End of Life Care

When I'm a Consultant...lets have some patient groups. Lets get everyone attending hospital with a COPD exacerbation together in one room. Lets speak to them about self management. Lets talk to them about what happens at the end of life. Lets get them to think about whether they want NIV - before it's a necessity. Do they want intubation? CPR?

Let them know that have the right to insist on ABGs?

Have stop smoking representatives.
Primary care (if if still exists) representatives.

We could create a patient passport - like I did for the diabetes things. Self management plans.

Maybe it would be the start of something good?

Patient Flow

Specialties do a lot of complaining about EM. And sometimes it's justified. But what I'd love to do is look at EVERY patient we admit and ask the specialities:

- if it was appropriate
- what tests they felt were missing
- whether we did anything that didn't need doing
- whether we provided appropriate treatment

And see whether the problem is that specialties are lagging behind in their knowledge, or we really really are providing poor care.

And then we can create pathways and address learning and see what happens. Chances are a lot of our "medical" admissions could go to CDU if we had the space... ...

I like the idea someone else had - one CDU + one elderly admissions CDU - full of "elderly med" specialist physio, social etc. Aim for a quick turn around. It'd be great.

But I think we need to engage with people, and not always be seen as the bad people. Emergency Medicine is great - we know a lot, we do a lot, but we also get a lot of grief for doing it...

Central Employment

Still being scared and never quite the same from induction, I think central employment would be a good idea. Why can't we be employed by the deaneries (or what ever they are now). They can induct us once...occy heath us once etc. The whole thing would be  a lot less stressful for everyone. It might even save some money. We might even get paid right.

I suggested this idea to a colleague. 

They took it further.

Why can't the NHS just be a big single employing authority. Why indeed. 

The variation each time you change trust is amazing. And exhausting. Job swap - over is stressful enough without adding the paperwork to it! Different expenses. Different study leave. And everything that goes with it. 

Added to that..other companies are much more supportive - help finance houses etc. I know we didn't join the NHS for the money but... ... sometimes a bonus would be nice! 

Educational Supervisors

Educational Supervision sucks. It's often pointless and you can't cover enough in the time available to you. How is a rushed meeting that you've had to come in early for helpful? I don't think it matters as much in the smaller departments where you work with your supervisor often, but in big departments...you never work with your department.

How about a weekly email update? The student can detail their progress, together with 3 good things and 3 things they need to work on. The tutor can read, comment if needed, and send 3 good things and 3 bad things. Maybe weekly is too often - but it is good to touch base.

I have no idea how I'm doing at the moment. I have this subjective feeling that I'm really bad at referring to the medics - but I'm not sure why...or how to work on it. It'd be good to know if this could be improved upon.

Personalities and Patients

My recent set of night shifts were surprisingly OK. I had a few problems, and as per usual, none of them were clinical. Management and personality issues were the biggest problems completely! One night was horrendous. I arrived and the Consultant basically said be as safe as possible, and don't worry about the target - you'll get there. We worked through and did really well. At handover in the morning, we'd prepared a list of patients who just needed a review by the social team, and would then probably be fit for discharge. It's our hospital policy to refer these patients to the medical team overnight, as they can't stay "under" the ED all night. The medics had accepted the referrals, but not seen the patients yet (as they were low priority). I suggested these patients were just referred by us to the social team - but was told they were no longer our responsibility. Which isn't really fair and isn't really playing the game. One of these patients had been referred to the surgeons for an opinion, she was medically fit for discharge, but over 80 and lives alone, so couldn't be sent home at 2am. The surgeons had referred to medics to wait for social review. I knew this, as I'd kept up to date with what was happening. I got told off for knowing what was happening with the patient, and told I'd explode if I kept up to date with the entire department. Which I agree. But. I do know my whole department because patients ask questions, so you check. And, before the patient gets to that point they've been discussed with me - and you don't forget that quickly. And. It's not necessary to do this in the middle of handover, in front of everyone after a long and very stressful nightshift. Another night we got to a 3 and a half hour wait. The Nurse in Charge wanted me to escalate to my Consultant - after some debate I refused and just cracked on and saw the patients instead. I'd identified that the problem was no Nurse in the waiting area, where most of the patients were. This meant the docs had to do all the repeat obs, urines, walk patients to x-ray, repeat ECGs, wounds etc. Which we don't mind doing - but when the docs are the slowest link in the chain, it's really time to be reallocating Nursing resources. In the time it takes me to walk a patient over to the main area, and back again - I could have seen another patient (depending on the patient!). There was a problem, and a solution, but no-one wanted to fix it. Of course, the whole problem is compounded by patients "wanting it checked before I go on holiday", and not wanting to wait more than an hour etc. to be seen... These are half of the reasons that emergency medicine is one of the most challenging specialties. It's not just the clinical aspect - every aspect is complicated.

