What I learnt this week: The dilemma of the ‘last’ patient #WILTW

This is the 95th #WILTW

It is late at night. Your shift should have ended a while ago. The department has started to quieten down. You check there are no more patients needing your input, acknowledge the hard work of the team and say goodnight. As you walk out the door a concerned looking mother walks into the department cradling a small infant in her arms. They are clearly not critically unwell but as the mother books the child in you overhear the anxiety in her voice. 

The team on overnight are not unskilled and are appropriately trained to deal with the emergencies that will present during their shift.

They are also not you. They may unnecessarily over investigate resulting in a prolonged hospital stay and increased maternal anxiety.  Or could they miss the subtle signs of serious illness meaning the child receives delayed treatment?

Dilemma Arrows

Most importantly is this arrogance on your behalf or a strong sense of moral duty to ensure high quality care? This is not a scenario specific to paediatrics, or even medicine. In any busy department or office the senior decision maker will leave in a state of mind determined by their personality and experience. This will range from anxiety to relief or an emotion absolutely nothing to do with the prior shift but just looking forward to what is for tea. Certainly my mindset at being able to leave that last patient has changed considerably in the short time I have been a consultant. Every so often though I get a twinge of guilt. A feeling I shouldn’t be leaving, a desire to complete what I had seen begin.

But there is little point delivering care that is dependant on having certain individuals present. All departments, emergency or otherwise, should be focused on ensuring their junior staff are developing the attributes and skills to provide set standards of care around the clock. While obviously a non sequitur in some ways consultants should have trained their staff so they don’t need to be there. It is also non-sensical to ensure that you see all the patients yourself. This is the fast road to burnout.

As departments become more crowded, as patients present later and later into the evening and as public expectation increases the judgement call on when to leave becomes more challenging. There are units with 24 hour consultant cover; typically the intensive and critical care specialties but there is a workforce challenge in applying this principle across acute care as well.

ED Demand
via BBC (click graph for original article)

Precedents in demand seem to be broken every day. This is not a situation that is going to improve quickly. Only through political will, adequate funding and health care professional engagement will solutions be found. But in the midst of this there remain individual patients who are more than numbers presenting in a given time. And there are health care professionals with these individual patients in their minds all the time.

What have you learnt this week? #WITLW

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