TRANSPARENCY for EQUAL ACCOUNTABILITY in MEDICINE

January 7, 2008

THE “GOLDEN HOUR” IN TRANSIT? – PROPOSED NHS “RESTRUCTURING” TARGETS A&E AND MATERNITY CARE WITH DANGEROUS CUTS THAT WILL COST LIVES.

The Golden Hour” in Emergency Medicine refers to the critical time frame following a serious or multi-system Trauma where intensive rapid intervention through definitive care in Surgery is vital to the patient’s chances of survival.

         This critical time frame, know as the Golden Hour, has governed American EMS, (Emergence Medical Services) planning and preparedness by dominating decision making regarding their complex nation wide network of Trauma response coverage for decades. It has remained the cornerstone of all EMS training throughout the US.  NHS restructuring touting potentially improved Trauma survival statistics, endorsed by this highly successful overseas model, must acknowledge the core principals of rapid intervention on which it was based.

American EMT’s and Paramedics are taught that their portion of the “Golden Hour” should be confined to ten minutes or less at the scene prior to rapid transport!  

But, will Government “restructuring” plans for the NHS ignore the necessary logistics of rapid transport?

        The Golden Hour concept evolved from US military experience, primarily during the Vietnam War.  The catastrophic Trauma of battle; multi-system failure; damage to vital organs; massive internal bleeding; extensive areas of burned tissue; shattered or severed limbs: in such cases nothing replaced immediate Surgical intervention.  Unable to withstand the abnormal stresses imposed on vital systems by such serious defects, the body deteriorates extremely rapidly: a process called decompensation. It was preventing the onset of shock with rapid decompensation that first dictated the urgency of transporting Trauma victims to a place where definitive Surgical care was available.  As a military Surgeon the late Dr. R. Adams Cowley recognized the significance of rapid transport to definitive care, noting that the chances of survival dramatically decreased following delayed Surgical intervention.  Credited with promoting this strategy, Dr. Cowley coined the term “Golden Hour” to describe what has now become a widely accepted critical time frame for Trauma survival. 

          Dr. R. Adams Cowley went on to develop the first clinical shock Trauma unit in America. This was made possible when, in recognition of his many years of groundbreaking research, the Army awarded him a $100,000 contract to study the impact of shock. The initial two beds became four as staff were specially trained and equipment installed by 1960.  Patients referred by other Doctors were ominously close to death when they arrived and the unit gained a morbid reputation as the “Death Lab.”  Dr. Cowley and his team focused on this critical phase of treatment and proved that, with their rapid intervention and highly specialized skill in operating procedures, a few could be saved. In pioneering this concept Dr. Cowley identified a “Golden Hour” between life and death where critically injured patients demonstrated a poor prognosis for survival if treatment was delayed beyond the first hour. He believed that even when death was not immediate following delayed intervention, irreparable damage predicted the patient’s inevitable demise.

Dr. Cowley described shock as:  “A momentary pause in the act of death” 

             His goal was to reverse this seemingly irreversible process.                       

University of Maryland Medical Center – R. Adams Cowley Shock Trauma CenterFor more information Visit:       http://www.umm.edu/shocktrauma/history.htm  

  

Some still  question the validity of a rigidly defined  “Golden Hour,”  but their doubts about this specific time  frame do not  negate the  core principals of  rapid  Trauma intervention.    In reality, to imagine that any critically injured Trauma patient might benefit from a delay in treatment necessitated by a protracted road journey is patently ridiculous! 

WORLD WAR I DATA SUPPORTING THE GOLDEN HOUR IN EMS

Above data found at:    http://www.trauma.org/archive/history/resuscitation.html 

The current focus on proposed restructuring dominates vital Trauma funding for the NHS, but attempts to selectively cherry pick the information that best suits drastic Government cuts!

     Well-documented time-critical treatment considerations exist in certain cases: 

  • Stroke Patients:  A risk/benefit 3 hour window of  opportunity exists  where the  risk of  major bleeding complications  is  outweighed  by  the  benefit  of  administering  clot-busting  drugs.

  • MI  (Myocardial  Infarction)  –  Heart Attack Patients:  “Time is Muscle;”  rapid  intervention  to  define and stabilize fatal  arrhythmias can prevent  sudden Cardiac death.  Reduced  mortality is time dependant  with a direct relationship between  time-to-treatment and the success of reperfusion  (restoration  of  blood  flow  to  the  heart).

