Welcome to A&E

confessionsofajuniordoctor:

I have no idea what it is that I like about Emergency Medicine.

The hours are terrible. The rota is indecipherable. You cannot plan to attend a friend’s birthday or a family gathering. Your social life is non-existent. The patients are largely rude, drunk, smelly and irreverent. There are never enough staff on shift. The urgent care centre referrals are sometimes ludicrous. The GPs send in UTIs as renal colic, PID as appendicitis, persistent patients that they can no longer placate. The specialty doctors think we are either lazy or lobotomised. You spend more time than you should at the centre of “specialty tennis”.

The four hour wait is a travesty. There are never enough observation beds. The pressure is immense. The clock never stops. There is always another patient waiting, another test to order, another result to check. There is always a diagnosis to be made, and treatment to initiate, a conversation to be had. You go from renal colic to brain tumours to heart attacks. You see depressed people, drunk people, old people, children. You see people at their worst. You see time wasters and hypochondriacs and then sepsis and deaths. You don’t have time to process. You don’t have time to think. You see, treat, refer, discharge.

People complain about the waiting time, disagree with your assessment, believe google before they believe you. You go home at night paranoid about the patient you sent home; constantly questioning your decisions, your abilities and your sanity. You see multiple patients simultaneously, you are a porter, a nurse, a cleaner, a friend, a confidant. You tell people good news, bad news, sad news.

You are charged with the unhappy job of treating people’s liver disease from excessive alcohol, lung disease from smoking, diabetes from overindulgence. People expect you to take responsibility for their lifestyle choices. You endure the abusive drunkards, the psychotic schizophrenics, the deranged elderly. You put up with the people who have neither an accident nor an emergency.

You exhaust yourself looking after these people, so much so that you go without food, without bathroom breaks, without the most basic of human needs. You are vilified by the media, who feel you are paid too much for what you do. You are misunderstood by friends and family who watch too much ER and Casualty. You become unacceptably irked by poor resuscitation techniques on TV shows. You complain about unnecessary attendances and then carry out wholly unwarranted tests because you are scared of being sued. You will inevitably have complaints filed against you for merely doing your job. You will make poor management decisions and people will die. You will make excellent management decisions and people will still die. You will defy the odds: CPR will work; the patient will recover from sepsis; be discharged from hospital, and then die at home a week later.

You will miss things. You will be wrong on a daily basis. Everyone thinks they know more than you. You finish a shift and barely have the energy to walk to the car; let alone drive home. You spend at least half of your days off comatose in bed. You don’t see your housemates for weeks due to opposing shift patterns. You do locum shifts during your time off because there are never enough doctors and you know how awful it is to work when they’re short staffed. The barista at Costa knows what sort of day you’re having based on whether you order a medio cappuccino or a double espresso. The packed lunch you brought 3 days ago is still sat in the refrigerator. Once you leave work you are unable to make the smallest of decisions because you have used up all of your brain cells.

You are stressed out, overworked and rarely thanked. And I can’t think of any specialty that I would enjoy more.

I wrote this post over a year ago. I am now back in ED as a specialty trainee, and the above is just as true as it has ever been.

I have loved this job in the face of so many reasons not to, and it will take more than contract changes or incompetent health secretaries to change that. Do your worst Jeremy, we will be doing our jobs long after you have finished doing yours.

Doctor, your patient is going to breach…

Last week saw the “worst week in A&E” since monitoring began in 2010.

Much has been made in the media about the number of people breaching the four-hour target. There is also a shocking lack of understanding of what the four-hour target actually means.

The target is not for patients to be seen by a doctor in four hours. The target involves patients being booked in at the front desk, assessed by nurses, triaged by frontline Consultants, having blood tests and other investigations performed, being fully clerked and examined by another doctor, having a diagnosis made, being referred to a specialty team, and then leaving the department to go to a bed on the ward, or being discharged home.

I don’t have to point out that the potential for delay here is almost unquantifiable.

During my shifts in ED I would frequently pick up patients who had twenty minutes to go. I would sometimes pick up patients who had already breached. Usually, these patients had been streamed to the urgent care centre, and then referred on to ED. Because it is technically the same department, they come through on the same clock… So, from the point of view of the four-hour target, we have failed before we have even started.

The target has good and bad points. It is an arbitrary, statistically useful but morally obsolete tool, to aid us in defining our parameters and assessing our performance. It is as useful or useless as any predetermined timeframe, and the number itself is not the issue. The problem occurs due to the fixation on the target above other priorities. Used properly, the target helps us identify areas of weakness, and departments that are struggling to see their patients safely. In an ideal world, departments with more breaches should get more funding, for higher staffing levels, for increased number of observation beds, for larger majors areas. In reality, breaching leads to stressful conditions, forced decision-making, and compromised patient safety.

There are a few funny internet memes floating around about the ED. One of them states “save three people’s lives and no one bats an eyelid; breach one patient and all hell breaks loose.” I have been blessed with working in an ED where there are excellent working relationships amongst the staff, and patient safety is consistently a priority. Even so, I have often felt pressured to make a quicker decision about a patient, to take down the half bag of saline still running, to amend the timing of my medical entries in order to have one less breach.

