ATLS, protocol and thinking

Wednesday morning has a sort of unit meeting/academic meeting feel to it. There is the regular morning report on all the recent resuscitations, followed by the ITU ward round, the morbidity & mortality meeting and a rep plugging some white elephant.

The M&M meeting was interesting. One case, for instance, was a stabbed heart. The reg who tried to fix this (yes, registrars repair stabbed hearts here) explained what happened, how the patient was transferred in, quickly assessed, intubated, cannulated and pushed to theatre, how they tried to repair it, almost succeeded and watched the man die five hours or so later. Meanwhile the consultants opposite tried to decide whether this was avoidable, unacceptable or inevitable. I understand that these meetings are for apportionment of blame and to deflect liability from the hospital. And I understand that recording these things may be useful. But for one consultant to restrict his response to asking if there was any deviation from protocol, and for the other to try to decide from behind her computer if the transfer time from the outskirts of the city means this was an avoidable death (to well-deserved derision from the registrars), is absurd. During the ITU ward round the head of unit said that there is no intellect in what they do because they just go through the systems and fix them. He meant this to reinforce a systematic approach to patients. It was disappointing to see the obvious progression of automatism in his consultant staff.

I did an ATLS course a couple of weeks ago. It was interesting and useful: I sort of knew how patients were meant to be approached before, but being shown how to do it, as well as being taught how to actually do a central line, cut down, DPL etc, was really useful and while I won't try, I feel like I could lead a resuscitation if I needed to. Central to ATLS is sticking to the ABCDE principles. When you don't have much experience, this structures are necessary. As you progress in experience and understanding, they become a reflection of what you do rather than the instructions. I hope that when I am a consultant I don't revert to decerebrate reflexes: not did you treat this patient, but did you treat this proforma.

There's a movement towards scrapping the four hour wait target in UK A&E departments at the moment. I understand that it is irritating and sometimes interrupts clinical practice, and I understand that it has helped bring down waiting times as part of investment and restructuring. Here, patients who have the misfortune to walk in looking relatively alive can wait for hours with no facilities (a problem shared by staff) and no indication of when they might be seen. The four hour target is a protocol which probably helps. It makes the staff's lives more difficult by making them actually work (I would love to see it implemented here) but it probably doesn't change outcome much. I would hope that a properly run department would have no trouble seeing the patients who needed it in good time, and I wouldn't mind seeing primary care patients suffer for turning up to the wrong place - here they get sent away. It probably causes more problems in small units than large ones, who may need to overstaff or fail it to cope with variable patient loads. It is a protocol, and is useful up to the point where you don't need it any more.