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Cardiac surgery in the Dunkirk spirit

BMJ 1995; 311 doi: (Published 16 December 1995) Cite this as: BMJ 1995;311:1648
  1. Tom Treasure


    At Dunkirk troops waited on the beaches with no certainty of a place in a ship, and then queued in line out into the sea to cross the Straits of Dover. The craft that took them were overloaded, the crews under pressure, tired, pushing their endurance beyond what was reasonable in any planned operation. But the circumstances were desperate. That rout came to be seen not as the retreat of a defeated army, but as a victory of humanity against the odds. There is something about the practice of cardiac surgery in the health service in Britain in 1995 that reminds me of Dunkirk.

    We struggle to stay within the 12 months' waiting time that the patients' charter promises. Each week we fail to make the progress on the waiting lists that we would dearly like because more urgent patients are in the hospital and demand our attention. Elective admissions are cancelled as we struggle to clear the inpatients, waiting like the queue in the water at Dunkirk. In order to cope we fill our intensive care units to capacity, shorten the stay of patients in those beds to the limit, and fast track them through progressive care and recovery facilities. As in wartime, we cut corners, we rediscover the concepts of triage, and we stretch our personnel to the limit. Sometimes important advances are made under such pressure. Human beings may emerge as heroes, but the moral leverage put on our nursing and junior staff to work harder, longer, and nearer the brink of safety is beyond what is a proper duty of respect for the standards of others.

    In the main, our patients can see the pressure that we are under and tolerate the waiting, the disappointment of last minute cancellation, and seem glad to have the opportunity of surgery, as they remind themselves that some others have been less fortunate. That is the Dunkirk spirit. The difference is that the evacuation of Dunkirk was a short term, desperate solution. What I am involved in goes on, and on, and on. Unlike Dunkirk, our patients feel entitled to complain about delays, lack of comfort, and the catering.

    The public is aware of what is available in modern health care. They expect the service to have the capacity to cope, in a reasonable time, with those who turn up suddenly and unexpectedly, and not for them to have to wait, becoming ever more desperate as they do so. Under our present circumstances the whole basis of the relationship between doctor and patient is eroded--the availability of an operating slot dominates everything. Contracts are shifted in job lots of 50 or 100 cases from one district to another. Proper preparation for surgery is disrupted by the chaotic on and off run up to the operation; plans are made to be changed, promises are made only to be broken. The well ordered process of adequate investigation, followed by psychological and emotional preparation for surgery has gone by the board.

    The usual response to a complaint such as mine is to diminish it by making it seem an isolated example. At the annual meeting of the Society of Cardiothoracic Surgeons in March 1995, in a session devoted to audit and organisational issues, there were papers from two major regional units, one in the north and the other in the south of Britain, describing their different systems for prioritising patients sitting in beds, waiting. In one unit 29% of coronary surgery was performed on an urgent basis and in the other 43% of practice was either urgent or emergency and never got on to a formal waiting list. A half of urgent cases in hospital for surgery on that admission waited in the cardiac unit over a week, some up to three weeks, for an urgent operation.

    In those units, as in ours, the surgeons are torn between responsibility to the patients on their waiting lists and these other patients waiting in the hospital. We are under pressure from medical colleagues to take patients with repeated episodes of ischaemia, on intravenous infusions of heparin and nitrates, who are teetering on the brink of an infarction, and possibly death, in preference to those we promised to care for months earlier. The mismatch between expectations and the reality of our resources is becoming intolerable. Most of my colleagues seem to be able to keep up the Dunkirk spirit and do not complain much, but I feel battle weary.

    What is the solution? We could point at allocation of resources, better organisation of our facilities, a more selective use of the surgery, and so on. All of these are important debates but, in the meantime, I ask us to be honest with each other. Talk of centres of excellence and other forms of self congratulatory cant are irksome.

    In our unit we perform 1200 heart operations each year and that volume of work is attained only by considerable effort on the part of the staff of the unit to get as many cases done as possible. It seems to be an impossible struggle. From my perspective it feels like the descriptions of Dunkirk: noble in memory, but grim in reality.--TOM TREASURE is professor of cardiothoracic surgery in London