All medicine is acute

Orthopaedic surgeons are not renowned for their social skills.  Sometimes I think that as part of their training they are given a special course on how to be abrasive.  A long time ago in a far off land in a distant galaxy I once referred to orthopaedics a man who’d had the misfortune to fall from a height and land on his feet, fracturing both heel bones.  The orthopod took one look at the x-rays, walked over to the patient, and said, “Basically mate, your feet are stuffed.”  Hold this thought.

On Friday I visited the “acute campus” that is the site of the newly opened South Glasgow University Hospital complex.  I wanted, albeit reluctantly, to confirm something with my own eyes.  It is this fundamental fact about that most sacred of British cows, the NHS: that while there are some wonderful doctors and nurses who occasionally get together to run some wonderful units, by and large the great clanking juggernaut that is the NHS continues to have no respect for the patients it purports to serve.

I know this because, tucked away round the back of the hospital, 250 metres from the grand entrance into the enormous airport terminal atrium with its M & S, and W H Smith, its restaurant and coffee bars and cash machines and self-check-in consoles, there is a small sliding door leading into a low-ceilinged waiting room, about the size of half a badminton court.  This is a thing called “A & E”.  Next to “A & E”, but distinct from it, is another unit, the Acute Assessment Unit.   That is really all you need to know.  But I can tell you on the basis of this brief description that if you have the misfortune to enter a system like this as a patient, basically mate, you’re stuffed.

Let me explain.  Let’s go back round to the front of the hospital.  What is its purpose?  Since we now know that acute care is being delivered round the back, the front must cater for “elective” or “scheduled” work.  This is confirmed by the fact that patients can check themselves in, much as they would if they were getting a boarding pass for a flight in an airport.  The patients are “ambulant”.  They may be attending an out-patient clinic, a diagnostic facility, or presenting for admission for an elective procedure or for planned surgery.  Given the grandeur of the surroundings (in stark contrast to the modest facilities round the back) we may suppose that elective health care delivery outranks acute health care delivery both in importance and in bulk.  This is confirmed by acute care signage and terminology.  “Accident & Emergency”, “A & E”, “Casualty” – these are now all exclusively British terms.  “Casualty” is the title of the flagship BBC emergency medicine soap.  It is salutary to look up “casual” in the dictionary.  Chambers has:

Casual  adj.  accidental: unforeseen: occasional: off-hand: negligent: unceremonious:  (of a worker) employed only for a short time, without fixed employment. – n. a chance or occasional visitor, labourer, pauper etc: a weed not naturalised… n. casualty that which falls out: an accident: a misfortune… casualty department, ward a hospital department, ward in which accidents are treated; casual ward formerly, a workhouse department for labourers, paupers etc.

That Dickensian paragraph is essentially a description of a British “A & E”.  Unscheduled care is an add-on, a little piece of pro bono beneficence handed down to the poor and needy as a special favour, so long as it doesn’t interfere with the essential work going on at the front of the hospital.  Indeed, “A & E” (it pains me to use that term but I suppose that’s what it’s called around here) is hardly thought of as part of the hospital at all.  That is the origin of the “four hour rule” prevalent in most acute hospitals throughout the UK.  Get 95% of the patients out of here as fast as possible, either home, or into the hospital where they can be properly looked after.  If I were to tell a hospital manager that the Emergency Department (to give it its proper term) is the most important and vital location in the whole hospital, he would look at me as if I were mad.  That is because he does not know about the phenomenal diagnostic and interventionist power of a properly resourced Emergency Department.

But it’s true.  It’s true because all medicine is acute.

There are two groups of people who know that all medicine is acute.  One are the health care providers who work in any form of primary or “undifferentiated” care.  This would include doctors either in General Practice or in Emergency Medicine.  The other group?  The patients themselves.  The primary care doctors and the patients know that all medicine is acute because they are the ones present from the beginning.  Every episode in health care starts with a Presenting Complaint.  “I’ve got a cough” – “I’ve got chest pain” – “My sore hip keeps me awake at night” – “I’m miserable”…   The patient says to the doctor, “I’ve got a problem.”  Occasionally, in the spheres of screening and case finding, it is the doctor who says to the patient, “You’ve got a problem.” All presenting complaints are unscheduled.  Nobody looks at their diary and says, “I’m going to crash my car next Thursday.”  I was very struck by something somebody – not a patient – said to me once at a Christmas Party.  “A minute before I took my stroke I felt very well; I didn’t know I was going to take a stroke.”

