1. HISTORY APPENDIX XIII THE BIRMINGHAM ACCIDENT HOSPITAL ITS HISTORY, PRESENT-DAY ROLE, AND FUTURE One of the most unpleasant features of modern society has been the development of mechanically-caused injuries in the home, in industry, and on the road. The evolution of a society where almost everyone, during the course of 24 hours, comes into contact with dangerous machinery or forms of power has resulted in the treatment and study of trauma becoming a subject worthy of specialisation. Injury from accidents is now the main cause of death in males up to the age of 25 years, accounting for 33% of all deaths in this age group, and approximately 17,000 people die each year as a result of injuries. In 1936, the hospital problems caused by this new feature of society were examined by the Interdepartmental Committee on the Rehabilitation of Persons Injured by Accidents. In 1939, the Committee's report included the comment: "The most striking feature is the situation disclosed as regards delay One of the results of this observation was the founding of the Birmingham Accident Hospital, in 1941, to study the hospital arrangements necessary to avoid such delays. Since that date, well over one million injured patients have been treated, and rehabilitation attempted. It was in 1840 that the foundation stone of the building that now contains the Birmingham Accident Hospital was laid. It then was named the Queens Hospital, and was among the very first in the country expressly created to foster clinical instruction. For just over 100 years it continued in its role as a teaching hospital; by the end of the 1930's, however, it became clear that the building had reached the limits of its capacity for expansion as a teaching general hospital. At that time, a site was required for an experimental accident hospital, and as a result of the generous action of the Board of Governors of the United Birmingham Hospitals, the buildings and equipment of the Queen's Hospital wore handed over to a now Foard of Governors of "The Birminghan Accident Hospital and Rehabilitation Centro." Thus, on April 1st, 1941, the Hospital as it is known today came into being. This was, though, no age of new buildings or equipment; adaptations to existing buildings were the only solutions available. Aided by the untiring efforts of Professor W. Gissane, the organisation. developed into an active and skilled team. It is a credit to the surgeons and nurses that so much was and still is achieved in spite of the physical limitations imposed by the environment. The many thousands of injured who have walked or been carried through the doors of the hospital heve brought with them problems, both of diagnosis and treatment. Speedy and accurate diagnosis is essential, especially for stretcher-borne patients, and is determined by the immediate availability of experienced surgeons, and the existing diagnostic freilitics. The patient's blood volume must be restored to somet ing like its normal level as soon as is physically possible, and any necessary operations undertaken, both to save life and prevent deformity. Firally, the surgeon receiving the patient should cortinue his care and close supervision for reels or even months until the final result is achieved end the patient restored as far as possible to his normal function. - 2 The key to the saving of life or limb is thereforc immediate and effective nosis and treatment; yet behind this action must be full in-patient facilities, beds immediately available, and a comprehensive out-patient and rehabilitation w-up. Bearing these latter considerations in mind it has been submitted that proper treatment of accidents cannot be fitted into the tempo of work of a ral hospital without a lowering of standards. The treatment of the severe injury accurately illustrates this point; an injured brair cannot be brought to a reasonable level of activity by the odd hour of treatment, no matter how rienced the rehabilitation officer. It requires an intense and continuous effort over sometimes many months, by physiotherapists, occupational therapists, ch therapists, remedial gymnasts, surgeons and nurses, to bring a patient to the 1 where he can once again communicate with other people, and perhaps take up a ul occupation. True, of those patients that survive the immediate post-accident od there are the complete failures, but these, over the years, can be counted on fingers of both hands. It is a fact that a patient can eventually be brought a state of near unconsciousness to the capacity to work in a sheltered workshop, ven to take a job in industry, by the concentration of experienced and specialised f. The arithmetic is simple; the cost to the nation of employing such staff ld be weighed against the cost of life-span of 20 to 40 years in a chronic or geriatric hospital at a cost of about £25 per week, or at best, a life of inual unemployment, supported by social assistance. The equation is one of effectiveness, the break-even line is difficult to place. The hypothesis is it lies closely on the side of intensive staffing of small units, with the iso that the unit is of a sufficient size to justify a comprehensive service. and time again it has been found that the key to the rehabilitation of the red brain is concentrated and prolonged communication; the adult becomes an nt once again and must re-educate the remaining undamaged brain cells towards