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                                                                                                                      May 2006

                                             approved posts. It is useful for them to
Junior clinical fellow                       know that such posts – often described          CONGRATULATIONS
posts and Membership                         as junior clinical fellow or Trust SHO
                                             grade posts – are acceptable as time
                                                                                             Congratulations to Glyn Barnett, SpR in
                                                                                             London on winning a gold medal for
examination of the                           towards the Membership of the                   shooting in the Commonwealth Games
                                             College of Emergency Medicine provid-           in Melbourne.
College of Emergency                         ing the exam application includes a
Medicine                                     letter from the supervising consultant

The recent changes to the Home               N   the rota is the same as recognised
                                                 SHO posts,
Office regulations on permit free
training for post graduate doctors
and dentists may have a significant          N   the same in house educational oppor-
                                                 tunities including protected teaching
impact on the types of doctors who
are recruited to our training and non            is available,
training posts. The changes mean
that the majority of non EEA doctors         N   the same entitlement to external
                                                 study leave and exams,
will need to have a work permit to
work, study, and train in the UK.
The new rules also require that any          N   the applicant has received one to one
                                                 appraisal and development opportu-
suitable EEA nationals are considered
in advance of those doctors who                  nities during the post.
require a work permit. Emergency
Medicine, like other specialties, has           We suggest applicants confirm these
traditionally    recruited      relatively   facts at interview and that the super-
large numbers or trainees from non           vising consultants are prepared to write
EEA countries such as including              to the College confirming this if
India,    Pakistan,    Australia,    New     required.
Zealand etc.
   The likelihood is, therefore, that the
non EEA graduates will be looking at                       RUTH BROWN FRCS FCEM
"non approved" posts rather than                  Registrar, College of Emergency Medicine    To contact the editors:

                                                                                              Mike Beckett and Diana Hulbert,
                                                                                              Accident and Emergency, West
                                                                                              Middlesex    University   Hospital,
                                                                                              Twickenham     Road,     Isleworth,
                                                                                              Middlesex TW7 6AF (tel 020 8565
                                                                                              5486; fax 020 8321 2516; email

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    Consultant appointments February to March 2006. The information for the consultant appointments is provided by the College
    and any errors should be notified to them and not the journal
    Name                                            Hospital                                   Previous post
    Mr Dewald C BEHRENS                             Worcestershire Royal Hospital              SpR
    Mr Subramanian R DHINAKHARAN                    Bedford Hospital                           SpR
    Dr Fergal J DUNN                                Causeway Hospital                          SpR
    Mr Paul GROUT                                   Furness General Hospital                   Consultant
    Mr Brendan LAVERY                               Causeway Hospital                          SpR
    Mr M WEISE                                      Princess Alexandra Hospital, Harlow        SpR

