It is one of those days.

The problem is much more complicated. Changing mentalities is, if not
utopic, unrealistic in one's lifetime. It may be true that one sent away
from A&E will spread the gospel to another ten, but the converse is true as
well. One primary care satisfied customer treated in A&E will do the same...
I have spent 30 years of my life in a dictatorial system and I have seen
many things I would not wish to share with my best enemies. However, my
heart and soul melt when someone comes to A&E, having been seen by a GP, but
completely unsatisfied with what he was told or given. Only yesterday a 36
years old very fit man appeared, after being seen by his doctor, with an
extremely painful left knee when kneeling. Only by seeing the state of his
boiler suit over his knees (discoloured fabric, thinner than a china
parchment, with holes and dust marks) one's blitzdiagnose could have been
made. I felt sorry for a moment for his doctor who obviously missed the BBC
series "living in the past" where a common sight was a number of maids
dedicated in making those floorboards shining. This poor man was told that
due to his oversporty and adventurous activities the bone in front of the
knee is damaged and it is unfortunate that the nerve runs very closely to
that bone, hence the pain. The GP felt sorry, as well, for the patient as
"you are now getting old, and you have to put up with this". If I were to be
nasty I would say this doctor should not be allowed alone on the street. But
I am not.

Now, who would have the heart to send him back to the (same?) GP? I
couldn't.

"...Bacteria. Trillions. Good and bad. I regularly top up my good
bacteria.....Surely everybody knows that..." Doctors. Thousands. Good and
bad. ... Surely everybody knows that... GP training (GPVTS scheme) lasts for
two years with specialties ranging from psychiatry to general medicine,
passing through A&E, O&G, Paeds. Usually they are recruited immediately
after university and their academic knowledge extends over the topics
covered during those years. It was shown (although I have reservations in
accepting it fully) that SHOs in A&E are not cleverer after 6 months spent
in the department. Times four and they are not better at the end of their
GPVTS. Scary! How likely it is for this trainee to see a prepatellar
bursitis in his training? Almost nil. Meniscus tear, PFJ OA? More likely.
Thus the attempted diagnosis. (The sad part is that he was not a juvenile
GP.)

As soon as you try to look at a patient as if it was part of your family
your shields are dropping. What would you do if the only other open door
that may get you the solution you desperately want has an A&E banner over
it? Wouldn't you open it? No matter how inappropriate that may be? Oh yes
you would. It is even worse if your kids are involved (two days ago: 9
months old, precious child, known with eczema, develops rash over buttocks.
District nurse: "sunburn"(!?!). GP: "allergy". Grandma': "I want somebody
else to have a look at him as he is my only grandchild and I received
conflicting opinions." Surely the SHO did not refer that to the paeds! Oh
yes he did! So, specialist opinion in 2 hours for a primary care patient?
Yes yes yes! How about the gospel spread 30 minutes after discharge. Yes yes
yes, you guessed!

Mail at two o'clock. "Dear Doctor, I wonder if you could see this man
earlier than September. The injection you gave him for his trochanter
bursitis worked very effectively last year. Unfortunately it seems that it
is playing up again, and in effect, it is so painful that he can hardly get
out of his wheelchair now...". Why are we then moaning about 6 months
waiting lists? If I were to be nasty again I would say this doctor should
not be allowed alone on the street either. But I am not.

Half decent night sleep.

Tradition is good. Tradition preserves the past. Tradition attracts tourists
and money. That is the place for tradition. It has no role in medicine.
Traditionally doctors were trained that way. Society evolved in another
direction. Changing mentalities takes more that a generation (and life is to
short anyway to change your mentalities...). Mentalities are not changed by
us picking one here and one there of the inappropriates coming to A&E.
Mentalities are changed by the front page of the newspapers: "Life saved in
A&E - X-ray discovers cancer! (woke up this morning with sore shoulder. Came
to A&E and Xrayed - inappropriate, against guidelines etc etc by
inexperienced SHO. Sarcoma diagnosed). This is why we had 14 999 appearances
last week with people stung by wasps - "I read about it in the paper!").
This is what changes mentalities! There is an ever increasing number of
patients coming to A&E. Fact. There are no more stones falling from he skies
to get them to us, but more rashes, allergies, shorter training period for
students and doctors. Fact... A&E becomes a Mecca were problems are bound to
be solved. Because of the guidelines, NICE, SIGN, government, targets,
inexperience, least resistance, cannot be bothered to argue, empathy... If
we cannot change mentalities efficiently (look in a mirror and into your
eyes, then think of a "mentality" somebody told you about that is anachronic
- this can range from how you hold your spoon to who should treat cellulitis
-), lets make Mecca a better place. For all of us. Before I forget, while
you are looking at yourself in the mirror, be honest where would you (prefer
to) take your child if  unwell...

