Cork University Hospital’s Emergency Department (CUH ED) is now the busiest in the country seeing over 65,000 patients per year. CUH ED provides emergency care to adults and children and caters for all emergencies from major trauma, stroke, heart attack, sepsis to so-called ‘minor’ injuries, but the varying reasons many might make a visit aside from the above, can differ. Dr Gerard McCarthy, consultant in emergency medicine, CUH, outlines the various reasons.
“People come to the emergency department in three big ways: One is they are brought there, two is they present themselves there, and three is that they are referred there. Brought there can break down into by ambulance which makes up to 20-25% of attendances at CUH or a mixed emergency department of all ages, or anywhere outside of Dublin. The other is by a concerned carer or relative. In terms of people who are referred there, this would be by a general practitioner, although we would get referrals from optometrists, physiotherapists, other healthcare practitioners whereby people present to them for one reason, but the healthcare practitioner is concerned that emergency treatment may be necessary. Finally, we have people to self-present themselves in an emergency. And what is interesting is that there is far less difference between each of those groups than you might initially think.”
Speaking about ambulance presentations, Dr McCarthy would like to disband what he calls an “urban myth” which is that calling an ambulance makes no difference as to how quickly you will be seen in an emergency department.
“We are there to catch you when you fall with an emergency if you like, so if you think you have a life-threatening or life-altering emergency come on in and we’ll help you. However, the message can be presented falsely that ambulance care means you’re seen quicker because human nature is such that someone who did present with a life-threatening emergency and was seen immediately because they needed to be, tells someone else, ‘oh, they saw me immediately because I came by ambulance’ – which is not the way it works.
“We’re not able to see people in order of time of arrival for a comprehensive clinical assessment. We ask them, and then, the purpose of triage is to get those with these serious, urgent things seen faster, but other people will wait longer. That’s not to say that you don’t have a long-term serious illness. But it is to say that we cannot see something that needs urgent clinical intervention over and above the other patients.”
He highlights the triage process when it comes to processing what constitutes who will get seen first when it comes to urgent emergency care.
“Triage is applied by trained staff, generally nursing staff and is a very well-validated, internationally recognised means defining the urgency with which we need to do something. So what I often say about triage is, it’s kind of looking for the needle in the haystack. We get 1.3 million attendances in emergency rooms every year and about 300,000 of them need to be seen urgently.” And in terms of examples of that urgency, he explains you’re talking about potential chest pain, strokes, heart attacks and strokes and so on. “Obviously, if you’re unconscious, all of a sudden, that will get you right up there or anyone who presents with a disorder of the heart rhythm such that there’s a risk of them having a cardiac arrest will obviously be seen really promptly.” “Triage is really based on your symptoms, so many can present with chest pain, for example, that appears to be a heart attack, but isn’t. And if you say you have a pain in your chest, head or stomach, the triage nurse will then apply a series of questions, which will help to define it as likely to be serious versus not likely to be serious. And there’s about 50 or 60 different types of presentations,” he says.
“So what I tend to say to new staff coming in, in terms of the triage priorities, we have five of them. One and two are the most urgent and triage category one is actually only about one to 2% of our presentations, which are the really time-critical cases – this is a ‘leave the patient you’re with’ type of case. Triage category two, which would typically be your heart attack, your breathlessness but not unconsciousness, I’d say to medical staff, that’s the next patient you need to see.” Generally, people present themselves or are preferred to an ED for the following reasons, as Dr McCarthy points out.
“The most common ones we would get consistently are people presenting with chest pain, breathlessness and abdominal pain, followed by what we call a limb problem, generally an injury. The triage process would be designed to capture the odd patient who presents with a pain in their arm, but it’s really their heart. So those four: chest pain, breathlessness, abdominal pain and limb problems, tend to be the most common problems reported, no matter what department you go to, in varying order. Essentially, the kind of symptom or pain that stops you in your tracks means we need to investigate a little bit further.”
“The call taker on 999 is trained to go down to a list of symptoms, which are broader than triage, to get to that needle in the haystack, the person who needs the ambulance straight away, versus the person that can wait a little bit longer. The chain of emergency care begins with that call, or someone bringing you into the ED, and we will do the appropriate from there.”
When it comes to the ED, its staff are providing vital services and Dr McCarthy is keen to stress that certain misconceptions should be disbanded.
“A misconception that pains me, if you like, is the widespread belief that the worst possible thing that could happen to you is to end up in an Emergency Department,” he continues. “And this came out during COVID, that people who should be coming to us with chest pain and possible stroke, and all that kind of thing, don’t come to us, because all they can think of is three days on a trolley. The trolley issue is related to capacity throughout the entire system, not just the hospital. And what we often say about unscheduled care is it’s actually a remarkably predictable part of the system in general – COVID and cyberattacks aside.
“There is a relatively constant number of initials every day and sometimes they end up staying longer in hospitals and that affects how many beds are available.
“The trolley issue is no one’s idea of a good time, but we are worried as a speciality, that people with genuine emergencies will stay away – very often elderly people who are of a generation that don’t want to cause trouble, for example. One of the issues we have is the increasing elderly patients who are frailer in that there’s things a younger person will bounce back from that an elderly patient will not. So there’s great work going on with an older person’s programme, for example, to try and provide alternative services for elderly patients in the community.”
“The difficulty that we have is not people who present believing that they have a genuine emergency, but it turns out they don’t. That’s our job – to find out and reassure them and treat them humanely and give them relief of pain and that kind of thing. We just don’t want people who are our core business, i.e. those with life, organ-changing problems to stay away.”