Location based decision making

This is something that I’ve noticed happening to me for as long as I’ve been doing emergency medicine (coming up on 10 years now) – that the physical part of the department that you see the patient in has a significant impact on my decision making process. 

A patient with chest pain arrives in resus, the staffing ratio is much higher here. The expected rate of pathology for all staff working in the area is much higher. Before the doctor sees the patient it is likely that the patient will be on a trolley, on a monitor, often an IV cannula is inserted and lab tests are flying through the chute to the lab before anyone has even further assessed the patient. Often the patient is changed to a gown and an ECG will be done.

A second patient with chest pain arrives and is brought to the minors area. There are no cubicles so they sit in a chair awaiting a doctor’s assessment. No further testing or assessment is done. As there are still no cubicles available to assess the patient the doctor apologetically walks the patient to the psychiatry interview room as it is the only free space in the ED with a door that can close to give the patient even the slightest bit of dignity.

I find when I am the doctor in both those situations I make rather different decisions, or at the very least, I feel inclined to make different decisions even if I ultimately don’t do so. The assumption of course is that if the patient is in the minors area then it’s not possible for the patient to have serious pathology and indeed vice versa – if they’re in resus then it’s not possible for them to have minor pathology.

I suspect everyone working in emergency medicine as noticed this to some degree. Hopefully those who are thorough enough will be able to make appropriate and safe decisions (sometimes involving waiting until a cubicle is free and properly exposing and monitoring the patient) no matter what the environment.

However it is a useful reminder, once again, on how overcrowding in the ED is a threat to safe and effective medical care. Ireland has had its own crisis this week – which of course only means that we got in the papers; the ongoing major incident that is the result of the decision to locate all crowding in the ED has been going on for much longer… While people often view ED attendances as simply punters seen by nurses and doctors, there is rarely reflection on the on the fact that working in an overcrowded environment with the compromises it requires exposes patients to the harm of cognitive biases and poor decision making.

[featured image via wikimedia commons]

UPDATE: the good people at Emergency Medicine News have written an article about this for which I did a short email interview along with a few other actual smart people.

Exit Block: What it is and why it’s dangerous.

This a great video from the college on the significance of exit block and the effects it’s having on our patients and staff. This, along with the recruitment crisis is, I think the biggest issue facing emergency medicine in both Ireland and the UK.

Well worth a watch.

[H/T Simon Carley for the orignial tweet where i saw this]

Full Capacity Protocols

[image via NetDance on Flickr. CC License]

Hospitals are busy places. We have no space, no beds, no staff and inevitably less money to make this all happen. This is the situation we have.

We’re fairly pragmatic folks so we find ways to manage the work more efficiently and try and do more as an out patient or involve things like ADPs (accelerated diagnostic protocols)

But when we get slammed and have more admitted patients than you have trolleys to put them on then the system grinds to a halt and you can’t assess treat and admit/discharge anyone new.

In Stony Brook in New York, the hospital (and that’s the important bit, not just the ED) decided that when the ED was choked that they could put some of the stable patients as extras in the hallways of the wards. You can imagine what the ward staff thought of that.

This is a brief paper reviewing their experience.

Viccellio, Asa, Carolyn Santora, Adam J Singer, Henry C Thode, and Mark C Henry. “The Association Between Transfer of Emergency Department Boarders to Inpatient Hallways and Mortality: a 4-Year Experience..” Annals of Emergency Medicine 54, no. 4 (October 2009): 487–491. doi:10.1016/j.annemergmed.2009.03.005. PMID 19345442

This is a review of patient flow effectively and not a trial in any prospective sense. All they wanted to show was that this was happening and what the effects were.

It is not the highest quality science and does not claim to be.


  • 25% of those assigned to a hallway bed actually got a proper bed immediately
  • another 25% got a proper bed within an hour
  • the rest got a proper bed within 8 hrs.


Your hospital probably has more beds than they say they do. Spreading the crowding from one place to the whole hospital spreads the moral and professional responsibility to a hospital wide problem. It’s remarkable how that motivates resources.

Importantly it must be realised that this is no panacea for a poorly run hospital. In fact every time a hospital implements something like this it’s a sign that something is deeply wrong. However it can alleviate a crisis.

The Irish Association has a nice statement on FCPs. And indeed a nice EMJ paper on the same too.

EM docs are more burnt out than most but none of us are great…

The night shift insomnia that leaves me with about 4 hrs sleep a day has given me the chance to catch up with a bit of reading so here’s a paper for you.

