Resuscitation, 4, 255-257
Message from the President of the Casualty Surgeons Association (Great Britain) E. P. ABSON
I welcome the allocation of this section of Resuscitation to material concerned solely with the work of Casualty Departments. It is often assumed that casualty work is exclusively concerned with the treatment of medical and surgical emergencies, subjects well covered in the existing specialised journals and text books. Although there are indeed many compendia of emergency treatment, there are few, if any, journals focussing attention on those seen most often in these departments. A casualty doctor, to keep abreast of the times, has to diversify his reading and misses much. The assumption, however, is not correct. Only a small proportion of cases arriving at our casualty departments is in need of resuscitation or other intensive therapy. It is true that in nearly all cases the interval between onset of symptoms and examination is probably shorter when seen here than in any other field of medicine. This not only presents special problems of diagnosis and management - not covered in existing texts - but furnishes abundant clinical material for investigation and documentation. Much of the work is concerned with diagnosis - often overlooked because of the necessity for rapid treatment. Nowhere else is the full range of specialised medicine and surgery seen in one place. Other features are the assessment of acute multiple pathology and the exposed position in making that most difficult diagnosis of “nothing significantly wrong with this patient”. Casualty doctors also have unrivalled experience in many aspects of medicine wound dressings, the out-patient treatment of burns, pyogenic infections of skin and cellular tissue, minor hand and sports injuries, industrial injuries and illness - to mention a few. Their contributions in specialised journals are often not given the weight of the authority they deserve. In all these fields the Casualty Surgeons have found much common ground in meeting and there gained much from the interchange of views and experience, and they see this publication, dealing exclusively with their work, as a necessary extension of that communication, However, it is not only in the clinical field that common ground has been found. The whole subject of the organisation and administration of the Community Emergency Medical Service has been very neglected and has been the subject of much disquiet. In the British Medical Journal of 27th September, 1975, the Editor drew attention to a lack of authority in this field and, although referring specifically to major disaster situations, the criticism might equally well have been levelled at the service dealing with the lesser emergency situations occurring in the daily life of the community. These engender the patients who appear without warning in their numbers at the casualty door (ref. ‘An Integrated Emergency Service’: Casualty Surgeons’ Association Memorandum, 1973). 255
256
E. P. ABSON
The whole development of organised medicine in Britain since the Poor Law has been towards a comprehensive general practitioner consultative service and a stable Public Health Service. Although this has been achieved at a high level it has been largely on the assumption, if not of static disease, of a static and inert population. Witness the ‘recorded message’, ‘group practice’, ‘appointment system’, and the hospital in-patient and outpatient waiting lists. Those engaged on some enterprise, whether it be work, travel, recreation, or merely, for example, the solitary octogenarian on expedition to the shop, have always been at a loss for immediate assistance should it be required. At present some 10% of the population for 24 hours a day, and 70% for 9 hours a day, are so engaged, and are at risk of sudden incapacity in circumstances which render their practitioner either inappropriate or too remote to help. In Britain, which is relatively immune from earthquake and flood, this displaced section of the community, engaged in work, travel, recreation, is involved in, and sometimes responsible for, the ‘emergency situations’ and, unfortunately, most frequently, in major disaster. Organised medicine has so far failed to isolate this easily identifiable group and its problems as a separate group requiring a separate service, perhaps because it, and its members, can only be defined in sociological and not in medical terms. It has been acknowledged and catered for only by offering assistance, almost as a benevolent gesture through the back door of the hospital. It does not seem inappropriate to refer to these patients as the ‘Casualties’ of the communal enterprise. Restoration of the enterprise is, where possible, part of the service
required. Frustration underlies many complaints. It is important to recognise that the urgency for treatment of some of these patients arises as much from the circumstances surrounding their incapacity as it does from the nature of their illnesses. Their circumstances, rather than their diagnosis, define their right to attend the department and also the right - which should not be forgotten - of the casualty doctor to treat or refuse to treat another doctor’s patient. Both St Thomas’s and St Bartholomew’s Hospitals owe their foundations to the sick and lame truvellers entering London over the only bridge available from the South. Although the army and navy were soon to realise a need for obvious reasons, the first evidence in Britain of recognition of this need for a civil enterprise is to be found in the association of the Casualty Department, Nelson Street, Liverpool, under the direction of Hugh Owen Thomas and later Sir Robert Jones, at the time of the construction of the Manchester ship canal in 1887. Since then we have seen the Industrial Medical Services develop in association with particular enterprises, with the more hazardous 24 hour responsibility. Nevertheless, for the whole community there has been no clear acceptance of a special need in spite of the number of casualty attendances. They now amount to 10% of the population per annum and equal the total number of out-patient attendances. They are at present increasing at the rate of 1,000 per 100,000 population per year, perhaps an indication of the endeavour of our time. The main burden of providing this service has fallen on the hospital and this seems to be conditioned by the contingencies of the situation. The hospital is central, available over the 24 hour period, can deal with large numbers, and is most appropriate for the more serious case. By and large, attempts to limit or redistribute attendances not surprisingly have proved ineffective. The way in which the hospital service has evolved during this century to meet the
