Postgraduate Medical Journal (May 1972) 48, 268-274.

The accident and emergency service in Portsmouth-present and future

R. A. DENHAMF.R.C.S.

Consultant Orthopaedic Surgeon,Royal Portsmouth Hospital, Commercial Road, Portsmouth, Hants.

The problemFrom the beginning of the National Health

Service the organization for the reception, treatmentand after-care of accidents and emergencies in allspecialties has been limited. This fact did not arisefrom defects in training or lack of interest by themedical or nursing professions. Indeed a large num-ber of surgeons who took up orthopaedics after thewar had received a great part of their training inaccident work and it seemed natural to return to acivilian occupation which would include the skillswhich had been learnt over the previous bitter years.It is certain that the scope of the anaesthetist was notappreciated at that time and the facilities for workwhich is now carried out in the intensive care unitswas poor or non-existent.Work in casualty can be a challenge which is full

of interest, offering excellent training in mostbranches of medicine; spiritually rewarding but oftenmentally exhausting; very exacting yet thrilling whensuccess in an emergency has been achieved and anexperience of such importance that the RoyalCollege insists on a period in this department as anessential part of pre-fellowship training. How has itcome about that this appointment is thoroughlydisliked by most doctors, being the chore which mustbe performed by a junior doctor in training in arotation scheme through the highlights of generalsurgery, general medicine and gynaecology? Whyshould a training post with this wealth of clinicalexperience be the cause of threatened resignation orthe factor which may prompt the prospective candi-date to avoid an appointment which includes 'a fewsessions covering casualty during the evenings'?Although many advances in diagnosis and treat-

ment have taken place in recent years, changes in theorganization and structure of casualty have beenslow to follow. There are many reasons why thisdepartment has been neglected for so long. There isthe major problem of night and weekend duty andthe unattractive proposition of doing 'generalpractice' work for hospital rates of pay. There is theproblem of legal responsibility for errors made under

the pressure of multiple examinations and admis-sions. All too often there is lack of participation,supervision, and teaching from consultants whoform the pillars of the peripheral major Hospitals.These are the specialists in anaesthetics, ortho-paedics, general medicine and general surgery. Acommon failing is the lack of liaison and co-opera-tion between the hospital and the Local MedicalCommittee for there are frequent high level demandsfor integration between the hospital and the generalpractitioner services and it is in casualty that thisneed is greatest and most practical. Lastly, there isthe quite understandable problem of hospitalbuilding and equipment in an economy which mustsupply so many urgent demands.

DefinitionsIt is always important for descriptive terms to be

clear. In this paper the following definitions areimplied.A casualty department accepts both accidents and

casuals. The term casual refers not to a chancevisitor from another district but to a patient sufferingfrom a lesion which is not caused by an accident.An accident centre should accept only accidents,while the casuals, the acute general surgical, medical,dental, paediatric, gynaecological, psychiatric andattempted suicide patients should be seen and treatedin a separate reception area or in another hospitalwithin the group. A first-aid room is a treatmentarea in a general practitioner medical centre, afactory or a hospital where trivial and minor casesare seen. An intensive care ward is a highlyspecialized unit administered by an anaesthetistwho treats patients in conjunction with orthopaedic,general surgical and general medical colleagues.The severity ofa lesion is divided into three groups.

A trivial case refers to an accident or casual in whoma mild lesion needs minimal first-aid treatment. Aminor lesion describes an accident or casualty inwhom a problem of intermediate severity needsskilled medical attention and supervision. A severecase describes a patient in whom serious pathology is

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Accident and emergency service in Portsmouth 269

present. The term major accident or major incidentshould signify a group accident or emergency such asa train or aircraft crash which involves many people.A village refers to a community of some 1500

inhabitants, a small town to 50,000 and a big town toa population of approximately 250,000 people whilea regional area contains between one and a half andthree million people.The organizationMedical staff

