Small town excellence

Sometimes you have to turn things on their head and look at them in another way. I was made to recently by the boss…who had a slightly different (and of course far more experienced) point of view.

crackinthewall

I was grumbling to some colleagues about a subject that seems to be becoming my thing…the fact that where you live really shouldn’t determine if you live.

But it does.

Time and again I read and hear examples of this being so.

Scotland’s aeromedical service (@EMRScotland) only this evening pointed out on Twitter that London Air Ambulance (@LDNairamb) has 2 dedicated trauma teams on tonight, and Scotland has none. Northern Ireland has none. Dr John Hinds (@DocJohnHinds) regularly points out such inequalities and that trauma care in Northern Ireland is something of a lottery.

Where we live has consequences when things go wrong.

When my husband and I bought our beautiful cottage amongst the mountains we could not have been happier. For our youngest daughter, things were not so great. The day we moved in she became unwell. The bad nausea, vomiting, fever, photophobia, stiff-as-a-board type of unwell. I phoned the out of hours GP service and they sent an emergency ambulance. As Mr Edge went out into the dark to guide them to the house, I contemplated the longest time it would take to get us to hospital. I couldn’t help but question our decision to move so far from the big city.

But we chose to be rural and I know what you’re thinking. Scotland isn’t quite the outback…we aren’t relying on @ketaminh to fly us miles and miles across the land to definitive care, but none the less, where we live could have a huge part to play in whether  or not we live, should disaster strike. Distance to a local hospital might not be that great, but next stage distance to a teaching centre with ICU, neurosurgery, interventional radiology and dermatology (OK maybe not dermatology so much) being available on site must have an impact on the local population? Doesn’t it? Are there any studies?

Sure, we should strive to be centres of excellence in big cities, but we should be striving for even more than that if we are far away.

We have a brilliant District General Hospital. It is staffed by many talented,  enthusiastic and slightly eccentric but reliable and committed generalists. We are sometimes viewed by the specialists in the big city as being another ward of the Trust in which we all belong. Most of the time though we feel like the crazy Aunty that nobody wants to sit next to at a family wedding because she smells of mothballs.

Things are different here.

REBOA carried out on a London street to save the life of a young trauma victim is science fiction to us. If you suffer a traumatic cardiac arrest on the roads around here, you’ve had it. Sorry, did I use the word if? This is happening on local roads every single day just now. But I’m not just talking about the sexy trauma stuff. I’m talking about the other every day life changers: the tumours, the brain haemorrhages, the clots, the STEMIs and the time it could take to get you through the DGH system and on to definitive treatment.
Having a STEMI? The cath lab is quite far away, will thrombolysis do?
Emergency neurosurgery? Good luck with that.
Abdominal pain at night? Hi, I’m a new FY2 (seriously, that could be me you’re getting first).  I’m not really sure if DGH populations understand that? I didn’t before I came here.

The boss stepped in at that point…she stopped me in my tracks. She put it like this…

Of course it’s obvious that where we choose to live determines our chances….but our chances of what exactly?
Because of the geographical gap between us, it can make life harder to get people to the end result they might need but we do get people out the door and down the road when we need to. 
I believe that it is because we DON’T have all of their snazzy potential interventions and “things to try” at ANY cost, that we are far better at discussing and considering all the options, including death. Good old-fashioned end-of-life, death. We do palliation really bloody well. Sometimes, that’s what people really need and packing them off the big city might not be for the best. Providing a good death, with family nearby and consideration of comfort, dignity and DNACPR are as important when needed as ICU when it’s appropriate. I think we do that really well here.

She’s got a point.

The local population might not appreciate how different their care can be far from big teaching hospitals but maybe like me, they choose to live (and die) here anyway and for other reasons.

As for my daughter, after what seemed like a vey long trip, she jumped out of the ambulance, shone the pen-torch in her own eye and giggled on the long journey home with the packet of biscuits the nurses had given her. We didn’t sell up and move back to the big city. Not yet.

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I posted this blog post about 24 hours ago. Since then I have learned the sad news that Dr John Hinds died today in a crash doing what he loved…risking his life to save others. Northern Ireland deserves the same care services as the rest of the UK.

Where you live shouldn’t determine if you live…but it does. RIP Dr Hinds.

 

 

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