----- Original Message -----
From: "Dr Philip T Munro"

Mon - Fri Out of hours, weekends and public holidays
Call the On call Consultant
All patients admitted to the resus room with:
· Airway problem, respiratory failure or shock not responding to simple
measures
· Trauma
· Seriously ill or injured children
· Patients likely to require Intensive Care
· Diagnostic or therapeutic uncertainty
· "VIPs"  & patients in resus longer than 2 hours
All helicopter transfers, potential major incidents or team call outs
Waiting times in excess of 3 hrs
Clinical or administrative problems that cannot be resolved by the duty
middle grade doctor or senior nurse.
I am sure I would be burned at the stake in some places in the UK for this.

Too right Phil, those criteria look like you'd be calling a consultant every
few hours! I know some rural DGHs might work this way, but here in London
consultants rarely race in to their departments for specific emergencies,
partly because of the logistics of getting round this city. I personally
think you've got to practice A&E in the department or not at all. Tearing in
to catch the end of a resus is not good medicine, and suits the receiving
specialties much more, like orthopaedics or general surgery. We're supposed
to be there for the first 10 to 20 minutes, with other specialties gradually
taking over as resuscitation proceeds.

I do a mixture of resident cover and cover from home, and I can't remember
the last time I was called in from home, must be several years ago. Of
course I realise that the SHOs struggle when there's no senior (from around
1am to 8am). We could easily draw up a neat set of criteria for them to call
us when they've problems. That would keep the SHOs and nurses very happy,
the patients would benefit, and of course the managers would sleep better.
But we've resisted this path - it would be very nice for everyone else but
would rapidly burn us out. We could instead draw up contingency plans that
"use" other specialties when we're not available. Trouble is, other
specialties don't like doing our work just because its 3am, and who can
blame them? Besides I'm not sure I would want them to either - if other
specialties can sort out our problems at 3am, then management won't have any
incentive to move to 24 hour A&E cover. So we kind of muddle along, no
written protocols, no pathways, no contingency plans. When an SHO gets a
difficult case at 3am they struggle with various teams and eventually "sort
something out". The SHOs sweat, the nurses get frustrated and some patients
suffer. But I figure that's the reality of our specialty under its current
configuration and resources. Why deny it I say? Why should I paper over the
cracks with criteria and pathways and protocols? Sod it, if you arrive in my
department with a difficult problem at 3am, you're gonna get suboptimal
treatment - end of story. Trouble is, I've got to get my managers to see
this and believe it, before things'll change for the better. That's my
philosophy, it may seem polemic, but it makes sense to me.

Adrian Fogarty