                                                 complex multi-factorial causes of            violent individual by disengaging them
Targeting emergency                              such behaviour. Certainly providing a        from the police or getting the police to
department violent                               safe environment for staff is a laud-
                                                 able goal. The Royal College of Nursing
                                                                                              loosen the handcuffs a little, gaining the
                                                                                              individuals trust. Police officers occa-
behaviour: What                                  published its Working Well 2005 Survey       sionally imply that an individual is too
                                                 (            dangerous or violent, when they have
approach should we                               at_breaking_point_2005.pdf), which showed    just become entangled in the vicious
take?                                            high a level of harassment and abuse
                                                 among emergency department Nurses.
                                                                                              circle of violence and just need someone
                                                                                              neutral help diffuse the situation.
                                                 The Emergency Workers (Protection)           Heavy-handed tactics can often exacer-
The ‘Hippocratic Oath’ has undergone             Bill is proceeding through parliament        bate violence and has the danger of
many revisions since physicians first            and increasingly there seems to be a         becoming a self-fulfilling prophecy.
started using it as a moral code of              ‘zero tolerance’ approach, with state-          However, recently, buoyed by increas-
practice. The latest, and most relevant          ments by the Health Secretary Patricia       ing awareness of the policy and having
refinement, especially for UK doctors, is        Hewitt in the lay and medical press.         witnessed fellow colleagues using it, I’ve
the GMCs ‘Duties of the Doctor’ and                 However, the policies and guidelines      had the occasion to use it myself. The
‘Good Medical Practice’ statements. All          put a heavy burden on the senior doctor      individual had been involved in a
of these versions emphasize the impor-           on duty in that they need to ensure that     violent street incident late on the week-
tance of prioritising our patient’s wel-         the behaviour does not stem from a           end, fuelled partly or wholly by alcohol.
fare.                                            clinical condition, and that any delay in    He had obviously been waiting for a
   The emergency department is a                 treatment does not make the outcome          period of time, which he felt was
unique place, occasionally described as          significantly worse. We all know that        unacceptable; though it was probably
the ‘‘front line.’’ The street spills into the   without a thorough assessment, it can        less time than he perceived. He could
department and it often reflects what is         be difficult to come to this conclusion.     not see the action in other parts of the
going on outside. On a sunny summer’s            Even in my brief experience, I can recall    department from where he was asked to
evening the department can have                  several episodes in which acute psych-       wait. In his inebriated state he may have
numerous children with injuries from             otic episodes have been precipitated by      been concerned about how he was going
the trampoline, on a icy winter’s day the        iatrogenic or recreational drugs as well     to get home; the early hours of the
department can be flooded with elderly           as other conditions. This leaves me          morning were approaching with dwind-
ladies with Colles’ fractures; and on a          reticent to judge behaviour so quickly.      ling transport options. He was verbally
Friday or Saturday night, it is the              Even in relatively straight forward cases,   abusive, and though this was offensive
ravages of our binge drinking culture            the exclusion of individuals may delay       and unacceptable to the staff trying
that threaten to overwhelm us, occa-             treatment unacceptably. It may also          their best it is just the reflection of the
sionally confronting us with threatening         make it difficult to assess concurrent       language that is common on the street,
or unpleasant language or actions.               illness that may have significant con-       and possibly in the social environment
   Most hospitals now seem to have               sequences. Having set up a confronta-        that the person was exposed to. In
official policies and guidelines with            tion, we then lose the patient’s             retrospect there are faults with the
regard to dealing with violence and              confidence and he may not divulge            individual’s behaviour, as well as the
aggression towards staff, which may              information crucial to making an             system that had failed to make him
include issuing warnings, removal,               informed decision.                           realise what the delays were, as well as
and prosecution of patients. Some of                We have all seen that at times            the fact that the system did not provide
these seem more motivated to fulfilling          confrontation with security and police       any solution to his transport problems.
the Health and Safety at Work Act                can make these situations worse. One            Fortunately, I did not find the experi-
(1974), than to look at some of the              can often gain the cooperation of a          ence particularly pleasant. It felt that I
EMJ Supplement                                                                                                                          3

had succumbed to my basest and                observation wards depends on bed                These powers put the senior doctor in an
reacted; using the power of the organi-       availability as well as will power. The         unprecedented position. Of course, we
sation to stamp my authority; denying         inebriated individual’s risk being dis-         live in a world in which no one is
the patient wound closure and potential       charged too quickly; having to make             allowed unchecked power and patients
poor healing. How often are we swayed         their way home at a time when this may          are allowed to appeal. However, the
to make decisions by nursing staff and        be particularly difficult or hazardous.         social class most likely to fall victim of
other professionals.                             The hospitals policies have been             the new rules will likely be the ones
   Are we then in danger of jumping to        agreed and are available in black and           whose have least access to the formal
exclude people when other policies, like      white. The training in recognising situa-       appeals procedure.
building a database of ‘‘serial attenders’’   tions, de-escalation, psychological man-           But in the long term, will this
and pro-actively targeting them using a       agement of aggression, and other useful         confrontational approach be more suc-
multi-disciplinary approach, or auditing      techniques have not been so accessible.         cessful? Maybe we will have to await
violence hotspots and proactively work-       Certainly I’ve never had the opportunity        the Royal College of Nursing’s follow-up
ing with police with the aim of preven-       for such expertise; having picked up my         survey in five years time to see if
tion of problems, having been shown to        own methods through years of exposure           emergency department staff feel less
reduce violence?                              and experience on the ‘front line’.             threatened.
   There was a time when an inebriated           The unenviable position that this puts
individual could sleep it off on a trolley,   senior emergency department doctors
awaiting a medical intervention. The          under can be easily gauged. We are used
4 hour target has put an end to this          to make difficult decision and often                                      NAEEM TOOSY
practice as admitting formally to             make judgements about acceptable risk.                                    SpR, N W London

