Musings Of A New Doc

 

February is not the best of months to acclimatize in London. Granted, London’s fast-paced lifestyle is hard to catch up any time of the year, but for February, even the weather brings out a new surprise every morning. For my four weeks of electives break that I spent in London, I walked through thick snow (first that London received for the season), defied sharp cold winds, got wet in occasional showers and basked on some lovely sunny mornings. And then at the Hospital where I spent most of my time, the diversity of scenarios was even more exhilarating.





Having applied for an elective at King’s College London with Accidents and Emergency as my first priority, I was lucky to get it at St. Thomas’ Hospital –part of arguably the best NHS trust in the whole of UK. The hospital offers magnificent views of the Thames, the Westminster Bridge and London’s most iconic architecture –the Big Ben! Situated right across the Houses of Parliament, St. Thomas’ Hospital has been here in its present form since the 1860s. However, it has been described as ancient as 1215, and has since been central to development of modern medicine, surgical and nursing practices.



The pride of working at a historic and pioneering hospital was palpable across the hospital. Everywhere I met health professionals, doctors and even students, there was a weighty sense of decorum and respect for the health facility and its protocols. St. Thomas’ Hospital is a distinctly modern health facility given London’s proclivity for maintaining architectural heritage. The outer façade is entirely made of glass, while the corridors that run across the hospital are well-lit, functional passageways much like any modern purpose-built hospital would have. The A&E rooms themselves were built with functionality in mind. And seamless functionality these rooms deliver.

Each day, hundreds of patients walk in through the doors of Hospital’s A&E. The calm on the surface of the department belies the hectic but steady activity that goes on night and day. High professional ethics and tight governmental regulations factor in to provide good care for patients without undue delays. The department is stipulated to complete any patient’s assessment, treatment and further referral or discharge within a tight schedule of four hours. And with waiting lines that can mount fast during busy hours, everybody from top to bottom have their heads down and hands full.

However, there really is no top to bottom hierarchy in the traditional sense at the A&E. The rapidity of decision making and information sharing meant that distinctions between different grades were blurred. It wasn’t unusual for a patient to be clerked initially by a junior doctor, and then when in need of further expertise, a consultant being called in in a matter of minutes. Consultants were very approachable throughout the department, and while they supervised the ranks and files of trainees, they were hands-on involved with the patients and department work themselves.

The morning change-of-shift meeting is where I used to start my day at 0800. Consultants; ST and FY doctors; and nurses get their heads together once a day in the seminar room to discuss all cases of interest, patient prognosis and relevant issues as they arise. Then, the morning rounds begin at the CDU (Clinical Decision Unit). The CDU is a place to further investigate and assess medical problems after the patient has been checked by their GP or the doctors at A&E. Most patients stay here for less than 24 hours, during which further investigations and, as the name implies, clinical decision making, occurs. If the patients are fine, they go home. If trouble is suspected, the patient is referred to the relevant ward or a doctor with the applicable expertise is called upon. The process is systematic, and even though there is a lot of information sharing and documentation, it’s rather swift.

The major bulk of the A&E work happens in the ‘A&E Major Treatment Areas’ –essentially big rooms with plenty of bed space to deal with patients on a rolling basis. There are three Majors at St. Thomas’ with a total of roughly 30 beds –mostly curtained but some isolated in bricked rooms. Each bed has its own bedside monitors, a water dispenser and washbasin, and boxes of gloves and aprons. Somewhat 50 Sq. Ft. of space (which matched against London’s real estate value is absolutely fantastic) for each cubicle. Right in the middle of the Majors is a large staff area with plenty of computer screens and chairs for grabs. The long desk that doubled as a counter was an organized chaos with doctors drifting in and out of the work area. Paper work (as opposed to paperless documentation) was surprisingly minimal, and most handwritten documents, letters, X-rays, prescriptions, and complete medical records were digitized at source and flew through the wires on the computers.