      However, it is overly simplistic for the Government to selectively cite any one aspect of emergency response because in reality Medical emergencies are extremely varied. True, life saving rapid access to defibrillation can be performed by Ambulance crews, or an even less experienced layperson using a fully automated defibrillator (AED). 

So what else can we realistically expect from our trained Paramedics? 

While Ambulance crew can administer fluids in transit, they cannot combat the massive blood loss that requires definitive care in Surgery: they must “Scoop and Run.”   

        Trauma  injuries often require immediate  Surgery and  delayed access to definitive care will severely  compromise the possibility of survival.  Perhaps the most vulnerable constituents to be impacted by proposed cuts to emergency services at NHS Hospitals are those who don’t yet support the current Government?  Their voices will remain unheard for now as they are still far too young to vote for anyone!  The fact is that children decompensate far more rapidly than adults.  Too late to wish that we had opted to salvage the local A&E when the tragic death of a toddler hits the headlines or a fragile premature infant fails to survive the ride to definitive care elsewhere after a complicated delivery inside an emergency vehicle in transit.

HOW DOES EMS RESPONSE COMPARE THROUGHOUT THE EUROPEAN UNION?   PowerPoint Presentation           Review the European Emergency Data (EED) Project – EMS Data-Based Health Surveillance:  http://ec.europa.eu/health/ph_projects/2002/monitoring/fp_monitoring_2002_a1_frep_07_en.pdf

                                                                                                              

If the Medical Emergency or Trauma patient reaches a critical “Tipping Point” in their Medical crisis while still in transit the highly experienced team at a remote “Center of Excellence” Hospital will be too late to compensate for the damage!   

SO WHY IS THE NHS CONSIDERING  A&E  AND MATERNITY DEPARTMENT CLOSURES?

I fail to understand how this could possibly be in the best interests of tax payers served by the Hospitals where these drastic closures are scheduled to take place, especially in the light of important new research evidence.   

DIRE WARNINGS FROM A NEW REPORT:   Sheffield  University  Researchers  found that the longer the Ambulance journey took the more likely seriously ill patients would die.  

        Researchers  assessed an increase in the  risk of death in  relation to  distance traveled to  receive care:  for every 10km it rose by 1%.  In a study of rural, urban and mixed areas in England made between 1997 and 2001 over 10,000 life-threatening calls to four Ambulance services were reviewed.  People with breathing problems had a 13% chance of dying if the distance to Hospital was between 10km and 20km, but this increased to 20% if the distance was 20km or more.  Because a longer journey time to Hospital appeared to result in an increased risk of mortality for certain patients with life-threatening emergencies, researchers argued that closing local A&Es might increase the number of deaths among this small cohort of patients. The conclusions drawn from the Sheffield University Study were published in the Emergency Medicine Journal, calling into question Government proposals to close community Emergency Departments in favor of fewer, more specialized centers.                 For Links to access this report GO TO:

                                                   http://emj.bmj.com/cgi/content/abstract/24/9/665 

        Dealing with a chronic life-threatening condition in a youngster who might have needed to make frequent trips to local A&Es in the past is a constant emotional drain for already overwhelmed families.  Parents who have suffered the anguish of seeing their child struggling for breath during rapid emergency runs to the nearby Hospital cannot imagine the justification of risking any child’s life by prolonging this torturous journey to accommodate Government cuts!  They often become very familiar with the staff and feel confident in the care delivered locally.  They harbor justifiable concerns over whether axing vital services at community Hospitals will seriously endanger their child’s chance of surviving a future incident.  With all the money being expended on our  NHS  these dutiful parents do not deserve any additional anxiety and  understandably they  want their  children  treated  close to  home to  facilitate regular visits  without  extended travel.     I sincerely doubt that the Government has bothered to consider how families will manage to visit loved ones who are sent to Hospitals many miles away from where they live.

CONFLICTING INFORMATION MIGHT AT FIRST APPEAR TO BOLSTER THE GOVERNMENT’S CASE…                      The National Confidential Enquiry into Patient Outcome and Death, (NCEPOD),                      Just released a scathing report criticizing the standard of Trauma care in the UK.

To download this report Go To:         http://www.ncepod.org.uk/2007report2/Downloads/SIP_report.pdf 

       “We found that the  organisation of  pre-hospital care,  the trauma team response,  seniority of  staff involved and immediate in-hospital care was deficient in the majority of cases,”                                                                           said NCEPOD Clinical Coordinator, Dr.George Findlay.                                     The number of patients seen has a direct bearing on the experience and ability of clinicians to manage challenging cases,”   he added.

