In Stitches Page 3

  The next patient made me even more distressed. She was a lady in her 80s who was brought in by ambulance after becoming increasingly short of breath. She came in with her husband of 58 years. She had been very unwell the last five years since suffering a stroke and then having a series of mini-strokes causing a form of dementia (called multiinfarct dementia).

  The husband had refused all previous plans to put her in a nursing home, as he had made a promise to her five years ago that he would look after her himself. She was immobile, incontinent and had severe dementia, but he had still kept to his word. Day after day he lovingly cleaned her, cooked for her and held her hand and talked to her. He was an angel in every sense of the word.

  Before the ambulance arrived, we had got a call explaining that they thought she might have suffered a respiratory arrest (i.e. stopped breathing). As soon as she arrived, I could see how unwell she was. My SHO (junior doctor) gave oxygen and fluids and organised a chest X-ray, while I talked to the husband.

  It soon became clear what the situation was. Taking over her breathing and sending her to ICU was not an appropriate thing to do. It would be more humane to let her die peacefully. I explained this to the husband. He broke down in tears and just said, ‘Thank you. I can’t cope any more and nor can she.’

  I smiled and invited him in to be with her. She spent the last few hours of her life held tightly by her husband, listening to him telling her how much he loved her and recounting all the good times they had in the past.

  It was a sad but beautiful sight that I felt privileged to witness. Emergency medicine is not just about the high drama of trying to save someone’s life. Sometimes the most important skill in medicine is knowing when to let nature take its course and not interfere. It was sad to see, but also the right thing to have allowed to happen.

  Having to cope with the upset that these type of situations create is something that can never really be taught at medical school.

  Right and left problems

  I felt like a prat today. This eight-year-old boy came in after falling on an outstretched right arm. It looked like it was probably broken. I gave him my usual preamble with boys to make him feel at ease.

  ‘So what football team do you support?’ I asked.

  ‘Man City’, he replied. ‘Joey Barton is brilliant,’ he added. I told him my little joke about our hospital policy being not to treat Man United supporters as a way to save money. He laughed but I am not sure if his dad realised I was trying to be funny.

  ‘Blimin’ good idea that is. Bunch of pansies the lot of them.’

  ‘Oh dear’, I thought, and went back to examine the boy, then wrote an X-ray form. I wrote ‘X-ray R wrist please’. I always try and be polite on my forms–it usually helps to oil the cogs of the working day.

  He came back with his X-ray and to my surprise there was no fracture. I reassured him and his dad, and sent them on their way, with the advice he was to come back if it continued to hurt.

  Seven hours later he was back–this time with his mum–and still in pain. As he was a returning patient, he had to be reviewed by a middle-grade doctor (like myself) or consultant. Luckily (for me and my blushes) it was after 6 p.m. and I was the most senior doctor around. I examined him again, and explained that muscle injuries can be just as painful as broken bones.

  His mum then asked, ‘Do you have a policy of only X-raying the wrong hand if they support City, or does it not matter and you X-ray everybody’s wrong hand?’

  I was flabbergasted. I protested. Surely her son was making things up. I went and got the X-ray form to prove that I had written R on it. I had written R, but the radiographer had read L as, to be fair my R looked like a L. I looked at the X-ray–yes there was an obvious ‘Left’ written on it. What a dick I had been. I apologised to the mum profusely. A new X-ray form was written with ‘Right’ written instead of R and it duly came back with a small undisplaced fracture needing a plaster of Paris cast. Luckily, no harm was done.

  I apologised, held my hand up and admitted my error. I told the mother that I was never going to write R and L again, but spend the extra second finishing off the word. She seemed to accept my apologies. She also wanted to clarify that her nephew would be able to come to hospital if he ever got ill. He is a Man United supporter. ‘Oh dear’, I thought, as I went on to explain myself for a second time.

  A note to all readers. The Man United comment was meant as a sarcastic joke. All NHS hospitals will see supporters of any football club. Don’t worry…well, unless you support Chelsea–then you are on your own.

