Couldn't agree more, and it's a breath of fresh air to hear it from someone
other than a trainee. I began my A&E SpR training full of enthusiasm and
motivated by the belief that we were the experts in resuscitation and acute
illness and injury, that the specialty was moving forward with increasing
momentum, and that before long we'd all be doing RSI, ultrasound and so on.
Since then I lost count of the number of times my more traditionally minded
trainers in 3 different hospitals told me if I wanted to 'play' in the resus
room I should become an intensivist (it seems many A&E consultants would
rather 'play' in their office).
Despite clinical excellence being my own driving force I've come to the
conclusion that (at least in the eyes of the rest of the hospital) an A&E
department and A&E care are only as good as the last crap referral, and
round-the-clock senior availability is the only way we can become a 'real'
specialty. What good are highly skilled consultants and middle grades when
they're not in the department after midnight, and an unconscious patient is
referred for intensive care by an SHO without having their blood sugar
checked, or acute LVF patients are put on the wrong oxygen mask and receive
no nitrates before being put in the lift up to the medical unit? Orthopaedic
registrars are being called for anterior shoulder dislocations and surgeons
are assessing our patients with gastritis. We recently allowed a urologist
to do an A&E SpR locum.
I'm a specialist emergency physician and I'm damn sure when I'm on call
there's no-one in the hospital better qualified to deal with the breadth of
acute illness and injury than me. But like it or not I'm judged by the care
my department provides and at the moment my experience is of embarassing
inconsistency. It's no surprise that nearly 40 years after the Platt Report
other specialists still call it Casualty - a significant percentage of the
time (out of hours), that's what we still are. I KNOW there are resource
issues and I KNOW that our predecessors have made enormous progress in
developing the specialty into what it is today but the fact remains that
there is a large body of consultants who do not see their role as clinical
and who are opposed to increased intervention and investigation in the
emergency department, and who the nurses and juniors would not trust to look
after a sick patient anyway. This is not their fault - they're good people
who have been running single handed departments for years and couldn't
possibly have kept up to date in acute medicine and resuscitation, but it's
sad that some of them are SpR trainers and continue to oppose the consultant
based service the public deserve.
There we are, the taboo is broken in a decidedly unbritish fashion, but
hopefully some discussion will be provoked.
Cliff Reid FFAEM
In reply to:
When the day comes
and I am wheeled into hospital I would want the following;
1. The doctor to be there ready to see me (i.e. not on the wards, in a
clinic, etc. etc. etc.).
2. I would want them to be fully trained or supervised closely by the
3. I would want them to be skilled across the full spectrum of acute
clinical diagnoses and not rendered clinically hemiplegic (in this setting)
by a narrow training.
4. I would want the best resuscitator in the hospital.
5. I would want them to have a "Stat" mentality not "later will do".
6. I would want to be seen by someone with a particular expertise in
acute illness (probably not a GP, no offence). I would want to be medically
managed by someone best able to create a clinical picture from
the mosaic of probabilities that come from my clinical features (probably
not a nurse, again no offence intended). That means I would be hoping to
see an A&E consultant with up to date well honed clinical knowledge,
skills and judgement.
Call me old fashioned (I am 41 after all) but this is what this
patient/voter will want. I believe we can clinically justify the A&E
specialist in the same way that GPs can be justified, for the same reasons
that the RCP is promoting the Acute General Physician and even more so.
Besides it would be so inefficient to have all those specialists sitting
around or referring patients back and forth.
In the meantime though I believe we must pursue clinical excellence.
Currently in our departments, as you know, the best consistent level of
patient care offered is that provided by the least competent SHO (or maybe
nurse practitioner). Increasingly I believe this will not be tolerated, and
with due respect to these SHOs (or Nurses) nor should it be. Without
question in my mind
a career grade doctor based A&E service is the best option. We must trumpet
strengths and our vision and raise our sustainable game. We are under sold
(excuse the pun).
As for Mr. Milburn and A&E I still can not truely grasp his vision
I might need to explore further. I can tune into Clinical Governance but
sounds a bit wishy washy and overly politically trendy and correct.
At the moment its ideology waiting to be made concrete. A puff of
conservative wind might blow it away, though some of it might stick. Then
We are here for the long haul with a genuine steady focus on patient care.
where I now reside. Let the politicians blow back and forth, I'm keeping my
focus on the drive to clincial excellence and all that that
the requirements of my patients, staff and my professional bodies.
If after all that they move away from the most efficient, effective,
economical and currently abused system for managing these patients and kick
out, then there really is no point worrying about it is there?
You could always become a politician
(and rewrite the Platt report).
----- Original Message -----
From: S A Hughes <[log in to unmask]>
To: <[log in to unmask]>
Sent: Wednesday, August 02, 2000 5:59 PM
Subject: Alan Millburn wants to do away with us!
>I understand from my boss that the department of health thinks that A/E
>should be delivered by nurses and SHO's and that emergency medicine
>should be delivered by the specialties.
>He further tells me that plans include abolition of A/E as a separate
>The sad thing is that I find all of this rather believable in the
>current climate. If such plans exist, then I think we ought to be told
>so that valuable time is not wasted in pursuing a specialty with a
>I would be very interested to hear the views of the list.
>What should we all do instead?
>Stephen Hughes SpR Harlow
Get Your Private, Free E-mail from MSN Hotmail at http://www.hotmail.com