have all experienced the ED in the dire state it is in in the morning with a
dejected broken night team filing into the handover room, giant waits on the
tracker screen, apologies, unsaid recriminations, and the day team.
Girding their loins to sort out THEIR mess. No one wants us to be in that
situation, but this is where we find ourselves every day.
fight against a broken IT system that is literally from a generation ago,
specialities that think we are stupid and can be covertly or overtly
obstructive, overcrowding caused by dangerously long bed waits, and the
constant unrelenting arrivals from the waiting room the ambulance forecourt
from a community care system broken by austerity. We are constantly asked to do more for our
patients, blocks, frailty scores, delirium scores, pressure sore assessments,
and at no point does anything get taken away.
of us want to discover a STEMI or sepsis at 6, 8, or 12 hours, and we worry
that someone in the giant queue of patients is sick, and needs our help and we
don’t know and worry we won’t get there in time. That moral injury hurts
us all, and our nursing colleagues probably more. Nearly all of us have
found someone who would have done better if seen sooner, and we carry the
weight of that knowledge with us.
easy way out is to discuss the barriers to speedy assessment, our knowledge,
our IT system, the lack of space, the lack of engagement of other specialties,
the time it takes to get to XR, the time it takes to get that scan reported,
but that’s easy. These are systemic problems, and I’m sure we will touch
on them too, but that doesn’t touch on us, on how we operate, and why we do
what we do.
also doesn’t help, the above problems which are obviously the big drivers of
our own inefficiencies require a system wide approach to solve, and though the management
team in every ED in the world are trying to fight the good fight and some slow
changes are happening it doesn’t help the patient you see next week, or next
would therefore be easy then to gaslight everyone reading this, as we can’t fix
the systemic problems, so we need to be faster somehow, I have no
intention of doing that, and if it feels like I am, I apologise right
now. My intention is to get us all thinking about what we do, and how we
do it. A LOT of medical practice is ingrained, taught by observation, and
through hidden curricula, and very little of it is actually genuinely
beneficial to the people who are our patients. It is also important to note
in that vein that nearly everything I am going to discuss here is my opinion,
and as such should carry the weight of the feather of a pixie fairy fighting a
dragon. I am, I believe, an outlier with these opinions, so by all means laugh,
challenge, and ignore.
was originally a teaching session and it is adapted from my talking
notes. It is in two parts, the first I will make my case for speed, and
the second part I hope will be a more practical discussion of thought processes,
task management, and how and where it is safe be fast. But first I must make my
being fast important?
doctors are important, yet we are derided within medical subculture as stupid,
obnoxious, lazy, risk averse, jaded, broken and burnt out. This is
because all the other specialties don’t understand what we do, when you don’t
understand something you fear it. Emergency medicine isn’t easy,
converting an undifferentiated presentation into something more clear and
obvious is really difficult, prone to a lot of error, and poorly understood by
our colleagues. Yet they rely heavily on
the work we do, and don’t fully understand how we turn an undifferentiated
presentation into a patient with a problem list or a list of differential
an EM doctor are important, the system has made it so. EM doctors are at
the tip of the spear when it comes to providing treatment and diagnosing
patients. You have privileged access to the best diagnostic tests we
have, and some of the best nurses on the planet. You work in a close-knit
team that functions every hour of every day to look after people when they need
it most. You are right nearly all of the time, despite having NO TIME to
think. You have license to do ANYTHING – prescribe whatever antibiotic
you choose (even if it needs a code), put whatever chest drain in you feel
like, summon a team of the most senior specialists in the hospital with a
single phone call, and STOP the hospital to pivot to your patient. If you
can do ANYTHING, and you can do it faster and more efficiently than anywhere
else you breed behaviours that become counterproductive, (more on that later).
can come to us, we have access to certain blood tests, and diagnostics faster
than anywhere else in the NHS, and certainly faster than a member of the
general public, or a doctor in a clinic can muster. Even faster than
public know this. Our colleagues know this. So despite us viewing our
system from the inside as degraded, broken and inefficient, people outside
marvel at it’s brilliant efficiency compared to everywhere else.
we are important, ok. But why should we be fast?
