Curse of the Anchor

Most people work in jobs that do not expose them to rapidly changing situations requiring immediate responses with limited or incorrect information. The emergency services are different. Dynamic and dangerous situations with threat to life and personal safety can arise completely unexpectedly on shift, often in challenging environments due to crowds, access, weather, or poor lighting. Decisions taken can have tragic outcomes and very long reaching repercussions which will be subject to intense scrutiny retrospectively by people who have never been anywhere near that degree of risk exposure. 

In such incidents, under stress and with pressure of time to intervene, anchor bias is one of the main confounders. In my work both in the ambulance service and a busy major trauma centre, I have fallen victim to this problem in which the first piece of information forms the basis of the incident narrative to the exclusion of clear contradictory evidence. For example, the 999 call was for a collapse, but the patient is actually badly injured after a fall down the stairs. Medical causes of collapse are sought initially rather than a careful search for injuries (despite the slippers visible at the top of the stairs). Eventually a fracture is noticed which resets the assessment and takes it in a different, more appropriately focused direction. 

Anchor bias is related to, but fundamentally different from, confirmation bias where information is sought to confirm a pre-existing internal personal or institutional belief system. An example of this is ignoring abdominal tenderness in a drug addict with a life-threatening perforated bowel due to a belief that they are drug seeking.

The trick to prevent anchor bias resulting in a tragedy is to pause, slow down and review before committing to action (“take a beat”) and to have a healthy scepticism about the quality of the original information or diagnosis. Acquiring this skill takes training, deliberate practice (often in simulated situations), and hard won experience. Organisations can raise awareness of the risk through internal governance structures that review incidents critically and allow colleagues to experience the dilemmas faced by the first responders and consider alternative approaches. 

Correction of confirmation bias is different, requiring cultural shift especially to avoid misleading stereotypes of lifestyles, addiction, homelessness, race, and sex affecting judgement. Education as to the potential deleterious effects of prejudice can be provided to highlight how this can happen, even subconsciously. Not only does this need to be modelled by seniors, but also data and evidence collected to allow properly critical review of outcomes across different groups.

Addressing both types of bias require deliberate cognition and a humble self-awareness. It is vital for critical incidents in emergency services to be carefully reviewed and an understanding reached as to how key decisions were influenced by anchor bias or confirmation bias. The corrective action to help prevent disaster in the future is different. One requires responders to pause to pull up the anchor and review the whole picture, and the other requires an instilled discipline to be aware of potential characteristic confounders and be able to auto-correct using education received. 

After any tragic outcome, events will be commented on by people with their own personal set of biases as to what happened. They however have the luxury of knowing the outcome already, no pressure of time, and are unencumbered by the discomfort of facing these situations repeatedly and the attendant risks of getting it wrong. Lessons can and should be learned from any tragic event - but you can't fix poor training and lack of experience with a cultural approach, any more than you can fix a rotten culture with any amount of opinion based internal case review.

A Weak European at the Barricades

As a 5’8 63 year old with no martial arts or military training, I’m not going to be much use fighting in hand to hand combat against the destruction of civil society. I've led a middle class professional life with soft hands, put long hours into becoming an expert in a complex technical and academic field, and fully allied myself to the public service ethos.  A misty eyed faith in interdependence and common spaces, together with visceral hatred of discrimination and intolerance make me a woke snowflake. So I’m not sure I have the skill set for the new world order in which belief in science, human rights, and peaceful coexistence makes you a contemptible cuck. So how can an old urban liberal leftie defend the social democracy that seemed like the unassailable arc of history before populism, Brexit, Trump, and the social media racists? 

I can turn up in my NHS job, man the barricades, and resist attempts to corrupt and destabilise my own little battered corner of spending other peoples' money. Not sending emergencies away from A&E if alternative services are inadequate, inaccessible or poorly configured. Giving the same best possible care to refugees and the socially excluded as to wealthy businessmen and politicians. Contrasting rational, joined up public healthcare, free from financial incentives with the flashy, expensive private sector that can't cope with complications or complexity. Celebrating the diverse multi-ethnic mix of staff who provide the health and social care, and booting out those individuals who choose to act like a racist twat. 

The last global dalliance with mayhem, destruction and carnage led to the creation of my professional home to which a swear my undying allegiance. Reframing public service as an act of defiant rebellion is taking the fight into an arena where I can stand my ground. 

Fusion stories: Tikka Masala, Bluegrass and Prehospital Critical Care

Chicken Tikka Masala was invented in Glasgow by fusing tomato soup with chicken cooked in a Tandoor oven. Bluegrass music arose in Appalachia from the fusion of Irish folk and African jazz. Prehospital critical care similarly arose from the fusion of hospital-based emergency medicine with the incident management skills of paramedicine. 

Doctors with critical care skills have their cultural locus in the hospital. As such, they see the clinical course of disease and injury and develop hard-wired reference points to interventions that sometimes play out badly over the days following admission. Protracted weaning from ventilation, empyema or persistent air leak from chest drains, neurological damage from hypoxia or hypotension during intubation to name a few. They also tend to be at the front edge of new techniques, from point-of-care ultrasound to video laryngoscopy and on to ECMO and REBOA. The same is true of new approaches to intensive management such as early inotropes in sepsis, multi-component blood transfusion and protective ventilation strategies. Some prehospital situations however can be complicated by medical staff who don’t see the big picture. I’ve been stuck literally in a hole more than once wanting to provide impractical medical care when the priority (clear to the experienced paramedic) was evacuation from a deteriorating and dangerous situation.

