Primum non nocere

There’s a lovely story on the front page of this week’s West Highland Free Press.  A Gaelic singer performing at a ceilidh stopped mid-song and indicated he was feeling unwell.  He then suffered a cardiac arrest.  A member of the ambulance service, a firefighter, and a nurse who all happened to be in the audience commenced CPR.  They successfully used a defibrillator which had been installed at the venue.  An ambulance arrived minutes later, and the patient was transferred to Raigmore Hospital in Inverness where at the time of the report, he remained an in-patient.

The extraordinary thing is, this event took place at 11.30 on a Friday night in Poolewe.

Hold this thought.

This week I’ve been watching from north of the border, believe me without a trace of schadenfreude, the progress of the spat ongoing between Jeremy Hunt the Health Minister and the British Medical Association.  Mr Hunt wants to create a “24/7 NHS” in which high standards are maintained at all times, irrespective of the hour of the day or the day of the week.  “At the moment,” said Mr Hunt, “we have an NHS where if you have a stroke at the weekends, you’re 20% more likely to die.”  The doctors are worried that the contract on offer is going to leave them exhausted and burnt out; bad for doctors and bad for patients.  Talks have reached an impasse.  The doctors have gone on strike for the first time in over forty years.  That is a disaster.

Irrespective of the virtues or shortcomings of the proposed new contract I have to say I don’t think well of my medical colleagues.  In my opinion, doctors should not go on strike.  Strikes are designed to cause disruption.  Disruption in turn causes harm.  You might try to make a distinction between causing “inconvenience” and causing actual physical damage to patients, but you’d be hard pushed.  Even when the medical profession is firing on all cylinders, things can and do go wrong.  It is impossible to practise medicine in a half-hearted way.  It’s an all-or-nothing pursuit.  Hippocrates is said to have counselled us, “First, do no harm.”  The man who heckled the doctors’ demo and said, “This is against the Hippocratic Oath” – he was right.

I also find it reprehensible that the medical profession has failed to come together in order to tell Mr Hunt how to run a Health Service.  But the fact is that the medical profession has no clear leadership.  Medicine remains profoundly tribal.  All the specialties and subspecialties are preoccupied in claiming their slice of the budgetary cake and looking after it.

There is no meeting of minds between Government and the BMA.  It is not merely that they are not singing off the same hymn sheet; neither side appreciates what this argument is really about.  It appears to be about money and rosters and on-call commitments and pensions and all the nitty-gritty of a contract but deep down it’s about none of these things.  Deep down, it’s all about clinical medicine.  It’s about the delivery of health care.  It’s interesting that doctors talk about “managing” patients’ conditions; there’s no clear distinction to be made between clinical medical practice and the organisation of health care delivery.

What Mr Hunt is looking for (though I don’t suppose he knows it) and what the medical profession needs (they certainly don’t know it) is a Specialty of Emergency Medicine.  Think about it.  Medical specialties might be defined by age (paediatrics and geriatrics), gender (gynaecology), physiological system (chest physicians, cardiologists), pathological processes (oncology) and so on.  Emergency Medicine is defined by time.  Emergency physicians are interested in patients whose condition is time critical.  They know they can make the biggest difference within “The Golden Hour”.  That hour might be on a Monday afternoon or on a Sunday night.  Emergency Physicians are reconciled to the fact that they are liable to be busiest between Friday night and Monday morning.  They know that the most miserable day of the year for many of their patients is Christmas Day.  They are attuned to Mr Hunt’s idea of providing a round-the-clock service.  They also know about the huge and positive impact that early intervention and stabilisation (of the sort that occurred in Poolewe) can have on patient outcomes; and also the way that high quality prehospital and front-of-hospital care can take the pressure off intensivists, surgeons, interventional radiologists, endoscopy services and catheter labs by presenting them with stabilised patients and to some extent making emergency procedures semi-elective.

The tragedy of the NHS throughout the UK is that, although of course there are some wonderful emergency physicians and a few wonderful individual emergency departments, the Specialty of Emergency Medicine doesn’t really exist.  Emergency Medicine in the UK is about thirty years behind the times.  It’s reflected in the archaic language used to describe it.  “Cas”, “casualty”, “A & E”… If you talk to an Emergency Physician from Australia, New Zealand, or the United States, and you refer to your injured patient as a “casualty”, you will see him, or her, visibly shudder.

Doctors in training prop up acute care throughout the NHS.  They are demoralised and miserable, they are walking out, they are leaving for Australasia in droves, not because they are being asked to cover more weekends, but because they know in the deep heart’s core that they are propping up a ramshackle NHS.  Thirty years ago in Australasia a small group of doctors took on the combined might of the Royal Colleges and established the Australasian College for Emergency Medicine.  The college has never looked back.  This is a battle that has never been fought on these shores, let alone won.

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