Because GPs and emergency physicians are dealing with acute problems all the time, they are very good at gauging levels of acuity; they know who needs to come into hospital.  A GP will happily refer one patient to hospital during a day’s work.  If he refers two, he wonders if he is pushing his luck.  He will bend over backwards not to refer anybody else.  If he refers three, he will be abjectly apologetic.  “Sorry to bother you again…”  But it needn’t be this way.  We need to stop thinking that an admission to hospital represents some kind of societal failure.  Doctors call it “acopia” – failure to cope – the most cynical word in the medical lexicon.   In fact, helping patients who are unable to cope outside of hospital is what a hospital is primarily for.  That is why the preposterous opulence of the front door of the new hospital is such a travesty.  It’s a huge confidence trick.  All these people checking themselves in at the state-of-the-art consoles, they are on a waiting list.  The front of the hospital is designed to impress; it’s all about prestige.  Yet at the end of the day this is a cathedral dedicated to the art of waiting.  There’s an irony inherent in the very vastness of this atrium; it’s a monument to vacuity.  But Medicine is not remotely like an airport check-in counter, much as the managers would like it to be so.  Medicine is messy and complicated and unpredictable.  Hospitals that dedicate their grand entrances to the art of waiting are trying to remove themselves from the hurly-burly of life.  But they need to do precisely the opposite.  They need to roll up their sleeves and engage with the real world.  They need to move their focus of attention closer to the point at which pathological processes become evident.  So let’s go round to the back of the hospital again.

Something needs to be said about that other unit – the acute assessment unit.  In most acute British hospitals, there are two modes of entry into hospital for patients who are acutely unwell.  If a patient’s GP has made contact with an in-patient specialty to arrange an admission, then the patient is likely to go through the acute assessment unit, unless the patient is deemed to be unstable, in which case the transfer to hospital will be by ambulance and into the Emergency Department where there are resuscitation facilities.  If the patient self-presents, he will be “triaged” into the Emergency Department.  The GP-bespoke acute assessment patient has a higher status than the self-presenting “A & E” patient.  An in-patient service has already assumed ownership of the former, while the latter is not really in the hospital at all.  In other words, there is an apartheid system working at the front (ie the back) of most British hospitals.  If patients are unaware of this, it is because they have no idea of the tribalism, the ancient and acrimonious turf wars that exist among the medical specialties and Royal Colleges.  In particular, there is a schism between the specialties of Emergency Medicine and what used to be called “General Medicine” or “Internal Medicine”.  Many of the consultants in these areas don’t particularly mind.  The Emergency medicine consultants are happy to concentrate on unstable patients, and the physicians are happy not to have the acute responsibility of resuscitating them.   But neither side are prepared to give up their perception of their own sphere of interest.

I see an opportunity here which, if embraced, really could make British hospitals “world leaders” in acute care.  Emergency Departments and Acute Assessment Units should amalgamate.  Neither side would be giving up anything, but both sides would be taking on considerably more, while sharing the burden.  The greater change of mind set would be in that of the acute care physician working in the acute assessment unit.  I’m basically suggesting that, if a general physician wants to work at the coal face of acute care, he should broaden his diagnostic repertoire and become an emergency physician.

Then the amalgamated units should move out of the back of the hospital and occupy that absurd mausoleum at the front of the building, get rid of all the retail and the money changers, and turn the front door into a state-of-the-art Department of Emergency Medicine, designed, funded, and staffed to cope with everything that is thrown at it in an expert and expeditious fashion.  Put all the acute services together, right at the front of the hospital – the emergency department, radiology, diagnostic suites, catheter labs, intensive care, and theatre – all next to one another.  These are the locations where medical interventions happen.  The crucial role of the general ward is in observation and nursing care.  Here, patients get better.  It is a mistake to imagine that doctors cure people.  They merely try to engineer the optimal conditions that will allow nature to heal the patient, with the best possible outcome.  The mysterious thing about pathology is that the disease and the cure are one and the same.  And time really is the great healer.

We need to relocate the Department of Emergency Medicine to the hospital front door.  If we don’t do this, if we don’t practise a form of acute care medicine more appropriate for the twenty-first century, then basically, mate, you’re stuffed.

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