Paramedics with critical care skills (CCPs) conversely have their cultural locus out-of-hospital. As such they see how an incident might play out in several different ways and instinctively choose a course of action based on hard-wired reference points that balances risk versus potential gains. This may include expediting care that relies on speed to definitive intervention such as damage control surgery or delaying immediate “scoop and run” because they can better deliver the most urgent intervention on scene such as post-cardiac arrest stabilisation, relocating a badly displaced fracture, giving an antidote to tricyclic poisoning, or providing emergency sedation to an unmanageable patient. Other situations though require the longer or broader view of the physician, like sitting out intubating the critical asthmatic while the bronchodilators work, anticipating the profound bradycardia that accompanies pressors in spinal shock, or spotting digoxin toxicity driving complex arrhythmias. 

Some high acuity situations might be perfectly well managed either by two suitably skilled doctors or by two advanced practice CCPs. (Having only one skilled practitioner for a badly injured or critically ill patient who is paralysed and ventilated is clearly far from ideal). Both disciplines have similar skills to be deployed – intubation, ultrasound, surgical procedures, vascular access, ventilation. Who is better at any one skill is clearly a matter of individual experience, training and practice. But when the situation is non-standard, or where normal processes are overwhelmed as in a major incident, the best solutions arise from the cultural fusion of a well-drilled and experienced multidisciplinary team. Ideas can be blended from different places when the recipe book has a missing page or when a crucial ingredient is missing.

Arguments against multiculturalism in society in general or multidisciplinary teams in prehospital critical care often run along the same lines: societies or services must be protected from the very forces that allowed them to develop and flourish in the first place. In the case of prehospital critical care teams, professionals may be afraid of losing status or career opportunities, and the cheapest team configuration is vaunted as being the most cost-effective. Evolution and innovation however rely on access to a deep gene pool of different ideas, talents, experience and cultures in which creative DNA is regularly exchanged. As for value, the investment in sustainable, versatile, high quality prehospital care reaps real dividends in terms of avoidable death and preventable costly long-term disability for patients. 

The success of the Scottish Trauma Network has been largely built on the relationships forged between different professional groups across the chain of survival and recovery. At one end, stands the strong collegial relationships between a high-performing stand-alone CCP cadre, and the multi-disciplinary physician/practitioner critical care teams. Staff move between the two teams and are tasked by the same critical care desk in Ambulance Control. Both help the other to be better, innovation thrives, skills are shared, and jobs are scrutinised together for improvement opportunities. At the other end of the patient journey, the prehospital section of the network advocates strongly for investment and growth in the rehabilitation services, because without them the prehospital wins are dissipated. In return, the rehab teams argue that good prehospital critical care delivers them patients with the potential for a full recovery.

Planning prehospital critical care services might therefore be best done over a great Chicken Tikka Masala and with Bluegrass music playing to set the scene. The assembled multidisciplinary team can then lever all their diversity and passion to achieve the most successful evolutionary trick of all – collaboration in pursuit of a shared objective. In this case, excellent patient care.

A Wasted Weekend of Fruitful Effort

Just finished a weekend of late shifts in a busy urban emergency department. Pretty tired but worked with a good team and we got some stuff done. Felt like taxpayer got a reasonable deal paying for us to be there, especially the old folk who were part of a generation that fought to have the NHS there for them later in life when they needed help, and the patients who would otherwise have been dead or badly disabled without rapid on-site intervention.

According to some clever folk, however, we were part of a failed system that needs to be changed urgently to save the NHS. We didn’t meet our targets, and our very existence encouraged people to come to a hospital when they could be equally or better cared for at home. We are the past. In the future, we can sit in a call centre, consult by video call, organise home teams to provide treatment, and then get a private company to deliver electronic tags to the patients’ homes so that we can watch them recover remotely.

Questioning my own lived experience, I went back through my patients across the three shifts in the different areas of the department. Resuscitation first. Cardioversion, major trauma management, intubation and ventilation, inotropic support, joint reduction under sedation, transfer to theatre for immediate surgery. Some patients were obviously unwell or badly injured from the start, but a few came in through from minors as potentially low risk, with presentations such as syncope or dizziness.

Next, the Majors area. I admitted many of these patients to hospital. Severe abdominal pain requiring titrated narcotic analgesia, asthma requiring back-to-back nebulisers and a bed near an ICU, fractured hips needing pain-relieving nerve blocks then surgery, and acute cardiac conditions with a risk of malignant arrhythmias potentially needing cardioverted or angiography to prevent long term heart failure. Three patients had severe delirium requiring emergency sedation. A handful of isolated frail elderly with acute medical decompensation who were now unable to mobilise safely or attend to basic self-care needs without immediate 24hour care.

Finally, the Minors area. I sent most of these patients home. Some came in with “red flag” presentations like thunderclap headache, cardiac sounding chest pain or paracetamol overdose. Scan, blood test, home with good negative test, done. Some had injuries needing x-rays or sutures. Done and away. Some had new presentations that had resolved like GI bleeding, DVT, TIA or seizures. Basic stuff done, discharged, specialist clinic follow-up. One had a deterioration in complex neurological disease and was admitted for tertiary care. A couple were sent through to majors or resus from triage with higher acuity illness, and two were removed by police in the triage or waiting areas for violent conduct.

