RIP EM

Who will miss us when we are gone?

Emergency Medicine has had a red form completed. Talked about in hushed tones, its prognosis is recorded as “guarded” with a likely poor quality of life. Those watching it desperately struggling want it to be allowed to go now and for the suffering to be over. Even the specialty itself has agreed with its carers that it can’t go on like this. 

Overcrowded, miserable, making mistakes, Emergency Medicine is no longer coping, letting people down and making them cross. Its vital sign, the Four Hour Target, has been permanently in the red zone of its observation chart. Tales of its failing and flailing in the press make everyone uncomfortable, especially politicians. The patients in corridors, ambulances stacked outside, and the red 999 calls unanswered in the community serve as grotesque external symptoms of an underlying necrotic process.

So, arrangements are made for its demise. Resuscitation is to be handed to tertiary specialists for them to argue amongst themselves over who will look after the kaleidoscope of the undifferentiated unwell. Paramedics will need to call phone lines before transporting and be advised where to take their 999 calls when ED is no more. Some patients will be left with their problem at home, some will be signposted to community services that may or may not have capacity or even exist, and some will be shoehorned into clinical decision pathways that allow rapid one-disease-only processing in a same-day unit. Walk-in patients will be redirected to ABH (Anywhere But Here) unless they need resuscitation or can be made to fit one of the specific pathways. Once the last rite arrangements for Emergency Medicine are complete, the oxygen of staffing will be turned off, the monitor of four-hour target will be silenced, and the inotrope of senior experience will be discontinued.

Who will mourn its passing? For sixty odd years the Emergency Department has been a beacon of the welfare state. A place that in physical form, boldly stated that all people are important, equal, and worth saving. A light always on for lords and laggards. It became expert in ruling out and in tricky serious illness like subarachnoid haemorrhage, acute coronary syndrome, abdominal sepsis, meningococcal disease, tricyclic overdose, ectopic pregnancy, head injury and aortic aneurysm – especially in those high risk populations that felt unwell enough to call an ambulance. It skilled up to provide time critical treatments to ensure that vast teams of specialists did not need to be on hand all the times to intubate, start pressors, insert lines and tubes, treat severe sepsis, cardiovert, reduce fractures and dislocations, and sedate agitated delirium. It advocated for patients needing admission or specialty care even in the face of reluctance, resistance, and sometimes frank hostility from those guarding lofty silos. It took out rust rings, fishhooks, bits of Lego and misplaced vibrators.

Is it too late to ask for a review of the terminal diagnosis - without the boot of exit block on its throat? Especially given the number of its dependents.