CASUALTY SURGEONS ASSOCIATION: PAPERS
257
increasing demand, itself forms a chapter in the history of medicine. Great changes have been made and, the hospitals have generally become more and more orientated to emergency care. Certainly, in all specialties, more cases are admitted through the Emergency Room than ever before. Especial mention should be made of the advances made by orthopaedic surgeons, who have provided almost universally, the daily fracture clinics, and of the administrative medical officers who have provided our many new Accident and Emergency departments. It cannot be said, however, that development has occurred without controversy. Even the newly adopted title ‘Accident and Emergency’ - designed to limit abuse (by the public, if not by the hospital) contains an unintended but, nevertheless, at times, confusing duality (Rutherford, W. H. [email protected], vol. 6, no.4, 1975, page 363, and vol. 7, no.2, 1975, page 96). It has had the reverse effect. Almost.every specialty, and these have increased considerably, has expressed its concern and attempted to maintain a 24 hour service. Controversy has mainly been about the best way of integrating the many specialties involved into an effective homogeneous emergency organisation. The problem of whether to deal with trauma throughout by a traumatologist or a team of specialists, or to leave assessment and resuscitation to a high-grade generalist, is an example in point. Most of the arguments have appeared in specialised journals and in very many separate official reports. The most consistant recommendation has been for one leadership (Nuffield Trust Report Casualty Services and their Setting, 1960) and for an administrative authority (Report of The Central Health Services Council Accident and Emergency Services, 1962). Authority has in fact passed from Staff Committee to Accident and Emergency Committee and from the general surgeon to the orthopaedic surgeon, and now - where it is most likely to be effective, within the Emergency Department - to the casualty consultant. It is self-evident that there are many administrative problems in the casualty department, as it stands between the displaced section of the community on the one hand and the large number of sophisticated specialties on the other. The casualty consultants have here, too, gained much in discussion at their meetings and look forward to further exchanges in these pages. If there had been a publication focussing on the organisational problems within the department the development of Emergency Care within the hospital might have been easier. The success of any emergency operation depends as much on organisation as it does on the will to help and the expertise and facilities available. It is hoped that these pages will more clearly identify the aim, and help to achieve a more dynamic and ‘Integrated Emergency Service’, through the contributions to them from all concerned.
Message from the President of the Casualty Surgeons Association (Great Britain) E. P. ABSON
I welcome the allocation of this section of Resuscitation to material concerned solely with the work of Casualty Departments. It is often assumed that casualty work is exclusively concerned with the treatment of medical and surgical emergencies, subjects well covered in the existing specialised journals and text books. Although there are indeed many compendia of emergency treatment, there are few, if any, journals focussing attention on those seen most often in these departments. A casualty doctor, to keep abreast of the times, has to diversify his reading and misses much. The assumption, however, is not correct. Only a small proportion of cases arriving at our casualty departments is in need of resuscitation or other intensive therapy. It is true that in nearly all cases the interval between onset of symptoms and examination is probably shorter when seen here than in any other field of medicine. This not only presents special problems of diagnosis and management - not covered in existing texts - but furnishes abundant clinical material for investigation and documentation. Much of the work is concerned with diagnosis - often overlooked because of the necessity for rapid treatment. Nowhere else is the full range of specialised medicine and surgery seen in one place. Other features are the assessment of acute multiple pathology and the exposed position in making that most difficult diagnosis of “nothing significantly wrong with this patient”. Casualty doctors also have unrivalled experience in many aspects of medicine wound dressings, the out-patient treatment of burns, pyogenic infections of skin and cellular tissue, minor hand and sports injuries, industrial injuries and illness - to mention a few. Their contributions in specialised journals are often not given the weight of the authority they deserve. In all these fields the Casualty Surgeons have found much common ground in meeting and there gained much from the interchange of views and experience, and they see this publication, dealing exclusively with their work, as a necessary extension of that communication, However, it is not only in the clinical field that common ground has been found. The whole subject of the organisation and administration of the Community Emergency Medical Service has been very neglected and has been the subject of much disquiet. In the British Medical Journal of 27th September, 1975, the Editor drew attention to a lack of authority in this field and, although referring specifically to major disaster situations, the criticism might equally well have been levelled at the service dealing with the lesser emergency situations occurring in the daily life of the community. These engender the patients who appear without warning in their numbers at the casualty door (ref. ‘An Integrated Emergency Service’: Casualty Surgeons’ Association Memorandum, 1973). 255
256
E. P. ABSON
