I have been a doctor in emergency (A&E) medicine since 1999 (before the four hour target) and I can honestly say it has never been as bad as it is today. Right now. I have no idea how the clinicians, nurse and others will keep going to work everyday.
Evening Abby. Finally a question I can answer! There are many causes of a tachycardia. Sometimes it’s just a physiological response to the body needing more oxygen in the tissues, but it could also be an arrhythmia like fast AF or even VT. I hope that helps. Yours aye. Iain.
Hi Abby. It’s really kind of you to show such an interest. I think it’s probably getting an arterial line in under ultrasound guidance in a patient with no palpable pulse. There’s nothing like it. All best. Iain.
The uncomfortable truth that dare not be said is that many do not need to see a GP or attend A&E. Society is now about the individual not the whole. We’ve seen it for years- “so what if there’s dying people in Resus? What about my sprained ankle?”.
When you attend an A&E/Emergency Department.
1️⃣ We will see people in order of clinical urgency.
2️⃣Arriving by ambulance does not mean you will be seen quicker
Just for fun I asked our night team of doctors how many had been Head Boy/Girl at school. Over 50%. Sometimes we forget just how high achieving our colleagues are. They are (literally) the academic top 1%. We need to empower them, not patronise them in their roles.
I notice the
#JuniorDoctorsStrike
has dropped off the
@BBCNews
website front page and isn’t even the top health story. Press coverage often negative and patients undeterred from attending A&E. I fear HMG has no reason to negotiate. What’s the
@TheBMA
next move?
A 29-year-old farmer presents to your local ED with a bite mark over the upper left calf 🕷️ He is physiologically stable with a NEWS of 0.
How do you manage this case?
🆓
#FOAMed
➡️
@HassanNassar90
It is time for a national discussion about what it is reasonable to expect for emergency medical care from
#NHS
. We can no longer just see everybody and anyone who turns up at A&Es’ doors. It is just not possible. We have to be there for the acutely unwell and injured.
Never underestimate the toll it takes on you walking into a hospital every day. Surrounded by the sick, injured and sad it’s hard to remember that the whole world isn’t like that. I genuinely don’t think the public (or politicians) have any understanding of how hard it can be.
To remove some of the cognitive burden I have scripts I use on each and every trauma call. In essence I am playing a part, and leaving as much brain space for the complex thinking as I can. This is the script I use prior to the patient arriving.
#RCEMcpd
For the record: I work on the ‘frontline’ (sic) in the
#NHS
, I do night shifts and weekends but there is absolutely no way my work is anywhere near as difficult or tiring or stressful as that of a GP.
GPs are the true backbone of the
#NHS
and they deserve all of our support.
There seems to be an awful lot of pressure to “live your best life”. Some days I’m content just to live an average life: pottering along; trying not to shout at my children too much; eating only 2 of my 5 a day and letting the world pass me by. And not to feel too guilty about it
The bit I don’t understand is why no one telling the public that their expectations of the
#NHS
are simply too high. There needs to be an element of self care first for many. GP appointments are available, as are A&E services, but we cannot cater for the worried well.
I wonder of headline should actually be
‘Consultants standard hourly pay is less than almost any tradesperson who might work on your car, plumbing, tax return, divorce or house renovation’.
We often hear grand plans for A&E restructuring, but what small things would make your ED more efficient?
I’ll start...
*Printers that always work
*Not having to sign ECGs/VBGs for patients who didn’t need them in the first place
*An up to date contact list
Your turn....
Working in A&E over the next few months will be challenging, but I can’t be the only one who thinks it’ll all pale into insignificance compared to the night the lockdown ends....
Do you believe ultrasound is the future of Emergency Medicine?
Do you believe video laryngoscopy is the future of Emergency Medicine?
Do you believe HEMS is the future of Emergency Medicine?
Some of the questions posed by
@davidstantonza
at
#badEM19
🔟Being in a hospital does not make you immune from common courtesy or the law. If you abuse us physically or verbally we will call the police.
I’m sure colleagues may want to add to the list…
The rise in energy prices is a worry for us all, but as I sit here in a brightly lit A&E department at 4am I dread to think of the effect on the
#NHS
. An extra £700 per household? How much extra per hospital?
Should “Advanced Life Support” be renamed “Basic Life Support Plus”? Resuscitation has moved on past generic algorithms. ALS really isn’t advanced at all, but gives the impression to providers that it’s the standard to aspire to. And those going “beyond the manual” are rogue.
We often talk about flow out of the Emergency Department (A&E) but is it time to have a serious discussion about who gets in at the front door? The system simply isn’t capable of looking after the entire population’s range of health concerns. Do we need to redefine ‘emergency’.
A very senior surgical colleague once said to me ‘I have no idea why we expect you to make a diagnosis in four hours. After several days and multiple tests I often still don’t know what’s wrong’.
Those in healthcare aren’t leaving because they don’t want to make sick people better, they’re leaving because of the public demand to tell well people they’re not sick.
