The first Wednesday of August in England is known by some observers of the NHS as ‘Black Wednesday’, the more cynical ones calling it the start of ‘the killing season’.

Recent studies show there are 6 – 8% more patient deaths in the first week of August than in the last week of July. Although at first glance this is scary, it does need careful and cautious interpretation as it does not demonstrate a causative link between junior doctor errors and patient deaths.

With over 6,000 junior doctors starting new posts, some of them for the first time, it is no surprise that this is a worrying time for hospital staff, hospital risk managers and the public. Coincidentally perhaps, ED attendances have fallen over recent years on this particular day; perhaps it reflects public awareness of this phenomenon.

The Academy of Medical Royal Colleges (AMRC) have called for action to be taken. Although attempts have already been made to reduce the number of serious untoward events, it is clear that general standards of patient care including length of hospital stay need improving during this critical period.

It does not take a rocket scientist to work out that a supervised induction period will lead to better overall preparation for junior doctors and should improve patient care. A ‘shadowing’ initiative, suggested by the AMRC, has been piloted by several UK trusts with some success. On paper it is an excellent initiative; in practice however, how practical is it in a fast-paced and time critical environment such as an emergency department where changeover day only serves to stretch the already overstretched staffing debt? How can we ensure appropriate senior doctor/consultant cover during this critical period?

Induction should focus on systems, communication, crew resource management and patient safety. Standard systems and protocols nationally will certainly be one solution, as well as placing junior doctors in hospitals where they have trained as medical students; local knowledge will help.

Staggering the changeover period is another option; the downside is that a five-day induction stretches resources and not all hospitals with have the infrastructure to manage this safely.

Patient care is an absolute priority at all times but especially so during this time; we need to continue to support and encourage our junior doctors who are often facing one of their most difficult and challenging times of their professional lives.

Janos P Baombe/Sivanthi Sivanadarajah

Here are  the highlights from this month’s issue…

Location, location, location

Five departments in the South West replied to a survey to see if they followed the CEM guidelines about having immediate availability of antidotes to a variety of poisoning agents.

The questions asked if they knew were the antidotes were, if not how to get hold of them, and how long it would take to get them.

Results are revealing and should lead the reader to repeat this work in their own department as a worthy exercise! Do you know where the dicobalt edetate or sodium thiosulphate is kept, or how to get hold of more stock?

Here are  the highlights from this month’s issue… 

Ophthalmoscopy in the Emergency Department

Ophthalmoscopy is a difficult but essential skill in the Emergency Department environment. In this short report, the panOptic ophthalmoscope was compared to traditional direct ophthalmoscopy in conditions comparable to those found in most EDs. While the newer instrument was preferred, the actual clinical utility of doctors using both was worryingly poor. See the performance of trainee emergency physicians for yourselves.

Perfect World or Dark World

Emergency Department crowding is a problem just about everywhere. In this paper, a discrete event simulation created models of the Emergency Unit to explore the effect of various changes to physical capacity and human resources. The relationship (in the model) between the physical resource requirements and the number of clinical decision makers is particularly noteworthy.

Alphabetical handover

Emergency Departments abound with clinical risk: high numbers of new, undifferentiated and unwell patients, multi-professional and multi-specialty staff in unfamiliar teams, time constraints and a high turnover to name but a few. Anything designed to reduce avoidable risk is to be welcomed. Our colleagues from Imperial College, London describe the development and implementation of a tool for ED shift handover that clearly works for them. The papers are worthy of close study.

Buscopan and/or Paracetamol in moderate abdominal pain

We all have hobby horses (or fixations!) and I have to admit that one of mine is a profound desire not to give patients with abdominal pain a dry mouth, blurred vision and a raised chance of urinary retention in addition to their presenting problems. I was delighted, therefore, to see the paper that randomised patients with acute abdominal pain into groups that received either oral paracetamol or intravenous hyoscine butylbromide alone or a combination of the two. To see what they found and to find out whether my fixation was justified or whether I need to eat my hat you’ll have to read the paper!

To CRP or not to CRP, that is the question

Santos and colleagues from Sao Paulo report on a problem that faces us all—the uncontrolled rise of the easily requested, expensive yet ultimately clinically unhelpful test, juts like this well known, non-specific marker of inflammation. Their initial assessment of the problem involved an audit of current practise together with a review of the evidence of clinical utility. The most interesting story they have to tell is, however, in terms of the intervention they designed to combat the problem. It is well worth getting this paper out and studying it, as the lessons are generalisable to many situations and settings.

They think it’s all over

It wasn’t just the athletes and the gamesmaker volunteers who had to prepare for the London 2012 Olympics—there was a considerable, hidden public health agenda too. Part of this was the development of an Emergency Department syndromic surveillance system to help monitor the nation’s health. As Elliot and collaborators report in their paper describing the early part of this work, such a system is both feasible and useful.

and finally…

In a short report Reed and others from Edinburgh, Scotland report on a possible role for troponin assay in patients with syncope. Well worth a read.

Kevin Mackway-Jones

In this short blog, Aruni Sen shares his thoughts on a retrospective study he conducted with some of his colleagues around a 24/7 senior clinician delivered emergency care and the reactions from the profession. 

The philosophy we strive for in the care we offer in the Emergency Department at Wrexham Hospital is that every patient, if needed, deserves to be seen by a consultant regardless of time of day; if a consultant emergency physician is needed at 9am then the need is no different at 2am. This view is ridiculed by many of our consultant colleagues in the United Kingdom; a throw away comment that we are ‘working like a glorified registrar all our life’ is cynical, insults both registrars and consultants and often comes from those who are not clinically active in hours – never mind out of hours.

We reject this cynicism; our working pattern now includes night shifts and we did so because of the risk to patients left to the care of junior doctors at night; instead of expecting the middle grade doctors to work an unsustainable number of night shifts, the consultants decided to share the burden.

Do consultants make a difference by delivering care at any time of day? The answer is unclear during the day (as there are many consultants, middle grades and juniors working) but at night (a consultant or middle grade doctor with a junior) it is more straightforward.

Our recent paper in the EMJ reports what we found – that a consultant is more efficient and does the job better than others. This should be no surprise to anyone; after all a registrar trains to improve as a clinician, and so if a consultant does not outperform a trainee we need to go back to the drawing board and ask what it is all about.

The benefits that we reported are quantitative; our next step is identifying the cost savings that a consultant service offers compared to that by juniors. A harder thing to measure accurately and in a reproducible way however, is the quality of care given, namely rapid decisions, focused investigations, admission avoidance and comprehensive counselling to name a few. We are not sure how to show this on paper.

One certainty that cannot be argued against is that our desire for respect from other specialties is unrealistic while we allow the bulk of service delivery to come from juniors. The hospital is not blind. For those of our colleagues who accuse us of committing self-destruction in writing this paper (like turkeys voting for Christmas) we must ask the question what our patients will think if they hear these negative comments.

We can only wonder…

Aruni Sen