Triage after a bomb has gone off
Is emergency medicine right for you?
Kevin Mackway-Jones graduated in medicine from Oxford University in 1981 and, after doing medical, surgical, and anaesthesia and intensive care unit rotations as a junior doctor in Middlesborough, he trained in emergency medicine in Manchester. He was appointed consultant in emergency medicine at the Manchester Royal Infirmary in 1993, and the inaugural first aid emergency medicine professor of emergency medicine in 2001—a post he held until 2007. He is now professor of emergency medicine at Manchester Metropolitan University and continues to consult at the Manchester Royal Infirmary and the Royal Manchester Children’s Hospital. He is also medical director of the North West Ambulance Service, UK, head of the North Western School of Emergency Medicine, and civilian consultant advisor in emergency medicine to the army. He edits the Emergency Medicine Journal and sits on the BMJ editorial advisory board.
What inspired you to specialise in emergency medicine?
I was lucky because I was of the generation where you were allowed to experiment and try different things. After my house jobs, my first job was in accident and emergency. Next I did a medical rotation and, when I got the membership, I received a little book through the post, which said “these are the subspecialties of medicine.” Accident and emergency was the first thing in the book. I knew general medicine wasn’t for me. I couldn’t bear the thought of a career filled with patients with tingling fingers or who were complaining of not having had their bowels open for 28 days so I thought I’d go for the first one I really liked.
How is it different from other areas of medicine/different dynamics?
It’s focused. Emergency medicine is about identifying and dealing with the problem. You’re usually involved in rapid decision making and often have insufficient information, so it’s very different from other areas of medicine where you gather the facts and then decide. The algorithm in emergency medicine is more about identifying the problem from the patient’s perspective. As the doctor you have to come up with the condition or conditions that have the highest probability or most catastrophic consquences—and then decide on whether to use a “rule in” or “rule out” strategy while providing emergency treatment.
Have you ever had to deal with a major incident?
I’d been a consultant for a couple of years and I received a phone call at home one Saturday morning to say, “I don’t want to bother you Kevin, but a huge bomb has just gone off in the middle of Manchester (IRA bomb in Manchester 1996).“ I led the hospital response which involved setting up the systems (triage and treatment), overseeing the delivery of care, and even doing live television interviews and press conferences. It was an interesting experience—never before or since has somebody phoned me up and said, “Kevin, there are 60 beds available for you if you need them.”
Have there been any changes in the types of admissions to emergency department since you started your career?
Major trauma was more common when I first started—but there has been a trend for causes of trauma, like road and industrial incidents, to decrease over the past 20 years. Health and safety regulations, reduction in the speed of traffic, better protection for drivers of cars, and better awareness of children has helped. Even though major trauma was the big hook that drew many people into emergency departments (and always features highly in television depictions like Casualty), most of emergency medicine was and still is about medical cases.
What do you think of waiting time targets for emergency departments?
I have mixed feelings. I think it’s good that there is a “long stop” of four hours for patients to be seen in. To achieve that we have been given more resources and that’s been good for the patient experience, especially for those with minor illness and injury who sometimes used to have to wait for a considerable time to be seen. I do, however, have concerns that some of the target driven behaviours have not been in the best interests of patients with more serious conditions who would benefit from more than four hours in the emergency department. The pressure to prevent a “breach” rises between the third and fourth hour and sometimes the managerial imperative to move the patient out of the department overcomes their clinical need to stay. We have all had to set up systems to try and prevent that happening.
What advice would you give to medical students interested in pursuing a career in emergency medicine?
Firstly, decide whether you will like it. There was a piece in the BMJ Christmas edition a few years ago about how to choose your specialty. There was a flow diagram and the first question was: mad or not mad? If you’re mad, then you go to a second question, which asked: attention span or no attention span? And according to this, mad people with no attention span end up in emergency medicine. I’m not sure that’s absolutely right—but there’s a modicum of truth.
If you’re the sort who wants to know what you’re doing, when you’re doing it, and what your role is, you’re probably on the other side of the algorithm and should be looking at a different specialty.
The second bit of advice is to try it out. Get a student firm in the emergency department and just see if you like it. Don’t be fooled by the excitement of taking a patient’s blood or doing an ECG (electrocardiogram)—we’ll use you a lot for that—but look at what the doctors are doing and see if it is an area you would like to work in. You need to know if your character suits the specialty and if the specialty suits your personality—and you can only know if you try it.Matthew Billingsley, editorial assistant, doc2doc and specialty portals, BMJ
Competing interests: None declared.
Provenance and peer review: Commissioned; not externally peer reviewed.
Cite this as: Student BMJ 2012;20:d8138