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-----Original Message----- From: Doc Holiday [mailto:[log in to unmask]] Sent: Tuesday, January 23, 2001 1:16 AM To: [log in to unmask] Subject: Re: Consultants for ATLS at night >Would it suit you both, as a compromise, for a consultant to be within 30-40 >mins away at home, available for advice by phone and to come in for NOTHING >LESS THAN A MAJOR INCIDENT and for your good ol' registrars to cover nights >on site. >And new registrars can accumulate experience in day >shifts, with consultants on site, before undertaking their nights alone. Two problems with this approach: 1. If a registrar is as good as a consultant at dealing with critically ill patients, does that not imply that the training is too long? Why bother with consultants at all? Unless you're saying that consultants are for admin and major incidents (I have reservations about teaching if all the actual patient care is being left to registrars) 2. Registrar numbers: You spend 5 years as a registrar (maybe 2 or 3 of which you'ld be able to take on nights alone), 30 odd years as a consultant. Seems to me you need 5 to 10 times as many consultants as registrars to maintain a steady state (unless you're banking on leaving medicine, early retirement on ill health etc). 5 registrars to provided 24/ 7 cover. 25 - 50 consultants per department (all working office hours, coming in for major incidents). Massive expansion in office space. Wow. Interested in Adrian Fogarty's timing of trauma. But have you looked at medical emergencies as well? Here, our critically ill patients (including trauma, medical, surgical, paeds etc) are pretty evenly spread through the 24 hours. Evening cover is not the best solution for my hospital. There's two extreme look at this: 1. 24 hour consultant cover. OK, but expensive and dilutes consultant experience. May be one solution for hospitals where consultants can't live close (another solution, if I may put my pigeon among the cats, being for critically ill patients to bypass these hospitals and their A and E departments to be downgraded to minor injuries units) 2. Enough consultants to provide a consultant available 24/ 7 within 15 minutes to deal with critically ill patients. Crucially, the lowest number of consultants needed (and thus the highest level of experience and lowest costs) is achieved when consultants delegate as much of the more 'minor' work as possible (I don't foresee a department where any consultant is not seeing enough minor injuries to maintain expertise) i.e. where consultants come in as required rather than working fixed evening, weekend or daytime sessions. Might be the best solution for some hospitals is for consultants to be in the minimum time neccessary to provide teaching and admin support, and the rest of the time be on call from close to, even if that meant no consultant in the department for a large part of office hours, let alone evenings. Don't be appalled at consultants all going home at 5 if it means there's better cover for the sicker patients at nights, and they have more time to spend on teaching and audit during the day. Maybe we could provide a better service if we were prepared to work ourselves into the ground, but for a given amount of work done, a better service will be provioded if it is more focussed. BTW, on the number of consultants for 24/ 7 cover, check out the BMA recommendations: Evening work to count double; night and weekend triple. Works out at the equivalent of 389 hours/ week to be covered. Even accepting Alan Milburn's 8 NHDs (28 hours) fixed sessions, still needs 14 consultants plus cover for leave to have one person in the dept. May not be realistic, but if we start out with an idea of resident cover with 8 consultants then negotiate down... One thing to remember about the US experience is their burn out rate (12% p.a. among attendings). Not something to aim for. Liked Jim Thompson's contribution. Agree up to a point. Problem is that nurses are good at compying with protocols- fine if you're strict ATLS, but sometimes you need to deviate; nurses have limited practical skills compared to consultants (sometimes as consultant team leader I need to go hands on because there is a technique that nobody else is good at); and UK consultants probably get little enough serious trauma experience anyway without diluting it further. Also, if there's going to be a consultant available anyway for other critically ill patients... Still, for the old style departments with SHOs and absentee consultants it may be an idea. Matt Dunn Warwick