‘failing to plan for failure’).
  • Failing to locate/use appropriate equipment (e.g. waveform capnography).
  • Failure to follow usual protocol due to high stress levels and novel distractions.

In order to combat these examples of avoidable error in the ED, NAP4 recommend:

  • Development of excellent communications between specialities involved in emergency airway management – this encourages cross-specialty planning for commonly encountered airway problems.
  • Joint training of EM/anaesthetics/ICU staff. Ideally simulation and team training.
  • Regular audit of emergency airway management in resus.

Crosshouse Hospital and the Royal Infirmary of Edinburgh have demonstrated that adherence to NAP4s recommendations is more achievable with a collaborative approach to emergency airway management.

Opportunity for EM to take a leading role

Here in the UK, the reality is that most of us probably work in hospitals without protocolised co-operation and support from anaesthetics, and find ourselves frustrated by an institutional reluctance to us utilisating our skill-set.

If EPs/EM trainees can take a leading role in the pursuit of a closer relationship with the anaesthetics department, then perhaps the process of ushering in culture change can happen more rapidly, even in the traditionally less progressive hospitals.

The key is building better communication channels with the anaesthetics department. ACCS trainees have an important role, as they are perfectly placed to ‘start the conversation’ whilst working in theatres and ITU. Joint training initiatives can be lobbied for, and enthusiasm can be expressed.

Even if local policy dictates that anaesthetists are the only practitioners permitted to perform ED RSI, EM can still take the lead with auditing/surveying practice. This will foster improved communication and joint teaching (might stimulate creation of EM/critical care joint audit meeting).

Screen Shot 2016-08-15 at 01.58.09Surveying ED RSI practice via a questionnaire filled in by the intubator post-procedure is a project that I have initiated at my own hospital. The project was inspired by the papers mentioned in this post, and the Australia New Zealand Airway Registry, which I was exposed to whilst working in Melbourne. If emergency clinicians can identify opportunities for improving ‘anaesthetics practice’ in the ED then attitudes might start to change.

EM-led quality improvement projects involving airway management will almost certainly be welcomed by anaesthesia, being the leading specialty that they are for pioneering patient safety initiatives. For EM trainees keen to manage airways (like myself), demonstrating a persistent interest (i.e. beyond the 6-month anaesthesia rotation) should be considered as important as demonstrating competence, as it will be that interest which stimulates local, and UK-wide culture-change.

The appropriateness of an ED doctor at the head-end has been a circular (and boring) debate for years. Anaesthetists will always maintain a greater level of technical prowess when it comes to advanced airway management for obvious reasons. However, an EP who has demonstrated competence and ‘currency’ is perfectly qualified to manage the airway, and will have the advantage of more familiarity with the resus environment, and the luxury of initiating proceedings without delay. Bottom line? The ‘anaesthesia versus EM’ argument is moot – specialty is irrelevant when it comes to these patients, it is the skillset which matters. Anaesthetics? EM? ITU? We are all resuscitationists.

Final thoughts

It is worth remembering that EM is a specialty which struggles to retain trainees in the UK. An enormously attractive aspect of working in A&E is the critical care element, but all too often, our time in resus gets trumped by pressures to meet targets (‘the anaesthetist has arrived, go back to majors and pick up another patient’). The ability to manage the airway is symbolic of a true resuscitationist, and empowering trainees with that responsibility will galvanise those already in training, and attract more junior doctors to our great specialty. In the long run it will pay off.

Robert Lloyd
@PonderingEM

Worth Reading/Listening

‘RSI in the ED; should EM be taking the lead?’ – HEFTEMCast (podcast)

‘JC: ED RSI – you can do it’ – St. Emlyn’s (blog post)

‘John Hinds on Airway at RCEMBelfast’ – RCEM FOAMed Network (podcast)

‘NAP4 Major Airway Complications in Emergency Departments’ – Professor Jonathan Benger (lecture)

 

ADD-ON (23/08/16): An Important Tweet…

The day following publication of this post, a leading voice in the world of EM tweeted this:

On 1 December 2015, the Royal College of Anaesthetists and the Royal College of Emergency Medicine released a joint statement on emergency airway management (5). It echoes the recommendations made by the NAP4 report, and is very progressive with regards to the role of the emergency physician, and the importance of interdepartmental training. The statement dovetails beautifully with the points made in this blog, and is essential reading. Here is a snippet:

‘Opportunities for the maintenance of rapid sequence induction and tracheal intubation skills by emergency physicians should be provided within each acute hospital.’

Many thanks to both colleges for making their position clear on such an important issue in UK EM, and to Dr. Reid for bringing this to the attention of the author!

 

References

  1. Benger J, Hopkinson S. Rapid sequence induction of anaesthesia in UK emergency departments: a national census. Emerg Med J. 2011 Mar 1;28(3):217–20
  2. Stevenson AGM, Graham CA, Hall R, Korsah P, McGuffie AC. Tracheal intubation in the emergency department: the Scottish district hospital perspective. Emerg Med J. 2007 Jun 1;24(6):394–7 
  3. Tracheal intubation in an urban emergency department in Scotland: A prospective, observational study of 3738 intubations
  4. Cook TM, Woodall N, Harper J, Benger J; Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments. Br J Anaesth 2011;106:632-642.
  5. Emergency Airway Management: A joint position statement from the Royal College of Emergency Medicine and the Royal College of Anaesthetists

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

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.

 

 

 

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

EMJ blog homepage

Emergency Medicine Journal blog

Analytical approach to the developments and changes in the field of Emergency Medicine Visit site



Creative Comms logo

Latest from Emergency Medicine Journal

Latest from EMJ