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Article 7. Money, money, money. (Where does it come from, how do we control it, and how far should we go to get more?)
  1. J Wardrope,
  2. S McCormick
  1. Correspondence to:
 Mr J Wardrope, Department of Accident and Emergency Medicine, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK;
 Jim.Wardrope{at}northngh-tr.trent.nhs.uk

Abstract

This is the seventh article in a series on management within the emergency department. This article focuses on financial aspects, including budgets and funding.

  • finance
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Supplementary materials

  • SIMS ARTICLE 7: INTERNET PAGES

    The Internet pages are divided into "feedback" and "in tray". Feedback gives some of the actions taken over the previous management problems.

    Article 6 - IN TRAY

     

    Note of conversation with Sister Oak

    Sister Oak very concerned about the handling of a paediatric resuscitation case by Dr. Ireland. Child had meningococcal rash and early signs of shock. Sister Oak wanted to call paediatric team and anaesthetics but Dr. Ireland said he would make the decisions. Had trouble in getting venous access and tried an intra osseous route. This failed. Sister Oak then called for paediatrics and anaesthetics. Child stabilised and transferred to regional Paediatric Intensive Care Unit.

     

    Letter copied to Dr York

    Dear Mr. London,

    I hope you are well. It was good to see you on the APLS course and I hope we can call on your services as an Instructor once you get through your instructors course. Your skill and experience shone through on the course and you impressed all the faculty.

    However I feel I should share some concerns about a recent case transferred to this unit. I was involved in retrieving the child from your resuscitation room. I had a discussion with the paediatric SpR who said that he felt that he had been called very late to help in the resuscitation and felt that your SpR had acted quite inappropriately when he arrived saying that he had not asked for him to come. I was told that the child was ill, had no venous access and had not been given antibiotics although he had been in the department for almost an hour.

    I am glad to say that the child is now doing well but only after a very stormy time on PICU. The child�s parents said that they felt the A&E doctor was rude, shouted at them and seemed not to be in control. They are just so thankful that their child has recovered that they do not wish to complain.

    In the past I have been impressed by the standard of care shown to sick children in your unit, especially when you have been around. I am sure that this is just a "one off" problem but I felt that you might like to have a "reflective teaching experience" (yuk) with your SpR.

     

    Information

    A patient is admitted to your unit. She is 84 years old and is unconscious. She has taken an overdose of antidepressants. Her husband accompanies her and gives you a bundle of papers. These include a typewritten living will of the type issued by a society that advocates euthanasia. The will is signed, dated and witnessed by two people. The husband confirms that he is aware of the situation. There is also a suicide note that confirms the patient's wish to die and explains the situation to the police and coroner.

    The patient has a Glasgow Coma Scale of 6, blood pressure of 70/50 mm Hg a respiratory rate of 14 and oxygen saturation of 85% on 10 litres of oxygen per minute by face mask. What do you do?

     

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    Medical Report

    Name Mrs. Susan Smith

    DOB. 29.2.55

    Address. 16, Plane View, Jamestown

    Occupation. Shop Assistant. Right handed

    Married. Two children

    Date of incident. 2.2.01

    Report prepared on behalf of the Court by Dr. E.S. York, MRCP,FFAEM, Consultant in Accident and Emergency Medicine.

    Purpose of Report- To consider the causation, condition and prognosis of injuries sustained in an incident on 2.2.01.

    Date of report 1.12.01

    REF- SY/CB/11.01.25

    Instructed by

    ----------------------------------------------------------------------

     
    Introduction

    I have been asked by ......................................... to examine Mrs. Smith and her medical records and give an opinion regarding the causation or injuries sustained during an incident on 2nd of February 2001, to report on the present condition of those injuries, to give a prognosis for future recovery noting any effects that the injury might have on every day activities, employment or sport and leisure activity.

     

    I confirm that I have examined the general practitioner records from 1965 to present.

     

    In preparing this report I confirm that I understand my duty is to the court, I have complied with that duty and this report is addressed to the court. I full understanding of my duties as an expert witness are given in Appendix 1.

    An abbreviated curriculum vitae is given in appendix 2.

    Report from GP records.

    Concerning injury 2/2/01

    3/2/01 seen following an RTA. Rear end shunt. Neck Pain. Limited range of movement. Treatment, Physiotherapy. (sickness certificate for two weeks).

    17/2/01 Still neck pain not seen physio,(two weeks sickness certificate)

    3/3/01 Improving Return to work 10/3/01.

    There appear to be no other mentions of this injury.

    Review of previous notes

    5/9/00 3 weeks history of neck pain. Stiff in mornings. No trauma. Range of movement good but with limitation of rotation and extension. Probable spondylosis. Analgesia. Advice on mobilisation.

    5/10/00 Neck much better. Full range of movements.

