In Stitches Page 5

  I enquired why he had a health visitor and how often she came round to see him.

  ‘She comes round once every three weeks, just to see how I am and help me…you know.’

  I wasn’t too sure what he was talking about, but I thought he must have been describing a new government scheme, whereby community matrons visit patients with chronic conditions at home every couple of weeks to check that they are OK. They then liaise with their GP and try and implement plans to keep them out of hospital. I asked him if that was what he meant by a health visitor.

  ‘She isn’t organised by the GP. I organised her myself about three years ago. She has been very good to me,’ he responded.

  Now I was confused. Naive as well, as it turned out! I continued in my questioning.

  ‘So does she help round the house then?’

  ‘No my friend.’ He leaned forward and in a theatrical whisper said, ‘She comes round to help me ejaculate as I can’t really do it myself. It was when she was playing with me that I got the chest pain. It was so bad that she had to stop and call the ambulance.’

  ‘What a bloke’, I thought, ‘Honest and still enjoying life, and very friendly’. I smiled and in the notes wrote pain started on ‘mild exertion’. It is encounters like this that make my job pleasurable.

  How targets can hurt patients and staff

  In principle, a target to see and sort out patients within 4 hours is a fantastic aspiration. Unfortunately, it is like a lot of targets and reforms–they comply with the law of unintended consequences by creating an unintentional distortion in clinical priority, which impinges on the quality of care we provide.

  I don’t think Labour has deliberately tried to harm patients care at all, or that it has deliberately tried to piss off NHS staff. I think that its heart is roughly in the right place, it’s just that it has implemented some ridiculously stupid NHS reforms without realising the consequences. Do you remember, during the last election, someone complaining to Blair on Question Time that they couldn’t book follow-up GP appointments? He had no idea that his policy of making all GPs guarantee that they would see people within 48 hours would mean that they would stop making follow-up appointments a week or so in advance. It was an unintended consequence. He was clearly shocked and promised to sort it out.

  Well-intentioned cock-ups like this have happened throughout the NHS. Within A&E, we have the 4-hour target–we have 4 hours from when a patient arrives to either discharge them or admit them; 98 percentof patients need to meet this target. Don’t get me wrong; on the whole, the 4-hour target has banged heads together and brought about some good changes to the way we work and treat patients. Patients no longer wait 12 hours to see a doctor for a broken toe and being admitted to hospital has been streamlined. However, unintended consequences do exist and they can be harmful for patients. Let me explain with a couple of examples.

  Last week, we were having a very, very busy day. There were massive delays in X-ray and an old lady who had fallen had had to wait 3 hours and 40 minutes to confirm the diagnosis of a fractured hip. She had been given some morphine while waiting for her X-ray, but was still in pain. The clock was ticking–it was 3 hours and 55 minutes since she had come in and the porters were about to be called to take her to the ward. In 5 minutes I could have given her some more morphine. However, it has side-effects such as slowing down the respiration rate (she also had a chest infection, which had caused her to fall in the first place) and nausea. What is just as effective but without the complications of a second morphine injection, is an injection of local anaesthetic into the area around the nerve going to the hip. It numbs the area within 10 minutes, and around 12 hours of pain relief is provided. However, it takes around 15 minutes to do. I told the nurse in charge that I wanted the patient to have the injection and not go to the ward just yet. I was told that she would fail her 4-hour target. This is known as a ‘breach’. In these days of targets it is so hard to argue back. If a patient breaches, then the consultants have to ‘examine’ why. If too many patients ‘breach’, then the NHS managers come down on the hospital like a ton of bricks and there are potential financial penalties.

  But aren’t we in the job to provide the best possible care for the patient and not there to worry about targets? No wonder so many nurses and doctors are leaving A&E. They are doing so because they are not allowed to do their job properly–caring and managing patients.