  What a waste of talent

  I am writing this passage with an almighty hangover. What a night. We had a lot of celebrating/commiserating to do. Three of my close colleagues are quitting work as A&E doctors. One is retraining to be a GP, another is moving to Australia and my third colleague is retraining to be a management consultant–she doesn’t want to give up medicine, but she has kids at school and a mortgage to pay and is worried that she is going to be unemployed in August, because of the uncertainty of the new recruting system. All are fed up with the lifestyle and the way they are treated.

  However, it is not just A&E where hospital doctors are feeling fed up and angry. Hospital doctors, both junior and senior, throughout the country are becoming more and more disillusioned and are leaving in droves. These decisions have been entirely justifiable for the individuals concerned, but for the country as a whole it has been an enormous waste of talent and money. This is happening at a time when more and more money is being pumped into the NHS. How can this be? There are a number of reasons, but ultimately it is because hospital doctors are feeling undervalued and are being blamed for the NHS’s ills; they are fed up with poor working conditions, ungrateful management and feeling unable to direct the reforms occurring in the NHS. Tragically, there has been a new way of recruiting junior doctors, which is impeding some of our best-qualified and most experienced junior doctors from getting jobs and thus forcing them to leave the NHS. The problems for hospital doctors are exacerbated when they see that even when they do qualify there are apparently going to be too many consultants and not enough jobs to go round. Will they finish all their post-graduate training to end up working only as subconsultants?

  Junior doctors are feeling especially angry. It is true that there is no longer the ridiculous culture of 48-hour shifts. However, there are still unpleasant lifestyles associated with working as a doctor. Once qualified, there are the chores of having to rotate round various hospitals every six months, the stress of post-graduate exams and the worries of having to apply very frequently for new jobs. They say one of the most stressful events in life is moving and/or starting new jobs (along with getting married and having children). Junior doctors do this every six months–not the kids and marriage bits. The government has tried to rectify this by implementing changes to doctors’ training but has only managed to demoralise a whole cohort of doctors in training (see next rant).

  Hospital juniors are also getting annoyed because of the way they feel they are being treated compared with their GP colleagues. The GP trainees have much more training built into their rota, they get more supervision and are not just thrown into the deep end when they start jobs, as is sometimes the case with hospital jobs. Then there is the question of pay. I do not begrudge GPs their money–that much (the average GP does not earn as much as the press says), but when I am doing an A&E shift and a GP is doing a locum out-of-hours shift round the corner he is often getting more than treble my pay. When you know that, you feel undervalued and underappreciated. However, by comparison, I have absolutely nothing to complain about compared with the nurses, receptionists, cleaners, etc.

  Consultants are also becoming more fed up and some are reducing their commitment to the NHS as a result. There are numerous reasons for this but they include disillusionment about the NHS reforms, loss of continuity of junior staff and having to work to artificial targets as opposed to clinical need.

  The NHS is its s
taff. We need a hospital staff with high morale instead of this disillusionment we are all experiencing. It is not about money–it is about having job security, feeling valued and having our time and skills used appropriately…The only good news is that with more people leaving I am getting to go to more and more after-work drinking sessions. My wife can’t really ban me if they are for long-standing colleagues’ leaving dos…

  MMC–mangling medical careers

  A few weeks ago doctors organised a march against what the government is doing to junior doctors’ training. I have never seen so many placid, conservative, non-volatile people on a demonstration before. They were campaigning against a programme called MMC–Modernising Medical Careers (otherwise known by some as demoralizing/mangling/mismanaging medical careers). It certainly has benefits in terms of organising doctors’ training from when they finish their ‘foundation jobs’ (the first jobs they get after qualifying). In A&E it has the added benefit of ensuring that every junior A&E doctor works for a time in anaesthetics and intensive care–jobs that are often hard to come by but that can teach you vital skills.

