> There is a question of training and expertise. This is
> the major objection I have to running the MAU as the
> physicians want. I reckon I could give a reasonable
> opinion on respiratory medicine and cardiology. My GI
> is not bad and neuro is ok
So on the whole, better than many medical consultants at acute general
medicine.
> I know what the loin
> pain/haematuria syndrome is, but I'm well out of date
> on drugs, investigations etc. This doesn't matter
> because there is a medical consultant available,
> My weakness is the chronic
> disease management side. The tweaking of medication to
> keep someone ticking along.
You'd be surprised how many physicians are out of date outside there own
field. At present there is no HST in acute general medicine. We are
appointing respiratory physicians, GI physicians etc. who are not up to date
in each others' speciality. (Lack of general clinics and less frequent acute
takes) There is something to be said for the model of A and E looking after
the patient until stable and a provisional diagnosis made and then passing
on to an appropriate specialist rather than leaving a cardiologist to tweak
respiratory medications.
But what you deal with regularly you get up to date with quickly.
> I don't do terminalisations or tendon repairs. What is it
> that makes people
> think these are appropriate A&E interventions whereas other operations
> should be referred to surgeons?
Historical. And the idea that an operation done under local anaesthesia is a
lesser operation. Also the fact is that these are true emergencies- the
earlier you sort them out, the lower your incidence of infection. Passing on
to an orthopaedic SHO who then consults his registrar, who tries to book
theatre (but there are other cases to do, and the staff won't allow it after
midnight) brings in delays. The fact is however, that our consultants and
middle grades often have these skills (last time I checked, still part of
the HST curriculum). If you're not going to do these, where do you stop-
don't do any suturing at all? Not saying this is a bad thing, just asking-
one possible future I can see for the speciality is dropping minor
altogether. But if we are to continue to deal with minors in any way, we
have to maintain our skills and knowledge. If we've got the knowledge, why
not run the clinics?
> How else could one justify taking a consultant
> away from the
> teeming masses of trolley emergencies and otherwise
> unsupervised juniors for
> an hour at a time?
The 'teeming masses' for the most part are not real emergencies- most
trolley patients can be adequately assessed by juniors and referred for
admission. The critically ill patients and major trauma requiring direct
consultant input make up a fairly small proportion of out work. Which is a
better use of a consultant's time: dealing with a moderate asthmatic while
an ortho SHO attempts a tendon repair or repairing a tendon while a medical
SHO deals with the asthmatic?
> And since when does a patient who can come
> come back to a
> clinic constitute an 'emergency'?
Semantics. Rather than thinking 'We're emergency bods and won't see anything
else', look at our skills. Do we have the skills to follow up complex soft
tissue problems? (And I developed these skills as a HST because I recognised
that clinic or no clinic it constituted a fair proportion of my workload-
patient gets RSD, in a lot of areas they come back to A and E rather than
their GP. So you read up on RSD. Then a patient says they think it's
fibromyalgia and can they have a sick note for 3 months. So you find out
more about fibromyalgia. Same sort of thing with post concussions- you start
of scanning and back to GP with a vague 'nothing much wrong' diagnosis. But
GPs each don't see more than a case every couple of years, whereas- of we
run clinics- we can build up the expertise). If so, why not do it?
> I fear there are still far
> more accident
> specialists then emergency physicians in the UK. No wonder there is a
> perceived need for 'acute medicine specialists'.
An interest in 'minor injuries' does not in itself conflict with an interest
in emergency medicine. What you have to do is to cut down the proportion of
your time you spend on unselected cases. By running clinics I can ensure
that a good service is provided to minors with a consultant opinion being
available to all those who need it; but by seeing mainly 'sieved' minors I
cut down on the time I spend dealing with patients with simple or self
limiting minor injury and free up more time for critically ill patients.
> I
> maintain that with
> our SHO-based minor injury service we're a long way off from
> deserving any
> credibility.
Not sure whether you mean we should drop minor injuries or we should offer a
consultant delivered minor injuries service. Could you clarify? The latter
option could get a bit boring after a few years.
>
> Am I not a proper A&E consultant if I don't have these minor surgical
> interests?
You can be a proper A and E consultant without these interests. However, to
make yourself a good A and E consultant you should probably have an
understanding of these and ideally developed the skills- just as we should
all have done some anaesthetics even if we finish up using anaesthetists to
do our RSIs and regional blocks.
> Don't cry, you'll make me cry. Group hug?
If I'd wanted that sort of thing I'd have gone into general practice
(leaving aside the fact that as a speciality we tend to be a physically
rather unappealing lot).
Matt Dunn
Warwick
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