Until we all acknowledge that the ED/A&E doesn’t have endless capacity, that corridor care is unacceptable and that the risk must be shared across the whole healthcare system nothing will ever change. I’m tired of inpatient teams using “but we’ve no beds” as an excuse.
Yes children, phones used to look like this, were attached to a socket and (best of all) when we answered we repeated our own telephone number. Yes. We repeated our own phone number (I can still remember ours from 40 years ago).
A patient with known advanced cancer shouldn’t be in an A&E at all. They should be directly admitted to an oncology or palliative care ward. This misuse and misunderstanding of what “A&E” is for is a major part of the problem.
5️⃣ Clinicians in A&E are specialists, but in the management of emergencies. We are no good at rashes, chronic illness and other medical problems that have been going on for more than a few days.
6️⃣ We are not a substitute for ‘I don’t have a GP’
As I am sure many medics have, I had an email from a national newspaper today asking me to comment on the current state of emergency care. I redirected them to the
@RCollEM
Communications Dept who are doing an excellent job. Important we have a single strong voice.
Honestly. If he can’t get an increased care package to keep him at home what hope have the rest of us got?
Prince Philip taken to hospital as a 'precautionary measure'
A quick guide to how Consultants in the
#NHS
are paid (as this may be a hot topic over coming weeks).
The basic unit of pay is a ‘PA’ or programmed activity. In ‘normal hours’ a PA is four hours. A full time contract is 10 PAs (40 ‘normal’ hours per week). 1/10
Good question Katie. I’m no cardiologist, but it would usually be via your femoral or radial artery as far as I know. Although, of course, in an emergency a clamshell thoracotomy would work too. Enjoy your dinner. Iain.
As Trusts seem to be competing to outdo each other on the quality of their “goody bags” at
#induction
, I can’t help but feel most starting new posts would swop it all for a (decent) rota in advance, no pointless stat and mand, access to parking, a commited Ed Sup and a pay cheque
Just my occasional reminder that being a Clinical Lead in a specialty in an
#NHS
Trust is an almost impossible job. Trade Union leader and Line Manager. Two masters with often very different needs and you’re stuck in the middle. Did it for three years: it almost killed me.
The
#COVID
pandemic has been hard for everyone, but I count myself very lucky that as a doctor I’ve been able to go to work (and get paid well) throughout, had daily interaction with colleagues to keep spirits up and been able to ‘do my bit’.
7️⃣ We are not a substitute for ‘my GP doesn’t take my problem seriously’ (which, by the way we don’t believe).
8️⃣We cannot get your out patient appointment brought forward.
9️⃣ Shouting at us doesn’t make us want to help you
Our next
@UCATofficial
question.
Personally I think Ariel is pretty brave to stand up to Robert. All too often medics stand by and let bad behaviour happen. Ariel isn’t doing this and fair play to them. I’d answer A. (Robert is just the sort of person you’d dread working with).
Gosh Katie, I’m surprised I’m opening up to you so soon after meeting, but I’d say spending 10 years trying to tweet someone funny, only for someone else to post the exact same thing 12 hours later and getting 21 thousand more likes than me. At least I was his “inspiration”. Iain
I’m a former Clinical Lead of a Major Trauma Centre Emergency Department and current consultant in EM and prehospital care and due to participation in the AZ
#vaccine
study and the
#NHS
vaccination programme I have been the very proud recipient of four vaccines.
I currently can’t afford the £1000 for APLS and NLS, but need to put it on a credit card. 18% APR for the next 5 months, which isn’t insignificant. Doesn’t seem like anyone cares about this?
Saddened to hear one of our very promising FY2s has withdrawn from their place on the GP training scheme for next year. His future is now uncertain, but he said he simply ‘can’t see myself doing that job’. Urgent action is needed.
I have decided that it’s misleading for patients when surgeons use the prefix Mr/Mrs/Miss/Ms after passing an exam. Much better if they use Dr Their Name FRCS. Otherwise patients might think they are not seeing a real doctor.
Here’s an idea- for 24 hours why don’t as many people as possible post their positive experiences of working and training in Emergency Medicine. It doesn’t have to be monumental, just the little things that make it all worthwhile.
After some reflection I have concluded that Emergency Care in the UK has never before been under the constant, unrelenting pressure as it is now. Every shift feels like a struggle (and I’ve been doing it a while). How do you keep yourself positive on shift (and after)?
We’ve been trialling a new way of ‘front door’ working this week at
@UHSFT
. My biggest take home-we need the most senior decision makers possible available as early as possible. This may make some uncomfortable and echoes of ‘that’s not in my job plan’ will bounce off the walls…
When, as trauma team leader, you suggest to the newly ATLS certified registrar that the haemodynamically normal trauma patient with an isolated limb injury only needs one cannula.
3️⃣Our clinicians each see on average one patient an hour. If there are 70 patients waiting to be seen when you arrive and there are 10 clinicians, and your problem is not urgent your wait will be at least 7 hours.
4️⃣ More tests does not mean better care. Perhaps even the opposite
How has medical parlance made its way into your everyday language?
