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The Daily Rhino
Monday, October 15, 2007

Four hours to drama
My regular column in Medical Student Newspaper has been reprised this academic year. This year it is, of course, 'F2. Woohoo.' Originally published in the October issue,


I’M CANCEROUS. Yes that’s right, I’m back for a fourth year running. This year, I come to you from the dizzy heights of the most superlative foundation doctor there is, THE MIGHTY F2.

A new generation of fresh-faced F1s replaced me and all my ilk. Now I’m supposed to know shit, you know, and stuff.

A&E’s a funny place to work. Over 90% of you will spend four months ‘on the medical front line’ as I am now. Unless you choose to pursue this field (ya crazy fool), your A&E rotation will be the job that brings you more excitement, boredom and frustration than any other. Mostly frustration.

No longer is the emphasis based on diagnosis, which is what draws so many into medicine, but on exclusion. Can you send this healthy 30 year-old chap home...are you SURE he hasn’t had an MI? Let’s refer him to the medics for a twelve-hour trop and take up a hospital bed just in case. It’s mind-numbingly un-stimulating at times.

There are many positives about working in A&E. Exposure to a wide range of problems, dealing with genuine emergencies, seeing instant results. My particular hospital has four great consultants and as St. George’s is a Centre of Excellence for countless specialties, I see some crazee sheeyrt.

However the one overwhelming negative is that it is A&E. There is no area of medicine that has been toyed with by the government as much as the emergency department.

Because waiting times are so easy to quantify and brag about before an election, A&E is a convenient place to pull numbers from. It is also one of two first points of contact for patients. The other is, of course, general practice, which has been tinkered with almost as much, chiefly to the detriment of A&E departments.



The ridiculous lack of sufficient out-of-hours GP provision, NHS dentists, the creation of stop-gaps like NHS Direct and obscene waits for GP appointments mean we are inundated with complaints that are neither accidents nor emergencies.

Yet each person that attends A&E has to be seen, diagnosed, treated and moved out of the department in four hours.

As all five Rohinplasty readers will know (it’s going up), I am obsessed with a solid evidence base. I use that as a chat up line sometimes. Anyway, one would like to think that those responsible for these four hours used all the available data to construct a sophisticated model of a working A&E and thus extrapolated a suitable figure.

The truth is probably more along the lines of pin-the-tail-on-the-number, with an arbitrary figure being plucked from the air.

The reality is a shambles. Of course no standard duration can be applied to A&E patients, as there is no one type of A&E patient. Some are out within ten minutes but some need several hours.



A far more sensible system, as I’m sure an honest government would concede, would consist of clinicians deciding how long each patient needed to be safely dealt with.

However politicians make decisions, not doctors, so that ‘four hour waits’ can be political weapons.

Only 2% of patients are allowed to ‘breach’.

I figured, like many others, a cavalier attitude was the way forward and thought I would ignore breaches and put the patient first. The NHS doesn’t work that way.

Unwell patients often need to stay in A&E until they are stable enough to be transferred. Pissheads need to sober up before they go.

The Medical Assessment Unit, or MAU, that most of you will be familiar with by now, owes its existence to the four-hour-wait. MAUs were created to stop the clock. The vast majority of patients admitted to a hospital come under the care of the general physicians. Hence all medical patients now go to MAUs where there is no timer.

There is no guarantee they will be adequately treated by the time they arrive there and there is no guarantee they will be seen by the doctors looking after them, hence negating the entire reason for the four hour rule.

I must be careful with what I say about my employer, so suffice it to say that unfortunately cooking the books MAY OR MAY NOT OCCUR at SOME hospitals around the country. Will that sound sufficiently vague in court?

Picture the scene. A patient needs a urine dipstick to make a diagnosis of a UTI. However a nurse is off sick and the nursing staff is over-stretched. No one gets the urine sample. The patient breaches. If this breach were recorded perhaps management would see that missing nurse’s value.

However if the number of breaches is the same as on any other night, the hospital realises she’s unnecessary and sacks her. They congratulate each other on more money saved. The system is broken, nothing changes.



We have some bizarre A&E mentality now that stipulates the customer is always right. But the patient is rarely first.

Nurses will drive you slowly mad with a phrase you will quickly grow tired of, “come on, your patient’s about to breach.” I normally cave.


Title reference to Nine Hours to Rama.

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