> What hospital do you work in? In all the units I've worked in 
> there's been
> resident medical, surgical, orthopaedic, paediatric, gynae 
> registrars etc
> etc. Sure, they're not in the department - obviously, they're 
> often needed
> elsewhere, but they're readily available for advice. That's all I'm
> suggesting for A&E - middle grades readily available for 
> advice, 24 hours a
> day. 

Yes, I think we're coming at the same thing from different angles- in London
you have to be resident to be readily available. In the sticks you can get
in from home quickly- when we respond both A and E consultant from home and
other specialties' residents, as often as not I'm first into the ER. 
I guess it's down to practicalities- A and E senior staff should be readily
available. Whether this means resident depends on local circumstances,
unless an argument was being made for prevention of missed problems by
having every case seen/ signed up by a senior/ middle grade (I accept that
you are not making this argument).


> Bullshit, a tiny minority die, a significant percentage have 
> the potential
> to die if we don't sort them out.

I was going by the London Ambulance Service study (sorry, I can't remember
the reference- can anyone else?)

> And besides, we need senior/middlegrades
> for the non-lifethreatening stuff too. And we need it evenings and
weekends
> too, you can't let this stuff pile up for monday mornings.

Yes, but much of it is either fairly straightforward (most fractures); needs
referral to another specialty and we can't sort out ourselves (patients who
need admission for observation- unless you have a CDU; surgical patients) or
benefits from a reassessment after a few days (burns; suspected peroneus
tendon injury etc). Again, we're in broad agreement. The question for
individual departments is how many patients per shift at each time of day
would benefit significantly from being seen by a senior A and E doctor. If
it's 2 patients an hour then the doctor needs to be in the department; if
its one every 5 shifts, on call from home in areas where it's possibly to
live close to the department may be more appropriate. I know I'm thinking
like a manager again, but to get extra funding for increased staff, we have
to show it to be cost effective (remember NICE guidance on GpIIb/ IIIa
inhibitors- £5,000 per life saved was OK; £30,000 was too much). My own
thinking is that the easiest area to show cost effectiveness will probably
be critically ill medical patients (OK, I could well be wrong...)

> I agree entirely, but the whole point of having resident 
> middle grades is
> for them to act as middle grades, just like the other 
> specialties do. 

I'm not sure exactly what you mean by this, though. (Equally, I say much the
same thing myself and am not sure exactly what I mean either). Do we feel
that with more experience we will significantly improve the quality of care
to the majority of our patients; do we mean expanding our role of
stabilisation of the critically ill patient along the lines of ITU; do we
mean HDU care (BTW, I'd argue that if HDU emerges as a specialty, A and E
training is probably the best existing training for it); do we mean 24/7
care of complex soft tissue problems by specialists (I'd argue against this
unless we have 24/7 availability of x-rays (for all patients), ultrasound
scans, OTs and physios); do we mean A and E doing all extensor tendon
repairs/ primary closure of difficult facial lacerations (and not every A
and E middle grade or consultant is trained for this); or do we mean A and E
taking on other people's out of hours work (A and E senior= 'generic SHO')?
Bottom line is if you train someone to consultant level, then pay them to be
in a department at night doing things that can be done as well by a nurse
practitioner (? or SHO from another specialty) or better by a GP; you're
either wasting money or underpaying your consultants and not spending enough
on higher specialist training.
All up for debate, anyway, but are we agreed an expansion of A and E
seniors/ middle grades should mean a change or role of the specialty (in a
direction yet to be decided)?


> I do see a
> problem however if we abandon our SHOs every night to the mercy of the
other
> teams' middle grades!

I agree with you there; but being non resident is not abandonment. I'm
completley with you if you mean being unavailable, though.

Matt Dunn