I once attended a lecture given by an expert in stroke management who asked the audience what was the definition of a transient ischaemic attack (TIA). Somebody volunteered a traditional definition, that it was a “cerebrovascular accident” (there’s an archaic term) whose symptoms and signs resolved completely within 24 hours. “Too long,” said the lecturer. Somebody else suggested resolution within one hour. “Too long.” “We give in,” said the audience. The lecturer said, “Three minutes, four at the most.”
It makes sense. We know that the success of cardiopulmonary resuscitation in the context of cardiac arrest drops off drastically with each passing minute of delay. A neuron deprived of oxygen will die in a few minutes. Therefore a TIA that lasts longer than a few minutes is not a TIA; it is a stroke. The deficit may be subtle, but it will be there. Nature may be said to be kinder to us in the context of myocardial infarction. Heart muscle deprived of oxygen will survive for longer. But “time is muscle”. We talk here of “the golden hour”.
I thought of this on Friday when a retired GP told me she had been with a patient who was clearly suffering a heart attack. She phoned for an ambulance. She came up against a call handler who was clearly working through an algorithm. “Is the patient conscious and breathing?” “Look. I’m a doctor. The patient is having a heart attack and needs a blue light ambulance immediately.” “Is the patient conscious and breathing?”
In the event, the golden hour elapsed without the ambulance arriving, and the patient died.
This story has become painfully familiar. Sometimes an episode like this is described as an “anecdote”, as if it were some kind of amusing after dinner entertainment. But the anecdotes mount up. Just before the lockdown I was in a restaurant in Glasgow when somebody collapsed. I phoned for an ambulance. Four times. But the ambulance never came. It was a Saturday evening and they were too busy. Earlier this year I tended a patient who had collapsed in the street late one evening. Another 999 call, for an ambulance that never came.
What’s the problem? I’m told that the ambulances convey patients to hospital, but cannot offload them, because the hospital is full. There is no room in the inn. So the patient stays in the ambulance, parked at the hospital’s front door, until space is found. The patient in the ambulance is said to be in an environment which is “safe”. That may be so, but it is the next patient out in the community who is not safe. The ambulance is out of action because, in turn, in-patients cannot be discharged via the hospital’s back door, because there is no viable social care service. So the entire system is constipated. I’m reminded of a piece of whimsy from the number theorists. If a hotel has an infinite number of rooms filled by an infinite number of guests, can the hotel accommodate another guest? Yes. You move the guest from Room 1 to Room 2, and the guest from Room 2 to Room 3 (or is it 4? – a subtlety that eludes me), and so on, thus freeing up Room 1. Actually, you can accommodate an infinite number of new guests this way. However, hospitals are not like this hotel because the capacity is finite. You really need to discharge people, but it seems that hospitals are like the Hotel California, or Heartbreak Hotel, from which there is no escape.
An immediate, makeshift solution to the ambulance problem seems obvious; you create an emergency holding bay which mirrors the safe environment of the ambulance. Why has this not been done? I can only assume that hospital managers don’t consider that something adverse happening out in the community is their problem.
I’m intrigued by the lack of a sense of urgency that is often shared by people occupying senior roles in many walks of life. You certainly see the same thing in the justice system. It does not appear to bother purveyors of justice, that justice delayed is justice denied. Here, a police investigation has been rumbling on for years now concerning certain alleged financial irregularities within the Scottish National Party. Operation Branchform. (For some reason I keep wanting to call it Operation Trench Foot.) A report has been, or perhaps shortly will be, or perhaps never will be, submitted to the Procurator Fiscal. It sits there, static, like an ambulance parked outside the Emergency Department; or like a mobile home parked beside a suburban garden lawn in which has been pitched a tent of the sort you see when forensic scientists start digging up the bodies.
But sometimes, when the Establishment gets a fright, they move with extraordinary rapidity. When there was civil unrest earlier this year following a series of murders at a Taylor Swift-themed dance class, summary justice saw the perpetrators tried, found guilty, sentenced, and jailed, almost overnight. National emergencies call for quick action. In 1982, when Argentina invaded the Falklands, a cruise ship, the SS Uganda, was commandeered in the Mediterranean, emptied of school children, sailed to Gibraltar, and converted into a hospital ship virtually over the course of a weekend.
But when it comes to the constipated NHS with its protracted waiting times, outside ED in the short term, or on an elective surgical waiting list in the long term, while people certainly get exercised, the great and the good don’t seem much bothered. Yes, the politicians knock spots off one another, but they don’t really have any original ideas, and sadly, the medical profession has not offered much by way of leadership.
With respect to the queuing ambulances, I believe that hospitals need to be “front loaded”. Patients should not be transferred to some diminutive, miserable “Cas”, but rather to an extensive and well equipped, well-staffed Department of Emergency Medicine which should be the hub of the hospital. All medicine is acute.
I once wrote into the Herald to say that I thought that Emergency Medicine and Acute Medicine (two putatively disparate specialities) should dump the silo mentality, bury the hatchet, and amalgamate. Some wag wrote in to say the newly formed specialty would be the Scottish College Royal of Emergency & Acute Medicine, or SCREAM. Well in a way that’s quite funny, but you know, it betrays a profoundly British sense of cynicism and hopelessness. How often do I hear it? That’s pie in the sky. It’s not going to happen.
We should make a conjoined, societal New Year’s Resolution, to dump negativity. There’s nothing worthy that cannot be achieved, if men and women of good faith set their minds to it. But, especially in medicine, time is of the essence. Carpe diem.
jamescalumcampbell 