biggest issue we face is our queue, the line of people waiting to be
seen. Waiting for the decision maker, which is us, to decide what the
problem is and how they can be helped is something only you can do.
studies have tried to work out what constitutes an ‘inappropriate ED
attendance’ but the fact of the matter is that only after we’ve looked at
someone do we know with any degree of certainty whether they need us or
not. The faster we can move through the queue, the faster we can find the
people who truly need us.
faster we can move through the queue, the fewer people who are in the queue,
the less overcrowded the department is, the easier it is to see the next
patient. The faster we all move, the better it is for all of us.
many things stop us being fast, I’ve alluded to the environment, the IT, and
the other systems that slow us, but there are deeper, broader forces at work,
demanding a variety of things from you that slow you down.
point in anyone’s medical training has anyone ever been given any teaching
about how to manage a queue of tasks or decisions, we learn through experience,
trial and error, or by watching others.
you’ve got a queue of 15 things of varying levels of complexity is it best to
manage the quick things first and do the things that will take longer
afterwards? Is it best to tackle the complex issues first, and then whip
through the fast things at the end? (Actually, if you tend to tackle the
harder issues first you might end up generating more tasks for yourself or for
others, so it’s probably best to tackle the quick things first!). This is before we even start thinking about
delegating tasks to others.
There is also, I think its fair to say, an atmosphere of fear that lingers over acute care in every sector. The long shadow of a variety of GMC and other cases that castigate clinicians for making mistakes inside broken systems but fail to recognize the broken system in which they are operating. It doesn’t take a genius to see that this actually forces a slower approach for each patient. This makes the queue longer, and makes overcrowding worse.
*have* to be thorough, you aren’t allowed to miss anything, even if deep down
you know that the likelihood of serious illness is laughably low we have to go
through the motions just in case we might be wrong. This is because we
are frightened our organization won’t support us, and our regulator will
deprive us of our ability to earn a living.
no answer for this, other than that we need to be brave, as the more of us who
are brave, the less of an issue this becomes – that’s the Bolam or
think that this sometimes leads to that phenomenon where you feel you need to
enter someone into a diagnostic pathway but feel a bit dirty doing so because
they don’t fit. The CT head ‘because they are here’ the first trop
begetting the second trop (which heamolyses) and before you know it the patient
has been present in the department for 12+ hours, and clearly isn’t having an
MI, but is very very tired.
Part of this is that the people who write guidelines never think about their effect on the system that they operate in. There is also the phenomenon where we feel obligated to use a diagnostic pathway following the request of another clinician, for ED that’s often those in primary care.
thing is, we forget our own agency. We can STOP things like this, should
you or I choose to, this sometimes requires more effort than just letting the
metaphorical diagnostic ball roll down the hill.
patient who gets to go home earlier may thank you, and yes, there is undeniably
a slightly increased THEORETICAL risk to them if you’ve not exited that pathway
properly, there is also, undeniably an increased risk open to you as you’ve
‘gone rogue’. However, was that pathway really the right choice?
If you choose wisely, and share the risk with your patient how much
increased risk is there? Really? What is the downstream effect of
that patient going home and freeing up a cubicle space and yourself to get to
the next patient faster? The next patient you see won’t thank you, they
may even complain about their wait.
it will be safer for them.
being faster will mean we do LESS for the patient in front of us, but this
isn’t always the case, sometimes it just means doing the key bits. We
should embrace this, we should only do what must be done, and never anything
more. However we are all under constant pressure to do more for these
patients. Especially the admitted ones. This is because we are
being abused by the inpatient specialities.
you just order
you just put a
you just send
of a serum cortisol?’
work in the most efficient part of the hospital, so the hospital tries to get
us to do the hospital’s job too. Resisting this is hard. Your job
is the decision, and the critical interventions to keep people alive. It
might include a diagnosis, but it does not have to.
to do something that a patient obviously needs never feels good, and it feels
like your friend the specialist (who is also up against it) will suffer, as
will your patient, as the next bit of care is delayed slightly. Win-win
to do it here? Again the patient in front of you doesn’t suffer, but your
next patient does, as it takes you an extra 30 minutes to get to them.
are so important and your time is so precious, yet you are forced to act like
you aren’t important, that what you do with your time doesn’t matter but it
Nearly every single F2 and some of the HST’s I supervise worry about ‘not being fast enough’. I think there is a widely held belief that some doctors are just faster than others, and that this inherent. I hear people say things like ‘I’m not like that’; now if we think of speed just as a collection of behaviours, then it’s just another cognitive skill, which we can learn and refine. The reason some doctors are faster than others is because they like being fast, and they work at it. So if you can learn to be fast, and get faster if you want to, then anyone can.
