To ask what A&E docs do when they are not with patients?

[coffeeforone]

I recently spent a night in the children’s section of my local A&E, and spent some time observing the docs/nurses work whilst DS was asleep on a monitor.

There were 4 nurses and 2 doctors sat behind a long desk (plus a registrar that seemed to pop in and out occasionally - busy elsewhere I assume).

It wasn’t especially busy. We were there for 6 hours and in total about 5 or 6 children came in and were seen by one of the docs (after waiting about 3 hours). After triage, we waited about 3 hours to be seen by a doctor. It seemed like they had an awful lot of paperwork/discussions, but didn’t have much time to consult with the actual patients. I did wonder what was taking up all their time. AIBU to think they could have had a more efficient system?

but they didn't have the authority to discharge...?

They have to check with the senior doctor on duty.

Ds recovered within an hour or two but they needed to see him have two clear hours of normal observations to make sure everything has worked OK. There are processes that have to be followed.

We spent about 6 hours in A and E and yes, a lot of that was waiting but we were seen immediately and treated brilliantly.

There’s very little slack in the system these days - remember what you see as a patient with limited understanding isn’t what is necessarily going on.

I know nhs workers do a bloody hard job for not a great salary but the system is inefficient- numerous times as an inpatient I’ve seen first hand practices that just would not happen in the private sector.
Op you are getting a bashing but I know where you’re coming from it’s not always the case and I’ve not found it on a and e but other wards definitely noticed the same.

You are not wrong in what you observed, there are big inefficiencies, these are due to the amount of paper work, compliance and having to constantly cover your back. The exact same problem exists in the police force. One day technology will catch up and reports will ‘write themselves’ by voice command combined with video footage or something like that. We don’t a have a doctor or police shortage if you took away all the time consuming nonsense.

However much you support the NHS and above all, those who work within it, which I do wholeheartedly and thankfully, you cannot hand on heart say that it is the most efficiently run organisation in the country, because it isn't.

Priority goes to urgent cases. Urgent is the kid in a car crash, the kid turning blue as they come in and the kid bleeding out.

there was a separate section for this. The A&E section we were in (covered by the 2 docs and 4 nurses), was for non-urgent cases.

this is what they had to deal with in the 6 hours we were there:

1. a girl with an injured foot (she was there when we got there and discharged on crutches shortly afterwards)
2. a toddler with an allergic reaction via 111 (playing happily and discharged after a few hours)
3. a young boy who had had an asthma flare up (waiting to be admitted to a ward - he was in the bay next to us and seen once by a doctor in the 6 hours we were there)
4. a young baby who had been projectile vomiting (referred by 111) - parents spoke to the nurses and walked out after 3 hours, as she hadn't vomited again.
5. possibly another boy who was in the waiting room with a cut on his head, but never appeared in a bay
6. and my DS (referred by 111), with an initial very high temp.

Unfortunately those who work within it have very little say on how things are run. They can only do their best with what they have.

How do you know so much about the other patients, do you think it's ok to be telling us about other people's children.

Again, if you think it’s so easy and can be done better then get in and fix it all yourself. And good luck with that

You are just sounding ridiculous now OP. Do is all a favour and move to another country and see how you get on with their system. And next time your son has a minor complaint, use your common sense and take home to a pharmacist or GP like everyone with a brain does.

2 hours is Avery short wait in A&e by the way. Your son is fine. Have some gratitude.

Did you make notes OP?

A very high temperature isn't a minor complaint though... The OP did call 111 and was told to go to A and E.

Yeah and her son was treated within 2 hours.

You haven't the first clue what they do on a shift.

How do you know all this stuff about other patients and who referred them?

Yeah and her son was treated within 2 hours Really doesn't mean he shouldn't have been there or was unwell.

And next time your son has a minor complaint, use your common sense and take home to a pharmacist or GP like everyone with a brain does.

It was 9pm. His temp was 40.3 and would not reduce after both calpol or nurofen. I was wrong to call 111?

Hmmmm I'm a bit torn on this because to me I believe our nhs staff work extremely hard but my last experience of a and e - I sat in there for 5.5 hours untill I eventually was taken to the correct department that then decided I needed surgery that day . There were no more than a handful of people in there for the most of that time and while I'm not complaining I just wondered how they would manage if the place was actually full !

Depending on how junior the doctors in a&e were, they may have been waiting for a registrar (who would most likely have been covering the wards too) to be free to talk to before seeing a patient - if it’s something they don’t know much about they may need advice before starting to take a history/examine/make a management plan. A very junior doctor seeing kids in a&e won’t be allowed to make independent management decisions as they won’t have enough experience to do so.

Depending on what was wrong with the child they may be actually allowing a period of observation before seeing the patient - if a child came in with a high temperature and high heart rate, but had a normal heart rate once some paracetamol/ibuprofen kicked in the management plan would be very different to a child who still had a high heart rate with normal temp. When I worked in general paeds I would often wait a while before seeing a child to allow a temperature to settle/inhalers or steroids to kick in for wheeze or croup/see if a vomiting child tolerated oral fluid and so on - a parent may feel they were waiting for anything to be done but that waiting period was often a part of my assessment. In the meantime there are results to chase and action, notes and discharge summaries to write, patients to be followed up, work emails which may include important patient safety announcements etc so can’t be ignored til later, incident reports to deal with, scans to be arranged - many of these things can actually be done whilst having a cuppa and a chat - this may be the only chance to have a drink all night, and talking about non work things is often a much needed break from taking about the cardiac arrest that happened earlier in the shift or the fact that the quite well looking child who’s just been seen probably has leukaemia but you can’t break that news to the family yet as you don’t have all the results back.