I'll start: I say that things have "nadired" (verb) all the time, and that it's "not unreasonable" to do a given thing.
Ex: My mood had nadired, so it seemed not unreasonable to eat an entire box of Oreos.
A very senior surgical colleague of mine once said ‘I don’t know why we expect you to make a diagnosis in four hours, when often, after they’ve been an inpatient with us for two days I still don’t know what’s wrong with them…’
Would be interested to know the thoughts of UK surgeons on this, particularly those who don’t think surgery should be taking referrals from ED without a confirmed surgical diagnosis
@MStott88
?
Well Katie, a combination of:
Zygomaticus major and minor: Pulls up the corners of your mouth.
Orbicularis oculi: Causes the eye crinkle.
Levator labii superioris: Pulls up the corner of lip and nose.
Levator anguli oris: Raises the angle of mouth.
And a few others. Iain.
Having high blood pressure with no symptoms is not a medical emergency. It’s a risk factor for future disease. Yes it needs attention, but only in the same way smoking cessation does. And for many the first step isn’t tablets…
Thought this question and answer from
@UCATofficial
was really interesting. As a consultant I definitely wouldn’t have answered D. Junior doctors are highly trained professionals. Simon sounds like a conscientious doctor, making a patient centred decision.
Two very simple words, uttered by both patients and staff, have crippled healthcare.
“What if?....”
This has lead to increased attendances, increased length of stay and overinvestigation. I fear this can never be reversed. We seem incapable to accept any risk however small.
I’m a complete devotee of the original Morse books (and TV) but having just binge watched the latest series there’s a chance I like
@EndeavourTV
even more. Beautifully played by all involved.
Yes there’s an aging population and COVID, but do we really believe that public health is worse now than two decades ago? Phone consultations work because it is a trained person absolving the individual of the responsibility for their own health that they are not willing to take.
Hi Abby. Just wondering how we can break down barriers between ED and inpatient teams: to work more collaboratively and less in silos; to understand each other and walk in each other’s shoes occasionally. Surely that would not only help staff but patients too? Best wishes. Iain
Just a gentle reminder that the answer to A&Es/EDs being busy is not to cancel planned teaching sessions. Value and look after your staff and they will give back tenfold.
And if you do cancel these sessions don’t then say you care about ‘wellbeing’
Lots on
@Twitter
about current ‘pressures’ on the
#NHS
. Some advice from ‘thought leaders’ is frankly absolute nonsense. Here are some
@stemlyns
resources that offer practical thoughts.
There are so many good people in the world of Emergency Medicine. It’s a specialty of endless learning where you can do genuine good on a day to day basis. There is huge pressure on EDs at the moment and we must support each other with as much energy as we can muster.
This is the key to
#wellbeing
I believe. People don’t need fancy schemes, just decent working conditions, the ability to take leave when they’d like and a rewarding work environment for a fair salary. Spend the money (and time) on HR support, not chocolate.
Let’s be clear- this is association and not causation. When there aren’t strikes most A&Es across the UK are on the verge of a critical incident. The responsibility for this lies squarely at the door of those running the
#NHS
not the staff.
BREAKING: A critical incident has been declared at Nottinghamshire hospitals due to sustained pressure on the NHS and reduced staff because of the junior doctors strike
📺 Sky 501, Virgin 602, Freeview 233 and YouTube
Ok, Simon Carley has 25k followers and educates on a platform of Emergency Medicine. I have 7K followers and I’m really jealous.
Can we make my ‘voice’ as loud as his on Twitter?
Follow and RT me. Let’s do this 👍
PS. I know he is a Professor and all that, but I’m really needy
Hello again Abby. You have so many questions! Right now I’m wondering if the patient with atypical chest pain really did need a CTPA and an Echo, You really can’t be too careful. Or maybe you can. Oh gosh. It’s tricky.... Take care. Iain.
Just been to our new
@UHSFT
staff gym for the first time. Easy online induction, security added access to my pass without fuss and in I went. Nothing fancy, but a good range of machines and hot showers in the changing rooms. All good stuff.
Our health system is being killed by the ‘just in case’ attendances followed by ‘just in case’ over investigation, the latter fuelled by a fear of criticism and reprimand.
As a doctor in an A&E I keep myself sane by focussing on caring first for those who really need it and I’m afraid the rest may need to wait. But I don’t feel guilty about that: that’s just the system we all work in.
Fundamental change is needed. But who is brave enough to do it?
This will come as absolutely no surprise to anyone working in emergency care. A few thoughts on why things have changed so much over the last decade (and why ‘attendance numbers’ are not comparable). 🧵
I realise this may be rather controversial, but is it time we update the expected clinical examination for medical students to reflect real life? Palpating an apex beat for example. Has this ever really changed a single diagnostic decision? There’s plenty more of these examples…
“You’ve got this. If you need any help look at me”.
Surprising how much medical educators can learn from
@GlastoFest
Remember this next time you’re in Resus with a less experienced colleague and they too can be like
#Alex