Making (non)sense of emergency care models – where do the clinicians fit in? A follow-up to “Where to for EM?”

I read this post when it was first published last year. A great synthesis indeed. I then forgot about it.

Today I finished my first shift as a rat doctor (rapid assessment and treatment/triage/whatever) and followed up the day with an evening of studying crit care echo. For some reason I felt a nagging tension between these two functions, both of which are arguably core emergency physician skill sets. I was worried I would find it difficult to be good at everything under the EM roof. I wanted answers and ended up back at Mark’s blog post, but have frustratingly (and amusingly) found more questions.

Since signing up to ACEM as a trainee I’ve been an ultrasound enthusiast. But after some embarrassing over-calls (and probably a host of undercalls I’m oblivious of), with varying degrees of consequence, I decided to put my money where my mouth was and pay for an expensive university qualification in clinical ultrasound. As a result, I’ve aged prematurely… within a very short space of time I turned into the old curmudgeon grumbling about young enthusiasts who pick up the probe because they know where the “ON” button.

Critical care ultrasound seems to be an invaluable tool for providing patients with the best care during their moments of physiologic crisis. Unfortunately it’s not necessarily as simple as eFAST, EGLS or HI-MAP. Sure, for most of our “sick” patients it will be adequate, but if we really want to walk the walk of a critical care clinician we should probably develop more robust resuscitation strategies than giving 2L of CSL, intubating and starting a noradrenaline infusion +/- antibiotics.

To develop that kind of skill set whilst wielding a sector probe, it would take time, practice, and departmental structures that foster accountability and quality control/improvement. That being the case, how does the RAT doctor get time to practice diagnosing the viral myocarditis with fever? Or the short stay/fast track doctor practice their carotid VTIs after a passive leg raise? Should we trust the ultrasound guru who can get a good A4C view in the 200kg ventilated patient to always recognise the posterior fossa stroke in a patient with vertigo? I am not convinced these dilemmas are simply a matter of more education or a broader training curriculum. For me, as soon as I begin to become better at a particular skill, my ability in other advanced skills invariably starts to attenuate. So what kind of an EP should we try to train? And again, what model of emergency care do we want?

I agree with Mark – there just isn’t enough emergency critical care work to go around for everyone. Is there enough for EPs to keep their skills up? Is the critical care we provide “good enough” for the people who do roll through the door in compromised states, or should we leave it to the intensivists?

Most of the time our ED critical care is great. I think there are times when we can do better, however, and in the future it’s possible we may see the evolution of a more hybrid emergency department faculty to further improve patient care. FACEMs could bring to their departments different skill sets such as advanced echo skills, paediatrics, ongoing care provision, administration and logistics. They would be supported by having time to maintain their unique skill sets (possibly/probably outside of the ED), and operate as co-operative cogs in the day-to-day departmental sprocket, rather than trying to be an overheating dynamo aspiring to be excellent at everything for everyone. The ideal model won’t land in our laps, and it will be important to experiment with various styles and structures of care provision if we are to get there. Even if attempts to mix up the structural status quo fail, they’ll still be hopefully leading us closer to our wait-free ED shangri-las where patients are safe, staff are happy, and care is cutting edge but sensible. (And patients with acute ischaemic strokes are not thrombolysed except as part of ongoing randomised trials to identify the subset of patients who might actually benefit from the therapy.)

For the record, my ideal near future job would be 0.1 rotating to other units doing some sort of meaningful clinical work and building relationships with other departments, 0.3 critical care EP, 0.2 needle in haystack EP, 0.3 teaching EP, and 0.1 running the floor, boosting morale and talking trash in the fishbowl EP. If anyone’s advertising such a position in a few years time…

Postscript (in relation to “Where to for EM?”):
1) hospital gowns are rubbish. If there are any aspiring tailors out there with a new design of garment for patients to wear, get in touch because you’ve got three investors – thanks CK for the idea (however for the needle-in-haystack patients, their own clothes are probably fine)

2) I do not know how to stop the insanity of frequent obs other than through a culture of education and encouraging clinicians (doctors and nurses) to think sensibly. It isn’t just clinical observations/vital signs though: there is something seriously rotten in the house of medicine when you discover interns and HMOs filling out limitation of treatment/resus forms for toddlers and teenagers because there is a tick box on the generic admission form asking if it is done… (no solutions there sorry, only stones to throw)

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