----- Original Message -----
From: "Doc Holiday
> Rowley, Adrian, etc...
> 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.
> I have no stats to back it up, but I'm sure many would agree that a
> registrar can be trained (by consultants during day hours) past mere
> ALS/ATLS to exert the necessary controlling influence/motivation over the
> multi-disciplinary team. And new registrars can accumulate experience in
day
> shifts, with consultants on site, before undertaking their nights alone.

Yes Doc, I don't really want to be resident 24 hours either, and I probably
don't need to be at the moment, but being resident until midnight reaps huge
benefits for the service I believe. Our recent London-wide audit showed that
trauma is commonest in the capital at 7.30pm, remaining frequent until
1.00am. And these patients don't come neatly packaged by HEMS, as HEMS
doesn't fly that late. I only do one evening per week (and one weekend per
month) but this, combined with attending at resus for the rest of the week,
is more than enough to keep me "sharp". Having 6 consultants would make a
huge difference to the quality of our service for the remaining nights but
would not dilute my experience by much - I'd still do my one evening per
week, and help with some resus during daylight hours. And although I'm a
believer in a systems approach, I do agree that having a consultant (or a
senior SpR) leading a trauma case makes a big difference to how it runs. The
same goes for any critical "resus" case.

Your views, Doc, on registrars running trauma at night is a little
old-fashioned i.e. the service fodder view. We can no longer fill our
departments with registrars just to keep the service running - that's what
consultants should be doing, and registrars should be there for training as
much as for service. If your department has 6 registrars then it should have
at least 6 consultants. And what's the point of having all those trained
guys if they all knock off duty at 5.00pm? I'm not saying consultants should
be queue busting in minors at night, hell no, but they should have a greater
presence in the department out of hours to supervise SHOs (and SpRs) and to
run the critical cases. And phone call advice from home is a complete waste
of time; SHOs will do anything before disturbing a consultant at home, and
when they do phone you, advising about a patient you haven't seen is a very
risky business indeed.

I don't think we can get away from this type of working pattern, not if we
want to be taken seriously by our colleagues and by the government. The
smaller units and the rural units may be able to avoid this type of working
pattern for another 10 or 20 years I suspect, but the larger units in urban
areas are already changing the way they work. Nevertheless I realise these
views are not welcomed by many of my colleagues...

Adrian Fogarty
A&E Consultant
Royal Free Hospital