> Too right Phil, those criteria look like you'd be calling a
> consultant every
> few hours!

Probably not. We base our criteria on physiological parameters more (but I'd
guess we include mostly the same patients), and get called in maybe a couple
of times a week at most. I can't remember when I was last called in for a
patient who didn't need an A and E consultant.

> 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.

Rather controversial statement there. While you might make a case for
calling my department 'a rural DGH' (although technically we're in a
teaching hospital in the middle of a town- albeit with a large rural
catchment area) , I think Phil's department is in a large teaching hospital
not far from the centre of a major city. Logistics of coming in is a reason
not to provide cover?

> 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,

Other argument is you've got to provide 24/ 7 consultant cover for your
sickest patients. (And also I'm not overly happy about sharing on call with
middle grades- if a middle grade can deal with all clinical problems without
consultant input it suggests that either training is too long or that
consultants are mainly for managerial problems- in either case you are
arguing for a single consultant department supported by middle grades or
junior consultants). I don't tend to tear in to catch the end of a resus-
with critically ill patients I'm usually there before the resident
specialities can make it. Time is critical for medically ill patients but in
the sense that an hour or two can make a significant difference more than
that 10 or 15 minutes can.
It may be different in different departments, but here our sickest patients
come in with roughly equal frequency throughout the 24 hour period.

> 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

It doesn't- you keep up your interest. (And actually, it doesn't keep the
nurses particularly happy- when I started insisting on getting called more
about the sick patients I got resistance from nurses and from the more
confident SHOs) What results in burn out is coming in at unsocial hours to
work at basic grade level. Interesting work stimulates, working below your
level burns you out.
A lot of it is balancing the sides of your job- I don't spend many evenings
or weekends seeing unselected patients in the department (my staff grades
are well trained and can do that perfectly well). I balance that with coming
in more for sicker patients. My time is a limited resource. I spend it on
the patients who need it most.

> 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.

I don't think 24 hour on floor consultant cover is a change for the better
(I agree with Steve- on site but not in the department is pointless- if it
means waking you up from sleep with a phone call, then it makes no
difference where you are- apart from time to come in). If you've got enough
consultants to cover this, it cuts the experience each gets with critically
ill patients. Working on a 1:3 covering a population  of 300k and coming in
for the critically ill patients (a lot more medicine than trauma) seems to
be about right for me.
On cardiac arrests- I agree that you get survivors when patients arrest in
the department (during thrombolysis is a common enough one, I suppose).
However, patients who arrest and don't respond to DC cardioversion do badly.
I'd rather my staff though of shocking first and calling me after if
appropriate. I don't think I've got anything to add to ALS in the management
of the great majority of cardiac arrests.

Matt Dunn
Warwick


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