Townsville University Hospital ED: behind the curtain

Dr Luke Lawton is a man with a message. 

After nine years as a consultant emergency physician and five as the director of the city’s only public emergency department, Dr Lawton said he wanted to debunk the myths of emergency medicine, including patient wait times, ambulance ramping, and the very definition of ‘an emergency’.

He also wants to turn the floodlights squarely on emergency medicine in the modern age in a bid to help the community understand the challenges facing emergency departments in 2021.

“If I could say one thing to our community, I would say this: emergency departments are incredibly complex places and ours is no exception,” he said.

“If you need us, we are here, and we will always see you.

“But what I really need the community to understand is that the emergency department is a multidimensional place and every single presentation is unique and cannot, and must not, be lumped into the basket of ‘he waited too long’ or ‘she should have gone to the GP’ or ‘the ambulances are ramped’.

“It is never, ever that simple.”

If there is one issue that gets Dr Lawton animated it’s the contemporary question of what constitutes an emergency.

“It’s a very complex question,” he said.

“The answer is not simple, and it’s time to silence the argument on who needs to be in the ED.

“The consistent focus in conversations about emergency care on ambulance ramping (the time taken to be transferred from the ambulance to an ED bed) and wait times does a disservice to the public truly understanding what an ED is here for.

“The reality is we do ask people to wait.

“We have a lot of patients and, for some patients, if we don’t get to them quickly will die.

“If you’re having a major heart attack, how quickly we get you to the catheter lab (where heart blockages are treated allowing blood to flow back to the heart) directly affects the rest of your life.

“The relative mortality of a patient with sepsis (a life-threatening condition that occurs when the body’s response to a serious infection is to attack its own tissue) increases eight per cent every hour their antibiotics are delayed.

“In emergency medicine there are some things that really, really matter time wise and some things that don’t matter as much.

“If you sprain your elbow on the golf course, we’re happy to see you but you need to understand we have to prioritise the people that need us most because their lives may literally depend on it,” he said.

Dr Lawton said it was important the community understood it was unrealistic to run a department where everyone could be seen immediately.

“The very nature of emergency medicine is its unpredictability,” he said.

“We can see five people come through the doors in an hour or 40.

“And even if five come in one hour, if there were 40 before that we’d still be treating and clearing those patients.”

Dr Lawton said the job of the emergency department was to care for the people who needed it.

“My advice would be judicious about your decision to come here,” he said.

“Don’t come just because we’re here; come because you need care whether it’s a sporting injury, severe pain, a burn, a medical episode like chest pain, stroke, or a mental health issue.

“These are all legitimate reasons to seek our help and I believe that people can be trusted to make a judgement.

“We need to remember, though, that emergency departments can’t do everything.

“We’re not very good at working out someone’s six-month history of lower back pain on a Sunday afternoon but we are very good at working if that lower back pain is due to spinal cord compression or an epidural abscess or a back fracture.

“Medically, we’re set up for acute diagnosis and treatment.  Our specialty is not long-term longitudinal care, it’s critical care.  That’s what we do. The best place for that long-term care is in general practice, and our colleagues in this area do great work for our city.”

Dr Lawton said the face of emergency medicine was changing rapidly.

“I think if you asked the average person ‘what do you think emergency departments do?’ you’d get one of two answers,” he said.

“One is that it’s just like a GP practice and the other is that it’s a trauma centre.

“The truth lies someone in the middle.

“We do a lot of high-end stuff, but we also deal with many, many difficult problems like people in a mental health crisis, homelessness, domestic violence, sexual assault, and substance abuse.

“People in crisis often come in at very unsociable hours when nothing is open, and no one else is around.

“These patients are very complex, and their problems multifactorial.

“We accept that with nowhere else to go, of course they come to us. We’re literally often the only health care service with the lights on.”

Dr Lawton said another hidden truth of modern emergency care was the increasing care of the elderly.

“The ED is by far the biggest admitter of geriatric patients to the hospital; it is a significant part of emergency care and we’re seeing numbers that we weren’t seeing a decade ago.

“This has meant the creation of teams of specialist healthcare workers who look after these niche patients.

“We have a seven-day-a-week allied health team who can assess frail patients and often get them back on their feet and home; previously this could have meant a lengthy admission with a not-so-great outcome. We know that elderly patients lose muscle mass and develop delirium in direct proportion to the length of their hospital admission.

“We also have teams, run by emergency specialists, that look after elderly patients in nursing homes and patients treated at home under the Hospital in the Home program.

“This is work that just wasn’t being done in emergency medicine 20 years ago.”

Dr Lawton said the ED also provided telehealth support to critical patients via a partnership with Retrieval Services Queensland (RSQ) and coordinated every aeromedical asset north of Rockhampton under the same umbrella.

“Our ED staffs the Northern Zone of RSQ, which is an arrangement different from almost anywhere else in Australia,” he said.

“What many people don’t realise is that the ED actually does a huge amount of work that doesn’t have anything to do with car crashes,” he said.

“Your 21^st century emergency physician is a far cry from what you see on the TV shows where they’re doing chest compressions and intubating patients every 10 minutes,” he said.

Dr Lawton said another challenging cohort of ED patients were those socially isolated ‘regulars’ who couldn’t access mainstream healthcare.

“From many reasons, social and financial, these are people with intractable health problems that can’t get to a doctor.

“We have a team in the ED which links in community organisations, the non-government sector and the NDIS to try and get those people on the mend.

“They can keep coming to us and we can keep doing blood tests and x-rays but that’s not going to fix the problems of homelessness, or social and medical disenfranchisement.

“They come here with complaints that can vary from chest pain, intoxication, low-grade suicide ideation or overdoses and their care can be highly complex, but it is what we need to do in caring for our whole community.”

When Dr Lawton is asked whether he thinks staff who work in the emergency department have a skewed view of society, he considers the question carefully.

“We see a lot of social disadvantage that ends up manifesting in emergency department presentations,” he said.

“That’s been a huge pivot for EDs over the past 15 to 20 years.

“There is a massive difference between a patient with chest pain who needs bloods and a referral for a stress test to a homeless 16-year-old who presents at 9pm on a Friday night.

“The four-hour rule (the National Emergency Access Target of four hours from arrival to admission or discharge) flies out the window.” 

Dr Lawton said to top it all off, the emergency department was a major education and research centre, with intrahospital and external collaborations with institutions in Brisbane, Melbourne, and London, as well as with James Cook University.

“One of the most exciting things I see is how involved we are in teaching our medical students,” he said.

“I love the chance to deliver lectures and talk about some of what modern medicine includes. Training our next generation of doctors is core business for us.”

Dr Lawton said he believed most people would be surprised by what the Townsville University Hospital emergency department of 2021 looked like.

“What we bring to our community is so much more than a trauma centre.

“Our emergency department is a pretty impressive enterprise and I’m proud of it.

“Trust us to look after you but please remember why we’re here and what we do.”

The Townsville Bulletin is partnering with Townsville University Hospital to take you behind the scenes of one of Queensland’s busiest emergency departments. Meet the people who care for our community and share in their stories and challenges in looking after more than 90,000 people a year who come through their doors injured, sick, drug affected, scared, dying and all in need of help. Come behind the curtain for a unique perspective on emergency medical care in the 21st century.

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