I suspect most patients were reasonably happy with their care, except the ones that waited ages to be seen in minors because we were short staffed and providing default care to ward patients stranded in ED due to bed block. We are told however that 66% of this effort was wasted on “inappropriate” people who don’t need to be there, and who should be treated virtually in the future to free up capacity. 

Reviewing the shifts, this is puzzling. We admitted those who needed critical care immediately, and those who had the potential to deteriorate and need defibrillated, ventilated, or invasively monitored. We investigated for potentially life changing conditions using readily available x-rays, CT scans and batteries of blood tests to allow the negatives to be safely discharged with a completed episode. Some definitive treatments were provided, all patients had the therapeutic effect of an in-person consultation, and some vulnerable patients were brought into a place of safety from precarious social circumstances.

Perhaps this is clinging on to the past and just throwing virtual sabots around. The dehumanisation of care is maybe just another part of the systemic social disconnection and downgrading of shared public spaces and services. For a patient to reap the benefits of virtual healthcare however will require living in a decent house, speaking English as a first language, and being young and educated enough to be able to make a monitored Avatar of yourself. Homeless, mental health problems, asylum seeker, elderly, no internet, illiterate, lonely? Please form a small queue for remaining hospital bed in the margins. The cost in terms of money and environment of all this innovation relative to centralised medical care is disputed. Certainly, a very large number of staff will spend a fair bit of time driving about or watching computer screens. A few private companies will make a lot of money supplying vast quantities of equipment. 

Once the transformation is complete, the patient left alone at home who collapses and triggers their remote monitor will flag up to one of the redeployed Emergency Medicine staff in the call centre. They will then try to find a critical care response to send and what remains of a real hospital bed to put them in. At least if/when they arrive at the down-sized real-world facility, they won’t be labelled as inappropriate – at least until the next innovation.

Distraction: "Closer to Home" Sings the Innovation Choir

Jimmy Carr used to have a game show where contestants performed challenges while unpleasant things were happening to them. This appears to have set the model for healthcare innovation. An NHS illustrative video shows how this will work to save the unscheduled care system.

In it, an elderly patient experiences red flag symptoms of a brain haemorrhage while baking a cake. Her concerned husband calls 999, an ambulance attends, and she is taken to A&E. Instead of being “admitted for tests and monitoring,” she is sent home to a virtual ward. Once home, she then answers a quiz on the phone and gets to test her IT skills by setting up a web-based monitoring system sent by courier, presumably while still dealing with the thunderclap headache and related symptoms. She then must make her way back to the hospital for the necessary scans at some point later. Unless that is, she collapses at home from brain haemorrhage complications, when her husband would presumably be guided to call the 0800 INTUBATE line for immediate help.

This novel approach replaces the outdated idea of using the first attendance at the Emergency Department to relieve the distressing symptoms and rapidly carry out a CT scan to exclude a potentially fatal but treatable condition.  An ED scan carried out within 6 hours means a lumbar puncture at 12 hours is not required so the patient can be rapidly discharged, and further complications avoided. 

Meanwhile on the bigger scale, hospital managers and planners get to play their own game of Distraction where the big question is on how to fix the overcrowding crisis at their front door. In this game however, the discomfort is borne by other people. Patients spend nights on ED trolleys without ready access to food and toilets, in bright lights, exposed and surrounded by noisy violent drunks. Staff burn out from witnessing their distress and the moral injury of being unable to provide the care they know is warranted. 

The answer, they reply with the confidence of evangelist preachers, is to discourage, redirect and procrastinate emergency patient care at every possible opportunity to reduce demand. “Closer to home” sings the Innovation Choir behind them. The voice of expert opinion, trying to supply the correct answer of focusing on shortening bed stays and maximising physical capacity, struggles to be heard in the background. Jimmy Carr laughs and raises an eyebrow. 

https://www.healthcareimprovementscotland.scot/publications/independent-report-finds-that-nhs-greater-glasgow-clyde-must-repair-relationships-to-improve-care/

My "Alternative to Darzi" report:

1. Act early in time critical conditions to prevent expensive disability and costs of long term care. Ensure equitable & rapid emergency access to STEMI PCI, stroke thrombolysis, prehospital critical care in trauma & cardiac arrest to stop secondary harm after primary damage. 

2. Investigate possible new cancer in days, not months to reassure most and intervene at stage 1 for those that need treatment before social and NHS costs mount up managing metastatic disease.

3. Protect ED capacity to rapidly rule out or treat NSTEMI, surgical abdomens, sub arachnoid bleeds, head injury, limb/mobility threatening fractures, complex wounds, poisoning, delirium, DKA, sepsis. Acute timely care with scanners & specialists, not fob off, redirect, and hope expensive procrastination does not lead to an adverse event and costly legal settlement.

3. Rehab the shit out of all admissions from day 1 to save money. Intensive and relentless focus on speech, mobility, ADLs, psych, diet. Maximise potential to get the patient home, looking after themselves, or even back paying taxes and caring for their dependents.

4. Prevent delays to social care. Empty out people lying about in wards losing muscle, confidence, & social networks. Pay carers properly, encourage overseas workers to come and stay, nationalise care homes. Way cheaper than blocking hospital beds, hobbling ED, & cancelling electives.

5. Support primary care as a medical home for long term care of chronic conditions with clinical continuity and regular medication review. Mental health, COPD, diabetes, frailty, arthritis, renal failure. Nip deterioration in the bud, keep them out of hospital. Clear, pre-agreed, treatment escalation plans for those approaching end of life.