‘I’m not fast, it’s just not who I am’ becomes a bit like saying “I’m not doing
maths its just not who I am.” Now we don’t teach ‘speed’, in fact the
overt and subliminal messages you are
bombarded with as you try to learn emergency medicine are that you need to look
for ever more subtle pathology, and ever rarer clinical syndromes, so we are
teaching you to be slow, and you are working in a regulatory environment that
wants you to be slow, and no one is teaching you how to be fast.
patients need us to be fast, and our colleagues need us to be fast too.
group of doctors who can throttle up their speed to seeing 2 patients an hour
for 3-4 hours would make the difference between a 11 hour wait in the morning
and a 2 and a half hour wait. So here we see speed is a patient safety
The other thing to think about is how ‘being fast’ gets turned into being a binary thing. You are fast or you are slow, however this is of course very silly. Speed of seeing patients is of course an analogue value, and just as there is a normal distribution of averages for cycle times for seeing patients, each individual will have times when they are faster or slower. Speed is analogue, and just like a car you can push your own accelerator to go faster or ease off and go slower based on the terrain you find yourself in. You have control of this.
Many doctors I see have one speed, whether it’s night time or day time, regardless of their location. They apply the same approach to seeing a patient in a decisions unit, to a patient in ambulatory majors, to a patient in resus regardless of the presenting complaint. These patients generally need different approaches, if you are aware of the different approaches you can take, you can modify it based on information you are receiving as you go.
see we are up against a variety of systemic pressures that push us to be slow,
and make being fast hard, requiring concentrated effort, complex thought, and
practice. It requires you to think further down the line for your
patients than many of us are comfortable with and it requires us to use
evidence and clinical reasoning in ways that are diametrically opposed to how
we often are instructed to operate, and to how we’ve been trained.
would be easy to talk about ways ‘we can better’ we can always be smarter, and
in some respects, being cleverer and ‘better’ than every other doctor in the
hospital is often what this boils down to. However that is the most
intellectually bankrupt solution to speed, but it is often bandied around in
some way or another.
So what can we do to be fast?
thyself – you need to be rested, hydrated, alert and comfortable. Take
your breaks. Do you have specialized knowledge from somewhere else?
Use it. Always. Share it with others. EM Clinicians love
learning new skills and new approaches to the same old problems.
approach for the right patient, complex obvious admission? Stop them dieing and
move on. Stuff that clearly doesn’t matter, ignore. Obviously on
the right pathway? Execute the pathway and allow them to leave.
Letting go of patients you’ve seen is difficult, but going back and re-checking things including investgations often doesn’t yield much. Remember how precious your time is. Decide what you are chasing and why. Only chase that.
note says they’ve got this and it fits? They’ve got it. Hospital
discharge note says this has happened before, great. Do the same thing
again (if it doesn’t seem silly). Patient thinks they’ve got it (and it
fits) they are right.
patient is on a trajectory that is going to require an investigation no matter
what, order it (a good example of this is pregnant patients who might have a
The downstream teams to do their job. Don’t clerk the patient for them. If the downstream team need a test, trust them to arrange it. We work in a big system, and are a big team. [You can insert a sports analogy here if you like].
need something before you can make the decision for that patient make that
happen next. While you are waiting for that to happen see another patient
(or do a quick thing). If you find a senior doctor they may not require
the test for the decision. Start to think about what tests alter decision
emergencies are relatively rare events, even in the ED, our big tertiary
referral trauma centre sees on average:
- 1 aortic
dissection a month
NSTEMI/STEMI/ACS a day
- 1 PE a
Cases of genuine ACTUAL sepsis a day
roughly 400 type 1 adult patients a day.