If hospital staff or general practitioners are to beattracted to either the accident or the casualty de-partment the hours of service, the career structureand the rates of pay must be correct for the workinvolved. It is essential for doctors and administra-tors to understand clearly the scope of their receptiondepartments. An accident centre should not acceptcasuals so if a division is made between these twogroups a separate area with its own 24-hr staff will beneeded for these patients. However, regional boardsfind that the staffing of one single casualty depart-ment is difficult enough without doubling the prob-lem by this division. Although the backing of anorthopaedic surgeon in the accident centre is un-disputed, his talents are either wasted or of doubtfulvalue in a large percentage of attendances to a casu-alty department. The same comments apply to theindividual consultants in anaesthesia, general surgeryand general medicine. In casualty a general practi-tioner 'consultant' is needed.

In the casualty department in Portsmouth whichdealt with 37,248 new and 15,860 return cases in 1970,one medical assistant and one senior house officerare needed for the morning sessions for 7 days eachweek, a third doctor works the afternoon period anda fourth is required for evening work. Night duty israted at three sessions and is covered by a rotation ofdoctors who have accommodation within the depart-ment. One-third of the patients attend in the 16 hrbetween 1700 and 0900. The typical distribution inthe number of new cases during the days of the weekis Monday 93; Tuesday 86; Wednesday 69; Thursday77; Friday 74; Saturday 90; Sunday 66. Thus,forty-eight medical sessions are needed each week fora population of 500,000 which may rise to 700,000during the summer holiday period.The work in most big towns is usually done in a

casualty centre by a medical assistant who is re-sponsible for the general organization of the depart-ment to one consultant who will accept administra-tive charge. In Portsmouth the orthopaedic con-sultant does this work. However, if the service is toimprove a number of different consultant clinics mustalso be held within the department. These shouldusually last for less than 1 hr and they should be heldwith one of the doctors who is working the morning

or the afternoon session. There should be two ofthese clinics each week for a series of orthopaedicconsultants and one for each of the other three mainspecialties concerned with the casualty and theaccident service. Each consultant will be asked tosee only those patients who belong to his specialtyand to make comments and helpful suggestionswhich would improve the organization and generalrunning of the department from his specialized pointof view. Thus, from Monday to Friday short dailyconsultant attendances for supervision, planning andteaching should take place. These short instructionalclinics would be of great value to nursing staff andmedical students, and they would stimulate thedoctors who often feel sadly neglected. All patientswho have attended for more than one return visit tocasualty should be referred to these clinics.

It is important for the College of Physicians andthe general practitioners to encourage their graduatesto participate in the running of the casualty depart-ment. A few months spent in this work soon afterqualification would be most valuable. As a morepermanent appointment it must be understood thatvery few general practitioners will be encouraged bytheir partners in group practice to accept more thanone session in hospital at the current remuneration.However attractive this contact may be from manyangles the financial drag must not extend to twosessions or the practice will suffer. Night duty andweekend work holds little attraction for anyone butit is a time when more than 50% of the new casesare seen (Parry et al., 1962).The question of the appointment of full-time

consultants to work in casualty is under considera-tion by the Department of Health at this time. Ifthese new posts could improve the staffing, super-vision and organization ofthe hospital 'shop window'without dividing responsibility they might perform agreat service but only if two important requirementsare accepted Firstly, that these consultants shouldwork in casualty, and secondly that they should notdelay the immediate transfer of patients to thespecialty which should carry out the definitive treat-ment. It is certain that consultant remuneration willbe most attractive to a large number of overseasgraduates very many of whom have higher qualifica-tions. These doctors whose entry and further trainingin U.K. is becoming more restricted by their owngovernments will no longer have the insecurity oftenure of the senior house officer or registrar grades.They will be independent of home rule and withconditions superior to the senior house officer thereshould be a great response for these new posts. Itmight be suggested that this method of staffing forthe many casualty departments in U.K. would be sosatisfactory that a division into accident centres andcasualty centres would be practicable. This would