ing a personality and re-learning the social language, Experience amassed over the years with the Birmingham Accident Hospital has vance to the planning and organisation of hospitals in general. The main lusions drawn from the Birminghan experiment were found to be, in 1956, as LOWS: The treatment of injuries belongs to no special group of surgeons. violence of an accident may injure any part of the body, the surgery of dents is general in the strict sense of that term. Since The surgery of accidents involves, essentially, e tecn approach by surgeons, esthetists, laboratory staff and nurses; it requires a special type of hospital vice which must be available for 24 hours in each day, and can work over this od at a tempo unfamilier to most general hospitals. The cost of intensive, skilled tre tment is not prohibitively high. The The evidence indic: ted that three najor hospital developments were essential ore a regional erd national hospital service for the injured could be considered quate. One was the improvement in the casualty departrients of general pitals, to trert and sort the ambulatory wounded that are numerically the ater portion of the two million injured attending the hospitals each year. ond was the building of accident hospitals or self contained units to be sited gside general and teaching hospitals, with a catchment area of a radius not eeding 70 miles. The final phase was the functional co-ordination of the By modern standards the hospital is relatively small; there are 218 bods, including a 40 bedded specialist burns unit serving the major part of the hospital region, and a six bedded major injuries unit. Total registrations in 1970 were around 43,000; a small sample survey of those figures showed that, of registrations as opposed to admissions, 35% were industrial accents, 25% domestic, 11% were "street" accidents (e.g. old ladies slipping in the snow, children falling over paving stones). Of those remaining, only 9% of these 43,000 registrations involved a motor vehicle. (The remaining 20% were "miscellaneous"). Total in-patient admissions were approximately 6,000. In contrast to the small share of total registrations road accidents account for 25% of the hospital's in-patient admissions, and 30% of deaths. introduction of drive and drink laws ir October, 1967, the national fluctuations in the number of road accidents have been generally reflected in the hospitals road casualty figures. Since the these (The Burns Unit Each team is on duty for the Space dous not permit a description of the total organisation of the hospital, One spect of which is fairly typical of many hospitals of a similar size. particular interest, however, is the organisation of the surgical services; are in the form of three teams, each herded by two consultants. has its own team which operates independently). reception and treatment of the injured, one day (24 hours) in three, and one weekend (48 hours) in three. Care is continuous, under one surgeon, from the initial treatment stage in the major injuries urit, through the wards, and finally through this continuity of care has proved to be of value to both patient and surgeon. Immediate diagnosis by experienced medical staff is available in the casualty and major injuries units, and this is supported by full inpatient facilities, with beds (as far as possible) immediately available, and a comprehensive out-patient and rehabilitation service. rehabilitation; Some indication of the intensity of work dore can be gauged from the numbers employed. The ratio of staff to patients is quite high; and yet the clinical and rehabilitative departments can in no way be said to be inefficient, a total of more than thirty medical staff includes eleven consultants, and oight, registrars; approximately 230 nurses (all grades) are employed, and thirty staff are engaged in the work of rehabilitation. Over 200 additional staff make up a total of around 550 for the hospital as a whole. group. Within the hospital, accommodation is provided for the Road Injuries Research This organisation co-operates with the Medical Research Council Industrial Injurios and Burns Research Unit (also on the Hospital site) into rosearch into the crusos, nature and treatment of injuries. valuable studios produced by these two bodies are included in the reference list at the end of this article. 4. RECENT DEVELOPMENTS Sone of the many one is concerned Out of many projects which have developed over the last few yoars, two perhaps may be singled out for description. Both concern head injuries; with the treatment at the acute staged, and the second has ovolved from a study of rohabilitation requirements. By air-filtration An attempt to provide better intensive treatment for severe head injuries was made, in 1965, by the opening of a 3-bedded tracheostomy unit. and conditioning, and the use of barrier-nursing techniques this unit attempts to tracheostomy patient is vulnerable. Experience has shown that such a unit is best sited adjacent to a major injuries unit, and should have at least six to eight beds, possibly divided into "intensive" cut out the main infections to which the and "intermediate" sections. continued 4. RECENT DEVELOPMENTS - continued ch an arrangement and size of unit allows flexibility and economy in the use highly skilled staff, and avoids the "blocking" of intensive care beds by tionts not quite ready for