FACEMs at Night: A Mattress Stuffed with Flaw

This is the second of two perspectives on whether FACEMs should work night night shifts, for the first, see Anand Swaminathan’s ‘FACEMs at Night: An American Perspective‘.

Let us take ourselves one fact. One, simple, undeniable fact. One cannot, after all, dispute a fact. A fact, according to most reputable definers of words (and a few, which are my more preferred sources, disreputable ones) is a truth. A thing that is universally known to be true. Merriam-Webster (American, I know, but in light of it’s lexicographically poetic etymology, we must forgive its murderous spelling) defines it as ‘a true piece of information.’

So I offer you a fact.

Patients presenting to the Emergency Department at night are safer if there is a FACEM present.

A simple statement, you will agree, and entirely plausible to you, dear reader, if this is the first time you have given the matter consideration. But, as luck would have it, you have evidence with which to securely back it up. There is not quite a wealth, rather a comfortable income of data to support it. The supply of this evidence, has, most fortunately, been done by somebody else who finds pleasure in the collation of such material, and I refer you to the references outlined in the article below.(1) Although there are no numbers upon which to convert this ‘fact’ into a NNT at this point, the balance of current evidence, opinion, and basic plausibility can safely move this idea well into fact territory. It has the added advantage of making good sense. You know that if a loved, or even moderately liked one presented to ED in the dark strange hours of night, would you not want them to be treated by the most experienced, knowledgeable and capable doctor possible? Thus once we’ve established that this statement is a fact, then we have no option but to act. Swiftly, decisively and with somebody else doing the rosters (yes, the person who left the room just before the moment of portfolio distribution). As for the pot of money required to make this happen, what matters this if it improves patient safety?

As an aside (and aren’t asides wonderful, as this is where all the good learning happens, out of eyeshot of the main tedious topic) we should take just a moment, leaning on our fence (not the one upon which Schrödinger’s cat sits) to narrow our eyes at what a fact really is. In truth (and there I go again) there are very few facts in the world. The Earth is (mostly) spherical – we know this as we have rather dreamy photos from space – however this was the opposite of a fact up until the 1700’s. It was a lie and a heresy. And aside for a few other scientific tenets, our fact cupboard is surprisingly bare. Take these others: The Eiffel Tower is in Paris, Miss Havisham’s adopted daughter is named Estella, and three plus two equals five. These things are all subject, with enough philosophical, scientific, and socio-linguistic wrestling, to a little crumbling, and possibly even frank disintegration. It is possible that there are NO facts out there.

So, to return to our now rather flimsy looking fact, it shouldn’t take much effort to dismantle it.

There are a number of cogent arguments put forward in our second exhibit (2), which argue against the presence of ED Consultants at night on the floor, however I am most interested in deconstructing that single fact mentioned earlier.

How could having FACEM’s present on the floor at night decrease the safety of patients.

  • Senior trainees need protected time when the ‘buck stops with them.’ If they are sheltered, and prevented from having these periods, they may possibly miss some crucial and unmeasurable experiences which will impact their management of future patients. Trust me, having grown up in the ‘I’ll give it a crack’ era of registrar training, the skill of self-reliance and independence is invaluable. It is arguable that even with the wisest, Yoda-like consultant, standing in the shadows at 0345, the impetus for self-knowing is reduced. Could the future patients of these doctors missing out on vital educational lessons be less safe?
  • This pot of money is finite. If resources are taken from other areas to service our fact, could we be putting other patients, elsewhere, in unknown corners at risk? Making them less safe?
  • If resourcing is an issue, and rosters not ideal (thank you very much, fictional roster person), could tired, grumpy, burnt out ED consultants make the occasional suboptimal decision? Leading to the odd less safe patient interaction.

I have no doubt, considered reader, now that you are on this savage and destructive path, peeling off layers of supposed truth from statements like a busy ED nurse trying to get an ECG on one of those delightful elderly ladies, who think nothing of wearing their entire wardrobe in on a summer’s night when coming in for a checkup, as you discard undergarments and petticoats and spencers and cardigans, you can see the pale wrinkly soul beneath. And she is just a slip of a thing, hardly there at all. All facts are like that, I’m afraid.

So, what do I think? What is my opinion in the yes/no debate? Well here it gets harder. My interpretation of this fact is entirely and utterly, slopping at the sides like a bucket full of mud, full of conflict. I am a FACEM and have worked in an inner city ED as a consultant for 14 years. Night shifts may well come. I would rather like to do night shifts. But not necessarily for the above fact, although that would be a rather nice collateral, if it were, indeed, true. No, it is because during the ashen hours, in the middle of a strange city, is when one of the strangest places on earth become even stranger. I love this part of my job (as long as it is in the once in a while category).

So the debate will go on for some time longer, and then Consultants will be rostered on for night shift, or they will not. As long as they are not done so under the guise of the fact that patients are definitely safer when there is a FACEM present on the floor. For a much more sensible discussion, I beseech you to read the two articles presented, and make up your own mind.

References and Links

  • Runciman B. Is it time for consultants to join trainees in working night shifts? Yes. Emerg Med Australas. 2014 Oct;26(5):506-7. PMID: 25196595.
  • Markwell A. Is it time for consultants to join trainees in working night shifts? No. Emerg Med Australas. 2014 Oct;26(5):508-9. PMID: 25186978.

Emergency physician. Lives for teaching and loves clinical work, but with social media, she is like the syndromic cousin in the corner who gets brought out and patted on the head once in a while | Literary Medicine | @eleytherius | Website |

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