One day last week I attended the 8 am medical handover in the Emergency Department of Middlemore Hospital, South Auckland, where I worked from 1986 until 1997. I was privileged to be the department’s Clinical Head from 1994 until 3 years later when I moved on to the University of Auckland, and Auckland Hospital. I’m flying back to the UK on Tuesday but before I leave I’m going back into the MMH ED 8 am handover. I’m very proud of what the department has achieved.
The story of the birth of the specialty of emergency medicine in Australasia is extraordinary. When I first came here in 1986 Middlemore’s “Accident & Emergency” (sic) was indistinguishable from any large urban “A & E” in the UK. The medical staffing largely comprised junior doctors, mostly two years out of Medical School, with very little supervision. Doctors sought advice on patient management from in-patient specialties, and from experienced nurses. Adverse events and poor outcomes were commonplace. Most Australasian “A & Es” had a medical director who for one reason or another had drifted into the role from another specialty. In the mid-1980s a group of such directors who were well aware of the parlous state of the front door of the hospital got together to see if improvements could be made. Their centre of gravity initially was across the Tasman in Melbourne Victoria, but allegiances were soon made with colleagues in the other Australian centres, and in New Zealand. They formed a society, but they realised early on that if they were going to make any real difference they would have to aim high. They formed the Australasian College for Emergency Medicine in 1984.
The birth of the college was not easy. In particular, the struggle to gain specialist recognition was protracted, and the acknowledgement from the ancient Royal Colleges that emergency medicine was a specialty in its own right was hard won.
The founding fathers of the college were tough, and astute. The first college president was a Scotsman, the second from Melbourne. Both had a surgical background, both were charismatic, and both were completely devoted to the idea that expertise in emergency medicine should reside with emergency medicine specialists. The college needed to set up a specialist training programme, an academic base, and a research programme. It became evident that a lot of medical students and junior doctors were interested in training in this new specialty, and it says a lot for them that they were prepared to invest in a career whose future was not assured.
I could write at length about the political struggles involved in acquiring increased resources for emergency medicine, and the gradual evolution and expansion of the discipline. But perhaps some statistics relating to Middlemore Emergency Department will suffice:
160 beds with oxygen and suction
Six resuscitation rooms
A 22 bed 24 hour short stay unit
105,000 patients per annum (including 23% paediatrics)
14 junior doctors
6 further senior doctors or college fellows
6.5 clinical nurse specialists
12 charge nurses
120 staff nurses.
Nothing like this, so far as I am aware, exists in the UK. Middlemore Hospital is “front-loaded”. The emergency department is the hub of the hospital’s acute care. Compared with the model of care of 1986, when I first arrived here, this is an entirely different way of working.
Of course it would be wrong to suggest that everything is rosy in New Zealand emergency medicine. Just like any hospital in the UK, the hospital is bursting at the seams. There is a huge pressure on the system, the public has an apparently limitless appetite for the service on offer, there is access block, hospital discharge delays, and a crisis in social care. In many ways, New Zealand emergency medicine is a victim of its own success. The more you can do, the more people ask of you. The safer your department is, the greater will be the pressure on you to hold on to patents who have nowhere to go. Sometimes Middlemore ED can resemble an intensive care unit.
Still, sitting listening quietly at the back of the handover, I was tremendously impressed by the work the doctors and nurses were doing, the comprehensive work-up, the appropriate investigations and interventions, the succinctness of the presentations.
Every generation has its challenges. We were trying to establish a specialty and demonstrate its credentials, while simultaneously seeing large numbers of patients and managing risk. The challenge now it seems to me is to study the work-load and try to work out precisely what emergency medicine’s role is and how the specialty can deliver, without its practitioners burning out within a decade. You need to identify the challenges of the day and then devote yourself to rising to them and taking the specialty to a new level. That is actually what is inspirational about practising emergency medicine.
But I think it’s a young person’s game. And you can only play it for so long. Then you must find a way to diversify. In terms of the current structures of the medical hierarchy, I was the first Clinical Head of MMH ED. My dear friend and successor still works there but relinquished the directorship to another ex-colleague who in turn has handed the role on so that she can act as the Chief Medical Director of Middlemore Hospital. A generation ago, that an emergency physician (a “casualty doc” they might have said) should fulfil this role would have been unthinkable.
So, four Clinical Heads. We’re all going to be there tomorrow. I’m hoping to get a selfie.