The whole development of organised medicine in Britain since the Poor Law has been towards a comprehensive general practitioner consultative service and a stable Public Health Service. Although this has been achieved at a high level it has been largely on the assumption, if not of static disease, of a static and inert population. Witness the ‘recorded message’, ‘group practice’, ‘appointment system’, and the hospital in-patient and outpatient waiting lists. Those engaged on some enterprise, whether it be work, travel, recreation, or merely, for example, the solitary octogenarian on expedition to the shop, have always been at a loss for immediate assistance should it be required. At present some 10% of the population for 24 hours a day, and 70% for 9 hours a day, are so engaged, and are at risk of sudden incapacity in circumstances which render their practitioner either inappropriate or too remote to help. In Britain, which is relatively immune from earthquake and flood, this displaced section of the community, engaged in work, travel, recreation, is involved in, and sometimes responsible for, the ‘emergency situations’ and, unfortunately, most frequently, in major disaster. Organised medicine has so far failed to isolate this easily identifiable group and its problems as a separate group requiring a separate service, perhaps because it, and its members, can only be defined in sociological and not in medical terms. It has been acknowledged and catered for only by offering assistance, almost as a benevolent gesture through the back door of the hospital. It does not seem inappropriate to refer to these patients as the ‘Casualties’ of the communal enterprise. Restoration of the enterprise is, where possible, part of the service
required. Frustration underlies many complaints. It is important to recognise that the urgency for treatment of some of these patients arises as much from the circumstances surrounding their incapacity as it does from the nature of their illnesses. Their circumstances, rather than their diagnosis, define their right to attend the department and also the right - which should not be forgotten - of the casualty doctor to treat or refuse to treat another doctor’s patient. Both St Thomas’s and St Bartholomew’s Hospitals owe their foundations to the sick and lame truvellers entering London over the only bridge available from the South. Although the army and navy were soon to realise a need for obvious reasons, the first evidence in Britain of recognition of this need for a civil enterprise is to be found in the association of the Casualty Department, Nelson Street, Liverpool, under the direction of Hugh Owen Thomas and later Sir Robert Jones, at the time of the construction of the Manchester ship canal in 1887. Since then we have seen the Industrial Medical Services develop in association with particular enterprises, with the more hazardous 24 hour responsibility. Nevertheless, for the whole community there has been no clear acceptance of a special need in spite of the number of casualty attendances. They now amount to 10% of the population per annum and equal the total number of out-patient attendances. They are at present increasing at the rate of 1,000 per 100,000 population per year, perhaps an indication of the endeavour of our time. The main burden of providing this service has fallen on the hospital and this seems to be conditioned by the contingencies of the situation. The hospital is central, available over the 24 hour period, can deal with large numbers, and is most appropriate for the more serious case. By and large, attempts to limit or redistribute attendances not surprisingly have proved ineffective. The way in which the hospital service has evolved during this century to meet the
CASUALTY SURGEONS ASSOCIATION: PAPERS
257
increasing demand, itself forms a chapter in the history of medicine. Great changes have been made and, the hospitals have generally become more and more orientated to emergency care. Certainly, in all specialties, more cases are admitted through the Emergency Room than ever before. Especial mention should be made of the advances made by orthopaedic surgeons, who have provided almost universally, the daily fracture clinics, and of the administrative medical officers who have provided our many new Accident and Emergency departments. It cannot be said, however, that development has occurred without controversy. Even the newly adopted title ‘Accident and Emergency’ - designed to limit abuse (by the public, if not by the hospital) contains an unintended but, nevertheless, at times, confusing duality (Rutherford, W. H. [email protected], vol. 6, no.4, 1975, page 363, and vol. 7, no.2, 1975, page 96). It has had the reverse effect. Almost.every specialty, and these have increased considerably, has expressed its concern and attempted to maintain a 24 hour service. Controversy has mainly been about the best way of integrating the many specialties involved into an effective homogeneous emergency organisation. The problem of whether to deal with trauma throughout by a traumatologist or a team of specialists, or to leave assessment and resuscitation to a high-grade generalist, is an example in point. Most of the arguments have appeared in specialised journals and in very many separate official reports. The most consistant recommendation has been for one leadership (Nuffield Trust Report Casualty Services and their Setting, 1960) and for an administrative authority (Report of The Central Health Services Council Accident and Emergency Services, 1962). Authority has in fact passed from Staff Committee to Accident and Emergency Committee and from the general surgeon to the orthopaedic surgeon, and now - where it is most likely to be effective, within the Emergency Department - to the casualty consultant. It is self-evident that there are many administrative problems in the casualty department, as it stands between the displaced section of the community on the one hand and the large number of sophisticated specialties on the other. The casualty consultants have here, too, gained much in discussion at their meetings and look forward to further exchanges in these pages. If there had been a publication focussing on the organisational problems within the department the development of Emergency Care within the hospital might have been easier. The success of any emergency operation depends as much on organisation as it does on the will to help and the expertise and facilities available. It is hoped that these pages will more clearly identify the aim, and help to achieve a more dynamic and ‘Integrated Emergency Service’, through the contributions to them from all concerned.
