Why Getting To The Right ED Is Better Than Getting To Any ED

Summertime.  Gala season in West Lothian.  

Bunting, burgers, bouncy castles. 

Beer, Buckfast, bust-ups, blades.

As night follows day, when British men and women drink in excess, tensions are unmasked, comments are misinterpretated, and the subsequent cultural response manifests itself as inter-personal violence.

Gary was doing that most dangerous of pastimes at the Gala at 5 in the afternoon after a day of “celebrating” – minding his own business – when he thought he had been punched in the belly.

5 minutes later, he was slightly startled to see blood soaking through his shirt, and having a closer look, even more surprised to see what looked like some inch wide worms squirming through the considerable wound in his abdominal wall.

His small intestine has made a bid for freedom.

The original crowd of miscreants has scarpered, and the next crowd of curious well-wishers rapidly gathers (all experts in penetrating abdominal trauma naturally).  An ambulance is called, and arrives at the scene rapidly.

Gary is loaded into the van, and the paramedics put an intravenous drip in Gary’s arm.  They give some pain-relief through this, and take some vital signs.  Gary’s pulse is fast, but his blood pressure is OK at the moment.  They cover the wound and his bowel loops with saline soaked gauze, and attach some fluids to the drip in case they are required en route to hospital.

There is nothing else that the paramedics need to do or should do at the scene.  The diagnosis is not in doubt, and they rightly assess that the most important next step is to get Gary to the nearest appropriate Hospital.

This is not the nearest hospital.  This is the nearest appropriate Hospital.

The paramedics get the lights and sirens on and hit the road.  St. John’s Hospital in Livingston is approximately 7 minutes away.

And they drive right past it.  


Of course, there is an Emergency Department at St. John’s Hospital – an excellent one that has great medical and nursing staff and provides care to a high standard to over 50,000 patients a year – but in some conditions where time to definitive treatment is the most crucial factor in a patient’s outcome, patients must get to the Hospital that can provide that definitive in-patient treatment most quickly.

Less than 20 minutes after passing St. John’s, the crew arrive at the Royal Infirmary of Edinburgh Emergency Department.

En route, the team have been alerted to the patient, led by the Emergency Medicine Consultant (who, incidentally, also works at St. John’s).  This Consultant quickly assesses Gary whilst simultaneously organising the rest of the team to get vital signs, X-rays and blood tests completed.  

Gary’s injury requires immediate surgery by a General Surgeon.  The surgical and anaesthetic teams are called and attend the Emergency Department within 5 minutes.  

Gary is whisked away to one of the emergency theatres less than 30 minutes after arriving at the Royal Infirmary, he has his bowel inspected under anaesthetic, a small (life-threatening) hole in it repaired, his abdomen washed out thoroughly, and the wound closed.  

Any contamination to the abdomen and life-threatening blood loss and infection has been limited by the rapid transfer to the Hospital where there is the Emergency Medicine, General Surgical and Anaesthetic expertise to deal with this particular injury as a team in seamless fashion.  One part of the team without the others is like trying to use a stool with only one leg. 

Gary does well, and is home in less than a week.  He has vowed to stop “minding his own business”.


Time well spent

All of us want the best for ourselves and our families when we have the misfortune to require the NHS in an Emergency.  In some cases, like Gary’s, that requires a collection of experts to all have input into a single patient’s care.  To be an expert at something, though, requires lots of training, and lots of practice.  If we had experts at every Hospital, then they would lose their expertise as their ability to practice their skills becomes diluted.  

This is why expertise is concentrated where the need for those skills is in most demand, or we set up systems to allow patients to have contact with experts in timely fashion.  This is true in conditions like major trauma, stroke, and major heart attacks, where the time to get the right intervention is critical.

This consideration of the timing of the whole episode of care, not just the time to get to a Hospital, can save lives.  

If Gary had gone to St. John’s first, he would have got there more quickly for sure, but he would have had to have been booked in, assessed, and then a transfer arranged to the Royal Infirmary to have that all repeated.  Despite the best will in the world, that would only have harmed him.