6. Insist private hospitals doing the quick and easy electives compete on same field as NHS by charging for clearing up their messes and half-arsed referrals to ED. And subject them to same critical governance and scrutiny. And charge a levy for using NHS trained staff. And legislate no exclusion clauses from health insurance policies.

7. Ban all NHS meetings that last more than 1 hour, or involve more than 7 people, or recommend setting up a SLWG to report back, or use the phrase "moving forward". Remind senior NHS managers that fixing problems is better than looking for who is to blame.

Summary: Early definitive & intensive interventions in acute problems. Continuity, stability and vigilance in chronic problems. Staffing, flow and urgency in hospitals. Make costs of private care realistic to prevent parasitism on public, universal healthcare. Cut out all the bullshit meetings, directives, zombie ideas given birth on post-it notes, hobby horse re-organisations and DO THE REAL WORK.

💙 NHS. 

You're welcome.

https://www.gov.uk/government/publications/independent-investigation-of-the-nhs-in-england/summary-letter-from-lord-darzi-to-the-secretary-of-state-for-health-and-social-care

The Fantasy Maths of Redirection

Here’s why the potentially risky and unpopular redirection of patients away from A&E is a distracting side show from the real cause of service failure. A long thread with sums. Take a medium sized average A&E seeing 200 patients per day.

50% patients are very unwell or have high risk presentations and need a full history, examination, ECG, X-ray, scans, blood tests, and treatment. This takes approx 120 mins in total of clinical time in a cubicle. Total time = 120 x 100 = 12,000 mins per day.

50% patients need a more focused quicker assessment for less complex, lower risk problems. This takes 20 mins for those that need a test, treatment or X-ray and 10 mins for those that don’t. Assuming 50:50 split: Total time = 50 x 20 + 50 x 10 = 1,500 mins per day.

30% of the all patients (60) need admitted to hospital and wait in A&E for a ward bed occupying a cubicle space. This wait is 60 X B where B is the bed wait in minutes. This is normally 60 mins when beds are available: Total time = 3,600 mins per day.

So in our average department, we need 12,000 + 1,500 + 3,600 mins = 17,100 mins of cubicle space per day with a 1 hour bed wait and no redirection. This works out at 17,100/1440 = 12 staffed cubicles.

If all the patients (25% = 50) who need neither a full assessment nor tests are redirected at the door, we save 10 mins per patient = 500 mins (assuming redirection takes negligible time). This reduces the staffed cubicles needed to 16,600/1440 = 11.5 staffed cubicles.

If instead the average wait for a bed increases due to a doubling of admission delays to 120 mins, the bed wait becomes 60x120= 7,200 mins. We now need 20,700/1440 = 14 cubicles to avoid corridor waits or queues for assessment.

And if those bed delays further increase to average out at 4 hours, we need 60x240 extra cubicle mins which means a requirement for the ED to have 27,900/1440 = 19 staffed cubicles.

So increasing bed delays (which btw add no clinical value and put patients at real risk of harm) from 1 hr to 4 hrs means the necessary ED footprint to avoid crowding and queues increases by 7 cubicles.

Whereas, redirection of every patient not likely to require the services of an ED reduces the necessary ED footprint by less than half a cubicle. 

Currently, bed waits can exceed 10 hours. But hey, let’s look over there at a few unfortunate patients who have for a multitude of reasons ended up seeking help from an overcrowded A&E rendered too small by the maths of poor hospital flow. 

The Laryngoscope is Mightier than the Paperclip

It’s that NHS no money time again. Every new paper clip to be signed off by the chief finance officer. Hiring freeze, travel ban, recycle the teabags. These savings are a matter of familiar ritual - as much as the spending frenzy of late March. Badged as efficiency, managers flex and pump their iron fiscal will on the profligate and wasteful clinical teams who get on with business as usual. 

In addition to the “efficiency” savings, the rationing chat volume gets turned up from normal distracting background hum to persistent shrill whistling. Can’t do everything for everybody, patients need to take more responsibility for their own health, care needs to be provided closer to home. Patients however continue to thwart and dodge the various hurdles set for them by having complicated illness that doesn’t algorithm too well and gets worse when ignored, deferred or redirected.

Meanwhile lurking in the shadows ready to burn through massive piles of fivers are the lost opportunities to prevent the eye-watering cost of disability and long term care needs. Patients no longer able to feed themselves because they didn’t have their airway secured quickly after their head injury. Families giving up jobs to care for a relative with severe neurological complications due to prolonged hypotension and hypoxia post cardiac arrest. Beds blocked for months by patients with complex infected compound fractures that lead to life-changing amputations for want of  early reduction and antibiotics. 

The dividend from good emergency care preventing secondary insults and early intensive rehabilitation adds up to an awful lot of paper clips and teabags. We can’t afford not to invest in preventing harm when money is short. As the man said: "Nothing is more expensive than a lost opportunity".

The Broken Bus: a Public Service Allegory

Once upon a time a bus station in a big city had only one broken bus on an essential route into town where all the services were. It spouted toxic fumes into the cabin and had three loose wheels and a broken back door. Now and again, passengers would die in it because it would crash, they were overcome in the toxic atmosphere, or the back door jammed and they couldn’t get out and asphyxiated. The bus drivers had been saying for 10 years the vehicle would wear out if it continued to be thrashed every day. 

They repeatedly contacted their managers about the safety of continuing to drive in it with passengers at high speed. Their managers said they were just poor drivers who just needed to do fewer journeys (like they did in a town far away who liked to speak to the government). Staff often went off sick rather than drive it, and some left for jobs with Uber.