Quite often, the balance of admission or discharge in ED hinges on a period of observation. It is impossible to accurately assess a patient’s condition in 20 minutes. The luxury of allowing them to sit in the department, with regular observations, and pain relief/a bag of fluids is often all that is needed to avoid an acute admission. Where I am working currently, they have recently reduced the number of ED observation beds from 20 to 4. This is in order to build a much-needed Acute Medical Unit, which in turn helps free up the ED by providing an exit strategy for medically accepted patients. However, this has significantly reduced the number of people we can observe prior to admission. These people are now sat on the AMU, occupying the beds that they would have occupied on an observation ward, only now they are being clerked by an additional team; there is a whole host of admission paperwork; and they will inevitably stay overnight, costing the NHS an additional £600 per patient.

The media is making much of the fact that higher ED attendances are leading to overcrowding and pressures on departments. This is only partially true. Yes, there has been a steady, expected increase in attendance leading up to winter. However, the total number of ED attendances in the “worst week”, were actually lower, nationally, than a comparative week in July of this year. So why the inability to cope?

Frequently, the reason for the backlog is the occupation of ED beds and trolleys by patients who have already been referred to specialties, but are either too unstable to transfer, or there are no beds on the ward. Obviously, if someone needs monitoring, and the only monitored bed is in Resus, then we are not going to chuck them out just because they are at 4:01. This has its own issues – what do you do with these patients when you have another blue light come in?

There have been so many headlines over the past few weeks:

A&E forced to turn away patients; Patients waiting 24 hours to be seen in A&E(!); A&E closures: the meltdown…

It doesn’t take much assessment to realise that when you close down an ED, the patients that would usually attend there will need to be seen somewhere else. And yet, it seems to have come as a massive surprise to everybody that in the wake of the closure of Hammersmith ED, the surrounding hospitals have seen increased waiting times, and Northwick Park Hospital has almost consistently been on divert, causing ambulance crews to telephone ahead and take patients to other EDs in the area. 

I am a huge proponent of closing dysfunctional departments. Having worked in a failing DGH last year, I strongly feel that no ED is better than a failing ED. However, there seems to have been no foresight with the closures, and the government very much seems to be expecting existing departments to pick up the slack with no extra room, resources, or staff. Yes, there are planned improvements to the services under strain, but it all feel a little perfunctory, and will likely be too little too late. Northwick Park’s escalation measures involve turning corridors into patient beds; this is not a sustainable situation.

The College of Emergency Medicine has produced several recommendations for fixing our ailing EDs. One of these is the STEP programme, which is basically common sense. It states that there needs to be higher staffing levels, more inpatient beds to free up ED assessment trolleys, and better access to, and knowledge of, primary care services. All of this feels a little obvious, and one wonders why there is less about how we can implement this in the media. But, I suppose, it makes a less catchy headline than “A&E 4 hour wait crisis”.

Aneurin Bevan is my hero

The NHS gets a bad press. 

As an organisation founded in 1948, it is no wonder that it is struggling to keep up with the growing demands and expectations of an ageing population. The fundamental principle of a free at point of service healthcare system for all, is something that I am immensely proud to be a part of. It is consistently portrayed as a decaying and inefficient system, with no option other than privatisation viable to sustain it. 

I think this is a mistake. 

I have first hand experience of the dedication of NHS staff to ensuring effective and timely management for patients regardless of their social status. With privatisation will inevitably come prioritisation, and we will be in severe danger of losing the ethos of our healthcare system.

Despite the overarching belief that the NHS is an outdated model which needs renovation, England still has the best healthcare system in the world. I think it is pretty spectacular that from first presentation at A&E to diagnosis and initial management of complex diseases such as cancer and heart failure takes on average only 48 hours. And 4 of those will be spent waiting in A&E…

My colleagues and I consistently stay beyond our finishing time in order to update families about patients’ progress, or to deal with emergencies that inevitably seem to occur at 5:30 when you are crabby and tired after a long day and should have left the hospital already. There is a sense of shared responsibility, a sense of duty and an underlying pride at being able to provide the world’s best medical input for people who would be otherwise unable to afford it. Yes, there are days when the inefficiency stifles me, when I get irreparably frustrated with our lack of resources and the dissatisfaction of patients and staff alike, but on these days I try to take a step back and remember the principles that our system is based on, and the ethos we are working for, and then the shortcomings don’t seem to matter as much.

The NHS has become a political model, and as such it is not left alone long enough to gain level footing. Every new government has to have a different plan for saving the NHS, and as such none of them are given time to work. Instead of giving up on it, we need to accept that as an organisation it is always going to require more funding, it is always going to be inefficient (because how can you legitimately price health?)..instead of lamenting this, we should be proud of it. There are few better things to spend our money on than health provision. We should be praising NHS staff, and supporting them, bankrolling them, celebrating them. We still have a reason to be proud of our healthcare system. We should not condemn it just yet.