All desktops are interconnected on the Department’s Electronic Patient Record system trademarked Symphony™. A large LCD screen in the center wall functions as a whiteboard displaying a running table of current patients, their time in the department and status. As I earlier mentioned, the department maintains a 4-hour target of discharging any patient from the point of entry. Hence the ticking clock next to each patient is something to keep an eye on. Other features include patient tracking from point of entry to triage to the treatment areas; keeping together all nursing and clerking notes; ability to accommodate scanned documents and patients’ previous digital medical record in files; and ability to generate letters to GP or the patient about treatment advice. All the information generated over a period of time is configurable further at times of auditing. In effect, Symphony has been simplifying data collection and management for each patient as he/she arrives so that doctors and nurses can focus on what they do best –patient care.

The use of novel information management systems doesn’t end there. St. Thomas’ Hospital has been partnering with other technology solutions providers (and presumably spending hefty sums) to regulate and simplify different aspects of healthcare that can often end up splayed. Pharmacy dispensing for example, is tightly regulated immediately at the point of care to track precisely how much of each drug left the medicine cabinet and at what time. Without something known as Omnicell™, this would mean manually registering each item at each cabinet and then reeling back all registers at the HQ and closely scrutinizing them all. Well, an Automated Dispensing Unit does just that, but is a whole lot cooler. The glass, temperature controlled drug cabinets are a hybrid between the regular medicine refrigerators and Coca Cola vending machines. The idea is to register each drug request and record before dispending the quantity and use of the drug withdrawn by the nurse.

There is one further tier above the Majors Treatment Area where patients make first contact with a healthcare professional –the Triage. The patients here are issued tickets and queued, and upon their turn, asked about their bio data and presenting complaints. A rapid blood and urine dipstick tests are conducted and an expert triage nurse briefly inquires about main symptoms. The patient is assessed very quickly for his/her condition and appropriately sent either to the Majors or bypassed any other specialized areas, like the Critical Care Unit or Acute Assessment Unit (AAU).

So yes, a lot of ‘sorting’ of the patients to make sure the division of expertise works smoothly, but also real human assessment by trained professionals at each step to make sure no risk case is missed. The principle is to have step-by-step sensitivity tiers, and at each tier patients in which a diagnoses can be ruled out with reasonable certainty are dealt with, while those left over are sent one tier up for more rigorous assessment and tests. At the higher tier then, a higher baseline assessment means more specific tests to rule out relevant diagnoses in further patients, so that the patients sent even higher are those with a high index of suspicion. The system saves cost by limiting expensive testing to only those who have substantial indication for it. The patients benefit because it’s a given that when they really need the test, they will eventually climb up the tiers. And the doctors benefit by having objective and finely tuned protocols of decision making, reducing hassle and chaos.

The other major principle at the A&E dictates what kind of diagnosis to suspect first in any patient. As a clinical decision maker working in an A&E, your first suspicion is not supposed to be the most likely diagnoses; nor your gut feeling; nor even the most pressing complaint of the patient. The highest in terms of clinical priority at A&E are conditions that have the most morbidity and mortality if not immediately attended to. This principle was most brilliantly impressed upon me by one of my favorite consultants there –Dr. Savvis.

The patient, a homeless, presented to A&E after a car hit him. His hand was badly bruised and had severe pain and limitation of movement. He had other bruises as well on his abdomen. In our twenty minutes assessment of the patient, another KCL student and I took a detailed history of his accident and examined carefully his limb, joints and bruises over his abdomen. Later, we approached Dr. Savvis for a pair of willing ears. He, after running out of patience for our story about his limb and abdomen within a minute, asked me very abruptly:

‘Can his hand kill him?’

And I said, no. He goes on: ‘Of all that has happened to him, what do you think can kill him?’

And that got me thinking. The man could have anything from a massive intracerebral bleed to cervical fracture to kidney failure sec.to rhabdomyolysis/hemolysis to fat embolism –and that can all kill him. The fact that patient presented 12 hours after the incident may diminish the likelihood of such problems, but it is basically such conditions with smaller chance but grave consequences that concern an ER doctor most. So ER experience wasn’t just learning, it was also unlearning my medical student’s hunch for starting with the most benign/physiological/simpler explanations in my list of differentials, and turning it completely upside down to fit in!