    1994 Back pain. Physio. Three weeks off work.

    Examination if Mrs. Smith. St. Theresa Hospital. on 1.11.01.

    Mechanism of injury. Mrs. Smith was the driver of a Fiesta car. She was wearing a seat belt and a head rest was present and correctly positioned. She was stationary at traffic lights when her car was struck in the rear by another car. Mrs. Smith was thrown forward by the impact, restrained by the seat belt and then recoiled back wards. She did not strike the steering wheel or any other part of the car. She was able to get out of the car and exchanged details. Her car was still driveable.

    Injury. She did have some aching in her neck at the time of the accident but the following morning the pain was much worse.

    Treatment. She attended her general practitioner who advised her to take painkillers . She was certified as unfit for work. She had continuing pain and saw her GP again and physiotherapy was organised.

    Work. Prior to the accident Mrs. Smith was a full time shop assistant. She was off work for 4 weeks. When she returned to work she was unable to do any heavy lifting. It took about three months before she was able to do her job normally. She has had no further time off work.

    Activities if daily living. The neck was very painful initially. Her sleep was disturbed for 4 weeks. She took regular painkillers for 4 weeks. She was able to dress/wash/eat and cook. She was unable to drive for a five week period and when she did return she was very anxious and would avoid driving if possible.

    Household tasks/amenities She required help with heavier household tasks for a six week period. She still has some problems in doing her shopping.

    Hobbies and Leisure Mrs. Smith went to the gym once a week and swimming once a week. She was unable to do these for 4 months. She has returned to the gym but is still not doing all her normal exercises.

    Progress and present position.

    The neck was very painful initially with pain across the base of the neck, shoulders and down the right arm. The neck was very stiff. The symptoms improved after physiotherapy and after about 6 weeks she was able to do most things apart form heavy lifting. It took about 3 months before she could lift/hoover/shop although these did cause an increase in aching in the neck.

    At present the neck is much improved. She still has aching in the neck on most days and this is worse if she has been doing a lot of activity the day before. It is stiff in the mornings. The pain is at the base of the neck and between the shoulders. There is no longer any arm pain or parasthesia.

    She is still anxious when driving but this is mostly at traffic lights. She is has no flashbacks/nightmares and she does not avoid driving.

    Past Medical History. Mrs Smith has been fit and healthy in the past, no previous neck problems. No medication at present. No other bone/joint problems.

    Examination.

    Mrs. Smith is 1.67 meters tall and weighs 74 Kg. She appears a pleasant and straightforward lady.

    General. She can talk freely about the accident and the injury with no evident distress or anxiety. She walks normally, sits normally and moves normally.

    Neck. There is no swelling or deformity. There is tenderness over C6/7 in the midline, the right paraspinal muscles. Flexion is full. Extension is full with pain at end point. Rotation to the right is reduced by 20 degrees and is painful. Rotation to the left is to 85 degrees. Lateral flexion to the left is painful and reduced by 10 degrees.

    Neurological examination shows normal power/tone/reflexes and normal sensation. Balance and gait are normal.

    Summary

    Mrs. Smith sustained an injury to her neck during an incident on 2/2/01. She required treatment from her GP. She was off work for 5 weeks and had significant disabilities in everyday activities for six weeks. She was unable to go to the gym for 4 months. She has now made a reasonable functional recovery but still gets some symptoms on heavier activity.

     

    Opinion.

    Neck Neck sprains are common injuries following the type of incident described by Mrs. Smith. I think that this is the most likely cause in her case. I note in the GP records a diagnosis of cervical spondylosis in September 00. However this episode appears to have been short lived and resolved within one month.

    Neck sprains are very common and often give the types of initial disability described by Mrs. Smith. The time absent from work and length of disability with housework are in keeping with this diagnosis. While some literature claims little or no disability to be the norm following such incidents (see refs), one of the largest studies of this problem showed an average period of certified sick leave of six weeks.

    At the time I examined Mrs Smith 9 months had elapsed. She was making a good functional recovery but with some residual symptoms. It often takes such symptoms between 6 and 18 months to resolve. I would expect these residual symptoms to resolve over the next 6 to 9 months. While there may be some aching on prolonged or heavy activity I do not think there will be any diminution in Mrs Smith�s capacity for work or leisure activity as a result of the incident on 2/2/01.

     

    Anxiety.

    Anxiety and emotional upset are common after such incidents. The period of disability is not uncommon after such incidents.

     

    Further Recommendations.

    Mrs. Smith appears to be making a reasonable recovery but a formal report from a psychiatrist or psychologist is recommended if it is felt important to further explore this area.

     

    Section 35 statement (What is this?)

    Appendix 1 Declaration of agreement with duties of an expert witness (What are they?)

    Appendix 2 Abbreviated CV

    Appendix 3 References

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