Later another ED consultant rescued an elderly man from the waiting room with active PR bleeding and a tachycardia with a 50mmHg postural drop. He'd been waiting 8 hours in the waiting room.

I had a call from the haematology registrar about a patient he wanted to admit with platelets of 3 and a Hb of 60. I agreed with him but I told him quite frankly that I could not help him. The only way he could get care for his patient was for him to break arms on the wards in order to get a bed for his patient and then come in and provide the care himself. Similarly, [name removed] rang to send in a patient with a bowel obstruction and was told by another ED consultant that we could order the AXR from the waiting room but the patient was very unlikely to get a cubicle.

During all this time I must admit I was painfully aware that I did not have a handle on the patients I was supposedly in charge of and I was not in control of the ED in any sense.

As the waiting room ballooned (including many category 2 patients) we were unable to create cubicles by discharging to short stay because the patients, on the whole, hadn't been assessed in the cubicles yet. At one time, while the medical staff were being continually occupied in ER1 and ER2 only 2 of the patients in Team 1 (not counting Resus) had actually been seen and they both needed a ward bed. The Flow consultant made an effort to make lightning assessments on the rest of the cubicle patients and initiate things and suggested one of them might go to Short Stay. I warned her reminding her of previous consultant discussions where we have recognised that management plans based on lightning assessments in an overcrowded and busy ED constitute bad medicine and result in a higher risk of errors. I invited her to step back and reconsider. She did so and concluded that for the sake of the patients in the waiting room it was worth taking the risk with this patient in a cubicle. I don't blame her. I make the same kind of decisions at times. Later discussion with the ED Director about this included the mutual conclusion that we sometimes find ourselves having little choice but to cut corners and practice bad medicine on one patient in order to avoid what may be a larger risk on another patient. I am appalled that this is the quality of emergency medicine we practice. How can we defend this?

Tonight was a classical example of an ED that had been pushed beyond its ability to cope. The problem is that we have bad shifts almost every day but we only get really stressed now when it is extraordinarily bad such as this evening. We're used to working in an environment where patients are regularly put at risk. The pathophysiology of an overcrowded and understaffed ED is fascinating, particularly when high acuity and poor bed access combine. Small challenges which would otherwise be absorbed into the ED's workflow become large crises. An active chest pain should go to a cubicle but when he waits in the waiting room for several hours the ED consultant is notified and has to remedy the situation. Ambulances should be unloaded but they line the corridors and AV DTMs ring the ED consultant for a solution. A psych patient is assaulted in APU and needs a head CT but there is no room in the ED so the ED consultant has to get involved. Resus rooms are needed but they're full. Patients are waiting for hours and want to self discharge or deteriorate but there aren't enough doctors so the ED consultant has to intervene. The less the ED copes the more the ED consultant has to put out spot fires until the shift is one continuous flow of interruptions and all tasks are done in truncated 2 minute blocks. The nurse in charge shares this experience. The end result is both the ED and the consultant are almost ineffective.