Travelling further may be good for your health

It looks increasingly likely that FutureFit will finally bring some proposals to a public consultation in October.

I anticipate that there will be significant interest in the effect of travel times to hospital on patients with time-critical illness and injuries. There have been many references to the golden hour in social media.

The literature on the effects of distance to hospital and mortality is mixed and it is difficult to compare results across different countries and health systems due to differences in practice. The 2007 paper by Nichol et al is often quoted . You can read the whole paper here if you are interested. Nichol looked at data from more than  10000 seriously people who were taken to hospital by ambulance in England between 1997 and 2001. Their data showed that increasing travel distances to hospital was associated with an increased risk of death, perhaps no surprise there. Importantly the authors say in the paper “Changes in performance in recent years or new policies that have changed to both increase distances and either improve care at the more distant facilities or improve the effectiveness of prehospital care could attenuate the potential effect of increased journey distance upon mortality.”

So what are the implications of this for reconfiguring our local health system in Shropshire? I think we should think of travel time as one component of the time between the onset of an illness and starting effective treatment. Other important elements to consider are dispatch time (ie time from calling 999 to an ambulance arriving), the time between arrival at hospital and seeing a senior clinician and the quality of the care received on arrival at hospital.

The reorganisation of stroke services in London and Manchester showed that centralisation of services resulted in a reduced risk of death despite some patients having to travel further. In Shropshire centralising hyperacute stroke services at the Princess Royal Hospital has also led to a better service and improved outcomes.

There is a similar story for the centralisation of the treatment of patients with heart attacks which has lead to a 22% reduction in mortality. In Shropshire patients having a heart attack will usually be taken by ambulance to heart attack centre in either Stoke of Wolverhampton.

In 2012, a network of major  trauma centres and trauma units was set up in England.  Evaluation of the results of the first few years of the trauma network has shown a dramatic increase in the rates of survival for the most seriously injured patients.

So there are precedents nationally  for travelling further to improved services leading to improved outcomes. Locally in 2012 we centralised services for emergency general surgery at the a Royal Shrewsbury Hospital, within a year this had reduced the risk of death by 18%. In addition this made the service popular with consultants and trainee surgeons meaning that we can recruit when we need to. Now we just need to do the same for our other services ………..

 

 

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The doors fling open and they wheel her in on a trolley. Eyes taped shut, tube down her throat, flimsy hospital gown barely hiding her modesty. We slide her carefully onto the operating table and position her for the operation.  I know her, not well; enough to say hi and smile though. She’s young; shiny hair, slim limbs and smooth skin. Her belly is enormously distended in a grotesque parody of pregnancy; except there is no baby in there. Instead there is a tumour inside which has completely blocked the colon; gas and liquid shit backed up behind the tumour unable to escape. She came into hospital yesterday with constipation, feeling embarrassed and sheepish, hoping that an enema would sort her out. Instead she had a CT scan which showed us the tumour. Her caecum is distended and at the point where if we do not operate soon then it will perforate, sending litres of liquid bacteria-containing shit into her peritoneal cavity.  If that happens then the outlook is much worse. Fortunately there are no signs of spread outside the bowel, if all goes well we can cure her, I think to myself. I paint her belly with a red coloured antiseptic liquid, taking care to apply it evenly and making sure that there are no missed bits. At the head end the anaesthetist is adjusting some dials to get her settled for the operation. We carefully cover her nakedness with sterile green drapes, leaving a rectangular piece of abdomen exposed. We do our final checks and the scrub nurse passes me a scalpel in a sterile bowel. I pause for a moment, I need to detach myself from her as a person to do the next bit. Usually this comes naturally to me and I do not even think about it. Today is different, it’s hard. I look at the smooth unblemished skin which I must cut. It seems a violation, sacrilege, like painting graffiti on an ancient monument; yet cut I must. I summon up some detachment, somewhere deep in the surgical centre of my brain some neurones fire and the detachment comes, not before its time. I notice my assistant and the scrub nurse looking quizzically at me, I’ve no idea how long I have been in this reverie. I pick the knife in my right hand and a large white swab in my left. Now I can do it. I make a long sweeping cut down the centre of her abdomen. Bead of blood well up from the skin edges, we swiftly mop them up with swabs and I swap the blade for a hand held diathermy. The machine buzzes, lights flash briefly and the bleeding is stopped.  I cut through the fat layer and reach the shiny white fibres of the linea alba. There are fewer blood vessels here and swiftly we enter the abdomen. As I cut through the peritoneum, vast coils  of slipper, distended small bowel spill out on to the drapes. The colon follows, paper thin and tensely blown up with gas. I insert a needle into the colon, attach into to a suction machine and suck out as much gas as possible. Now I can see what is going on. I feel the liver, its nice and smooth  – no signs of cancer there thankfully. I feel down into the pelvis, there is an abrupt change in the diameter of the colon and at that point I feel a small hard, walnut-sized cancer- just as the scan predicted. My assistant pulls in the retractor and I use a swab to retract the distended colon towards me. I can now see the white line of Toldt, the surgeons’ equivalent of a cut-here line. I swiftly mobilise the colon and tie the blood vessels feeding it. We wash the bowel out, litres of liquid shit emerges from the other end of the tube. Once it runs out clear we cut out the cancer and then staple the ends  back together. I close the wound taking care that the skin incision is a neat as possible. A clean white dressing covers the wound and then we are done. Carefully I peel the drapes off and the person underneath emerges once more. We carefully rearrange her gown to preserve her modesty and gently move her back onto her bed.

Next day I see her on the ward. She look little pale against the yellow print on her hospital gown. She’s feeling a little sore and bit sick. I tell her it all went well, no unpleasant surprises – a tiny smile flickers across her face.

 

April is Bowel Cancer Awareness Month

Every year about 2,500 people under 50 are diagnosed with bowel cancer in the UK

Never too young

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