Some of the judgemental attitudes of older ( and some younger!) Emergency Physicians never cease to amaze me 
The fact is that the timeliness of providing care in Emergency Department is a real measure of quality both as it is perceived but also indirectly its delivery
I certainly am very cynical about streaming , self care,nurse practitioners, consultant Triage and "see and treat" as offering the solution - ED's simply need better resourcing in terms of space and staff. Alternate providers should "pull" patients to their service rather than have patients "pushed" reluctantly in their direction.
I do not live in a land of fantasy but it is hard work getting the message across
I am sure most who work in EDs have the greatest of respect for all of their patients and their reasons for coming to the ED. They should not be subjected to prolonged waits once they get arrive.
JohnC

-----Original Message-----
From: Alan Montague [mailto:[log in to unmask]]
Sent: Tuesday, 26 November 2002 10:08 p.m.
To: [log in to unmask]
Subject: Re: See and Treat


"Society based on equality"?? 

This ideal has existed in men's minds for millenia and
will never be more than an ideal. Our politicians,
less naive than us, find it a splendid smoke screen
for their mindless tinkering with our public hospital
system.

In emergency departments we help provide a service
free at the point of delivery. There is no penalty for
abuse of this service and inevitibly demand for it
will increase. It is only restrained,sadly, by the
delays we are now trying to remove. As we now empty
the waiting rooms so will they fill up in the future.

The only remedy can be by the exercise of firm and
fair  professional judgement controlling access to our
service. 

I don't see this happening now. Our complaint driven
hospital management culture has been sucessfully
installed over the last decade. It takes too long to
answer complaints and there have been too many
suspensions. The GMC's disciplinary ambit is expanding
rapidly as evidenced by its decisions and the
expansion of its code of conduct. Yes we have always
needed to be competent and kind. Now we must be nice
as well. We should have jumped in and sorted it ten
years ago.

An effective gatekeeper must be given power, judgement
and impartiality (as well as the golden tongue of
persuasion and reassurance). 

Incompatable with the present version of "equality"
imposed upon us.

Alan 
(a lurker no more)




 --- José_Angel_Jarne_Navalon <[log in to unmask]> wrote:
> Hello, good morning to all from Spain:
> 
> I want to send my first message to the list.
> I consider that, it is certain, the doctor's work
> and of the nurse it should
> be complementary and simultaneous.  In many
> occasions, the doctor, thanks to
> their academic and scientific preparation, he can
> carry out the work from
> the nurse to the perfection, and the nurse, due to
> their experience, also
> this qualified to exercise the medical work.
> It only separates them the law, a normative one that
> in numerous occasions,
> it is old and derailed in the time.
> I believe that the moment has arrived of to unify
> and to supplement both
> sanitary professions.  To my it doesn't fit me
> doubt, both should be
> complementary, mainly in the Medicine of Urgency.
> But I trust that the step of the time and the change
> of mentality, inside a
> society based on the equality, will achieve this
> goal so important for the
> sanity in any dimension that was located.  Plus
> still, in the Medicine of
> Urgency.
> 
> Cordial greetings from Spain:
> 
> José A.
> 
> -----Original Message-----
> From: Accident and Emergency Academic List
> [mailto:[log in to unmask]]On Behalf Of
> Adrian Fogarty
> Sent: Monday, November 25, 2002 3:13 AM
> To: [log in to unmask]
> Subject: Re: See and Treat
> 
> 
> Lots of good points Marcello.
> 
> Waiting times, they're not just about waiting to see
> a clinician, as a
> patient can often spend a further hour waiting for
> treatment from a nurse,
> and don't forget a further hour waiting for
> pharmacy. See and treat, I
> suspect, will try to resolve this fragmentation. It
> might actually force
> doctors and nurses to work together as a real unit
> again. It's gone full
> circle in my career; I started out working very
> closely with the minors
> nurse, who used to prepare the patient for
> examination, set up for suturing
> (for example), assist, do dressings, advise,
> document, etc. The modern A&E
> nurse figures that this is a bit too
> "handmaiden-like", and she prefers to
> let doctors work alone, while she keeps a polite
> distance*. I now call the
> patient from the waiting room myself (if the
> patient's still there), find a
> cubicle (if one's still available), prepare them for
> exam, bring them to
> theatre, set up for suture, dress the wound,
> document, advise etc. And for
> the things that need nursing input, there's further
> delay and inevitable
> communication problems, as I rarely meet the minors
> nurse now! Basically I
> spend well over 50% of my time in minors doing
> non-medical tasks that could
> be done better by a nurse or an assistant. Now I
> wouldn't really mind this
> if there wasn't a 4-hour wait just to see a doctor.
> Basically I could be
> twice as productive if the culture could be changed
> back to the way it was
> (points noted Ray). So to return to one of your
> points Marcello, there's a
> definite role for the minors nurse in "see and
> treat", and I see it as right
> next to the physician.
> 
> Other points: as our minors waiting times reduce
> we're going to see
> interesting spin-offs and side-effects. On the
> positive side it's much
> easier to deal with a "reassurance" case if you see
> them in 30-40 minutes
> rather than 3-4 hours. Try telling a "punter"
> there's nothing wrong with
> them after they've waited 4 hours and you'll get
> grief. But tell them the
> same thing after 30 minutes and they're quite
> relieved! Secondly the "Bevan"
> factor will kick in; as patients get wise to the
> rapid turnaround in A&E,
> they'll not bother with their GPs anymore (and who
> would blame them);
> they'll head straight for A&E, and this will tend to
> offset any advantage
> we've gained.
> 
> Interesting times...
> 
> AF
> 
> * gender chosen purely for "poetic licence", if
> that's still allowed these
> days... 

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