Editorial 65 Blocked, bothered and bewildered am I Patrick K. Plunkett European Journal of Emergency Medicine 2006, 13:65–66 Correspondence and requests for reprints to Patrick K. Plunkett, Department of Emergency Medicine, St James’s Hospital, Dublin 8, Ireland. E-mail: pplunktt@tcd.ie In a paraphrase of those great songsters, Rodgers and Hart, I offer the following emergency physician’s anthem: I’ll speed for him, lead for him Succeed for him, plead for him Blocked, bothered and bewildered am I Access block is a situation in which an emergency patient, once resuscitated and ready for definitive care, stays in the emergency department (ED) awaiting a formal in- patient bed. The presence of such a patient distracts the emergency personnel, both in terms of caring for them and in terms of preventing access for those new emergency patients who have not yet had the benefit of evaluation by a healthcare professional. Politicians and media personnel continually bombard practicing emergency physicians with the suggestion that it is the inefficiencies of the ED that lead to over- crowding and that too many people with sore toes and cut fingers spend 4–24 h lying on trolleys in the ED when they should be treating themselves at home, or seeing their family doctor. Patient representative groups speak of being ignored, left in hallways, examined within sight and hearing of many other people and of being made to wait for many hours at the whim of lazy, overpaid doctors. Are there, however, other perceptions of this reality? The majority of countries have salaried doctors working in EDs, who make significantly less money than their counterparts in other specialties. Furthermore, it is one of the few specialties that assumes that each hour in the 24 h of the day may bring equally critical workloads. Even those specialties with 24-h direct patient care, such as intensive care units, have a more clear diurnal variation, with the lights being turned low at night – unlike the beacon of the ED, at the junction between the public street and the hallowed halls of the hospital. Many countries use nurses, general practitioners (family doctors) or other healthcare practitioners to deliver care to those with minor injuries. These interactions between the patient and the professionals tend to be brief, very focused and do not require much more space than two seats and a dressing trolley. In some countries and areas, they can represent 55% or more of the patient numbers, but use 20% or less of the resources. To divert them requires inordinate use of other resources, and tends to be ineffective. Furthermore, why try to enforce a solution that fails to meet consumer demands when the ED has to be open, with light, heat, security personnel, medical, nursing and support service staff supplied throughout the 24-h period for the critically ill? It is difficult to propose solutions that are likely to address universally the diverse settings of care delivery throughout the world. What is abundantly clear, however, is that, in healthcare settings as diverse as metropolitan, urban and rural USA, Australia, Canada, New Zealand, Ireland, United Kingdom and others, the same difficulties seem to continually arise. The inability to deliver quality care to the next critically ill patient coming through the door is caused by the failure to move the survivor of the last emergency medicine encounter to a ward bed, outside the physical confines of the ED. All those patients lying on trolleys are in-patients, requiring the specialist services of a hospital and its specialty medical personnel, not those of emergency physicians who have already delivered their element of care and who need to move on to the next patient, a patient who may die if the emergency physicians fail to work rapidly and effectively. What effect, however, do these ‘boarded’ in-patients have on professional staff? Most of us pass them by, avoiding eye contact, lest we be asked to do something – anything – to expedite their delivery from the rings of Dante’s 7th Circle where they perceive themselves to have fallen. I note that it is for sins of violence that one is confined to the 7th circle. If called, we continue to move away, saying we will send someone to help – rather like a vessel on the ocean passing a man on a life raft and saying ‘Help is coming y on the next boat’ Why do professionals seem to ignore the plight of their fellow being in such a manner? It is my belief that this is a matter of self-preservation for the doctor involved. If he (or she, as a large proportion of emergency physicians are female) engages, he will be forced into a position of personal conflict. He owes a bounden duty to the patient, yet owes allegiance to the institution. How can he deny that his institution is failing his patient? How can he reconcile this with the moral obligation to fight on the patient’s behalf? A certain element of depersonalisation occurs, with a withdrawal from the very essence of being a physician, namely, to give of oneself to others. The 0969-9546  c 2006 Lippincott Williams & Wilkins Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.