Medical Matters: A doctor’s dilemma in midwest with hospitals stretched to capacity

‘I heard on the radio that the casualty department in Limerick is unsafe.”A group of GPs in Nenagh were meeting to discuss rotas when we heard this announcement. And I am sorry to say that nobody was in the least surprised. In fact, the momentous news was greeted with, “Sure everybody knows that.”

That is the doctor’s dilemma, if the doctor is a GP in the midwest. Suppose you have a woman in her 80s with pneumonia. She is a citizen of Ireland, through good times and bad, she has paid her taxes and never asked for anything. You have tried antibiotics and steroids and she is getting worse. You ring the Medical Assessment Unit in Limerick, where she should be seen and treated promptly. But they see only five patients a day. (This in a catchment area of thousands of people.) So you tell her she will have to queue up on a trolley in the emergency department for a few days or so. She will be at risk of falls, bedsores, dehydration and cross-infection. You might make her worse.

This proud woman refuses to go, and tells you she would rather die. You decide, against your better judgment, to fill her with more antibiotics and steroids.

You wonder what the safer option is and what you would tell her family, and the Medical Council, if you got it wrong.

Of course you could send her to Mid-West Regional Hospital, Nenagh. It is uncertain whether Nenagh hospital will have any senior house officers from July on so it looks as if it will close its doors to inpatients at last. The Health Information and Quality Authority (Hiqa) report that deemed Limerick emergency department unsafe finished up by commending the Mid-West for reconfiguration; this is otherwise known as the emptying of Ennis and Nenagh hospitals of patients.

This commendable behaviour will apparently be extended countrywide so don’t feel complacent. Limerick is the standard bearer for reconfiguration. Nobody seems to have calculated that if you effectively close down two out of three hospitals, you will find the third gets busier.

You can spend all you like on fancy buildings that are deserted in the evenings; the people on trolleys need to be sorted out first.

You could send her farther away, maybe to Ballinasloe. That is a small hospital too, and under threat. The excellent maternity service is in immediate danger, you have heard. (I recently sent a patient to Letterkenny for admission. He sensibly remarked that during the four or five hours it would take for him to be driven there, he would still be waiting to be processed in Limerick.)

So how about the Galway Clinic, or the Beacon in Dublin?

“Hang on,” says the woman. “They are small hospitals, as small as Nenagh, which is across the road from your office. Did anybody try to close them down because they were too small?” She leaves with a prescription, and your heart sinks.

The next patient who needs to go to hospital is a six-year-old girl. You think of the night that is ahead of her in the mad, crowded emergency department with the sick and the drunk and the dying: the sights she will see; the things she will hear. It is the modern doctor’s dilemma.

It is now eight years since Brendan Gleeson made his impassioned plea on The Late Late Show to sort out the emergency departments of Ireland. You could fit the entire second World War and most of the first World War into that time span. And he said that at the height of the boom.

For all those years the brave and hardworking doctors, nurses and ancillary staff have been doing their best in hellish conditions in the casualty departments of Limerick and Ireland. The unsafe conditions put pressure on other hospitals with scarce resources, on sick people suffering at home and on a primary care system that is already stretched to capacity.

At the time of writing, Nenagh and Ennis hospitals are still open, just about. Maybe we should think again, roll back the centralisation of the health services, and put some services and staff back into the remaining smaller, safer hospitals and primary care.

Dr Pat Harrold is a GP practising in Nenagh, Co Tipperary. Dr Muiris Houston is on leave.