'Twas the night before Christmas

Frozen turkeys on feet is just one of the seasonal injuries seen by physios in A&E. Matthew Limb hears about the rest

Some slip and fall on snow. Others trip and stumble as a result of too much alcohol, or an over-enthusiastic shimmy and shake on the dance floor at the office Christmas party. Frozen turkeys can be dangerous too. Whatever the reason, it's the physiotherapists working in accident and emergency departments who deal first hand with these special seasonal injuries. And while physios in A&E don't have to face midnight revellers, as their clinics aren't open overnight, they are part of the team cleaning up the morning after. It's all part of being an A&E physio. The Friday before Christmas is meant to be the busiest time of the A&E year. Marco Ronchetti, a physiotherapist in A&E at Maidstone hospital in Kent,  says: 'They are busy periods. One or two days before the Christmas holiday you get a build-up of patients, who want to sort things before they go away. Afterwards it gets busy as well. If you work on Boxing Day you see people who have dropped frozen turkeys on their feet - stuff like that.' Physio Dave Baker worked over two Christmases in A&E at Homerton hospital in London. 'You see people looking very sorry for themselves the next morning, with broken ankles or wrists,' he recalls, adding that sometimes the stories behind the injuries are particularly interesting. He doesn't reveal more. While Christmas can be chaotic, what about the rest of the year? Television dramas can make A&E seem a lurid place all year round. But is this fictional world, in which allied health professionals are rarely glimpsed, one which physios in A&E recognise? 'Not really, no,' says Sandy Tubby, laughing. Ms Tubby was one of the first specialist physios working in A&E (she started in 1996), and eventually clocked up 11 years at the sharp end of a Southend casualty department. She comments: 'I think they take all the really manic bits and put them together to make a show.' Physio Alison Collins, a colleague of Marco Ronchetti's at Maidstone hospital emergency care centre, agrees with this assessment. 'It's not like television,' she says. 'Working in A&E is very interesting, but it can also be very mundane. It's quite amazing the trivial things some people come in with.' Typically, patients are routed to physios via triage nurses or 'navigators', and the physios therefore see minor rather than major injuries. The role of the A&E physios, whether they're clinical specialists, emergency physiotherapy practitioners or extended scope physiotherapists, is to see, assess, treat, advise and discharge as appropriate. Working alongside emergency nurse practitioners and emergency care practitioners (the latter are mostly paramedics), physios liaise with A&E doctors as well as occupational therapists, hospital orthopaedic teams and social work and mental health staff. Injuries are predominantly musculoskeletal and acute: ankles, knees, shoulders, backs and necks with myriad sprains, strains, breaks, bruises and whiplash. Ms Collins says: 'It makes very different demands on you compared to routine physio. Patients are often distressed, particularly children. Unlike normal outpatients they are here unexpectedly, so they're not prepared emotionally or mentally.' ON THE FRONTLINE Mr Ronchetti, a musculoskeletal practitioner at band 7, divides his week between A&E (two days) and outpatients (three days).'It means I see people in A&E for the very acute stage, but as we refer some patients into the physio department, I get to see them occasionally further down the line as well.' He notes significant differences between outpatients and A&E. 'In outpatients, people tend to have been filtered by the time they come to you. But as we are first- line practitioners, the management of someone at the very acute stage, and how you assess them, differs.' It means the onus is on the physiotherapist to make sure they're not missing anything – this calls for first-rate assessment skills. 'We've picked up people having strokes who've come into the minor injuries clinic with shoulder pain. A colleague of mine picked up a lung cancer,' says Ms Tubby. 'Your differential diagnosis needs to be good. You can't afford to make mistakes in A&E because it's one of the most litigious areas in a hospital.' Working on the frontline means being alert to all possibilities. Superficially routine injuries may reveal stories of domestic violence and child welfare issues. 'You have to gauge situations and judge whether there's potentially a threat… it's like a constant analysis process, alongside your actual physio assessment and treatment process,' says physio Gail Hitchcock. 'You have to be a certain type of person because it's such a changeable environment,' she adds. While it's not all high drama, A&E can be a tough and unpredictable arena. Staff can be subject to threats and personal abuse, and have to deal with the effects of drug and alcohol misuse.  Working there does mean facing constant change, and requires people equipped to deal with that – professionally and emotionally. 'You have to be someone who doesn't mind what your work rate is going to be,' says Ms Tubby, who admits she is an 'adrenalin junkie' who likes working 'off the cuff'. Painting a vivid picture, Victoria Blanchard, a physio in A&E at the University Hospital of North Durham, says: 'There are definitely days when ambulances are coming in, the waiting room's full, the beds are blocked and it's noisy, and there's so many people rushing around.' Many physios in A&E have extended scope training and responsibility to carry out a fuller range of services and treatments. These include requesting x-rays, taking blood tests, administering pain relief, managing minor wounds and arranging MRI scans. 'I can't prescribe but we have patient group directives for basic analgesia – paracetamol, ibuprofen – so we can supply and administer them in A&E,' says Ms Blanchard. She has completed an injection therapy course, and can carry out procedures, such as knee aspirations, without having to wait for a senior doctor. She says physios in A&E need to be 'quite strong' in order to establish themselves as respected clinicians. A GREAT LEARNING ENVIRONMENT It can be tough, but there are many opportunities working in A&E. For one, it is a great learning environment, says Mr Ronchetti. 'You have doctors and nurses who have so much experience; you tend to find most days you're learning something new.' Medical staff are also benefiting by learning from the physios, says Ms Collins. 'The A&E consultants and the clinical directors are very supportive and positive about our role and input. The middle and junior grades also value our opinions.' She says the latter frequently refer to the physiotherapists for guidance and assistance with musculoskeletal management. 'Our colleagues, the nurse practitioners and the emergency care practitioners, are very happy to have us in place to assist and treat many of the musculoskeletal problems, particularly the shoulders and knees, which none of them seems to enjoy assessing.' While it's over 10 years since physios began working in A&E, it is unclear how many posts now exist. Ms Collins says: 'I think there is a growing trend for this role and it is definitely becoming more prominent. Our consultants are very supportive of us. One said this morning that he dreads to think what impact removing us would have on reattendances and waiting times.' The impact physios have made in A&E is confirmed in audits, say practitioners (see panel: Auditing A&E). Despite this, the role of physiotherapy in A&E can still be overlooked. 'I still feel that in the media, nurses are represented as the angels and the doctors as the saviours. I don't think we're always fairly represented,' says Ms Hitchcock. Perhaps the time is right for A&E physios to get a starring role – on screen and off. FL Auditing A&E A pilot research project carried out at Homerton University hospital, London, in 2004 to 2005, showed the effectiveness of using extended scope physiotherapists in A&E. The study examined a scheme using two ESPs to triage patients identified by A&E junior doctors as having sport and musculoskeletal injuries. It found there was a significant drop of around 40 per cent in the number of referrals from A&E to orthopaedic consultants and outpatient physiotherapy clinics. In addition, a cost-analysis showed the triage service offered value for money. Dave Baker, an ESP at City and Hackney primary care trust, who helped carry out the study, says statistical analysis and independent audit indicated patients with sport and musculoskeletal injuries were seen more quickly and for less cost. He comments: 'We received some feedback from the orthopaedic department that the triage system afforded more time to focus on surgical cases, as the department was relieved of a significant portion of soft tissue injuries.'

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