Dr Pat Plunkett says he knows an emergency when he sees one - StJames's A&E was in crisis last Thursday
In 1974, as a volunteer with St John Ambulance, I had my first experience of disaster - the Dublin bombings. My task, in the casualty department of the old Jervis St Hospital, was to place the bodies in temporary coffins for transportation to the City Morgue.
In 1985, as a senior registrar in Manchester, I led my hospital's response to the Manchester air disaster. For hours we expected casualties and received none, while another hospital was almost overwhelmed - the bus driver with 40 minor casualties on board did not know his way to the correct hospital.
In 1989, when a bus crashed in Dublin late on a Friday night, I was responsible for the reaction of the emergency department at St James's Hospital. We had many patients, and a lot of stress for relatives who were unsure if their loved ones were living. Again, communications were fraught.
War is one form of disaster, major accidents another. One should always, while praying for peace, prepare for war. Emergency departments, the world over, plan for disaster, both major and relatively minor.
The definition of major accident in the St James's Hospital Major Incident Plan is one where there are 12 or more seriously injured victims, or where such numbers are likely, or where a combination of events results in overloading of the emergency services
On Thursday, February 5th, 2004, I dialled a restricted number. Having identified myself to the switchboard operator at St James's Hospital, I said: "Activate the Major Emergency Plan now, please." Within a brief period, in addition to my own staff, we had consultants from intensive care, general, orthopaedic and plastic surgery, laboratory medicine and internal medicine in the emergency department.
What was the disaster? It was the fact that an emergency department with nine cubicles and three resuscitation bays, one of the largest in the country, was overwhelmed. Not with 12 seriously injured patients, but with 41 patients, all of whom were so ill as to require emergency admission to hospital.
To deal with these patients, some there for many hours, we had taken additional trolleys from the X-ray department and even from the recovery area of the operating theatres. We had patients who should have been in beds in wheelchairs or on plastic seats and walking around, pushing drip-stands before them.
We could barely move between these sick people. Many required oxygen, but we had run out of oxygen bottles. Staff struggled to find a spare piece of floor to meet the next patient on an ambulance stretcher.
How could this happen? In a civilised Western democracy, with a thriving economy, how could we tolerate our aged and infirm being pushed from pillar to post like refugees fleeing Armageddon?
For many years the health service has been underfunded. More recently, funding has been increased markedly and our Minister for Finance calls for greater efficiency. If he is putting in twice as much money, he expects twice as much output.
However, if we use a version of the Micawber philosophy, the issue should be obvious. "Annual income €4, annual expenditure €10; result - disaster." Increase the income to €8, against a background of decades of under-financing and of no provision for equipment replacement. The result? We are still in deficit despite the doubling of funding.
How come an emergency department, which regularly admits 35 patients a day, has 41 in-patients residing and being provided with all their care in a department with one wheelchair-accessible toilet, no facility for hot food other than tea or instant soup, and no semblance of privacy? Where, rather than ensuring privacy for those in crisis, some dying, we label cubicles designed for one with an "A" and a "B" side?
Simple. A quart will not go into a pint pot. Even the Department of Health has accepted, on the advice of its experts, that the Irish Hospital Service is short of 3,000 acute beds. And many of those nominally available in hospitals are filled with people who, while needing nursing care, are not in need of the services deliverable only in the acute hospitals. Their needs could readily be addressed in beds in nursing homes or long-care facilities, freeing up the acute beds for those patients sitting in wheelchairs, queuing up for access to them .
In St James's Hospital, the proportion of beds so occupied has in the past few months reached almost 25 per cent of the available stock because of the "drying-up" of long- stay beds provided by the health board and the difficulty in achieving funding for private nursing home beds. This is predominantly a combination of cash-flow problems and poor planning. We can predict, very clearly, the likely need for such beds and such funding.
Yet, as a patient is lying on a trolley in the emergency department, awaiting access to an acute bed and to urgent surgery, our health service prioritises money to have people waiting over 12 months for varicose veins or hip surgery. I defend the right of such patients to have access to timely healthcare - but should it be at the expense of providing immediate care to those who cannot wait?
Much is often made of the "two-tier" health service in Ireland. But there is no "two-tier" service in emergency departments. The whole issue with private health insurance is that access to a private hospital is closely regulated for optimal patient flow - and patients are admitted knowing that, in the vast majority of cases, their length of stay is predictable. The flip side to this coin is that unplanned access is almost unheard of. Where does a person with private health insurance go with a heart attack, a stroke, pneumonia, a perforated bowel cancer or a breast abscess in an emergency? Certainly not to the private institutions.
Such emergencies go to the local public emergency department where they are entitled to the same care as the poorest widow, the victim of violence and the most sick of drug addicts. Like the poor, they receive the best care we can provide.
"Why are we waiting?" is a cry often heard from the lips of the sick and the destitute - a cry that usually falls on deaf ears. On Thursday, February 5th, I was unable to ignore that cry any longer. My consultant colleagues agreed with me. By activating the internal major emergency plan of St James's Hospital, 26 patients were placed in beds within a two-hour period, with conditions for the others improving to the extent that they were no longer sitting cheek-by-jowl with each other.
I applaud the response of my nursing, medical ancillary, and clerical/administrative colleagues. They performed the tasks they were trained to perform, in a situation of immense stress, and did the right thing for their patients.
But what was the official response later? The health correspondent of The Irish Times, Eithne Donnellan, wrote in Friday's edition that the spokesperson for St James's described reports of activation of the major emergency plan as "untrue".
As Winston Churchill said: "The first casualty of war is always truth". But should we simply accept this or respond as Dylan Thomas: "Do not go gentle into that good night; rage, rage against the dying of the light?"
Dr Pat Plunkett is a consultant in emergency medicine in St James's Hospital