Time is running out

“The patient in cubicle 4 is about to breach…”

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So greeted my illustrious return to the NHS and the world of emergency medicine. Sounds like a whale giving birth doesn’t it?

What the poor patient in cubicle 4 had breached was the 4 hour transit time target that all A&E patients are meant to meet. Not that the poor patient knew any of this, nor was meeting this target their responsibility anyhow. Why are we talking about the patient anyway? They’re hardly important.

The idea is that all patients should spend less than 4 hours in an A&E department. From turning up at the front desk till either transfer to a ward or discharge home. The 4 hour targets are Department of Health dictated policies, who unfortunately are in charge of handing out the money for the whole ‘Health Service’ carry on, including the greenbacks I take home at the end of the day.

Now the idea of spending less than 4 hours in an A&E department does indeed seem like a fine and noble idea, if I have a broken ankle, I want seen, investigated, and home in a plaster cast before 4 hours is up. I think 4 hours is not too much to ask.

However if I’ve just flipped the car on the M1 and mashed my good self to a set of malfunctioning organ systems held together by drips, ventilators and sticky tape then I don’t want neglected so that the staff have to leave me to sort out that broken ankle just cause it’s about to breach.

Even then I don’t think I should have to wait 4 hours to get my ankle sorted. The sensible thing to do seems to be to provide more staff so that they can do both at the same time. Or maybe that’s a bit of a crazy idea…

Or say, for example, my 50 year old, overweight, smoking, diabetic self gets brought in with chest pain. I get seen promptly and some medication and the pain settles a bit and they do some blood tests and an x-ray and they’re still not entirely sure what’s wrong with me. But look, it’s been 3 and a half hours already and I’m about to breach and all of a sudden I’m dumped/bounced/thrown/admitted to a medical ward with a label of ‘chest pain, query cause’ where I languish for a further 6 hours till the ward doctors get a chance to see me (cause they’ve been seeing a long list similar patients with labels like ‘sick, query cause’, ‘unwell, query cause’, and ‘turned up in A&E, and wouldn’t go home, query cause’.)

And so roughly 10 hours after admission I get bored waiting and decide finally to rupture the aortic aneurysm in my chest that was causing the pain in the first place, the aneurysm that would have been seen on the CT scan I probably should have had done in A&E at the 3 and a half hour mark. And so as the cardiac arrest call goes off and I head towards the bright white light, I think that it’s crazy the lengths you have to go to get some attention round here…

You see I’m not sure that staying less than 4 hours in an A&E department is necessarily good for you, or what we would call ‘in the patient’s best interest’. I’m not sure who came up with idea that 4 hours is better than 6 or 8 or 10, I’m pretty sure they’ve no idea how the concept of emergency medicine and diagnosis is meant to work. Though I’m sure they have an acute awareness that if you measure the numbers meeting 4 hour targets at the beginning and then measure them a year later (after shouting and screaming that at people that you must make numbers better – adopt Kim Jong-Il type rant if needed) then you can probably say that you’ve made the numbers better and well, OK, we’ll stay in government for a while longer then…

And so your beloved trained scrub-monkey is gutted and disillusioned that we’ve sold our souls so cheaply to a system that resembles a man flogging a dying horse instead of getting it a nice new set of heels and a nose bag full of barley and perhaps even a fellow work house or seven to share the load.

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October 2007
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