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270 R. A. Denham

permit 'accident' surgeons with the FRCS andfurther intensive training in recognized posts oforthopaedics, general, neuro, thoracic, faciomaxil-lary and plastic surgery and 'casual' physicians withthe MRCP and further experience in anaesthesia,intensive care and psychiatric medicine to continueto treat the 4% of cases who, as a usual average, aretaken to the wards from casualty. These doctorswould be able to maintain continuity of treatment inthe ward and theatre knowing that the 96% ofpatients who form the backbone of casualty atten-dances were being cared for by the new generationof overseas casualty officers who might now beanxious to staff this department following the stimu-lus of the new career structure. Until this unlikelytime is reached it would seem more practical toappoint a 'consultant' general practitioner with wideexperience in all branches of medicine and surgerywho would continue to work in casualty in co-operation with the established consultants inanaesthesia, general medicine and surgery andorthopaedics (Fig. 1).StructureThe accident service in the Wessex region should

be organized at four levels (Table 1). In the villagesthe reception, diagnosis and treatment for the trivialand minor case is always done by the generalpractitioner in his own surgery. Severe cases are

sent by ambulance to the casualty department of thebig town.A small town may have a general practitioner

hospital where a first-aid room is already wellstaffed by a rota of practitioners. It seems fashion-able to condemn the cottage hospital as expensiveand inefficient, yet much valuable work is done forthe casual and for the accident service. In thishospital and also in the general practitioner medicalcentres an organization should be established where-by the qualified nursing sister can legally see andgive first-aid cover to patients with trivial complaintswho are then referred to the correct general practi-tioner's next surgery. This organization eliminatesmuch wasted time for the patient and does notrepeatedly divert the general practitioner from hisrounds. Minor injuries must be seen by a doctorwithout these few hours delay and the sister mustkeep the patient until the practitioner arrives.Knowing that he will not be called for trivial casesthe doctor will make every effort to come quickly.All severe cases should be diverted by the ambulanceservice to the big town accident centre. The first-aidrooms should be situated where they are easilyaccessible to the public, well signposted and clearlymarked in positions of maximum density of popula-tion.

In the big towns an alternative to the maincasualty department should be available for the

Special departments - Casualty department Trivial and minorCasualty doctor * accidents and casualsGP'consultant' to own GP

I------,-- ia t. \\----Intensive care unitConsultant anaesthetist \

Acute surgical Acute medical Accidents and orthopaedicConsultant surgeon Consultant physician emergency workConsultant orthopaedic

FIG. 1

TABLE 1. The organizationLocation Staff Population

Area or regional Neuro, plastic, thoracic,faciomaxillary surgeons 1i-3 million

Big town Anaesthetist, orthopaedic,general surgeon and physician 250,000

Small town General practitioner 50,000Village General practitioner 1500.150

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Accident and emergency service in Portsmouth 271

emergency diagnosis and treatment of trivial andminor accidents and casuals. To the patient, thesmall cut on the head of a child or the developingabscess in the axilla of a labourer is no small lesion.If rapid effective treatment can be obtained easilyfrom the hospital which operates a 24-hr service thepatient will go there without delay. It is under-standable that he may be a poor judge of the severityor the prognosis of a disease. He is entitled to earlyand effective treatment under the National HealthService and he must have it quickly and politely. Atthe present time these patients come to the mainhospital casualty department but if there were aneffective alternative they would be glad to use it.First-aid rooms staffed by general practitioners andnursing sisters organized in the manner which hasbeen previously described should be located inpractitioner medical centres or near hospitals. InPortsmouth City itself there should be three.The smooth running of a casualty department

must depend firstly upon the method of receptionand secondly upon the facilities for support.ReceptionA radio link with the ambulance service is essen-

tial, a sheltered reception bay backing onto anentrance with electrically operated doors is needed.A short, direct, wide entrance to a large resuscitationroom is necessary where all the modern equipmentis easily accessible to multiple helpers. A separateentrance is needed for walking cases, and sepsisshould be completely segregated within a section ofthe department with its own nursing staff. Docu-mentation must be at the entrance and overlookingthe waiting space, children need special rooms.

