aka Postcards from the Edge 011
This ‘postcard from the edge’ comes to us from Dr Sandy Inglis, a peripatetic FACEM (currently) based in France, who recently visited the Northern part of the Emerald Isle.
The thick, cool Guinness slid over my tongue, it’s rich, dark, malty exuberance resonated in my mouth. The creamy head caressed my lips and the dewy cool glass felt refreshing in my trembling fingers. I gazed out at the patchwork green fields and the ever present grey canopy of sky. It felt good to be back in Ireland. Except that I was back for work, not pleasure. This time an “A&E” locum in a small ED not far from Belfast. I nearly didn’t get there though thanks to a slight technical glitch at immigration. My UK passport was being renewed so I decided to use my Kiwi one. On arrival, a perplexed immigration officer quizzed me earnestly. ” So you are a New Zealander born in South Africa and living in France and want to work in Ireland? Sorry that is illegal and you need a visa and we cannot let you in!”. “Oh! But I’m actually British…”… the queue was long gone by the time we resolved our differences but “to be sure, to be sure” they let me in to do battle in their overcrowded ED.
Working in Ireland puts Australasian ED ‘s in perspective. 80 000 presentations per annum and just three FCEM ‘s and a director ever busy and involved elsewhere in the hospital, can make life tough. The congestion and space limitation make our ED’s feel like airport hangars and “trolley waits” of almost 30 patients explained why I didn’t see the back wall of “majors” for the first 4 days of my time there. The Resuscitation area also serves as triage and ALL patients are assessed in this 7 bed area first, where it is impossible to sit on the one chair at the one desk to write your notes without being swept aside by a trolley squeezing into one of the tiny bays where one has to walk through one bay to get to another! After initial assessment here patients (most of whom don’t need resus) are wheeled around to majors where they continue their work up and/or become part of the chaotic demoralizing trolley wait. Of course, the corridors and every inch of space serves as a holding area and a queue of anxious Paramedics gaze at one expectantly every time you pass, in the hope that you might relieve them of their cargo and liberate them from the chaos.
“Minors”, as always, is a misnomer and heaves with back pains, epistaxis, complex fractures, eye problems and ‘minor’ MVA’s. It is run mainly by nurse practitioners with a junior Doc to handle the more complex cases. I spent half an evening there in an effort to empty it out before midnight and was impressed by the panorama of pathology and how this is invariably handled by nurse practitioners and junior docs. The patients sure are patient and despite frequent waits of some hours in a cramped inhospitable waiting room, they invariably responded with warm Irish humour. The trolley wait patients were invariably sharing cubicles but the majority were lined up three deep, obscuring the back wall of majors and making confidentiality and close observation impossible.
The ED tea room was about the size of my office and served as tea, lunch and nurse handover room. Staff bags and coats were chaotically piled up amongst store items in an annex and all staff shared one toilet accessed through the crowded minors waiting room. The consultants shared broom cupboard size offices and spoke frequently about the difficulties in running the ED and how exhausting the job was.
Junior staffing seemed reasonable but with only three registrars and the odd staff grade or GP, the middle tier was weak. Formal departmental handover was non existent and staff arrived and simply rolled up their sleeves (they have a strict “nothing below the elbows” policy) and got on with the job. Folk were expected to finish their patients making handover largely unnecessary.
Exhausted consultants are ever busy supervising and co-ordinating the ED and spend a large part of the day trying to create space and move patients on. Teaching, procedures and close supervision is a luxury. The computer patient tracking system, although comprehensive, required clicking into a second screen to determine which doctor was seeing which patient, which was cumbersome. It does, however allow for instant GP letters which are immediately e-mailed to the GP. Also x-rays and scans are ordered via computer which is tidier than forms and walking around to X-ray.
The thing that probably grieved me most was seeing how our Irish EM colleagues, probably thanks to poor senior staffing and overcrowding, had sacrificed the acute management of critical patients to their anaesthetic and ICU colleagues. I witnessed an assertive anaesthetic invasion for the management of a simple isolated head injury in an alcoholic who needed RSI and a CT. Then again for the instigation of CPAP for the management of pulmonary edema. I was disappointed to see some of our core EM work being carried out by our intensivist and anesthetic colleagues. On addressing this with my colleagues the answer was inevitable… Too busy, too few seniors and helps get patient out of ED fast.
It wasn’t all bad and despite the mayhem, critical staffing and overcrowding, the junior staff and nurses were excellent. Equipment and drugs were comprehensive and a new ED is under construction. For now they have to make do and to put up with locums and rely on their Irish sense of humor and good spirit. Despite all this, I for one, would go back. Maybe it’s the Guinness!
from the edge
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health, a Clinical Adjunct Associate Professor at Monash University, and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of LITFL.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of two amazing children.
On Twitter, he is @precordialthump.