Thursday 19 September 2013

Ninjas not Nanas


Ninjas not Nanas

What is the point of Emergency Medicine? Heroic life saving? Round the clock universal medical care? Gatekeepers to hospital beds? Traffic wardens for patients within complex health system? Initial surrogates for expert care? Specialists in vague but risky symptoms? Safety net for a caring society?

Probably all of the above, often in one shift. We are, however, allegedly in “crisis”. Victims of a "failing" NHS acute care system, in a specialty no-one apparently wants to do, trapped, burnt out, powerless at the bottom of the medical heap. We have become pitied, weak, frail and in need of rescue, broken down at the side of the health highway.

However, although sometimes it is quite nice for people to empathise with our difficult job, the big money is now being quietly loaded into trucks to be driven away from the perceived embarrassing train wreck of “A&E” and given to others who confidently declare (without supporting evidence) they have the answer to the acute care problem.

At this point, however, before it is too late, it is time to tell the emperor he is naked and may have received some poor tailoring advice. The truth is that emergency medicine one of the most successful, least dysfunctional part of the entire system. It is simply the visible bulge in the balloon caused by pressure on all sides.

On one side, primary care is seriously hampered by vast variations in practice. Some GPs are outstandingly dedicated, provide excellent patient-centred care and make superb timely referrals. Others appear to be too risk-averse, possibly lacking interest or experience in acute care, or have insufficient access to either simple "rule-out" investigations or chronic care plans for their complex patients to mitigate hospital referrals. As a result, some of the most so-called “inappropriate attenders” at an emergency department are there because the GP sent them in: patients who need a simple blood test like d dimer, or an x-ray or non-urgent scan, or elderly person with a social care crisis. In the absence of community alternatives, the latter group will get admitted for a prolonged hospital stay, perhaps for minimal benefit other than simply accessing services.

On the other side, the in-patient specialists frequently provide the emergency team with a complex array of referral arrangements seemingly designed to protect them from interference with their special interest, elective and sometimes private work. They have layers of junior staff who can be astonishingly dismissive of legitimate emergency referrals through either fear of admitting the “wrong type of patient” and wearing it from the boss on the ward round, or simply through their own inexperience and overwork. “Selling patients” becomes a core skill for the emergency department, with some shifts feeling like a long day cold calling for double-glazing telesales. Furthermore, whatever the bed state of the hospital, the in-patient specialty teams continue to admit electives. Each day seems to bring the same surprise that a number of emergency patients have turned up who also require care. Delays to in-patient review and admission are the major cause of emergency department overcrowding and stress.

So, in addition to emergency medicine doing its own core work of sorting out and resuscitating acute undifferentiated illness and injury, it is picking up the deficiencies of its neighbours. This is undoubtedly straining an otherwise highly successful model of care. Emergency medicine consultants have been shown to improve survival in critical illness and injury and to reduce admission to in-patient beds. An enormous number of patients are still appropriately treated in a very timely manner by international standards to a high level of satisfaction. A&E remains one of the most successful brands ever, in terms of popularity with the public, and local departments are fiercely defended by their communities. Arguably, along with the system of holistic general practice and free-at-point-of-care access, UK emergency medicine plays a major part in keeping the NHS consistently one of the most cost-effective and equitable health care systems in the world. The current “crisis in A&E” is like a highly-functioning airport becoming overloaded during an air traffic dispute. Once the planes take enough passengers away again through departures, the airport works perfectly well.

So, rather than look for alternatives to emergency medicine to solve the current crisis, we should do the exact opposite and give emergency medicine more control of its immediate pressure points:
Telephone advice and support to GPs from emergency medicine consultants backed up with rapid access to community lab, x-ray access and outreach home care teams. Direct admission rights to all in-patient specialty beds without hindrance or delay, together with simple contact arrangements for senior members of duty specialty teams. The emergency department as the hub of operational management for the hospital with the ability to cancel electives during critical occupancy periods and to mandate the redistribution of medical staff from non-urgent duties during activity peaks or critical roster gaps. 

As emergency physicians, we need to stop feeling less like nanas, be more like ninjas, and retake control.