What I do on my holidays, by Alan Grayson, aged 37 and a half. St.Emlyn’s

 

The most amazing place in the world!

Thanks to @TropicalEDdoc, @Lanafeld and @abc730 for the prompt for this.

 

 

 

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Drugs and music have always been a fairly potent combination. Unfortunate deaths, such as the above are thankfully rare, but do happen. Malignant hyperthermia and Serotonin syndrome are hard enough to treat in conventional EDs, but at a music festival, held in the dark, in a field, it’s a daunting prospect.

 

This has been acknowledged, in the UK, at least. The Health and Safety Executive published a comprehensive guide in 1999 on how to organise your music festival, available here, with links to their updated web pages. The original document is fairly comprehensive, but of interest to us, amongst the sanitary regulation is specifics regarding medical cover and facilities.

 

Surprisingly maybe, for a government document it’s rather pragmatic and advises a risk assessment in conjunction with local services, bearing in mind the population, venue, entertainment and likely intoxicants. For example, at the time of writing, (a *****,*******,*******-*******,*******) that nice chap who does a lot of good work for charidee, Justin Bieber, is playing at the Manchester arena. the potential medical need here is most likely to be sprained ankles and a sore throat from all that screaming. Volunteer services can handle this; anything worse can be shipped out to St.Emlyn’s shiny new children’s hospital. A bit different to when TakeThat played and St.Emlyn’s was besieged by “refreshed” middle aged women. We tubed 4 in a week because of alcohol intoxication and I never want to smell rose wine vomit ever again. Compare this with Coldplay who also played on one of the same nights – 1 patient only from a crowd of 50 000; the complaint? Suicidal Ideation. Chest pain. Troponin was negative.

 

I like my music somewhat more visceral than this, as you may have gathered. To combine work and pleasure I have spent free weekends in the summer volunteering with Festival Medical Services, a charity who have provided medical care at festivals in the UK for 30 years.

 

When it started, FMS was my mate Chris, a West Country GP, in his astra van, providing ad hoc care to patients that he encountered as a punter at the nascent Glastonbury festival. As the festival has evolved, the medical needs of the population has changed. Glasto is now the biggest and most famous festival in the world with over 250 000 people arriving on a 300 acre farm to work and party for nearly a week.

 

The model of care has shifted too. It’s had to. The age range has changed from the hippies who came in 1971 – there are births at Glastonbury, tons of kids and plenty of old hippies wandering about, some naked. Consequently we see the full gamut of medical conditions and have to be prepared for everything.

 

Rationing affects everything in health and FMS is no different. Although the charity does get a fee from the festival for services, this is all spent on equipment and drugs, all the staff are volunteers, the quality is amazing. I had a look at the roata tonight on my way down and there is an ED consultant present 24 hours daily in the main medical centre. There’s Consultants in most other specialties available should they be needed. Accumulation of kit over the years means that we can now fully equip three field hospitals each with resus area and obs ward, too!

 

I like the model of care too. After registration and triage where necessary, patients are seen by a multi-disciplinary team, including docs, nurses, physios and podiatrists, as all that dancing in your wellies does lead to cheesy feet and worse. If you’re free, you see the next patient in the queue you can deal with. I spend a lot of time working on how I can make this model of care work in the real world. Majors and resus are seen separately with about 1% shipped off to hospital, usually because of significant trauma or worsening of pre-existing medical conditions.

 

The case-mix? Fascinating. Everything I’d see in normal every day practise, but as I, like most urban senior ED clinicians, rarely get to see any minor injuries these days the trend towards this end of the ED spectrum is a welcome change. I, like you, appreciate the ways in which people conspire to  comedically injure themselves. The responses are often hilarious too, usually due to various refreshers; one patient told me that “he’d bust his banjo-string”, after prompt treatment, he left happily, joyously informing the entire waiting room that it was ok but that he was a tad put out that he couldn’t masturbate or partake in sexual intercourse for six weeks. Clearly, he was on something. For most people, that’s Somerset’s famous mind-rotting cider. Problems with drugs do occur, but thankfully, deaths as mentioned above are rare.