The drivers were fed up and decided to take the bus to an allegedly independent garage who said they would review it. Unfortunately, the garage didn't look at the vehicle - they just asked the managers who said it was fine. The drivers then asked the garage owner to look again properly, and he apologised and said he would do a proper mechanical inspection. Meanwhile, the managers bugged the drivers rest room and threatened disciplinary review of anyone suggesting the vehicle wasn't roadworthy. 

The managers finally offered to visit the drivers to understand their issues, despite them being very busy and important people. They explained that they have superior knowledge of driving buses and were very passenger-focused, but that they would make time to visit the bus station to show staff how much they care. The garage report on the vehicle could wait, they said: "We are all one big team that needs to respect each other, and actually fixing a bus is difficult". 

The drivers told the managers they would prefer not to meet until they had the garage report. “We believe it needs a new exhaust, a working back door and three new wheels. There is no point in meeting until it is safe to drive again. Then we can meet with you and discuss how we maintain the vehicle and expand the fleet to prevent this problem in the future.”

So the meeting was cancelled, the vehicle was fixed, and passengers arrived safely. The managers were given MBEs for services to transportation and lived happily ever after. The End.

The Good, the Cheap and the Fast: the Iron Triangles of ED

The Iron Triangle is a model that describes the relationship between good, fast, or cheap in any given enterprise. Two sides of the Iron Triangle dictate the nature of the third.

 

Increasing speed may compromise quality unless further resource is deployed. Increasing the quality (or range of services provided) may require additional resource to be spent unless more time is allowed. Decreasing the cost requires a compromise in either speed or quality. Emergency Medicine is subject to the same trigonometry, but only one format prevents the shape from corroding and fracturing.

For an Emergency Department, each attribute might be defined and measured as follows:

1. Quality: How “Good’ is the ED? 

Look at the key performance indicators for clinically important conditions such as hip fracture, major trauma, cardiac arrest, sepsis. Next review the ability of the department to fulfil its role in the provision of emergency health care by looking at its breadth of service. A “Good” department will protect primary care and the in-patient specialties from work best addressed in an Emergency Department by Emergency Physicians, such as the rule out of serious conditions, reduction of fractures/dislocations, wound management, and front door critical care interventions such as emergency anaesthesia. It will reliably deliver “well-packaged” patients to the in-patient units and avoid hidden cost and delays downstream. Finally, a “Good” department will have low rates of bad outcomes as measured by x-rays misses, left without being seen, reattendance rates, death after discharge, drug errors, procedural complications, and other serious or adverse events.

2. Speed: How “Fast” is the ED? 

This is more straightforward. The most significant overarching metric is the 4-hr target. This can be broken into component parts such as time to triage, ambulance offload, first assessment, decision to admit and discharge from the department. 

Fast is not only popular with patients, but also reputationally good for the hospital (and managers and government) and prevents the harm resulting from crowding and delays to admission. Speed will be determined by the input demand, staff processing capacity and the speed of discharge to the community or an in-patient bed. These factors are then inextricably linked to “Cost” in terms of staffing and bed availability.

3. Price: How “Cheap” is the ED? 

The most easily measured cost is the direct staffing cost in the Emergency Department, together with the related cost of supporting services such as radiology access, lab tests, and administration. Higher staffing levels are likely to be associated with better quality and higher speed if effectively deployed.

The direct ED costs are however only part of the story. Flow out of the department is critically dependent on bed availability in the in-patient wards, and this is directly related to hospital occupancy. Keeping occupancy at the ideal level for ED flow of around 85% requires a commitment to covering the cost of some flexible bed capacity. Running at higher occupancy is superficially more cost-effective but leads to severe impacts on ED speed (and subsequently quality).

Departments that offer limited scope may divert work to other places concealing the true cost. Extensive pre-hospital screening such as phone advice lines designed to reduce ED demand may be expensive, and savings are only possible if this additional tier diverts very significant numbers with minimal or no costly errors. Redirection to primary care may displace cost to the community sector which may not be recouped as these patients are likely to be the “cheapest” (especially if primary care is less well equipped to process the nature of the conditions diverted e.g. injuries requiring x-ray). Similarly, handing off specific conditions or tasks to in-patient specialties such as chest pain assessment or resuscitation may mean costly duplication of “front doors”, when these tasks were previously all efficiently covered by the Emergency Department.

So, what departments can we have (assuming any two of three Iron Triangle conditions can be met):

Department A: Cheap, Fast. Not Good. Low staffing, limited scope – work is displaced to community or in-patient specialties and may be of low quality. ED staff either hate it or love it depending on their philosophy. Costs hidden elsewhere due to work displacement. Popular with managers (good 4 hr target) and patients who are not displaced or damaged (quick turnaround). Unpopular with specialties and GPs unless resourced (see hidden costs). FAIL

Department B: Good, Cheap. Slow. Low ED staffing, high hospital bed occupancy leading to processing and discharge delays. Scope often attempted to be maintained, but quality eventually suffers due to harm from crowding and delays. Unpopular with managers (poor performance on target), staff, and patients due to delays and adverse events. Ends up costing more anyway due to complications and issues with staff retention. FAIL

Department C: Fast, Good. Expensive. Well-staffed, low bed occupancy so excellent flow. Costs high and visible upfront. Comprehensive scope, good outcomes, low adverse events. Popular with staff, patients, and managers. Perceived as not cost-effective by accountants. Significant downstream savings in absence of hidden diversion costs, staff retention and avoidance of adverse outcomes for patients. PASS.

