Why people die in A and E (Accident and Emergency)

An elderly woman has died after being stuck queuing in an ambulance outside Flinders Medical Centre for more than an hour.

The union says distressed paramedics did what they could, but she should've been treated inside the hospital.

Newspaper quote dated 13 July 2025

It was the year 1812 and the vast army of the Emperor Napoleon of France was crawling back through the frozen waste of Northern Europe. Of the 500,000 that began the journey towards Russia barely 35000 French remained. The horrors that befell these men have been the subject of many historical works exemplified by the thousands of frozen dead soldiers, many in their teens, who perished outside the walls of Vilnius, frozen to death, recently discovered in a mass grave.  

As the troops reached the Berezina River a bottle neck developed so that only a trickle of people could get through. Suddenly there was a cry among the soldiers.

Dominique Jean-Larrey, Napoleon’s surgeon general had arrived. This great doctor was so revered by these soldiers that they lifted him over their heads, with his medical supplies, and passed him over the mass of men gathered there so he could escape across the river.

The work of Larrey meant that among all the soldiers of Europe the best of medical care was to be found with the French and more of their troops than any other were likely to survive the terrible wounds of battle. This was the work of Larrey who had perfected the system of field ambulances and more importantly he invented the term Triage to refer to the way wounded soldiers should be dealt with.

From that time on the armies of the world used Larrey’s methods to sort casualties and the term then became used for all the accident and emergency units throughout the Western World. Used properly it meant that the most seriously injured troops received the most immediate care.

It was noted from the first Iraq war of 2001 when Iraq invaded Kuwait that no matter how seriously wounded a soldier was, if he could make it to a field surgical unit, his chances of survival was more than 80%.

Yet in hospitals, all around the world people are dying outside the doors of accident and emergency departments and, often patients, in, many cases, even if they do make it inside the doors.

Some die in ambulances which have queued for hours on the ramps outside the doors of the hospital. Many die even if they make it to consulting rooms inside because of poor care and incorrect diagnoses.

Despite the fact that these hospitals use the term “triage” to refer to what is done when a patient arrives at a hospital, the principles of Dominique Larrey, the surgeon general, and indeed the principle that all the armies of the western world used in conflicts over the last century, are not being followed.

James Tsindos, a contemporary victim of this failure, suffered a serve nut allergy after eating a burrito bowl. The paramedics who collected him administered adrenaline, the correct treatment. He was then wheeled into the doors of the local hospital at 3.44 pm and although he was handed over to nurses and seen by a junior doctor, he was left alone in an emergency room for 30 minutes trying to breathe with an asthma puffer.  

When more senior staff got to him, he was already dying and despite attempts to resuscitate him suffered a cardiac arrest. This story is typical of what happens in Accident and Emergency.  

Emergency staff complain that they are over worked and under-staffed. This is not the problem. The problem is a combination of inefficiency and poor training.

These failures illustrate the departure from the principles Dominique Larrey applied in his work. So, although the term Triage is used in these emergency departments, it bears little resemblance to that applied by the military. The death rate of soldiers with severe injuries in the Western armies of World War 1 was close to 80% but by the time of the Gulf wars in the last century this figure was completely reversed so that less than 20% of serious injuries died.

When a patient arrives at a hospital they are usually processed by a clerk of some kind or perhaps a junior nurse. The details are taken and some cursory history. They wait.

If they, the patients, present in an ambulance, vital observations are available and sometimes, even an IV line. These are handed into the hospital, but the patient does not go in and they cannot be handed over to A and E staff, they wait on the hospital ramp in an ambulance, sometimes for hours. This was the case for the unfortunate patient introduced at the beginning.

If the patient presents themselves to the hospital without ambulance, there is usually no history taken by anyone to pass on and they are processed by a clerk.

Often, the first health person to see the patient is a junior nurse who takes a history and makes further observations. They are then seen by a junior doctor who takes a more extensive history and makes a decision to treat or pass the patient up the line to a more senior doctor.

