A post like this was advertised at the Hammersmith about 6 months ago. I don't know who got it. I do feel 
that Jon is probably right, however. Major trauma is a very small part of our workload in the UK and general 
medicine a very large part already. I suspect that the general physicians are concerned as so many have set 
up separate medical assessment units (MAU) but in my experience these are shambolic and inefficient 
UNLESS one person is in overall control of process and policy and is prepared to make that stick. One of the 
many things I was well-trained in as an A&E registrar was this very control of process and policy (Gautam 
Bodiwala lectures very cogently on this) and so it would seem eminently sensible that your colleague looks 
hard at A&E medicine. MRCP provides a good way in, and so she will be well placed to run the type of A&E 
I envisage we should be working towards in the next ten years. 

I believe strongly that form should follow function. For efficiency, the ambulance service should have one 
portal of entry. This should be separated somewhat from the entrance for the walking wounded and screened 
in some fashion. Inside, the critical care areas should be grouped together; a resuscitation area, a minors 
area, an assessment area and an admission holding area. Imaging (including CT, MR and ultrasound) should 
be immediately adjacent, as should ITU, CCU (including a 6 hour lab) and the main operating suite. One 
Consultant should be responsible for all these services as Critical Care Director. That person would then 
have individual Consultants in A&E, Radiology, ITU, and Cardiology running each area. There would a 
Critical Services Business Manager to assist this Consultant. In this way, patients will enter, be triaged to the 
appropriate area as well as category and will either be discharged, or treated and sent to the wards for 
recuperation. These areas thus function as a tightly integrated unit and provide a high standard of care with 
a sufficiently large body of Consultants and middle-grade staff for a full 24 hour service - I envisage the 
radiologist doing her shift at night and being able to run a trauma just as I would expect the A&E Consultant 
to be able to perform an angioplasty or embolise a pelvis.

Best wishes,


Rowley Cottingham

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Before you criticise someone, you should walk a mile in their shoes.
That way, when you criticise them, you're a mile away and you have
their shoes.


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