Most EDs are currently a failing Model B with long waits due to high bed occupancy and understaffing. Quality and safety inevitably suffer, and staff leave. There is often a short-sighted executive / political push to move to Model A which better hides its failings, though ultimately it becomes just a shell triage service incapable of providing Universal Healthcare to those in urgent need and incurring heavy downstream and upstream costs. Model C is the only corrosion resistant Emergency Department Iron Triangle that maintains its shape.

RIP EM

Who will miss us when we are gone?

Emergency Medicine has had a red form completed. Talked about in hushed tones, its prognosis is recorded as “guarded” with a likely poor quality of life. Those watching it desperately struggling want it to be allowed to go now and for the suffering to be over. Even the specialty itself has agreed with its carers that it can’t go on like this. 

Overcrowded, miserable, making mistakes, Emergency Medicine is no longer coping, letting people down and making them cross. Its vital sign, the Four Hour Target, has been permanently in the red zone of its observation chart. Tales of its failing and flailing in the press make everyone uncomfortable, especially politicians. The patients in corridors, ambulances stacked outside, and the red 999 calls unanswered in the community serve as grotesque external symptoms of an underlying necrotic process.

So, arrangements are made for its demise. Resuscitation is to be handed to tertiary specialists for them to argue amongst themselves over who will look after the kaleidoscope of the undifferentiated unwell. Paramedics will need to call phone lines before transporting and be advised where to take their 999 calls when ED is no more. Some patients will be left with their problem at home, some will be signposted to community services that may or may not have capacity or even exist, and some will be shoehorned into clinical decision pathways that allow rapid one-disease-only processing in a same-day unit. Walk-in patients will be redirected to ABH (Anywhere But Here) unless they need resuscitation or can be made to fit one of the specific pathways. Once the last rite arrangements for Emergency Medicine are complete, the oxygen of staffing will be turned off, the monitor of four-hour target will be silenced, and the inotrope of senior experience will be discontinued.

Who will mourn its passing? For sixty odd years the Emergency Department has been a beacon of the welfare state. A place that in physical form, boldly stated that all people are important, equal, and worth saving. A light always on for lords and laggards. It became expert in ruling out and in tricky serious illness like subarachnoid haemorrhage, acute coronary syndrome, abdominal sepsis, meningococcal disease, tricyclic overdose, ectopic pregnancy, head injury and aortic aneurysm – especially in those high risk populations that felt unwell enough to call an ambulance. It skilled up to provide time critical treatments to ensure that vast teams of specialists did not need to be on hand all the times to intubate, start pressors, insert lines and tubes, treat severe sepsis, cardiovert, reduce fractures and dislocations, and sedate agitated delirium. It advocated for patients needing admission or specialty care even in the face of reluctance, resistance, and sometimes frank hostility from those guarding lofty silos. It took out rust rings, fishhooks, bits of Lego and misplaced vibrators.

Is it too late to ask for a review of the terminal diagnosis - without the boot of exit block on its throat? Especially given the number of its dependents.

 

 

Rage, Certainty and a Ginger Cat

I’m pretty good at opening doors with my elbows or car keys now.  I shower after hospital shifts rather than before, I carry sanitiser and hand cream around in my pocket, and I can do Microsoft Teams presentations while fending off a large attention-seeking ginger cat. All in addition to having developed near-perfect rituals of cleaning keyboards, donning and doffing PPE, and maintaining social distance in a subtly choreographed two-metre apart ballet with others.

 

These new skills have become familiar and almost comfortable against the profound shock at the loss of certainty during 2020. The number of score-outs in my paper diary bears witness to a year of cancelled family occasions, travel, courses, university terms, health appointments, football matches, concerts and festivities. The niggly fear that came with being in an age-related higher risk bracket and possibly ending up on a ventilator loomed over my anticipation of a healthy three score years and ten. The potential consequences of economic collapse, illness, unemployment, destruction of welfare state, civil disorder, even shortages of food and toilet roll all jostled regularly for headspace that sleep should have been occupying in the wee small hours.

 

Along with, and perhaps because of, the loss of certainty came the intolerant righteous rage of perceived selfishness and stupidity. Watching nonchalant young adults wander mask-less round supermarkets past elderly folk struggling to use a stick while fearfully adjusting their facemasks became the hypertensive equivalent of being tailgated on the motorway by a sales rep on a mobile phone. Listening to pandemic deniers recite Facebook anti-science with a partisan certainty and forcefulness normally confined only to evangelicals or football fans induced the temptation to share some inappropriately graphic stories from the frontline of destroyed lungs and lives cut brutally short.

 

I do however have 2020 to thank for bringing some ideas I like back in fashion. Inequality and environmental destruction make crises patently much worse and more likely. Science, tolerance and collaboration are clearly the past, present and future of Homo sapiens. Democracy as a political system is not about freedom to do what you want. It is rather taking responsibility for those around you and making decisions together that leave no one behind, especially the weak and marginalised. The NHS is a rallying flag because, at a touchingly emotional level of national consensus, people seem to love its inherent fairness and security. 

 

When things eventually start returning to normal thanks to the clever vaccines, just enough people not being selfish assholes to make the public health actions work, and the determination of a National Health Service not to let people who love it down, I wonder if I will miss my newly acquired skills. I will however probably have to take the cat with me to meetings for a while when they restart in person again. He definitely considers himself a key worker now having attended all the meetings over the last twelve months.

