MAYHEM, CLOCK AND ANTI

By Hamish Maclaren
Contact the author by e-mail at christopher.johnstone@ntlworld.com

‘At the accident scene, casualties were treated for shock before being allowed home.’
BBC radio travel report

Of course, they weren’t treated for shock at all. Shock, as every reader of hoolet knows, is a catastrophic collapse of the circulation leading eventually to irreversible anoxic cell damage. I was going to suggest that these people wandering around the scene wearing blankets and looking dazed have a kind of acute post-traumatic stress disorder, but I would hesitate to call this natural response to a bad experience a disorder at all. And if it’s not a disorder, why treat it? And what treatment would you choose? Sweet tea? Valium? “Counselling”?

Still, I have to say that the misuse of the word “shock” is the part of the BBC travel report that I find least objectionable. The terminology of the sentence is so antiquated that it sounds like a description of a dressing station behind the front line at the Somme. In Britain, the terminology of Emergency Medicine is nearly a century out of date.

This is not true of the rest of the English-speaking world. I was privileged to work in the field of Emergency Medicine in New Zealand between 1986 and 1999, the period of the development and rapid expansion of the Australasian College for Emergency Medicine. I started in “Accident & Emergency” at Middlemore Hospital in Auckland. For the rest of the hospital we were “Casualty” and some people even referred to us as “Cas”.

There is no such thing as an accident. We changed the terminology, literally overnight. The signage came down. We became the “Emergency Department”. When we lifted the phone we no longer said “A & E”, but, rather, “ED”. We put a swear-box in the clerical area of the department, to which staff members were obliged to donate ten cents every time they used the “A-word”. We borrowed this idea from William Hadden, the father of injury prevention in the United States who realised that trauma was never accidental, but a pathological entity with an aetiology, vulnerable to epidemiological analysis and, ultimately, prevention. The expression “RTA”, road traffic accident, was replaced by “RTC”, road traffic crash.

What was so gratifying about this exercise was the rapidity with which these ideas, initially greeted with scepticism and ridicule, were taken on board. To hear a paramedic talk about an “RTC”, or to have the hospital switchboard direct a call through to the “ED” was, actually, thrilling.

“Casualty” is the most detestable word in the Emergency Medicine lexicon. Reference to Chambers is salutary:‘
casual adj. accidental: unforeseen: occasional: off-hand: negligent... casualty... an accident: a misfortune: loss by wounds, death, desertion etc... casualty department... a hospital department, ward, in which accidents are treated; casual ward formerly, a workhouse department for labourers, paupers, etc.’

And yet, in this country, you hear clinicians, administrators, and politicians who occupy positions of influence in the realm of acute care using the word “casualty” to denote both an injured patient, and the facility in which the patient is being initially assessed and treated. Does it matter? Yes, it does. It matters that the lay public imagine that “shock” and “trauma” are states of mind, like angst. You might as well believe that disease is a kind of possession by evil spirits. But it matters even more that clinicians insist on hard-wiring into the language the notion that, for example, the 10 deaths and the 300 episodes of major trauma occurring on UK roads each day are inevitable. If you truly think the insult that befell your patient was a bolt from the blue you will never attenuate it for you will never predict it. If you truly think your patient is a pauper he will doubtless remain such. If the department in which he is seen resembles a Dickensian workhouse then its facilities and available expertise are liable to be of similar vintage.

So... four expressions to expunge from your vocabulary: Cas, Casualty, Accident, A & E

Tell your colleagues!

hoolet is the magazine of RCGP Scotland. It is supported intellectually, financially and emotionally by RCGP Scotland.

This issue maintained by Robert Hallam.