However, this does not rule out assessing general medical fitness of each patient that walks in. During the course of assessment, routine parameters are examined and if any anomaly is detected, for example raised blood glucose level, the patient is counseled and his/her GP notified. If the patient is deemed fit for any of the specialized programs run by NHS, for example: for smokers, asthma patients, adolescents with social problems, or elderly, the patient is informed about them and given guidance.

Of all the maze of rooms and areas described till now (it took me nearly a week to accurately map the whole area myself), the common denominator has been patients that are relatively stable and not acutely sick. But when they are, it is the Resuscitation Room where they are headed. Such acutely sick or vitally unstable patients may be brought in by an ambulance or presented by a caregiver. The six-bedded resuscitation room offers facility of continuous monitoring as well as staff and equipment for immediately life threatening illnesses and conditions. At most times however, Resus Room remains on standby since most patients are adequately treated in the Majors Areas. When an ambulance crew encounters a patient elsewhere in critical condition that is to be brought in, it gives a shout to the Resus Room over radio which in turn gets ready for patient’s arrival.

Conditions meriting a visit to the Resus can include anything from acute asthmatic attack to sudden collapse, drug overdose, sports injury or the classical myocardial infarct. Resus visit is usually transient, as once patients show signs of improvement and monitors have been stabilized, they are considered for a transfer to specialist wards for more expert care. As you can see, the A&E department works as a firefighting crew –they quickly get involved, quell the flames and then get out to make way for other experts.

Patient care in the UK is far more comprehensive and all encompassing in the UK than back home in Pakistan. Each aspect of patient care is carried by dedicated staff that is geared towards continual clinical excellence. The ambulance crew, for instance, comprises of highly trained men and women who can not only transfer patients to the hospital efficiently, but are also trained to insure his/her survival and wellbeing right from the call of help. They give expert instructions to bystanders or even patients right on the phone when anyone calls on emergency hotline. As soon as help arrives, they systematically collect useful information about the incident, the circumstances and the surroundings while the patient is assessed for his/her ABC and bodily injuries, quickly. ECGs are routinely performed en route and breathing assistance, oxygen or resuscitation is provided as need arise.



Upon arrival at the hospital, the ambulance crew reports all relevant information to the doctors including circumstantial evidence and their own assessment. Their level of information and insight about common emergency situations can often be even greater than that of in house doctors, and hence the information they give is considered invaluable to patient’s diagnoses and treatment.

The A&E nurses similarly have earned the reputation as professionals to get things done. At a ward as frantic as A&E, it’s for the nursing staff to efficiently and reliably carry out all procedures and routine tasks on each patient that there is any semblance of organization and achievement. Nurses form the backbone of the A&E machinery and without their tireless support, the physicians simply won’t have the room to peaceably plan a patient’s prognosis. As I have witnessed all too often in Pakistan, ineffective nursing staff casts a shadow of doubt in physicians’ minds as to whether care instructions would be reliably carried out. This skews their decision making in favor of simpler procedures that won’t require continuous follow up. At the St. Thomas’, the A&E doctors are relieved that while they perform their duties of clinical decision making, the nursing duties would be carried out as expertly as it can be.

And while the duties of the A&E department may end there, the doctors there make sure that adequate patient care is provided even following discharge. Usually, a letter is sent to the patient’s own GP, mentioning the reason for the visit and the treatment given. If follow ups are required, district nurses would pay regular visits to patients’ homes and provide care for the patients and their family members. Apart from this, they have a list of other jobs, including assessing the patient’s living conditions and social status and provide counseling about likely medical ailments.

The A&E experience at this top notch hospital gave me a glimpse of what a functional healthcare system looks like. The A&E sits at the cross-section of UK’s healthcare that offers a broad overview of almost all aspects of the system. It gives a deeper appreciation as to how teamwork and organized effort can improve the outcome manifold for patients. UK’s healthcare system has clear objectives, and different aspects of its working reflect those objectives, so that when the pieces fit together, the communities get impeccable healthcare facilities. No wonder, UK residents enjoy a unique sense of peace knowing their health is always in good hands.