A Ketamine of a Year

One of the first patients I ever gave ketamine to was a forty-year-old man with a nasty open dislocation of his ankle. After having the distorted joint snapped back into place, he burst into tears and told me Jesus had visited him and turned him Irish.  Another patient, an elderly lady with a displaced leg fracture, was entertained by a troupe of dancing cauliflowers while her displaced tibial fracture was being set.  Most patients however report later they recall nothing much after ketamine, and are surprised the unpleasantness is all over so quickly. Some though, have a profound but brief moment of clarity on the way out of the “k-hole” in which they get a glimpse of existential terror.

 

I’ve never had ketamine myself, but after 2020 so far, I feel like I have. A trip to New Zealand in March to see heart-achingly distant adult children morphed into a dissociated weirdness of only seeing them through the glass of an AirBnB isolation house, plus occasional dream-like episodes of jogging through sunny empty city streets.  

In April, folk clapping the NHS in the UK, and fire trucks sounding their bells outside Emergency Departments in New York induced a teary intoxicated pride in being a key NHS worker. It was hypnotic recruiting-band music for selfless public service and the ideals of universal health care. Back in work itself however, clinical care with multiple new PPE rituals to remember, and a nightmarish new disease felt like a flashback to the first anxious imposter shifts as a newly qualified house surgeon dealing with sick patients with the Oxford Handbook open.

 

The summer months carried on into a sort of timeless partially sedated unreality. FFP3 masks, sticky hand gel, and yellow & black chevron tape on the floor. Endless Zoom calls into colleagues’ front rooms with their ensemble cast of young children and pets. All formed the blurry backdrop to a drama increasingly devoid of ongoing serious action. Painful stimulation to a higher Glasgow Coma Score mostly only came from new intolerances of other people’s behaviour: a mask under the nose in the supermarket or anti-vaccine posts on social media the equivalent of a brisk sternal rub.

 

Now the 2020 emergence phenomena are starting to break through with flashes of panicky alarm. Second waves, economic collapse, mental health crises, racism, climate change and anarchy all smashing through the bathroom door with Jack Nicholson grins announcing a serious intent to mess you up. If this were happening to a patient, we would do two things. Reassure them they are safe and that this will quickly pass. Then reach for the Midazolam to smooth their passage back to sentience and rationality. 

 

As 2020 moves to the autumn of its unpleasant and bizarre k-hole, there is unfortunately no sign yet of the confident clinician with the calm voice and a big syringe of normal.  Perhaps eventually, after the cauliflowers stop dancing, and we no longer feel compelled to speak with a Dublin Brogue, it will all seem to have passed in an instant. We will wake up groggy, but with all our essential parts back where they should be.

Totally Inappropriate

There were ten mourners at James’ funeral; two paramedics, two staff from Gregg’s bakery, and six staff from the A&E department. 

The paramedics brought James to A&E every morning after a 999 call for “man with SOB”. The A&E staff gave James his morning COPD nebuliser with a cup of tea, and the Greggs staff across the road gave him a breakfast pie after he was discharged. He spent the rest of the day walking around with his tartan shopping trolley before returning to his bed in a hotel doorway.  He always refused admission or social work, and never saw a GP. James was an inappropriate A&E attender. He should not have been there contributing to overcrowding. 

Inappropriate attenders roll in across the shift.  An older woman with new abdominal pain and vomiting whose worried spouse very reluctantly called an ambulance for her. A middle-aged builder, who for the first time ever, self presents with the worst headache of his life.  A diabetic man books in with new chest discomfort after a heavy meal last night. Two CT scans, a couple of ECGs, a bunch of blood tests and all are discharged home. Total waste of resources - A&E over-investigate everyone.  Gastroenteritis, migraine and reflux are never investigated like that in primary care. If only they could be redirected we would save a fortune and A&E would have enough space for proper emergencies.

  

Across in minors other inappropriate attenders wait and wait. Swollen optic discs from the optician, blocked catheter from the district nurse, intractable back pain from the physio, suspected drug ingestion from the police cells, suicidal thoughts from the social worker, post –op wound infection from the private surgical clinic, off legs from the nursing home, needle stick injury from the medical ward.  If only all these patients realised just how busy the ED is tonight, they would have thought twice about following the instruction to book themselves in - especially as there are no cubicles because of properly sick patients waiting hours and hours for a bed in a very full hospital.

The minister at James’ short crematorium service said he was glad that James had people who looked out for him:  “It is such a comfort that the A&E department always keeps a light on for any and all of us whenever we are sick and have no-one else to turn to”.  

Bizarrely, the four-hour target didn’t improve after James died.

NHS Tattoo

I think I need to bite the bullet and just get the NHS logo tattoo on my arm I’ve been thinking about for the last 20 years. I’ve nearly had a tattoo only twice before. The first was on the Incirlik Air Base, Turkey in 1991 en route home after the Kurdish Refugee Crisis. The American Army tattooist was however decidedly opposed to adorning the arm of a tipsy British civilian medic with an enormous campaign eagle. The second was after completing the Rangitoto Swim in Auckland. I’d promised myself a volcano tattoo if I managed the 4.6k open water crossing in a wetsuit, but was put off after being overtaken by bunch of teenagers effortlessly completing the swim in just their shorts.