troatmont on the gonoral wards, to the exclusion new of.808. It is towards the provision of a larger tracheostomy unit that e hospital is attempting to move at the prosent time. Increased skill and knowledge into the immediate treatment of acute head juries has led to the second development, that of the "Hoad Injuries Workshop". present rates the Accident Hospital produced approximately ton "crippled ains" each year, and it has been realised that to provide rehabilitation and en sord the patient home to be a burden on his family was not enough. Many -potionts wore incapable of industrial work; changed personalities, ustration at an inability to communicate or physical as well as montal impairment oduced problem people. Ono way of helping the patient back to a use of his mbs and brain was by occupational or industrial therapy but this was a limited lution. What was requirod was a community which included a place of steady rk and a chance to devolop friendships with similarly afflicted patients. In 1967, with the gonerous help of the Nuffield Provincial Hospitals Trust, former eye hospital was converted into a workshop. Approximately 30 patients tond daily, and do industrial work, which is by any standerds constructive and teresting; holidays and outings are arranged, and under expert guidance, the tient is encouraged to rodovolop his personality and abilitios. Already, the ›rkshop has produced good results, and several patients have returned to industry › earn their own living independent of support, It must bo omphasised howover at this is but a welcome by-product and that the main ain of the workshop is to rovide occupation and assistanco to the permanently afflicted patient, the victim 10 can never proporly fit into our industrial society again, The problem of head injuries has been singled out for special mention scause of the improvements which have taken place recently. It must bo tressed, howover, that the problem is small in relation to total turnover, 3 mentioned above, total registrations in 1970 woro 43,000; of theso, 6,000 atients were admitted. A total of 567 admissions were absorbed by the 40 edded burns unit, while the romainder included a large majority of fracture ases, with only 80 to 90 head injury patients (all types). THE FUTURE The question may already be forming in the rundors mind as to the rolationhip of a clinically independent, specialist unit, on a site ronoto from other ospitals, to the presont day concept of the large general hospitals, serving defined or tohment area, and providing treatment in all the major spoolalties. his question was also in the mind of Professor T. McKoown, whon, in 1958, he roduced a papor on "The Concept of a Balanced Hospital Community", in which he rged, with particular reference to large cities such as Birmingham, that the ospitals of the future should be largo hospital complexos, each wholly serving he hospital needs of the population of their actchment area. This concopt as lator, on a national sole, to be embodied in the Ministry of Health's ospital Building Plan, published in 1962; in the moantino, howover, the ideas roused the interest of the Birmingham Regional Hospital Board and of the Board f Governors of the Unitud Birmingham Hospitals. The prosent Quvon Elizabeth ospital, set in a 100 acre site in the suburbs of Birmingham, was chosen as he base for a 2,000 bedded comprehensive hospital, to serve a major proportion f the Birmingham City area. For some time, the concept was no more than an nteresting project, discussod at various levels, but lacking adoqunto finance. hree years aftor study of tho plan had commonood the opportunity to bring it o fruition arose; the Regional Board offurod to transfer to the Toard of overnors the capital allocations available for the rebuilding of the Mirmingham Accident Hospital and the Mirmingham Eye Hospital, to enable them to e built on the central sito, as part of the "Balanoud Toaching Hospital". This offer was gratefully accepted, and a working party, including representatives from the main interested parties, was set up. Since then, planning has noved steadily ahead; the many conflicting interests and a first sight insoluble problems had been resolved, and plans finalised. Building has now commenced. The new Accident Hospital will, together with the Eye Hospital, be incorporated into the new west wing of the Teaching Hospital Complex. It will include approximately 200 trauma and burns beds, together with a major accident reception and treatment centre and associated out-patient facilities, a further 65 beds for "reconstructive" surgery will be available on a convenient site. The intention is to continue, unchanged, the present clinical function tard take advantage of the improved clinical and research facilities available from close association with a tooching general hospital, and Birmingham University. By 1978, it is hoped that the actual rove of patients and staff to the new site will be complete. Many problems need yet to be resolved; but foremost in the Linds of the staff of the Accident Hospital is the need to ensure, whatever may be the organisation of the new hospital, and its relationship to the overall working of the Teaching Hospitals Centre, that there is no loss of the team work and single-mindedness of purpose that has characterised the Accident Hospital since its cre tion thirty years ago September, 1971. |