The health conditions that warrant a trip to A&E and the ones that don't

When A&E doctor Mark Harmon’s elderly mother slipped on the ice recently, he knew that the hospital was the last place that would be good for her.

“Hospitals should be the last resort for anybody,” says Dr Harmon, A&E doctor and Clinical Entrepreneur at eConsult. “Unless you’ve broken a bone or are seriously ill, it's the worst place for you. You pick up infections in hospital - I'd advise all my friends and family to do everything you can to stay out of hospital.”

And yet too many people are showing up at A&E with non-life threatening injuries. “About 30 percent of patients at the moment are turning up at the wrong place,” says Harmon.

His first question is usually: ‘How can we help?’ Often they talk about chest pain or back pain that’s been going on for six months. Harmon has to explain that it's not an emergency.

Recently he went out to collect a patient who was waiting in A&E with abdominal pain, only to find the 23-year-old woman eating a McDonald's.

“She was overweight and diabetic,” states Harmon, who explained to her that it wasn’t the best thing for her health. “People need to take responsibility for their own health,” he says. “We fall into the trap where we think medicine will solve everything. That we can just carry on the way we live and medicine will fix us.”

While GP shortages and a backlog of major health problems built up over Covid, are partly to blame, a lot of the conditions showing up at A&E are lifestyle problems.

If people want to make sure they don’t end up in A&E he says some of the steps people can take are obvious. “Eat healthily, take as much exercise as you possibly can. 50 percent of patients on medication don’t take them. Engage with clinical teams who are looking after you. If you’ve been given physio exercises to do, do them.”

Another element is to understand the avenues available before A&E. There are urgent treatment centres in most hospitals, which can provide help when it’s not a life-threatening emergency (broken bones and sprains, cuts, stomach pain, vomiting and diarrhoea, high temperature and mental health), minor injuries and walk-in centres (helping with many, but not all, of the same problems as urgent treatment centres ), NHS 111 (if you are not sure what service you might need), and pharmacies (for aches and pains, coughs and colds, flu,, earache, skin rashes and cystitis).

There are increasingly digital triage systems such as e-Consult, that Harmon set up, that are widely used within the NHS.  It allows you to describe your problem and sends the details to your GP practice so that they can help you. While it depends upon your being digitally savvy, the hope is that it will soak up enough tech literate patients to take the burden off in-person appointments.

Only five per cent of the population use private GPs but there are increasingly private healthcare providers such as HCA who offer acute admissions walk-in consultations.

Morad Benkaifer, Urgent Care Physician Lead says: “We’re not an A&E but we’re here to help when primary care is not available. We see a lot of patients who can’t get a GP appointment. We can help them be referred quickly to the NHS if they need to be.”

So when is A&E appropriate?

Heart attacks

If you're over 35 and you have central crushing chest pain that feels like someone sitting on your chest or pulling a tight belt around your chest and it's radiating to your arm or neck: “You need to go to A&E immediately,” says Harmon.

Rather than waiting for an ambulance, get someone to drive you if you can: “Ambulances are supposed to respond within 9 minutes, but currently it's 90 minutes.”

Stroke

The FAST test (Face, arms, speech, time) helps you understand the signs of stroke.

Any facial drooping, speech disturbance, sudden onset numbness or weakness: “That’s a sign you should get to the hospital pretty quickly”.

There are two major types of stroke. Eighty-five per cent are Ischemic stroke means a clot in the brain blocks the flow of blood. “You have 90 minutes. If it's acted on quickly you can bust the clot and restore flow to the brain. The longer it goes on without treatment the less good the prognosis.”  Rather than waiting for an ambulance, get someone to drive you. Get to the hospital and don’t stand at the back of the queue.  

Bleeding

Blood in the stool or vomited or coughed up, isn’t immediately life threatening. “It can look extremely dramatic and scary but actually it isn’t,” says Harmon. It does need to be investigated however; ask for an urgent GP appointment or get help from 111.

But if you've been in an accident and you've severed a finger, a limb or an artery then you need to get to hospital pretty quickly. “If you're feeling dizzy, if you're having palpitations, if you pass out, all these are very concerning signs and show your blood pressure is dropping as a result of the blood loss.”

Harmon says to apply pressure to the wound. “You can make a tourniquet using a cloth or plastic bag placed 5cm above the wound. If it’s a stabbing, the key thing is not to remove the object as it’s acting as a tourniquet to stop the bleeding.”

Allergies

Anaphylaxis is rare but certainly life threatening. “If you're having difficulty breathing or your tongue or lips are swelling up, absolutely you need to get help urgently,” says Harmon. “However if you just have a rash and nothing else, absolutely not.”

Asthma is very serious and a big killer. “Patients don't take it seriously. If an asthmatic comes into A&E with shortness of breath I would never criticise them. This is one of those things that can change very quickly.”  Again, rather than waiting for an ambulance, get someone to drive you.

Harmon says asthmatics should be using their brown inhaler to prevent symptoms, “religiously, even when you're feeling well.”

Falling

A fall is the biggest killer of the over 65s. “It's the consequences of the fall,” explains Harmon. “They end up in hospital, become bed bound, get pneumonia, lose muscle mass and a lot of them never get out. It’s tragic.”

The key thing is not to fall in the first place, “but even with the best of intentions it's not easy.”

If you’re deciding whether to go to A&E the key things to look out for are broken bones. “That manifests in pain, difficulty in moving and being unable to bear weight.”

A hip fracture might be very fine and hard to recognise. “If your leg is shortened and the foot is turned outwards that's classic signs of a hip fracture.”

If you hit your head it might not be immediately clear you need to go to A&E but if over a few days you become less lucid, have a dull headache and feel drowsy: “That can be a sign of a subdural haemorrhage, a low pressure bleed that should definitely be investigated.”

Abdominal pain

Acute sudden onset pain could be appendicitis. “Often around your belly button and down into your right groin area could be a perforation of the appendix (and should be seen immediately).”

If you're pregnant and you have excruciating pain around the ovaries: “It could be an ectopic pregnancy. That is urgent and needs to be seen.”

Sepsis

A tricky one as the symptoms can be quite varied and vague. Such as high fever (e.g. above 38.5 or below 36), acute confused state, fast heart rate combined with dizziness, not passing urine within 12-18 hours and acute abdominal pain or neck stiffness. “Often it is the combination of symptoms that are more concerning.

If patients are on chemotherapy or immunosuppressed in any way, then they should have a much lower threshold,” says Harmon. “Often present in elderly as a change in mental state/lucidity (often initially due to a simple UTI).” Time is of the essence; sepsis can deteriorate very quickly and can kill an affected person in as little as 12 hours.

Temperature

Many parents can worry about this. “If your child is running a temperature above 40 seek help.” You need to rule out meningitis, especially if your child has a stiff neck, a rash that doesn’t fade when you press a glass against it, is bothered by light, is drowsy and hard to wake, has a high pitched cry that’s not like their normal cry, is vomiting or having fits. Like sepsis, meningitis can deteriorate very quickly.