This got a very amount of Twitter attention when it came out as it was a bit of a headline grabber:

Shanafelt, Tait D, Sonja Boone, Litjen Tan, Lotte N Dyrbye, Wayne Sotile, Daniel Satele, Colin P West, Jeff Sloan, and Michael R Oreskovich. “Burnout and Satisfaction with Work-Life Balance Among US Physicians Relative to the General US Population..” Archives of Internal Medicine (August 19, 2012): 1–9. doi:10.1001/archinternmed.2012.3199. PMID 22911330

First a quick run through of the study and then some thoughts


  • this was a massive survey of the AMA register of doctors compared with the general population. It was done effectively by mass emailing
  • the survey used the “gold standard” of burnout: the Maslach Burnout Inventory
    • the only problem here is that it’s a bit of a cumbersome tool so they let the docs fill in the whole survey whereas Joe Bloggs only filled in what the authors state are the predictive bits of the survey. They say that doing this has been studied before and is kosher but there you go…


  • only a 26% (7000/27000) response rate in the docs. A response rate of somewhere closer to 70% is considered important as it’s giving a much more representative of the people you’re surveying. If you think about it could be only the pissed off, grumpy docs answering the survey. Or maybe even the opposite and only the calm and cool docs with lots of free time filled it out
  • bottom line was that a lot of docs feel overworked and burnt out. And this is higher than the general population
  • the people with the highest symptoms of burn out were the EM docs. By a clear country mile it seemed. We were much better than the surgeons in terms of work-life balance but despite this we were still burnt out.


I think this is vitally important stuff.

Emergency Medicine is like a puppy – it’s for life not just for Christmas but it seems increasingly both from my own anecdotal experience and now represented in study form in various settings that we’re going to have real difficulty keeping docs in the specialty.

In the US there are comparatively huge numbers of trained Emergency Physicians compared with the UK/Irish model. These guys work shift patterns often for their entire career. They are well paid and work reasonable hours (I was quoted that 30 hrs a week was an average for an EP in the US – can anyone corroborate this?) Despite their resonable work life balance these guys are really burnt out.

Now the UK/Irish model is a service delivered by trainees and non-board certified EPs, (the “sickest looked after by the thickest” as some have joked) these guys are paid less and work more hours than fully trained EPs, of whom we have vanishingly few. Just imagine how much more burn out might apply to those docs who deliver hands on emergency care day in, day out (or night in, night out)…

As I enter my ninth year since graduation from med school with no clear end in sight to my training (largely my own fault I’ll admit) the importance of work-life balance and the threat of burn out becomes more and more apparent. Workforce planning is one of the biggest problems (along with overcrowding) that EM has to face in this part of the world, but if we are to address it in any way we must address sustainability and burn out.


Graham Walker did a survey for EM News on burnout that’s worth a read


Waiting room medicine

No not that waiting room medicine.

We’re all resus jockeys aren’t we?


Most of us in FOAMed community love resuscitation. We love the critically ill. We love the drama, the excitement. We love all the mr EMCrit has taught us.

I’m one of these people. Give me a full day in resus any day – bring on the sickies.

Unfortunately, if your ED is in the real world, you’ll realise that the vast majority of our customers don’t need resus. Our world is a seething waiting room of ambulatory patients with a bewildering variety of symptomatology.

How do you manage the waiting room? Most places have triage  – there is clinical justice with the sickest seen quickest (listen to this talk by my current boss.) Unfortunately if you get a lot of sick people and don’t have a system in place the lower triage acuity patients wait so long that they eventually leave. In the US this means your hospital doesn’t get paid. In our systems, we all breathe a sign of relief when patients do not wait to be seen. Not so much when they re attend twice as sick the next day, or are found dead.

Our traditional approach is rule out serious pathology. And we’re not bad at that. You’ve hurt your ankle, the x-ray shows no fracture – therefore we have accomplished our job as EPs.


Once you’re in resus as a patient, you get lots of attention. Our spidey sense is immediately higher – purely because of your physical location in the department. I am much more likely to order certain tests when I am in resus because my mind is in a certain place. This is obviously a bit of  a problem.

One of the hardest things to do as an EP is to pick out both the serious pathology and the important diagnosis (because some really important diagnoses won’t kill people or even bounce back on us but will cause a  lot of morbidity for the patient) from the teeming mass of NSN (non-specific nonsense) that fills the waiting room.

Be careful with a diagnosis of soft-tissue injury

Be careful with non-specific abdo pain

Be careful with all the non-specific nonsense – a lot of it is really quite specific for something you’ve not heard of.

It’s a jungle out there guys. Tread carefully and good luck.