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Emergency measures in the public interest

Prof Patrick Plunkett has held many titles over his long and distinguished career in medicine. In October, he received yet another one — winner of the 6th Annual William Stokes Postgraduate Award. The Award was established in 2011 to promote continued innovative and clinical developments and research among consultants at Ireland’s largest university teaching hospital, St James’s Hospital, Dublin.

Nominated by his colleagues for his enormous contribution to the field of emergency medicine, Prof Plunkett was presented with the prize by Minister for Health Simon Harris at a ceremony in St James’s. He recently retired from his role as the hospital’s Medical Director following a 28-year-long career at St James’s and was described as an “unsung hero” by Minister Harris.

“I know that our young medical graduates will be inspired by the example of Prof Plunkett and the previous Award winners to set no limits on what they can achieve in the interest of medicine, in the interest of research and, most of all, in the interest of patients,” the Minister said.

A graduate of UCD, Prof Plunkett was appointed Emergency Medicine Consultant in St James’s in 1988. He is the Founding Fellow of the Faculty of Accident and Emergency Medicine in Ireland and was on the Education and Examination Committee of the Faculty for over 20 years. Trinity College Dublin also awarded Prof Plunkett the position of Clinical Professor in 2010.

“I was absolutely thrilled to receive the Award,” he tells the Medical Independent (MI).

Changes

Prof Plunkett has witnessed many changes in emergency medicine during his long career. However, whatever new changes will come, emergency medicine doctors still need to think on their feet.

“There isn’t always a given or set answer to a problem,” he says. “There is a lot of repetition but every now and again you come across something that you never met before but you have to go back to first principles and work it out.”

The ongoing crisis of overcrowding in emergency departments (EDs) is also something that will continue to affect the Irish health system, he adds.

“We have dug ourselves into a hole and it’s going to take an awful lot of effort to get out of it.”

Part of the reason for this is the reduction in bed capacity, as well as an ageing population with much more complex medical problems.

“They need to come in for treatment. They can’t be dealt with in primary care and they take longer to discharge. It’s a simple mathematical equation; we’re pouring a quart into a pint pot.

“We are running on very tight staffing on the wards also. In a Swiss or American hospital, you would have a separate housekeeping team who would come along, strip the bed, clean it, and turn it around and the nursing staff would just nurse, however it is nurses and healthcare attendants doing that job in our hospitals. We are trying to do an awful lot with fewer people and fewer beds.”

The effort is physically taxing on healthcare staff and can lead to a vicious cycle of demoralisation and emigration.

“I have always held the view that part of the solution in ED overcrowding is an increase in bed capacity. However, now we don’t have the staff to man those beds or operating theatres,” he says.

When asked about the full capacity protocol that is now supposed to be in operation in all public EDs in Ireland, launched with great fanfare last year by then Minister for Health Leo Varadkar, Prof Plunkett acknowledges it is still a source of controversy.

“It comes from the US and works in their system, where almost every patient is in an individual room and where a nurse’s station overlooks a corridor. It is more comfortable for the patient to be on a quiet ward than in the bustle of ED…. But the bottom line is there is insufficient capacity in the entire [Irish] system so the full capacity protocol in one sense is doomed to failure anyway.”

However, additional bed capacity should not equal more EDs. Ireland has too many smaller EDs around the country, he says when asked.

“You cannot get sufficient patients going through them to keep the skill level up. Volume is very important so you can keep your skills up to date… You need to consolidate and run departments well and properly.”

Prof Plunkett also has little time for moralising about some of the presentations that a typical ED sees.

“There is that whole issue that ‘It’s full of drunks and drug addicts who don’t need to be there’. They do need to be there. They may have lost their airway, they may be vomiting.”

He is also uneasy about the use of public funds to treat public patients in private healthcare facilities.

“I fear for the Irish health service. What troubles me, as someone who has worked in the public health service for decades, is we are putting more and more workload through the private sector and the private sector has to be making a profit to keep going. It must be costing more in the private sector than it would in the public sector if it were properly resourced.

“And I find that upsetting, to be honest.”

The public money used to purchase treatments in the private sector could be better spent in the public sector, Prof Plunkett maintains.

“If you take St James’s… we have done the lion’s share of colonoscopies (for decades). But our equipment has come to the end of its life and beyond that, but we can’t get it replaced within the budget from the HSE… efficiency has gone down because the HSE will not fund replacement equipment. Any other business would not do that.”

However, challenges in the healthcare system are being met too. While increasing waiting lists often make headlines, the increasing activity in hospital rarely gets the attention it deserves, he adds.

“There’s less budget, fewer personnel, fewer beds, yet we are getting through more admissions, more operations and more emergencies, so we are doing more and more with less and less.”

‘There’s less budget, fewer personnel, fewer beds, yet we are getting through more admissions, more operations and more emergencies, so we are doing more and more with less and less’

Ambulances

During the William Stokes Award ceremony, Minister Harris praised Prof Plunkett’s work, not only in hospital emergency medicine, but also with the Eastern Regional Ambulance Service and the St John’s Ambulance Brigade. He has also been reappointed by the Minister to the Pre-Hospital Emergency Care Council.

The recent Lightfoot report highlighted ongoing concerns over ambulance response times in Ireland, particularly in rural areas. However, a speedy response is secondary to appropriate treatment, Prof Plunkett believes.

“Unless you have an ambulance fully crewed 24 hours a day next to you, you are not going to get an eight-minute response time. What you do need is a good-quality response when you get it and for your local community responders to deal with the problem in the meantime.”

He suggests the US could provide a good model for Ireland to follow.

“In a lot of the country they have scattered populations and it’s the local community who provide the first response in a lot of cases. They all respond in eight minutes and they then hand over to the statutory ambulance service as soon as it can get there. So the patient has had the life-saving intervention and stabilisation in the first instance and then gets handed over. That’s a much more efficient and cost-effective way of doing things.”

Management

Last year, Prof Plunkett became interim CEO of St James’s for five months. It is an experience that left him with a new respect for hospital managers.

“It was one of the most interesting parts of my career. It’s a huge job and has engendered enormous respect in me for those who did it before me and since,” he says. “Doctors and nurses on their own cannot run a hospital; you need an administrative structure.”

At St James’s, the management system has tended to strike the right balance over the years, he adds.

On the new National Children’s Hospital, Prof Plunkett says he welcomes it and that the choice of the St James’s campus is the right one. However, maintaining funding levels for the hospital’s services is key.

“If you let James’s fall apart, then the reasons for having the children’s hospital there also falls apart.”

Following his retirement, Prof Plunkett says he is back in the dissection room, teaching first-year medical students.

“I think a full understanding of anatomy is important for students. Rather than learning it as a pure topic, having a clinician explain what you need to know in relation to real-life injuries or illnesses is very important.”

He also hopes to teach professionalism and communications to more senior classes.

“Communications are so important and they are where you can make or break a doctor-patient relationship.”

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