 

We do get deaths, sad, but perhaps inevitable with such a huge population. Some make the headlines more than others, especially if they are politicians, but there is also the usual variety that we see in ED practice. Some are allegedly related to drug use, but not all. I was involved in a sad case a few years back – a patient, found collapsed, fitted, tubed by Pre-Hospital Care team as in cardiac arrest,  resuscitated to ROSC after lots of bicarb, calcium and cooled fluids and helicoptered out. There was unfortunately no difference in outcome. Thankfully, his family made it to ICU to say goodbye. I managed this initially in a hospital tent at the periphery of the site rather than at the main base medical centre; I phoned the senior doc on duty for advice and got it, from a past-president of CEM! Thanks, John, and I’ll buy you a cider this year!

 

Most of the problems with drugs are purely overindulgence; like a lot of our Saturday night specials, a sleep in the recovery position and half a gallon of water is necessary, prior to discharge in search of lentil koftas and chai; psychedelics seem to respond best to a bit of vitamin D (diazepam, rather than sunshine) and a brief intervention from the mental health team; mushie heads can be seen looking rather green – there is little remedy till the nausea has passed. Newer drugs come around all the time – I tried searching toxbase for BZP about 8 years ago and it had nothing; there was a rush of BZP poisonings from a herbal high. Scratting around for what we had, a policy of 5 mg diazepam, 1g paracetamol, 10 mg metoclopramide and a jug of water seemed to work. We packed the worst off to hospital, but most had capacity enough to refuse transfer. That’s a really interesting discussion to have, especially for a wonk like me; How is capacity affected by a drug you’ve no experience of, and what do you do about it?

 

Let’s talk numbers. 250 000 catchment area. 2 500 new patient attendances in a week. 100 hospital referrals, so it’s skewed to minors.

 

What does a typical year look like? 2 tubed. 1 cardiac arrest. Lots of minor dressings. 1 diagnosed MI. 3 Rockstars treated. That’s just me, in 2 shifts, out of over 60 pissed satisfied patients. It’s a PBR dream. The main medical centre saw up to 500 a day with 3/4 doctors (ED senior – usually consultant; ED junior; 1/2 others) and 4-6 nurses (triage, treatment and ENPs) per shift. There’s physio and podiatry cover 8-10 and on-call consultant surgeons, obstetricians, psychiatrists and paediatricians. And a radiologist as there’s a huge x-ray truck out the back. There was an offer of an MR scanner, but that was turned down as they were clearly taking the piss impractical. Oh, and there’s a couple of mental health nurses providing dual service between liaison psych and obs ward nurse.

Hope this is a bit more what you expected.

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Addendum:

We’ve changed since this was written in April. There has been a flurry of protocols over the past fortnight. All of them are reasonable, if a little dull – rather like most NHS protocols. I, like my fellow shift leaders, will run a tight ship and aim to provide care comparable to that that you would receive in your local NHS ED. I may be wearing a comedy hat, but MrsDrG has insisted the onesie stays at home.

 

I’d still like to suggest that if you’re an Emergency Physician at Glasto who doesn’t come and work, then come and say hi. Have a look in the tent and see how, when the bureaucracy’s removed then magic can happen, much like our colleagues do in Bastion.

 

I’ll happily buy you cider and recruit you for next year!

 

BW

 

AliG

(currently in an hotel in Wiltshire, on his way to Michael Eavis’ annual mud and cider party…)

 

 

 

 

3 Comments

  1. Kath Woolfield

    Looks amazing Alan.
    Bring it down under!

    Reply
  2. Gareth Roberts

    Hi Alan I had no idea that it was such a professional set up.. I was expecting a couple of St Johns drivers, a leaky tent, some big lads paid to sit on the ones that are freaking out and various mint based sweets to treat the punters. (which was pretty much all there was at Parklife in mancheste!!!r)

    Reply
    1. Alan Grayson

      And that’s why StE’s got bombed out every year that Pondlife was at Platt fields!
      The local authorities should really read the orange book, but they have little appreciation of what actually goes on at a festival, let alone potential risks.
      If you want quality, you need to pay – and the money goes to some very nice charities in Africa and India to promote basic needs such as sanitation and water and education.

      Reply

Thanks so much for following. Viva la #FOAMed

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