All of these stages take time and at each the A and E department satisfies itself that something is being done. This process can take hours. If the wrong decision is taken or the assessment is not correct as in the case of Tsinidos, the patient will die. The things that are killing patients are misdiagnosis and or a lapse of time.

The military are more effective do things differently. The first point of contact is with the most senior available officer, usually a surgeon or similarly qualified specialist doctor.

As the patients arrive, they are brought to him. ‘’Does the patient need surgery? Off to theatre.’’ “Does the patient need sedation? Administer immediately.”’’ Does the patient need an Xray? Off to the Xray department.’’

“Is the patient emotionally distressed?” Some nerve cases do turn up in Emergency. Here sedation and referral to the hospital psychologist or equivalent is the response.

As each patient arrives, he or she is quickly resuscitated if necessary and sent to the relevant department or given appropriate medication or prepared for surgery. If specific medication is needed, a script is written. The nurse conveys this to the pharmacy department.

Those fortunate enough to witness this in practice will be astonished to see dozens of casualties being processed hourly and sent off appropriately. There is no waiting around in ambulances, the so-called “ramping” alluded to at the beginning.  

The ambulance arrives with a patient with chest pain and the paramedic hands the specialist the ECT (electrocardiograph) and a heart attack is diagnosed and treated immediately.

This process is so simple and so obvious that turns the modern A and E department on its head. The senior doctors are no longer waiting up the line, reading notes and lecturing students. They are at the forefront.

The process should work like this. The most senior and experienced doctor attends each patient in the first instance and allocates priority and determines treatment. He or she is attended by a nurse and a junior doctor.

As each case arrives the A and E specialist directs the case in a particular direction. At the beginning in all emergency departments 20 – 25 of patients have conditions which can be solved with a simple script, blood test of letter to the patient’s general practitioner written by the junior doctor present.

Of the rest, cardiac patients with signs of heart attack on ECG are sent immediately to cardiac resuscitation,  minor wounds are sewn by the junior doctor or referred to the minor theatre, more serious wounds or fractures to go the trauma theatre. Stroke cases are given immediate anticoagulation and are sent on to recovery. Psychiatric cases comprising 5% of admissions are sent to the on case psychiatric nurse and psychologist of the Acute Care Team.

There is no delay in assessment or treatment, blood tests or x-rays. These are ordered immediately. In many cases portable x-rays can be obtained on the spot as an adjunct to the work of the specialist’s tirage team.

The model is that of the military field dressing station where specialists and surgeons are collocated with triage staff. The other principle is that delay is the enemy of recovery.

Any person attending an accident and emergency department will be astonished at the number of patients and nurses waiting around for something to happen. Wait is waste.

The other principal with military triage is that patients must not be left alone to deteriorate in cubicles. Increased efficiency and through-put means that each case or one of two cases, depending on nature of the injuries, has a nurse caring for them, taking observations, providing fluids and watching IV drips.

Again, anyone working in conventional civilian A and E departments, will be astonished at the number of times a cubicle curtain is pulled back to reveal someone who has died or is in the process of dying.

Why are civilian accident and emergency units so inefficient and why is there so much delay? The simple answer is that Triage as Dominique Jean Larrey meant it, is not happening even though hospital administrations claim it is. At the end a long wait are the senior doctors engaging in endless discussions with junior staff, having cups of tea and pouring over x-rays and blood tests that should have been interpreted by someone else hours before.

To understand what is happening the reader should treat his or herself to an episode of the television show House starring Hugh Laurie. As the show progresses junior doctors and nurses stare at X-rays and scans, argue endlessly about possible obscure diagnoses when suddenly in walks Dr. House who looks at the patient and places his finger squarely on the diagnosis.

 Accident and Emergency Departments need to turn House upside down and have Dr. House (Hugh Laurie) arrive at the beginning instead at the end of the long queue of junior staff.