Dr Larry Fitton has been an emergency department consultant for the last 11 years and is currently the divisional director for medicine, rehabilitation and cardiology at Oxford University Hospitals NHS Foundation Trust. He joined the Council of the Emergency Medicine Section at the Royal Society of Medicine in 2009 and is currently the President of the Section.
When I was doing my trainee jobs, I was drawn to intensive care medicine and resuscitation, procedures and acute medicine. For me, branching into a broader role in emergency medicine was more appealing than pursuing a specialist surgical or medical career.
Emergency medicine demands a generalist outlook combined with a high-level of knowledge across a multitude of specialties. It covers a broad range of presentations at different stages of the clinical syndrome, with the challenge of multiple, differential diagnoses. The emergency physician will concentrate on life and limb threatening conditions and will treat accordingly.
When I’m on shift there’s a lot of shop floor management. Maintaining focus and making sure people don’t get lost in the mêlée. There need to be regular touch points with junior staff to make sure that they’ve got plans going in the right direction for patients. The department needs to be decongested as much as possible by discharging people that don’t need in-patient care or further procedures.
Ensuring safety for patients and resource balancing are key – essentially moving the right people with the right skill set to the right areas. A lot of big emergency departments now have different areas with very different set-ups that can be quite displaced, depending on the hospital. Key areas are resuscitation, major injuries, minor injuries, urgent treatment centres at the front door and separate areas for rapid triage and assessment.
Shifts are very much dependent on increasing numbers of patients attending the emergency department later on in the day – between 4pm and midnight is when we see the majority of patients arrive.
We’re seeing increasing complexity and acuity of patients, particularly in resuscitation areas for major trauma centres. And we’re also seeing volume. There’s a significant increase in patients compared with two years ago.
All of this makes efficiencies within the department very difficult to manage.
Everyone working in emergency departments is working very, very hard and it can be quite stressful, with hours geared towards out-of-hours working. Weekend frequency is high and the out-of-hours work is stressful and difficult. If you’re looking for a 9 to 5 job in medicine and ended up in the emergency department you’d be deeply disappointed.
While there’s an understanding among our colleagues in other specialties, they have their own competing pressures and tensions in their own departments and they don’t necessarily feel as if they’re part of the solution. For many, it’s someone else’s workload.
All good hospitals need to ensure two things. One is that urgent care needs to be a system solution that works from front to back. From pre-hospital, right through to the discharge process to the patient’s home.
Also, that within the organisation there is cross-section accountability because urgent care pathways are not owned by a single service. They are dependent and interact with a lot of other services.
There are often tensions within organisations between planned care and unplanned care but they are symbiotic – you can’t just focus on one or do one without the other. They need to be very much joined up and move as one.
Flow is the currency of urgent care and it’s everybody’s business to make that as good as possible for the patient.
But it is complex and multi-factorial. Access to urgent care is about 111 and 999 pathways, urgent treatment centres, ambulatory flows, hospital occupancy and the relatively new world of virtual wards and how they can help look after patients who are not in the bed base.
It’s vitally important that we can get as much capacity within the bed base as possible to deal with the massive backlogs in elective work.
I joined the RSM when I was a junior doctor as part of my ongoing CPD. I loved coming to 1 Wimpole Street, which is in a great part of London, and enjoyed not just the education, but meeting people from different regions, different organisations and hearing from people who were sharing the same issues.
As a junior it was very beneficial talking to members of the Section Council who were in senior management positions and who had seen a lot of reinvention of urgent care wheels over time. Talking to them helped me understand things from a wider perspective, gave me confidence to present at Council meetings and to express opinions and work to a common goal.
Joining the Section Council and then moving up the ranks gave me the opportunity to learn from others about how to chair meetings and bring my own ideas when it came to my current role as Section President.
We were quite consultant-focused and London-based when I first joined the Council and I was very keen to spread the reach of the Section out through a wider group, with a broader representation of healthcare and different skill sets.
We’ve now got a much wider reach of people both outside and inside London with a good mix of allied health professionals, including advanced nurse practitioners and emergency nurse practitioners.
In emergency medicine there’s a natural focus on trauma and the ‘big stuff’ but I was very keen that we brought a broader remit to our education. A lot of the things we talk about in our education programmes now are how national policies are reflected back into simple service delivery.
We’ve had a big push on clinical syndromes after COVID to try and re-engage people with clinical topics and broaden things out as much as possible.
The other area we’re looking at is health inequalities which in emergency departments you see at the sharp end.
We’re aiming to work up an education programme that will examine health inequalities from an emergency medicine perspective, such as the effect of deprivation on inner-city emergency departments and the difference in health inequalities between urban and rural settings.
It’s likely to include mental health, drugs and alcohol, frailty, homelessness and social care interactions. We’ll also be looking at benchmarking what’s being done in other places and what aspects work for different regions.
People love the networking aspects of the RSM and personally I really value face-to-face conversations, which we’ve all missed over the last two years. Looking ahead, we want to re-engage with social meetings, dinners and so on, because they have worked very well in the past.
It’s imperative that everyone on the Section Council gets on. You’ve got to be fairly structured and have a very clear vision of what you’re trying to achieve.
Set out a plan, look three or four events ahead and make sure you’ve got your speakers lined up.
Have a big enough Council so that it isn’t the same small number of people doing all the work. We have about 20 people on the Emergency Medicine Section Council so are able to spread the workload.
Having strong people in top positions is important, as is good succession planning with people knowing what the plan is and stepping up at the right time.
From Covid to clinical emergency medicine: Keep calm and carry on learning will take place at the Royal Society of Medicine on Friday 24 June.