 

The reason why I want the NHS tattoo now more than ever, is that over the last four weeks, I’ve realised it is my existential axis. To me, it is simply the best idea in the world: the ultimate demonstration of a civilised country, a pinnacle of social evolution. I’ve worked in it since I graduated, with the exception of an eight-year stint in its New Zealand equivalent. I’ve belligerently defended its many failings and faults, citing the sheer universality and measureable efficiency of it as a system. It is the Sydney Harbour Bridge, the Hoover Dam, the International Space Station – a massive visible-from-space triumph of collaboration, equality, courage, vision and public expenditure. I have taken great pride over the years in delivering exactly the same health care to the homeless drug addicts and asylum seekers as to Members of Parliament and celebrity sportsmen. Even in the many interminable management meetings, in which any kind of binding decision comes as a pleasant surprise, the break point is always what provides best care for patients.

So after the last four weeks in New Zealand Covid-19 quarantine and then lockdown, having spectacularly mistimed a visit over to see my two adult sons, I find the gravitational pull back to my Glasgow NHS team overwhelming. Getting back to answer this visceral call is not easy. Multiple flights have been booked, then cancelled by the airline and not refunded. I’ve started to feel like a spawning salmon instinctively drawn to its home; leaving the calm, safe, sunny waters of Auckland, and the comfort of being within a 500 mile radius of all my children (even if I still can only Skype them), to leap upstream into the uncertainty of working in a Scottish Emergency Department during a novel pandemic.

Emergency Medicine doctors always have a sense of FOMO when big thing are happening and they are not on duty. They have an intense desire to be part of the action, do a great job and receive the dopamine squeeze, inner validation and external acclaim that follows. This time it is different as there is real uncertainty, and risk, both physical and mental – but the sense in the NHS of resolve, camaraderie and destiny is not only palpable, it is reflected in the reactions of the public as they applaud in the streets. This respect for the NHS as both an entity and an idea resonates within me like a harmonic frequency. Every pub argument with a private healthcare supporter, every tough A&E night shift wrestling with drunks, every email written to document gaps in care suddenly have context and purpose.

Perhaps my NHS tattoo won’t actually happen. I expect like the eagle and the volcano, there will be others who already deserve one much more by the time I’m back moaning about yet another backshift in Minors.

Little Sums

My local supermarket is pretty good at managing crowding. They seem to staff the various areas according to predicted demand, while holding some extra staff in reserve tasks to cover surges in essential activity. They also know exit block at the tills is usually the major bottleneck, and understand the need for escalation actions (like opening more tills) when impeded flow is causing crowding in the aisles. Crowding quickly impairs the core business of the supermarket, and shoppers become frustrated and leave, so the duty manager must respond effectively. The formula that the retail industry uses to understand crowding in their stores is Little’s Law: Average number customers in store = average rate arrival X average length of stay.

In the much more complex environment of A&E, control of length of stay is even more essential, as the consequences are not lost business revenue or someone running out of milk, but unnecessary deaths. In an Emergency Department setting, Little’s Law can be adapted to: average number patients = rate of arrival X length of stay. Some patients may be suitable for a waiting room, redirection elsewhere or “see and treat” (the equivalent of the supermarket 12 items or less queue), and can be excluded from the space calculations. However, the “majors” need not only a clinical space for assessment and treatment to occur with any dignity, they also require timely and potentially life-saving care. The rate of arrival of such patients is surprisingly predictable for most departments, with a steady peak between 11am and 11pm. Therefore:

Number staffed A&E trolley cubicles needed = average peak majors arrival rate x average length of stay.

(Example: If there are 31 suitable staffed spaces and average peak arrival rate of 12 patients per hour. The average length of stay must be 2.58 hours or queues for spaces will develop and persist until the rate of arrival subsides. If there are 61 staffed spaces and the same average peak arrival rate then the average length of stay can be 5.08 hours.)

What dictates the balance between number of cubicles and length of stay? Most discharged A&E “major” patients need a minimum time of 2 hours (for triage, assessment, investigation, review, discharge). 4 hours is thought to be a reasonable time frame for the majority of the admitted patients to be worked up by A&E, referral to in-patient units made and patient transferred out. Clearly there are important clinical exceptions, but the concept of a maximum 4-hour target length of stay sets an overall reasonable mean length of stay for majors of around 3 hours. If A&E departments are properly configured in terms of trolley space by Little’s Law and staffed for their expected workload to meet these timeframes, then the transfer out of A&E to in-patient beds remains the only significant variable affecting length of stay (equivalent to queues at the supermarket tills). This figure is closely related to hospital occupancy as it relies on the ready availability of the in-patient beds.

In a full hospital, patients awaiting admission cannot be moved out of the ED. Once average length of ED stay then exceeds the calculated required average for the number of staffed majors cubicles, there are no longer safe and appropriate spaces for new patients and A&E becomes overcrowded.  In an overcrowded,A&E there are multiple well known adverse consequences. Violence to staff, increased complaints and critical incidents, missed diagnoses, missed treatments, complications of long trolley stays (bedsores, infections, DVT, falls), all resulting in 30% increased mortality in admitted patients and 70% in discharged patients.

Despite all the evidence of overall positive effect of time targets from around the world, there are now voices in the UK health sector calling for the abandonment of the A&E 4-hour time target. The emphasis it places on rapid treatment of acutely ill and injured patients requiring admission is no longer being portrayed as an essential safety requirement, but as an encouragement to over utilise the allegedly overpriced and inefficient free acute care supermarket.  The future, we are told, is in developing health delivery alternatives analogous to small local stores and home delivery services. However it is very unlikely that emergency departments will be short of business as a result of any changes in that direction, and without ED crowd control time targets, every day in them will feel like Black Friday.