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.