Permanent GP in A&E (24/24) alongside A&E staff. One triage door, two
directions for patients. One exit door. One pit stop. Initial cohabitation
may prove less than a honeymoon but settling is the norm in short time. The
machiavellic added shade is that both are under permanent, untold, scrutiny.
It will take more guts and convincing, good medical practice, to
cross-refer.
One step further would be to consider east-european experience. The health
system may be in shambles (equipment etc), but waiting lists are unheard of.
There is a place called "polyclinic". Ten storey high building. 200 doctors
inside plus nurses etc. These doctors are consultants or senior registrars,
of all specialities. Some with permanent contracts. 9 to 5 job. Some
on-calls at the nearby hospital (if so wished). Dermatologist,
rheumatologists, orthopods, surgeons, cardiologists etc etc. 30 minutes
slots per patient. You turn up at the door of the polyclinic, sent by GP or
self referral. You are given a number and you join the queue. Seen by
specialist that day. If hospital needed ok, if home needed, ok again. These
polyclinics are present in cities, and attract many doctors who want/have to
stay in the area (family, spouse job etc). Probably more than 50% of the
orthopaedic patients seen in hospital are discharged after just one
appointment. Freeing operating time by such patients been seen in
polyclinics makes waiting lists unknown of. And keeps primary care ones out
of hospitals as well. There are so many SHO's out there wanting to
specialise but stuck in the bottleneck. We are all losing immensely by
keeping these people dreams up for several years for them to become
frustrated GPs as they cannot progress further (and they are not stupid!).
They lose, we lose, the society loses.

I am happy that this list exists.

And while you had the mathusalemic patience to read,  my blown gasket has
self repaired. I have stopped rattling and shall be quiet now, for a while.


Dr. Tudor Codreanu MSc(Med)
Staff Grade
Accident and Emergency Dept.
Dr. Gray's Hospital
Elgin
tel: 01343 543131 ext 67360
dir: 01343 567360
fax: 01343 552612
e-mail: [log in to unmask]

> -----Original Message-----
> From: Dunn Matthew Dr. (RJC) ACCIDENT & EMERGENCY - SwarkHosp-TR
> [SMTP:[log in to unmask]]
> Sent: 13 August 2003 13:16
> To:   [log in to unmask]
> Subject:      Re: Turn them around[Scanned By SOPHOS]
>
> > > Our physicians have decided they will no longer take
> > > patients with fractures unless the fracture is
> > > secondary to a medical condition that needs sorting.
> > > So simple falls with pubic ramus fractures in elderly
> > > or patients with Colles fractures admitted because
> > > they live alone and can't cope are being sent to
> > > orthos now! I'm standing back to watch the fireworks!
>
> Fine as long as the orthos take them. Otherwise the patient and the A and
> E
> department are caught between interdepartment pettiness.
>
> > Not
> > only do they take
> > pubic ramus fractures and colles fractures (clearly medical
> > conditions!?)
>
> The other side of it is that pubic ramus fracture and Colles' fracture are
> outpatient conditions (unless Colles' fracture is in a patient unsuitable
> for day surgery). If the patient requires admission it is because of one
> or
> more medical conditions.
> If you put a patient with undertreated or undiagnosed Parkinsons, small
> PEs,
> cardiac failure or hypovolaemia on an ortho ward they'll mobilise slower
> than if admitted under a good general physician.
>
> > Pretty soon, I bet
> > they'll be taking
> > head injuries because the local surgeons aren't trained in
> > the management of
> > head injuries.
>
> I hope so. General physicians do seem the best placed (apart from possibly
> neurologists or neurosurgeons) to have the skills (experience in long term
> care of brain injury, experience in care of fits/ epilepsy, experience of
> proper observation medicine, diagnosis and treatment of non specific
> neurological disorders, outpatient follow up) too look after head injuries
> not needing surgery. It always seemed that the admission under surgery (or
> A
> and E as a branch of surgery) was based on historical precedence (the
> single
> surgeon doing everything) rather than the needs of the patient.
>
> > As a GP, I'd like to endorse your comments. I would be
> > more than happy
> > if my patients (inapropriately attending A&E) were diverted
> > back to me.
> > Those that do attend (in my experience) have done so of their
> > own accord,
> > often against GP advice.
>
> This accords with my experience. There are a lot of patients who say they
> were told to come by their GP or that their GP had no appointments with
> whom
> investigation reveals that the GP had free emergency slots that day. It is
> odd (but true) that some patients will come to A and E because their GP
> won't visit.
>
> Redirecting patients to other health care providers is good medicine. Can
> generate a bit of bad feeling if done by the doctor after the patient has
> been waiting 6 hours (or 75 minutes in the new NHS), so ideally done from
> triage, but even if done by the doctor it is useful (public education: a
> dissatisfied customer tells and average of 10 people. Use this to your
> advantage). Use of a sensible triage nurse empowered to act professionally
> and discharge outside protocols is probably the best way forwards
> (although
> Stoke experimented with consultant triage and sent away about a third);
> but
> local adaptations of the Coventry guidance would be a pretty good start.
> The
> difficulty is in persuading staff that just because a patient comes to A
> and
> E you don't have to treat them.
>
> Matt Dunn
> Warwick
>
>
> This email has been scanned for viruses by NAI AVD however we are unable
> to
> accept responsibility for any damage caused by the contents.
> The opinions expressed in this email represent the views of the sender,
> not
> South Warwickshire General Hospitals NHS Trust unless explicitly stated.
> If you have received this email in error, please notify the sender.