       Findlay  suggested new  protocols  allowing  Ambulances to  bypass the  nearest  Hospital  seeking more specialized treatment elsewhere; however this provision existed back in 1963 when following my mother’s car crash a severely injured fellow passenger was rushed to East Grinstead under police escort. I doubt Findley intended to endorse the wholesale downgrading of so many regional A&Es across the country. The enquiry found that NHS Medical staff often failed to appreciate the severity of illness, displayed little urgency in caring for patients, or made incorrect clinical decisions; this clearly demonstrates the need for significant improvement through additional investment in training. 

        In US  Trauma Centers like  Ryder at  Jackson Memorial,  a teaching  Hospital in Miami, besides the Medical Director and a select core of veteran Trauma specialists, most of the  Doctors leading Trauma teams are completing their Trauma rotation, not necessarily with years of experience handling hundreds of complex cases. A Trauma fellowship candidate spends a longer period working within a teaching facility like Ryder in preparation for a career elsewhere in the country leading the team at another Level One facility.   A consistent standard  of Trauma preparedness is sustained among the regular Nursing staff and Techs who must all maintain at least ACLS (Advanced Cardiac Life Support) and often PALS, the Pediatric equivalent, as do a reasonable percentage of all ER staff.  Short certification courses, like ACLS, PALS or PHTLS, (Pre-Hospital Trauma Life Support), taken on a regular basis, are certainly a vital, affordable training option that must receive sufficient funding.  The proposed centralization of Trauma receiving units in the UK might well attempt to deny the need for this essential  training regimen or cruciaL disaster preparedness among staff at downgraded local facilities.

 

This current Government is setting the stage for disaster by creating an extremely dangerous situation where it will be logistically impossible to contend with a serious Mass Casualty situation with so few trained personnel at only a very limited number of selective locations. 

          I question  why we  should  accept  that  what is  often the last  remaining  Hospital in a  sizable town with a  rapidly expanding population cannot have an experienced Trauma team on call with the necessary organization and support structures, especially where they already exist today.  Despite numerous local Hospital closures to achieve centralization of care, the Government is seriously contemplating diminishing access even further, rather than responding appropriately to the demand for more training among personnel. Commenting on the report Dr. Jonathan Fielden, Chairman of the BMA (British Medical Association) Consultants’ Committee, confirmed that it demonstrated how Consultant expansion was vital to improvements necessary to reach the “Gold Standard” for Trauma. The BMA endorsed NCEPOD recommendations for Consultant led teams in the management of Trauma patients to achieve the best survival statistics.  Lack of sufficiently qualified Consultants within the NHS to provide coverage for local Hospitals and insufficient experience dealing with the complex injuries sustained in a major road accident were cited as the main reasons for substandard performance.

This is difficult to reconcile after witnessing our eager young Doctors marching in protest over lack of placement opportunities in this country!  Why aren’t we targeting fulfilling this need for more trained Consultants in Emergency Medicine rather than closing existing A&Es?

         British  survival  statistics  do not  stack up well  compared  to  other  industrialized  nations   like  the  US, but does this justify the concept of Trauma specialty centers funded by closing A&Es?  This is misguided; it requires a lot more thought before we rush to judgment regarding how to revamp EMS throughout England. Analyzing both practices and survival statistics in the US makes sense as we work towards achieving that “Gold Standard” for Trauma.  America has a network of dedicated Level One Trauma Centers, some of them highly sophisticated stand-alone Trauma facilities, plus Emergency Departments at most local Hospitals.     

        Major logistical differences that have dictated how this system was organized in the US should not be ignored.  There are vast distances to be taken into consideration in the US as they try to provide a safety net that does not exclude communities in sparsely inhabited remote rural areas of the country.  However, even relatively small towns in rural America still have a Hospital with an Emergency Department, and that isn’t solely because it’s the only resource for the uninsured.  With more guns in circulation, there is a much higher incidence of violent crime and penetrating Trauma in the US, but we are starting to see more of these types of injuries in the UK and we should prepare staff to handle such cases.  Americans insist on the independence of vehicle ownership, in some remote areas it’s a real necessity, but many people still drive their car well beyond the point where they are capable of driving safely.  America also has an alarmingly high rate of heart disease so rapid access to definitive Cardiac care is a big priority in EMS funding.       