  However, its implementation is what is really pissing off a vast number of doctors, damaging morale and, in the future, may damage patient care. Again, the intention was sensible enough–streamline doctors’ training and try and make job opportunities fairer–but the implementation is farcical. Instead of bringing it in gradually, there has been a most ridiculous attempt to transfer a cohort of doctors from the old scheme to the new one at the same time as implementing the new training scheme for the very junior doctors. As a result 30 000 doctors are applying for 22 000 jobs.

  It is the way that they are being forced to apply which is outrageous. The ‘system’ consists of a computer-based questionnaire that assesses your ability to write politically correct crap in 150 words. Doctors with experience, exams, research and wisdom are losing out to others who have been on a course on how to fill out the application form.

  The lucky ones who are offered interviews are faced by senior doctors who have not seen their CVs and who have had to mark 600 applicants’ forms in a weekend–but only one question on the form–and so they cannot possibly get an idea of the candidates. The lucky ones get jobs, but often in different parts of the country from where they live and where their kids go to school. They only get told about their jobs at short notice, then have to scramble to find somewhere new to live and somewhere to send their kids to school.

  I know of so many doctors whose current contract is finishing in August and then do not know what they will do. Individually, it is upsetting; these doctors, who have debts from medical school and haven’t hit high earnings yet, are left with the threat of no job and no future in the NHS. Collectively, it is a disaster; it costs £250 000 to train a doctor–we are losing thousands of doctors and that is millions and millions of pounds that we as the tax payers have wasted.

  Tragically, no-one seems bothered. There is a campaign group (http://www.remedyuk.net) and a few Internet blogs that have taken a big interest such as http://www.nhsblogdoc. blogspot.com, http://www.drrant.net, http://www.thelostdo ctor.blogspot.com and http://www.drgrumble.blogspot.com. However, the national media has not seemed that concerned about the plight of the country’s junior doctors and the fact that many of them are leaving the NHS at our expense.

  How did this happen? I think it is government arrogance. They thought they knew best. They ignored the advice of the British Medical Association, which was to ‘slow down, take stock and do this sensibly’. They rushed it through and now, despite a last-minute review, we are faced with this disastrous outcome. They then had the audacity to blame the senior doctors (via the Royal Colleges) who were the very ones urging caution against this whole system.

  I know the politicians have said that doctors need to live in the real world and not expect a job for life and should expect competition for popular jobs. That is completely fair and in the past it was totally wrong that some doctors were helped by an ‘old boys’ network’. However it is the utter lack of care that the system shows for its employees that is upsetting. No other group of workers would accept such a shambolic arrangement: where thousands of junior doctors have had their contracts expire in August and then have to apply for new jobs where they can’t show their CVs, don’t know where they will work or what their pay or conditions will be. Then if they are lucky and get a new job, they will only have a couple of weeks notice to uproot themselves and their families before they start their new jobs–remember, this is not just happening to people just out of medical school, but to doctors in their mid thirties who have up to eight years experience and who have roots and families which they need to consider as well. The only people smiling at this mess are the employment lawyers who could be in for a windfall. Oh, and the Australian health service, which is getting loads of very good, well-trained doctors at the British tax payers’ expense. No wonder the application system called MTAS (Medical Training Application System) has been nicknamed Migrating To Australia Soon.

  P.S. Since this was written a review group have looked at how to try and improve everything. They are hatching a last-minute plan to try and save the government’s blushes, and thousands of junior doctors’ livelihoods. I wish them luck–they’ll need it.

  Still off duty?

  When I am not at work, I love Saturdays. In the mornings I play for a local football team and in the afternoons I go with my dad to watch my apparently professional football team play in a depressive mid-season battle. However, this is only when the wife allows and so is becoming a rarer treat. Saturdays are now usually DIY-based–or screaming at some random IKEA instructions-based –as I fondly think of it.