Some doctors and some nurses are just lazy or inefficient - we’re all humans and some of us are just naturally more efficient than others. However, even the most lazy wouldn’t deliberately not see a patient for hours - as once you’ve seen that patient, if nothing else is going on you actually can have a break! If you don’t know what’s going on and you think you’re being kept waiting for no reason, just ask, it’s less annoying being kept waiting when you understand the reasons why

How do you know all this stuff about other patients and who referred them?

It was a small A&E everything said by parents, nurses and doctors was in earshot of everyone else.

I have spent 2 13 hour shifts literally sprinting around a hospital from one hideously sick patient to another - an op complaining that her child with a temperature had a very short wait in a&e grated a little. Especially as having spent 2 days having very little sleep food or water I am now miscarrying. If somebody saw me maybe stopping to have a quick chat with a colleague and complained about me on mumsnet...

The registrar that was popping in and out was making all decisions - checking everything etc, while the other two docs appeared to be stuck idle a lot of the time.

So the Registrar is the Paediatric doctor with many years of paediatric experience, the two juniors are probably relatively new junior doctors, perhaps rotating through A&E and doing some shifts in Paediatric A&E without much practical experience of paediatrics. I did a similar jobs as a young junior doctor.

In one hospital as a junior doctor without much paediatric experience I was making decisions about when to discharge kids from A&E and only speaking to the Paeds doctors if I was concerned. Obviously in a system like that sometimes the junior doctor can miss subtle things as they don't have a lots of experience with children. Often it is picked up by the Paediatric Nurse, or the parents brings the child back, but not always.

In another hospital I worked at the junior doctors (who weren't Paediatric trainees) were advised to discuss all patients with a paediatric doctor before discharging. This was sometimes slower for patients, but safer as the paediatric doctor would suggest better treatments, or pick up things that the junior had missed.

I know which hospital I would take my sick child to!

Of course it would be better if they either staffed Paeds A&E with paediatric junior doctors or had more Paediatric Registrars on shift, but firstly that would cost more money and secondly there are rota gaps in some hospitals as they can struggle to recruit doctors.

A lot of A&Es are really struggling to recruit regular doctors and rely on locums who may not know that hospitals procedures well.

If your son only had a high fever and no other symptoms such as altered consciousness, difficulties breathing etc then they would not be a priority.

Kids can have really high fevers and be OK - what’s important is the whole clinical picture not just the number on the thermometer. Ds has had fevers of 41.8 and we’ve treated at home because he had no other concerning symptoms. The night we ended up in A and E he only had 39.

The toddler with the allergy would have needed certain observations done - you can’t just send them home you need to wait.
Kid with asthma will have also needed treatment and waiting to see if he improved.
Kid wothvthe head injury - well that could have been anything from a light knock to serious trauma - I’m guessing if you didn’t see him walk out he was admitted.

My point is you don’t know the clinical details of each of those patients. Maybe that kid with the cut head deteriorated suddenly and was being worked on. Maybe that doc was covering other wards. It’s not that unusual for them to be covering multiple areas.

Be grateful we even have Free A and E. In the USA you’d be facing a bill with quite a few zeroes on it. Your child was treated, is OK and was discharged. So they did their job. A and E cannot see non urgent cases on the timescale you want. A better place would have been out of hours or walk in.

Especially as having spent 2 days having very little sleep food or water I am now miscarrying

I am really sorry for what you are going through. That is awful, but you need to raise this with your seniors because if you had 2 days with little sleep food or water, i would be questioning whether you were safe to be working. This has got to change.

Take care of yourself.

just to clarify - I think the majority of people accept that while the doctors are out of sight they are probably prioritising someone sicker. It is difficult when you are on the patient side to watch qualified people 'just standing there'.....even when you know that they are waiting on results/ senior review.

I see my juniors do it and it drives me nuts. And it is in part because: 1.medicine has become much less hands on - why bother listening to someone's chest when you're going to have to have an Xray as 'proof' anyway.

1. junior doctors used to have too much to do, now they have too little as much of their work has been reassigned to nurse practitioners (not judging, but (for example) JDs used to learn wound care on the job, ANPs actually get trained in it. Wish they could've trained JDs to do it, but it's more expensive for the NHS so they don't)
2. JDs not trained as well or for as long because NHS workforce planning wants to regulate and be able to predict the number of specialists coming through in 5 years, 10 years etc.
3. and as mentioned earlier, they have nowhere to be while thumb-twiddling - surgical juniors used to come to theatre and learn when they could, now it's allocated by rota, and you can;t just pop in, and they don;t want to come in unless they're going to 'do' something, which no senior is going to let them do if this is the first time they've seen them....vicious cycle.