       Undisputedly the dynamics are quite different, but the US has not achieved their success by closing Emergency Departments in an “either/or” fashion as is being suggested in the UK.  Improved results for Cardiac Arrest have not been accomplished by reducing the number of specialist treatment  facilities.  Seattle, Washington  achieved an  impressive record by establishing the “Chain of Survival” with a combination of ACLS trained Hospital staff; excellent Paramedic manned Ambulance fleets; a comprehensive Air Ambulance service for rapid transport from rural areas; Automatic Defibrillators (AEDs) in shopping and community areas; plus public sector awareness and training.  AEDs can enable relatively inexperienced citizens to provide early, life saving, intervention even before an Ambulance crew arrives on the scene, but that doesn’t mean critical patients should then endure an unnecessarily protracted road journey.  

So how will the NHS improve Emergency Services to stack up against this US model? 

  • Will there be more ACLS trained Hospital staff or will funding such training focus on “Super Centers” alone?  
  • Will the Government fund more highly trained Paramedics in greater numbers for local Ambulances?  
  • Will the Government take over the funding of Air Ambulances for rapid transport to Centers of Excellence?  
  • Will private businesses and public spaces provide AEDs for use in Cardiac Emergencies?
  • Will there be greater emphasis on funding awareness and training of ordinary citizens in the community?

Establishing so called “Centers of Excellence” does not justify any significant cuts on the local level or a drastic reduction in funding for EMS personnel at most local Hospitals, as proposed by the Government, since all of the above points are necessary to achieve genuine success.  

         In the US the majority of standard emergency cases are still directed towards regular ERs even in urban areas where several ERs and possibly more than one Trauma Center serve a dense inner city population.  Severe Trauma cases benefit from rapid transit by Ambulance if they are within close proximity of the Hospital, but for greater distances they are flown by Air Ambulance to the nearest Trauma facility.  The use of helicopters in the US is dictated by the vast distances that must be covered, not by the absence of trained emergency personnel in all but the largest of towns and cities across the country!

                                                                                           

The Government is choosing to endorse successful aspects of the American Emergency Management system while ignoring inconvenient logistical details like the additional cost of using Air Ambulances for rapid transport or suffering the consequences of serious delays on the road.   Taking the “rapid” out of “rapid transit” will ultimately cost lives!

        Rapid transport is the key to remaining within the Golden Hour that has dominated the emergency response system in the US for decades.  American Level One Trauma Centers would not have such excellent statistics on saving lives if the precious time critical to the survival of patients with catastrophic injuries from a car wreck was squandered just getting to the facility!

Will NHS restructuring just create a logistical nightmare with regard to patient transport?

       The shift in focus from locally managed Trauma coverage to centralized treatment in heavily touted “Super Centers” will require more Ambulances, with additional trained personnel, to cover longer journeys by road. It will also increase the burden on Air Ambulances with more frequent use of rapid transit from areas where the current A&Es are scheduled to close.  Helicopters are prohibitively expensive to operate, but is the grater reliance on air lifting patients to Super Centers even being taken into account? In the UK Air Ambulance services are managed differently depending on regional funding. In England and Wales they are funded by various local charities targeting the specific coverage needs within each region; in Scotland the national parliament agreed to state funding. Will charities be expected to somehow cope with the increased demand for their services or will Government funding take over paying for the growing need?  

         While America’s minor rural Hospitals still maintain an ER and Maternity services, this Labor Government is proposing to means test sizable towns throughout England to selectively close existing A&E, Maternity Departments, or both, based on current population density that marginalizes the impact of immigrants.  When I was a child there were four Hospitals in my home town of Hastings with an A&E, plus a choice of two local Maternity units and a separate Hospital in Rye. Despite the campaigning efforts of Sir Paul McCartney, Rye Hospital closed.  Only the Conquest Hospital remains, now ravaged by threats to close our last local A&E and limit Maternity care.  Meanwhile the population has mushroomed with a huge influx of refugees and eastern European immigrants, but this downgraded access is disgracefully portrayed as improving the standard of local services.

                                                                                                                                                                                                                                                             

Please visit Hastings “Hands of the Conquest” Campaign:  http://www.handsofftheconquest.org.uk/                                   For a list of Links to NHS Hospitals threatened with closures GO TO:   http://www.savethedgh.org.uk/   

        Our  Government is still  trying to ascertain  the exact number of people  entering the UK and  their estimates remain way off the mark.  Citizens worry about the impact that uncontrolled mass immigration is having on the delivery of local services like Medical facilities. Towns with widely underestimated numbers of undocumented migrants are judged to have insufficient population density to warrant keeping their local A&E.  The authorities that feel the most overwhelmed by recent waves of immigration are still obliged to provide public services no matter how they feel about the question of whether migrant workers benefit the economy.  For most UK residents it is not the arrival of people from overseas that concerns them it is the harmful impact when critical services like Medical care become overwhelmed.  