  But this Saturday I was allowed to play. We were playing top of the league and for those of us excited by regional lower division non-league football, boy, this was a big game. It started well. My fitness training had worked and I had played a blinder. One–nil down at half time had only spurred us on and with 15 minutes to go I had just scored a screamer from 40 yards to bring us level. The crowd was singing and I was feeling fantastic. Five minutes later, the ball came back to me. A one–two followed and we beat the offside trap. My mate sprinted forward. Rushing towards goal he was tripped. A penalty was awarded, but he was in agony. I ran forward and realised that his shoulder was obviously dislocated.

  He was screaming and it ended up being my job to take him off the field and drive him to hospital, bypassing the queues and getting a friend to pull his shoulder back into position. But I didn’t want to be there. I didn’t want to be subbed just because I am a doctor. I wanted to score the winning penalty and then go to the pub afterwards. But alas no. I am still on duty even when I am out playing football.

  P.S. My wife has just read this and has reminded me that this book is based on reality not fantasy. I must confess I hadn’t done any fitness training, I was playing shit and we were 3–0 down and playing third from bottom–we are bottom. There was no singing from the crowd, just a bark from a random stray dog. The goal I scored was an own goal, which hit my bum as I fell over after my contact lens fell out. Sorry for the misinformation. The bit about the IKEA furniture and shoulder were true though. What is also true is that we both got back in time to join everyone for drinks. One perk of my job is that my mate bought my drinks for me to say thanks.

  I want muffins

  It was 6 a.m. and the canteen was closed. I was feeling hungry, having been on shift for 10 hours already. I went to help myself to a couple of pieces of toast. Admittedly, yes, technically it is for patient use, but it is one of the small perks of the job that we can get some free toast and tea in the early morning. This morning, on the front of the cupboard door, there was a new sign warning us that taking bread was theft and could end in disciplinary action.

  Come on, who writes such ridiculously rude notes? Why, when managers are trying to save money, do they do pathetic things like take away tea and coffee and bread, and not look at really serious issues? I bet they
had muffins at the meeting where they decided on this money pinching measure. If they are going to take away our bread, then let us have their muffins.

  Bloody trains

  For some unknown reason, I am on an eco-drive. I have spent a fortune on energy efficiency lights, become keen on recycling and started to come to work by train. I feel like an eco-warrior (a middle class one who is scared of climbing trees let alone living in one with a bloke called ‘Swampy’, but still in my eyes an ‘eco-warrior’). I feel good about myself. These feelings vanish, however, as I get off the 8.42 train…

  When I walked off the platform, there was a group of inspectors standing round a lady who was carrying a ridiculous number of bags. At first I thought she was shouting down a mobile phone. Then I realised that wasn’t the problem.

  ‘WHY DON’T YOU GET RID OF YOUR KNIVES?’ She screamed in the general direction of the ticket inspectors.

  ‘I KNOW WHY YOU WANT ME DEAD. BUT I DIDN’T CAUSE THE TRAIN CRASH.’

  I approached and was told to stand back as she was apparently dangerous. She was very unwell, but, no, she wasn’t dangerous. I recognised her straight away. She was in her 40s and was a known regular at A&E. She had mild learning difficulties and psychotic paranoia and depression; a diagnosis of schizophrenia had been made in the past. She had a problem with alcohol (i.e. she drank more than her doctor) and her coping mechanism for whenever she got stressed was to self-harm. For years she had been in and out of psychiatric hospitals, and was now receiving ‘care in the community’.

  In the past, patients like this may have been institutionalised, but they now are more likely to be cared for at home by community psychiatric nurses. However, these services are often under-funded and patients can slip through the ‘care’ bit of the ‘care in the community’ programmes. Instead, their ‘care’ is often provided by homeless shelters, police stations and A&E departments. This lady was one of these patients. She didn’t cooperate with any of the programmes they had tried to involve her with. She was getting sicker living in the community, but there was little anyone seemed to be able to do for her. As a result she had been to A&E 78 times in the last four years.