In Portsmouth, short stay beds within this depart-ment have proved a failure due to the uncertaindemand on the nursing staff and the indefinite con-sultant responsibility. The 24-hr X-ray service isessential and in our department has been efficientdespite very limited space. Trolleys with radio-translucent tops have permitted radiological examin-ations without moving the patient from the trolley totable. Secretarial services are very poor and facilitiesfor research and follow-up much needed. There isa full pathological service including blood transfusion24 hr a day, 7 days a week. In Portsmouth, attemptedsuicides at the average rate of two each day take agreat deal of time and attention from our staff. Weaccept all general medical and surgical 999 calls. Thegynaecological and ophthalmic emergencies are sentto special units elsewhere. Although faciomaxillarytrauma is very well covered, routine dental casespresent a considerable problem after office hours.Mental cases are time-consuming but much help isreceived from a good liaison with the mental welfareofficer. A similar close connection with the drug

squad is maintained. Police help is invaluable andmost willingly given in many ways. Our casualtydepartment was purpose built in 1955, at this timethe annual load was 33,357. Since that date numbershave increased by 1300 each year to the present totalof 53,103 in 1970. At this rate of growth we estimatethat in the 12 months of 1977, 70,000 patients and140,000 of their relatives and friends will pass throughthis building with its 4076 sq. ft of floor space. Wefind that with every patient who attends our depart-ment an average of two other persons accompanyhim. The combined fracture and orthopaedic clinic(3350 sq. ft) adjoins casualty. The intensive care unit,which contains six beds in an area of 1000 sq. ft, is inthe main body of the hospital 125 yards, two floors,and one lift from the casualty department.The facilities for resuscitation, emergency diagno-

sis and treatment of severely injured patients incasualty are elementary although some modernequipment has been installed. The 345 sq. ft availablein this resuscitation room is rather small for moderntreatment.

There is some segregation of emergency medical,surgical, and paediatric cases in the six small treat-ment rooms in casualty (total 609 sq. ft). Once againgross restriction of space in many small separaterooms makes adequate examination and treatmentvery difficult. It must be understood that a majorhospital rebuilding scheme with a greatly enlargedaccident, casualty and orthopaedic department hasbeen contemplated in Portsmouth for a number ofyears. Under these circumstances the regionalboard are justified in their reluctance to spendmoney on relatively minor alterations to existingbuildings. However, following the considerable de-lay of the major project £10,000 was set aside inMay 1971 for alterations within the existing frame-work of the present casualty department.

It is a pity that the recommendation of the PlattCommittee (paragraph 95) and now the OsmondClarke findings that 'in a large department a layofficer of suitable seniority should be responsible fororganizing the non-professional work of the Unit'has not been implemented.

SupportAn important supporting facility to the accident

and emergency reception is the intensive care unit.In Portsmouth this is well organized by oneanaesthetist, who works with the other three de-partmental consultants. In some cases the combinedforces of general surgery, medicine and orthopaedicsare all needed for their special skills, but usually onlyone other department is called for the immediatetreatment while the airway is being established andwhile transfusions are getting underway.

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272 R. A. Denham

It is important to accept that the emergencyservices of the neurosurgeon, thoracic, plastic andthe faciomaxillary surgeons are not usually availableto the big town organization. If special teaching,co-operationg and understanding is established be-tween these highly specialized branches, and the fourconsultant departments in the big towns, complexearly treatments can proceed smoothly. We find thatthe best single aid to a difficult diagnosis or treatmentin these cases is the telephone.Every morning a fracture clinic dealing with

between fifty and 120 cases is held in the orthopaedicdepartment which adjoins casualty. This greatvariation between winter and summer is due to theinflux of holiday traffic to our seaside area. Oneorthopaedic surgeon sees all acute hand pathology.Following this early treatment supervision is con-tinued in the weekly hand clinic.The orthopaedic surgeon must play a greater part