         This is hardly the time to start  inappropriately downgrading critical aspects of the infrastructure like our Emergency Departments, while we still have no real control on how many more people will arrive from overseas.  We should instead respond to the growing demand on local services by investing in insuring that adequate E&A and Maternity provisions are put in place at local Hospitals in anticipation of increased population growth as we continue to reap the benefits of the boost foreigners bring to our economy. 

 IS THIS ABOUT PROMOTING THOSE IMPRESSIVE “CENTERS OF EXCELLENSE?”

NO:  IT IS ALL ABOUT COVERING THE SHORTFALL IN MISMANAGED NHS FUNDING!

         While the unhealthy emphasis on “quotas” and the demand for religious monitoring of waiting times continues to divert precious resources towards redundant paperwork, an excessive number of pen pushers and unnecessary administration costs, Hospital patients will repeatedly suffer the consequences of depleted care.  What I refer to as “Deliberate Negligent Understaffing” of Hospital units is now no longer confined to greedy Corporate Healthcare giants in the US, it is a UK problem too.  With the huge increase in funding that has been pumped into the NHS, British tax payers deserve significant improvements in services not a dangerous reduction in local access to care. 

        Closing an Emergency Department has a knock-on affect that heralds further problems with sustaining other clinical units.  Surgical patients who normally enter via the A&E are treated elsewhere, so the Surgical Department is then downsized; other clinical areas are impacted and suffer a similar fate, threatening the viability of the Hospital.  When it becomes too late to reverse the damage of closing the ED, what will our Government tell us if those precious “Centers of Excellence” do not fill the void?  What excuse will they give when Super Centers fail to receive the necessary Government funding or become too overwhelmed to function as well as expected.  Will they too be stymied by cost cutting, crippled by understaffing or buried in the redundant paperwork of painstakingly nitpicking the details in typical NHS fashion?

                                                                                                     

The potential logistical complications and the  inevitable  consequences could be devastating.   We need to think very carefully and proceed with great caution before removing existing services at regional Medical facilities as we could pay a high price in human suffering and it will be extremely costly to undo the damage.

                                                                              

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Text in Blue: Concise definitions and data obtained from Wikipedia or other sources included in the cited Links.

WHAT QUALIFIES ME TO VENTURE AN OPINION ON THIS SUBJECT?

         Despite frustrating complications that have blocked my transition into an equivalent job role working within the NHS, on the subject of Emergency care and the rapid treatment of Trauma victims I feel more than qualified to render an informed opinion regarding the A&E “restructuring” proposals for the UK. I speak from years of experience working within the American EMS (Emergency Medical Services.)

         I was originally trained as a Wilderness and US National Registry EMT, (Emergency Medical Tech).  I spent three years working at the second busiest ER (A&E) in the America, Jackson Memorial Medical Center in Miami.  On weekend night shifts I joined the Trauma Resuscitation Team at Ryder Trauma, Jackson’s stand-alone Trauma Centre, a second generation state-of-the-art Trauma receiving facility in Florida that accepted critically injured patients from Miami, the Florida Keys, the Bahamas and the entire Caribbean.  I also trained as a Disaster Response Volunteer with the South Florida D-MAT (Diisaster Medical Assistance) Team, a reservist multi-disciplinary response unit, “Federalized” for deployment to provide Emergency Medical Services following a major national disaster like Katrina.

         After training as a Surgical Technologist I moved to Baltimore, Maryland where I worked at Johns Hopkins, another Level One Trauma Center.  My second specialty area of training encompassed providing care to Trauma victims in a city with an average homicide rate of over 300 a year!  During my five years in the OR (Theatre) I dealt with the devastating consequences of urban violence as Hopkins was the principal receiving facility for “Penetrating Trauma” (gun shot and stabbing victims).  My regular assignment working busy weekend nights during my last two years at Hopkins dictated my main Surgical specialty: Trauma and Transplant.

       I worked as a Disaster Relief Medical Volunteer after Hurricane Andrew in the US and for six months in Aceh, Indonesia after a massive tsunami devastated Asia.  In addition to assisting in Surgery at Cut Nyak Dhien Meulaboh Hospital, at the request of top functionaries at WHO and UNDP, I wrote the comprehensive report:  “Capacity Development of Emergency Preparedness Planning for Meulaboh.”  Because of my ongoing interest in Disaster Relief I have familiarized myself with every aspect of emergency response from the sophisticated network of rapid response in the US to the necessary practical compromises of a field Hospital after a major natural disaster.  

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