Nights

I think it goes without saying that most people hate nights. I quite like nights because there's no-one else interfering, and there's normally a great "survivor" attitude. You can't faff around arranging CTs and contacting GPs - because they don't do that overnight. And nor should we - a 24/7 healthcare service isn't viable at the moment. Yes, if it's an emergency - we'll sort your CT. But if it doesn't change your overnight management, and won't impact on your life - why should we? What I don't like about nights is not being able to do your job. I'm on nights this week, and they're looming up on me like a big dark cloud. I'm terrified - I don't know who my juniors will be, whether the Nurses will be helpful (most likely they will be, I know one or two of them), but most importantly, will I have the resources to do my job? Or will there be five hour corridor waits overnight? Will there be a three hour queue for radiology in the morning? Will the Consultant arrive in the morning and disagree with every decision I have ever made? Will I need to argue with the surgical SpR about something I believe is right? If I do- will my Consultants support me? Topped with that there's always the question of "should I ring the Consultant"? And moving from hospital to hospital affects that - here, if a trauma comes in either I deal with it, or they go to the MTC. In other hospitals, as soon as that trauma alert goes out, the Consultant is rung. And, in the heat of the night when you're tired, sub-optimal and trying to do everything - remembering where you are and what you do here isn't always easy. The news is always full one week about how shift work and night work is bad for your health - and then the next week it demands longer GP opening hours and a 24-7 Consultant lead health service. Well, I've got news for you. Doctors are people too - and they don't like working nights any more than you do, and the pressure has to stop somewhere. So When I'm a Consultant...I'll encourage my SpR to ring me, when ever they need to. If they think "shall I call the boss"...then they should. I'm sure that'll change after a few sleepless nights leading to sleepless day shifts. And of course, that's if they aren't non residential calls. As a specialty we wonder why people move to anaesthesia...I was always encouraged to call my Consultant, what ever time of day, when they needed to they came straight to the hospital, and never ever made me feel like I'd made the wrong decision. Is that the pressure of EM demonstrating itself, or just the personalities of EM consultants? I don't know - but I know what I'd rather.

Burnout in Doctors

I'm starting this blog because so many little things make me angry at work that I've got to do something about it. I've got a mental list of things I will, and won't do if I ever get to the dizzy heights of Consultant but I think I'm going to need to write them down to remember them all!

This blog is a sort of therapy for me, an a way to keep track of all my thoughts. I think that bits of it will indeed make me a better Doctor.

Today I read this article:
"http://www.theatlantic.com/health/archive/2014/02/for-the-young-doctor-about-to-burn-out/284005/"

And I agreed. It's the swiss cheese effect really - there are a lot of holes but if they line up, the cumulative effect is terrible. I think most people suffer from burnout at some point - and it might just be the ridiculous eight page long application form for an exam that tips them over the edge. We all know the problem - but what can we do about it? I have a few thoughts. I don't think implementing them now will be any good, but When I'm a Consultant... (or work in a supportive environment)

1. I'M SAFE
Kent Air Ambulance crew members use an I'M SAFE checklist at the start of their shift, as do pilots. Why shouldn't we? Maybe because we don't accept anyone might not be fit - because if you turn up for work...you're 100% right? It might be you're tired, so more likely to be sensitive. Or more likely to make mistakes. Or that you've just had a lump removed from your arm and can't do CPR - it's good for the shift leader to know. Tick a box - details only if needed.

2. Debriefs
We need compulsory regular debriefs after every death in the department - even when it goes well as a resuscitation effort, you need to know you did everything right, especially if the patient arrived alive. Start debriefing the deaths, and then move on to ITU admissions, etc.

3. Personal Health Training
As part of our training, probably at the beginning of each rotation, we should be told clearly what is expected from us. We should be told who to contact when things go wrong. We should be given methods on coping with the stress (self - hypnosis for me). And we should think about how to identify when we are stressed - as then we don't give good care to our patients. And that is why we work. Maybe we should all have compulsory chats with a counselor - it's good to talk after all!

Audits and supervisors...now that's another topic.