The Accident & Emergency (A&E) Department (also known as Casualty or the Emergency Room/Department) of your local hospital is very likely to be your first port of call if you are unfortunate enough ever to be injured in some form of accident or suffer an ‘acute’ illness (one that comes on very suddenly) and you require urgent assessment and treatment.
A&E doctors are trained in the fields of Emergency Medicine, including Trauma Medicine. The junior doctors are often known as Casualty Officers and the senior doctors as Consultants in A&E Medicine or Emergency Physicians. Emergency Medicine can be described as the field of medical practice based on the knowledge and skills required for the prevention, diagnosis and management of acute and urgent aspects of illness and injury, with the aim of providing around the clock care to patients who present with symptoms of acute illness and injury across the whole age spectrum. The doctors specialising in this type of medicine treat all types of conditions of acute onset, including relatively minor injuries, such as muscle sprains, to life-threatening conditions that require immediate treatment by way of emergency resuscitation.
The spectrum of problems and conditions that patients attend A&E with is huge, but the more common aspects of A&E and trauma work include: road traffic accidents (RTA) and other accidents at work or at home, often resulting in severe traumatic injuries, fractures and head injuries; acute surgical emergencies, such as appendicitis, bowel perforation, etc.; acute internal medicine emergencies, such as angina, heart attack (myocardial infarction), asthma attack, stroke, clot on the lung (pulmonary embolus), severe epilepsy (status epilepticus), etc.; drug and alcohol-related problems; and acute emergencies in children (paediatric emergencies).
If your illness or injury is not too severe, you will usually initially be seen by a “triage” or “assessment” nurse, who will take your details and then categorise you according to the degree of urgency with which you need to be seen by an A&E doctor. You may also have some routine investigations, such as blood tests and x-rays, in the meantime. However, if you require very urgent assessment, you should be seen almost immediately upon arrival by an A&E doctor. Following assessment and initial management, you may be discharged home (possibly with follow-up by your GP) or you may, of course, be admitted directly to a hospital ward under a different medical or surgical speciality. Some A&E Departments have their own wards to which you may be admitted for further assessment, treatment and/or observation before a final decision is taken.
Challenges of the A&E speciality include that many patients present without a known diagnosis (an “undifferentiated” illness) and/or present very unwell, requiring extremely rapid assessment and treatment. It is, therefore, often not easy to succeed in a clinical negligence claim relating to management in A&E, as patients are frequently already very unwell when they attend A&E and staff may be working in very difficult circumstances. However, things do go wrong, delays can happen and mistakes are made that can result in an avoidable detrimental outcome and a subsequent negligence claim, including for example:
- If a mistaken diagnosis has been made: for example, misdiagnosing angina or a heart attack as indigestion (“oesophagitis” or “gastritis”) and sending the patient home with the wrong treatment for the wrong condition;
- If a diagnosis has been missed: for example, missing a fracture on an x-ray, possibly resulting in permanent avoidable damage, e.g. in the case of a scaphoid fracture in the hand or a cervical spine fracture;
- If a diagnosis has been delayed: for example in a child, acute meningitis can result in severe neurological injury if it is not recognised and treated with antibiotics promptly; or, in an adult, an acute pulmonary embolus can be fatal if not treated with anticoagulation as an emergency.
A recent report published in November 2013 by Professor Sir Bruce Keogh, NHS Medical Director, stated that the A&E system was under “intense, growing and unsustainable pressure”, as a consequence of an ageing population and many patients attending A&E Departments because they are not sure where else to go. It has also been reported that A&E Departments are at “breaking point”. Over the last few years, the media has increasingly reported that our A&E departments country-wide are over-stretched and under-staffed, resulting in horrendous delays in proper treatment: in one case last year, one patient was apparently left for over 71 hours, with a further 12,000 people last year lying on trolleys in A&E for at least 12 hours.
Such problems can result in significant and unacceptable delays before proper treatment is implemented or staff inadequately assessing and treating patients because of pressure of patient numbers; this in turn can result in unacceptable and avoidable detrimental outcomes for patients. While there is political desire to reform how A&E care is provided, not least because it is likely to be an important issue in the run-up to the next election, sadly there appears to be little sign yet that patient care is going to change significantly for the better in the immediate future.