              *                         *                          *                          *                         *

                                              College of Emergency Medicine will also         the 21st century, need to adopt the
The College coat of                           need similar adornments.                        trappings of premature senility? Does a
arms                                             Emergency Medicine as a specialty in
                                              the UK is no more than 40 years old. Its
                                                                                              nod to antiquity serve any purpose, or
                                                                                              should we be unashamed at being new,
The Faculty of Accident & Emergency           origins lie firmly in the 20th century. It is   modern and (we hope) forward looking
Medicine – soon to be no more than a          a modern and evolving specialty that            and optimistic?
fond memory – though barely ten years         does not have substantial roots reaching           There are advantages in having a
old, had some of the trappings asso-          back into mediaeval times.                      college logo, and if we are to have one
ciated with more venerable medical               The old Colleges with their ancient          then it should be possible to commission
institutions. To become respectable it        libraries, panelled halls, and rows of
                                                                                              something suitable without reaching
was thought desirable to conform with         portraits of eminent but long dead
                                              presidents are rightly regarded as his-         back to the world of mock-Tudor her-
the expected regalia including a coat of
                                              torical assets of national importance but       aldry. A simple and memorable design
arms, chain of office, crested tie (mostly
still unsold), and scarves and certificates   this can be misinterpreted as signify-          would serve us far better than obscure
with insignia and flowing calligraphy.        ing traditional positions resistant to          symbols that mean little to those inside
   Now is perhaps the right time to           change. Does the College of Emergency           the speciality, and nothing to those
decide whether we believe the new             Medicine, the first medical College of          outside.

              *                         *                          *                          *                         *

                                              in Emergency Medicine to be openly              supporting, encouraging and mentoring
A round-up of news                            discussed (a presentation used in the           SAS doctors in our specialty, which will
from FASSGEM                                  road shows, which highlights the key
                                              points, is available on the FASSGEM
                                                                                              in the future become a role model for
                                                                                              other specialties (after all we do have a
                                              website).                                       greater proportion of SAS doctors in
A recent email survey has demonstrated           FASSGEM has welcomed the propo-              Emergency Medicine that in any other
that the FASSGEM membership is                sals, (discussed during the road shows),        specialty!).
highly supportive of the process of           that SAS doctors should be fully incor-
merging BAEM and FAEM into a new              porated into the College (with appro-           NEW CONTRACT
look ‘College of Emergency Medicine’.         priate representation) at all the relevant      It is highly likely that there will be some
The ‘road shows’ which took place in          levels of College activity.                     problems with the implementation of
March were a good opportunity for                It is the hope of FASSGEM that the           the new contract and the BMA may well
some of the aspirations of SAS doctors        College will set new standards for              be in a position to assist some SAS

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doctors with negotiations arising out of        Under the model contract currently        CONFERENCE 2006
contract related difficulties. In all prob-   being looked at, the Associate Specialist   Bookings are now being taken for the
ability the BMA will only represent           grade would be closed to new entrants.      Annual Conference, if you wish to
those doctors that have been BMA              Doctors working in this grade would be      attend please book as soon as possible
members prior to the introduction of          able to stay in it, while current staff     – hotel accommodation in the confer-
the new contract; therefore if indivi-                                                    ence venue is limited to 60; first come,
                                              grade doctors who are eligible would
duals think that they are likely to                                                       first served.
encounter contractual difficulties, they      have a ‘window of opportunity’ to enter
should become a BMA member as soon            (anybody who is in this position at
as possible to put themselves in a            present is advised to set the relevant
position where they can receive appro-        application process in motion as soon as                       ANDREW NEWTON
priate support, advice, and assistance.       possible).                                                         Chair of FASSGEM