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.

The Morning After in A&E

The atmosphere in A&E the Friday morning of Brexit was more subdued than normal. Medical, nursing and portering staff busied themselves with administrative tasks at the staff base rather than indulge in the usual noisy banter that acts as a team fist bump for the start of a shift.  Sometimes you get this sort of disconcerting quiet in an A&E when the normal routine exchange of gossip, inappropriate innuendo, informal medical education and war stories of previous shifts is temporarily suspended by a collective unspoken distress.

Usually this arises as a result of a particularly harrowing case: the death of a young patient or a staff member. But this time it was a political event: a democratic decision to leave a seemingly distant political institution. Why did this feel so upsetting and so personal to a bunch of people used to seeing tragedy and some of the worst of human nature? Young people with cancer, abandoned frail elderly, savage beatings, domestic violence, drug punishment stabbings and the ravages of drugs and alcohol are all part of the daily routine here, managed by resilient staff with empathetic yet technical efficient objectivity.

As the morning wore on and disbelief morphed into anger and alarm, the reasons started to crystallise as staff began to discuss the events of the previous evening in small huddles while beginning to attend to the first ambulance arrivals of the day. The common theme was one of a damaged sense of collective purpose and identity. The mirror of the referendum had been held up and we did not like how we were being reflected as a nation. Narrow minded, parochial, fearful, selfish, and most significant of all for A&E workers – not team players.

Some very limited consolation was taken from the Scotland result and the possibility of another Scottish Independence Referendum, but even here in Glasgow, 1 in 3 voted to leave, if they bothered to vote at all. One or two of the team even sheepishly confessed one or other of these sins to the silent incredulity of the others. Others searched for demographic groups to blame for the shame of lurching the country towards its isolationist, xenophobic and right wing future, oblivious to that irony.

But more and more patients rolled in, and as the shift busied up, conversations were replaced by frenetic activity. There were major road accidents resulting in life changing injuries, newly diagnosed lung cancers, a ruptured aorta, and many frail elderly patients with complex needs to care for. A committed team, guided by objective evidence, worked collectively to protect all comers from the misfortune that had befallen them, including those that had made poor life choices with very serious unforeseen long-term consequences.

By the end of the shift, the general mood had shifted somewhat back to normal. As the team changed out of their scrubs and headed for home, there was perhaps the reassurance that, within the walls of the A&E department at least, cooperation remained the best way of doing business.