> Surely it's about time our specialty provided decent levels 
> of internal 
> cover, and by that I mean resident shop-floor cover by day 
> and increasingly 
> at evenings and part-weekends, with dedicated single-unit 
> cover at night, 
> just as most other acute specialities do?
> 


Maybe in London. In Warwickshire, many acute specialities cross cover across
several sites.

Not so sure about the advantages of consultants in the department in the
evenings and at weekends as a priority. The way we work it is consultants on
call from home, come in according to how sick the patient is rather than
according to what time of day or day of the week it is. We have a fairly
even spread of sick patients across the 24 hour period. Means we can cover a
population of 270,000 with 4 consultants; all sick patients get seen by an
emergency medicine consultant within a few minutes of coming through the
door (in theory: some particularly expected medical slip through the net);
EM consultants concentrate their clinical workload on dealing with sick
patients rather than spending a high proportion of it dealing with minors;
consultants don't expect to get through their night on call without getting
out of bed, but don't spend a high proportion of their weekends on call
sitting in the department.
Use of orthopods wouldn't help particularly- most sick patients are medical.
Big (or even moderate) increase in A and E consultants might have problems-
I am concerned at the level of ongoing experience that consultants will have
if their is more than one consultant per 50,000 population (and an bit
concerned at the level with more than one per 100,000).
Another way of providing cross cover would be to look at what we're actually
seeing. For serious trauma (which is increasingly uncommon), you need the
surgical/ ortho consultant in anyway, so they could come in from the start.
May actually speed up getting the patient to theatre. Fits with the general
consensus that in trauma it's how fast you get the patient out of the ER and
into the theatre that matters more than what you do in the ER.

For medical cases (where the evidence is that it's what you do in the ER
that matters- as you'd expect: you can stabilise a medical case but not a
trauma case in the ER), cross cover for critically ill patients wherever
they are in the hospital between acute medicine, emergency medicine, ITU
etc. Means a patient gets treated according to what they need, not according
to where in the hospital they are. Also means you can have a smaller rota of
consultants for critically ill patients (one rota rather than three), so
don't have the issues with lack of experience.

Matt Dunn
Warwick


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