The WHEN “syndrome”

The WHEN “syndrome”

  • Issue 62

Gabriel Gurman | Chief Editor
gurman@bgu.ac.il

The idea of presenting an all too well known situation under this rather odd name came to me after I realized that the average European patient knows that there are some days and even hours during the week when it would be better to keep away from any medical institution.

I would like to make myself well understood from the very beginning. I do appreciate the level of medical management of our patients, all over the continent. All of our countries have the necessary framework to take care not only of “routine” cases (bearing in mind of course that to the patient their case should take priority) but also of special cases, an unusual diagnosis or a rare therapeutic procedure. And as each of us knows and feels every day, anaesthesia and critical care represent the “bottle neck” in all hospitals. Little by little, the anaesthesiologist has become indispensable, and today very little can be done without us particularly in emergent and urgent situations.

A quick glance into the system which controls and is responsible for our routine activity shows that everywhere there is a clear discrepancy between the organisational abilities to take care of our patients during “regular” days and hours and what we offer our patients during special moments.

The acronym WHEN includes all these situations: W for weekends, H for holidays, E for evenings and N for nights. These are the days and hours when the capacity of system, mainly because of manpower limitations, is reduced when it comes to offering quick and proper care to all those who find no other solution for their acute condition other than going to a hospital.

I am pretty sure that the situation I encountered recently in the middle of the night, in one of the most modern emergency departments of Israel, is the same in almost every hospital on our continent: overcrowded rooms, relatives losing their patience waiting for the next step of treatment of their children, spouses or parents, nervous physicians, overworked and apathetic nurses unable to keep the pace with the demands. Some of the reasons of this kind of situation are due to the simple fact that, beside the penury of staff, most of those working during WHEN are too often young and inexperienced individuals, who need more time to reach a final conclusion or to implement a decision taken by senior staff who have left the premises or given the advice over the phone.

This situation also characterises the investigations and imaging departments. Every single lab data or radiological procedure demands more time during WHEN, the waiting list becomes longer and longer, urgent cases get priority and the staff is unable to offer the patients and/or the families credible explanations for the delay.
We, the anesthesiologists, are in the middle of turmoil.
We are called for almost every single emergency procedure. Take, for instance, a classic example:
In the emergency room, a trauma patient is first examined by a trauma physician, but almost instantaneously an anaesthesiologist is called to give a short examination, followed by starting an i-v infusion , catheterizing a central vein, starting a sedation protocol and performing tracheal intubation followed by mechanical ventilation.
The anaesthesiologist is then asked to accompany the patient to the imaging department, supervising all vital signs throughout. From there, the patient is sent directly to the operation room. The anaesthesiologist’s task does not end there. In most cases the patient is transferred to an intensive care unit, and once again it is our role to accompany them and continue the fight for to stabilize function of vital organs.

I am not aware of any organisational medical system which has found and put into practice a way to analyse the real manpower needs in a medical institution during the WHEN days and hours. I would like to hear from readers if they know of a better approach to this painful reality. But, as far as I know, just about everywhere there is a discrepancy between the needs and the abilities of the system to cover 24/7 satisfactory care. The sad reality is that consequently no steps have been taken to implement change. In the absence of clear and significant data, the proposed measures to improve the described situation are, at least partially, unsuccessful. The first problem is that any organisational change would, by nature, only have a temporary effect. New hospital facilities become insufficient for the needs of the population the moment the new building is finished because of the increased number and level of qualification of staff. I vividly remember what happened in my own hospital, 40 years ago, when during one of the periodical military conflagrations in the region, the number of anesthesiologists on call was doubled. Yet within just a few months that new staffing implementation was actually overrun by the continuous increase in the number of (civilian!) casualties, emergencies and calls for the anaesthesiologists in almost every corner of the hospital.

One of the solutions proposed in the USA was the creation the hospitalist, a physician ready and able to take care of every patient in a hospital environment, their expertise not being bound by any strict limits of any medical specialty. Currently some 30,000 hospitalists are employed in American hospitals, however I am not aware of any study showing dramatic improvements in the patient care during WHEN hours.

A more successful solution seems to be the creation of the rapid response team (RRT), a team of quick interventions, able to reach an on-the-spot diagnosis in acute situations and also stabilise a patient’s condition and find a proper place for the continuation of treatment. Some data show a significant decrease in hospital mortality, due to RRT intervention. Nevertheless remember that the task of detecting a patient with an acute and severe condition is carried out by the “regular” staff in every single clinical department, which brings us to back to square one.

In some places, like Israel, the senior staff is designed to perform on calls from home, which means that the young physician, on call in the hospital, has a permanent point of call for any question. At all times, 24/7, an experienced specialist can be easily reached and asked for an advise or requested to come to the hospital. But this does not solve the most urgent cases, in which every single minute plays a crucial role saving a patient’s life.
This rather sad reality is common all over the world. Perri Klass, a well-known American pediatrician, wrote earlier this year that when a weekend is coming, she has the clear feeling that the hospital is not for patients, but only for its staff’s sake!
This fact increases the lack of confidence in the medical system capabilities to solve urgent situations. Two questions come to mind. First, does this situation affects the results of treatment during the WHEN time? The answer is not simple. I recommend the reader to look into the July 2015 issue of the European Journal of Anaesthesiology, which published a survey of the results of nonelective surgery at night and includes a well documented discussion about the data from the literature.
Secondly, what can be done in order to improve the situation? This question is to be addressed to healthcare organisations. They are supposed to have all the necessary means for analysing a situation and to take the necessary measures to improve the real sufferance of our patients.

I am not too optimistic, at least when it comes to the well-known manpower shortage in our profession. There are not quick fixes, but steps to make improvements are being taken. Without progress there would be regression, a worse situation, and much more difficult to mend. It is true, we are not the organisers, but we can and must trigger the alarm, ring the bell and offer expertise. It is not only the patients’ interest; it is our profession which is at stake, too.