in the organization and operation of the accidentservice. This work must not be left to the residentstaff to fit in when they are fortunate enough to finda vacant theatre and a duty anaesthetist.There must be special theatres, definite times for

out-patient and in-patient work and realistic con-tinuity in treatment for accident cases. This wouldnot only improve the accident service but would alsostabilize the orthopaedic department. All too oftencold lists are stopped by emergency admissions andoperations have to be cancelled, ward rounds areinterrupted by demands from casualty and ortho-paedic beds are taken up by accident work. It isimportant to share the time and the facilities in ourdepartments so that sufficient personal attention isgiven to both sections of our work.The problem of surgery for accident cases is

associated with both the lack of theatre space andanaesthetic cover. Usually no theatre sessions arespecifically set aside for accident or emergency workand the anaesthetic department has difficulty inmeeting the conflicting needs of emergency work.In Portsmouth, alterations have been made to divideworking hours, clinic space, theatres, beds andsupporting facilities between three teams of threesurgeons, and a fourth consultant. Each team, whichconsists of a consultant, a registrar and a seniorhouse officer, will do in rotation, 1 week on accidentduty and 2 weeks with the orthopaedic service. Thereis no difficulty in the primary supervision or treat-ment of accidents in either the orthopaedic depart-ment or casualty for these two are situated next toeach other in the same building. The accident theatreshould be staffed by an anaesthetic registrar of someexperience and three nurses. It should really beoperational for 24 hr each day, but under the presentpressure on theatre space it has to be used by anotherspecialty for the morning session. Extensive examina-

tion of admission records confirms that the disturbedhours on night duty for the resident staff should bediminished by the 3-weekly routine. A simple systemfor orthopaedic work in the 2-week period, un-interrupted by accident admissions, has beenplanned (Table 2). The fourth consultant heads ateam when the chief is on holiday. This fourth posi-tion rotates between the orthopaedic surgeons eachyear so that for 12 months each member is able toreduce his night duty and new case load by a largepercentage so that he can find time to consolidatehis knowledge and opinions. He should visit otherunits and with reading and research he should beable to form valuable opinions from reviews con-ducted with the help of the computerized follow-upsystem.Area organization

In the treatment of special problems it is essentialfor some consultants and their high cost depart-ments to be organized on a regional basis. Accidentsrequiring the services of the neurosurgeon, thethoracic and faciomaxillary and the plastic surgeon,or the intensive regimen of the burns unit must besupervised from a central point in the region. Thiswill usually be done from a town which, because ofits geographical position, accessibility and import-ance, is the county capital or university town. In thisregion, Southampton is the obvious choice.These area specialist centres should serve a

population of between 1J and 3 million people, theyshould if possible, be no more than 30 miles fromthe furthest big town. They should be on the edge ofa town, on the intersection of fast roads. A helicopterlanding area is needed.

It is wrong to provide these treatment centreswith all their complex facilities and staff in more thanone of the big towns. The highly specialized buildingsand equipment are too expensive for anything butarea commitments, and the continued experience,research and the training of all grades of medicalstaff is only possible in units where a large number ofcases are being treated.

This centrally placed area town must also havethe first-aid rooms and the accident centre or casualtydepartment already described. These should bequite independent from the specialized area unitswhich will accept serious cases from all the bigtowns under their care after discussion over thetelephone between the two consultants concerned.The area centre should only admit cases from

accident centres. These patients will be either recentuntreated injuries or burns which are in need ofextra special care and who are fit to travel, or thosepatients who have already had their primary emer-gency operation and who now require definitivesurgery. It is essential for all surgeons to understand

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The accident and emergency service in Portsmouth 273

TABLE 2. Orthopaedic work-Portsmouth

First week Second week AbbreviationsC Consultant

C WR C T J & N C4 The 4th consultantC4 OP V AM C4 OP V Reg RegistrarReg WR Reg F SHO Senior house officerSHO WR SHO WW

Z C OPL C T J & N WR Ward round5 C4 TJ&NM PM C4 TJ&NM T Theatre

Reg OP L Reg F OP Out-patientsSHO OP L SHO OP H WW Ward work

BT ConferenceC TM C TN Gen GeneralC4 OP Gen AM C4 OP Gen F Free time

> Reg WR Reg TNSHO TM SHO WW

L Long caseC OP Gen C OP L Sh Short caseC4 OP FU PM C4 OP FU FU Follow-upReg OP X Reg OP L V Postop. reviewSHO OP H SHO OP L H Theatre preparation

X Research projectC T J & N C WR WEC Workers emerg. clinic

> C4 OP Sh AM C4 OP ShReg TJ&N Reg WR

: SHO WW SHO WR J Major operations, M Minor operationsZ C F or OP V C F or OP V N Intermediate operations

C4 F PM C4 FReg OP X Reg OP FUSHO OP H SHO F

C F or OP V C F or OP V DUTYC4 WR AM C4 WRReg TN Reg WR Team 1 Team 2 Team 3

Q SHO WW SHO WWAcc. Orth. 1 Orth. 2

3 C OP FU C OP Gen= C4 TJNM PM C4 TJNM Orth. 2 Acc. Orth. 1

Reg OP FU Reg TM-M - -SHO OP H SHO T M Acc. Orth. 1 Orth. 2

C T J & N C OP Sh Orth. 1 Orth. 2 Acc.C4 WR AM C4 WRReg T M Reg OP WEC etc. etc. etc.SHO T J & N SHO OP Sh

5 C BT C BT; C4 BT PM C4 BT

Reg BT Reg BTSHO BT SHO BT

Nil Nil________________________

the importance of selected intake, and early dis-charge to the centres of origin. The high cost beds atthe area centre must never be blocked by convalescentcases for the pressure of work through them must begreat to justify the expense.The surgeons in these specialized area centres have

two inter-related tasks. Firstly the treatment of re-ferred cases within their own units and secondly bytactful co-operation, instruction and visits to theperipheral centres, help to improve the standard of

treatment in their specialties in the big towns withintheir region so that the appropriate patients may betreated in the correct place at the right time.

ConclusionFor years it has been said that casualty depart-

ments must be reorganized. The need has becomeurgent following the withdrawal of many immigrantdoctors from this country. It is suggested that thechange in name from 'casualty' to 'accident and

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274 R. A. Denham

emergency' has done harm as it has confused thepriorities without altering the structure of the de-partment.Although the accident centre must be under the

combined supervision ofthe anaesthetic, orthopaedic,general surgical and general medical consultants alarge part of the work in a casualty department isneither accident nor emergency. It is this group ofpatients during night duty and weekend sessions whocreate the problem. There is a world shortage ofdoctors so the hospital casualty departments must bestaffed either by making this work compulsory inmedical training, or by attracting doctors whowould otherwise stay overseas, go overseas, orqualify for general practice. Consultant status wouldachieve the second requirement, but it is absolutelyvital to avoid overlap with other specialties and toensure the most rapid transfer of patients to thecorrect department where definitive treatment is to

be given. There must be no delay and no division ofearly responsibility for all admission to hospitalfromthe casualty department.

In Portsmouth, greater consultant participationfrom all four specialties might increase interest andefficiency. An attempt is being made to share theurgent accident and emergency orthopaedic admis-sions between three teams of orthopaedic surgeonsso that each may concentrate on the accident servicefor one week in three. This should prevent thedisorganization of routine orthopaedic work byemergencies, and ensure that acute orthopaedic andaccident patients will receive their fair share ofconsultant supervision.ReferencePARRY, C.P., COOPER, D.B., SHELSWELL, M.E., DUNKER-

LEY, G.E., DENHAM, R.A. & MURRAY, C.M.M. (1962) ThePortsmouth casualty survey. British Medical Journal,2, 909.

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