  After a 10-minute delay, we all agreed that it was in the patient’s interests to give her this injection and the figures were fiddled. (I deliberately do not get involved in this fiddling, because I think we should be producing honest figures so that something gets done rather than just massaging the ego of the Secretary of State for Health.) The department pretended she had left A&E 20 minutes earlier than she had. The figures said that she stayed 3 hours and 59 minutes. It is ridiculous that so much time and energy is spent trying desperately to meet targets, but when we fall short, someone has the job of adjusting the time. I don’t blame the A&E department for adjusting the figures. There is such pressure on us to comply with the target that adjustment is seen as acceptable. It means the hospital won’t get penalised financially or by a reduction of its ‘star performance score’ status. By fiddling the figures, it also means that we can concentrate on looking after our patients.

  If there hadn’t been this target culture, then there wouldn’t have been this unnecessary stress and pressure on everyone. Perhaps if targets were used to identify where more resources were needed, rather than to punish failure, patient care might be improved. This time the potential breach was caused by a delay in X-ray (which often occurs). The solution might be to hire an extra radiographer. If this was done–if cash was invested to sort out this problem–then this delay might not occur again. But no, we fiddled the figures so we didn’t lose money and hence no one could highlight the problem. And the government could say everything is lovely-jubbly.

  Another example was a 16-year-old girl who came in last Thursday. She had been drinking in the joyous surrounding of the local park. (Oh, the joys of the Anglo-Saxon drinking culture.) The ambulance was called because she was unconscious in the street. She needed fluids and a period of observation. At 3 hours and 30 minutes, my colleague reviewed her and determined that although she was now conscious, she was not well enough to go home yet. She needed another few hours to ensure that she didn’t still choke on her own vomit, etc. Before the days of targets, she would have stayed in A&E until she was well enough to go home. However, now we could only keep her for 4 hours, although she needed more time. My colleague was then told to refer her to the paediatricians to go and sober up on the kids’ ward. This was not appropriate. The paediatricians were busy enough and didn’t need to see a patient that my friend knew didn’t need their specialist skills, but then there is this bloody 4-hour target. Except in a very few clinical exceptions, we are not allowed to care for someone for longer than this time period. My colleague refused to succumb to the pressure of the nurse managers and did not refer her to the paediatricians and ended up getting a lot of grief for it.

  She reviewed the girl 2 hours later. She was fit enough to go home with parental supervision. However, she was discharged about 45 minutes earlier than would have been ideal. The next day the doctor was expecting an interrogation into why she had let someone ‘breach’ but the figure had been fiddled and the patient was apparently discharged at 3 hours and 59 minutes. Again, I can understand why the figure was fiddled, but if we hadn’t fiddled the figures we might have seen the problem and a solution–a properly staffed paediatric A&E observation bed, where patients can be admitted while staying under the A&E team.

  Figure fiddling happens everywhere. A recent survey by the British Medical Association and the British Association of Accident and Emergency Medicine showed that 31 percentof A&E doctors admitted to working in a department where ‘data manipulation was used as an additional measure to meet emergency access targets’. In other words, they admitted to work
ing in an A&E where the figures were fiddled (for those of you who want to read more on this please go to http://www.bma.org.uk/ap.nsf/Content/Emergencymedsurvey07).

  This is further backed by research from the City University business school that looked at the records of 170 000 A&E attendees and applied ‘queuing theory’. The conclusions were reported by lead researcher Professor Les Mayhew, who said:

  ‘The current A&E target is simply not achievable without the employment of dubious management tactics. The government needs to revisit its targets and stop forcing hospitals into a position where they look for ways to creatively report back, rather than actually reducing waiting times for real people.’ (further information is available from http://news.bbc.co.uk/go/em/fr/-/1/hi/health/6332949.stm).

  When the Department of Health spokesman responds by saying back to the BBC, ‘It’s absolute nonsense to suggest that the A&E waiting time standard is not being met,’ who do you believe?

  It is not just the raw data that is manipulated. There are other ways in which 5 hours to you and me means 4 hours to the Department of Health. Examples I have heard from various colleagues throughout the country include:

  1. Corridors are re-designated admission wards by the simple application of a curtain rail. As soon as you are admitted to the ‘admission ward’ the clock stops.

  2. Patients are discharged on the computer before they have left the A&E (i.e. before they have got their discharge drugs or similar).

  3. As soon as a bed on a ward is allocated to the patient, the patient is transferred to that bed on the computer, regardless of whether they have to wait an hour for the porters to take them to it.

  4. Patients can be admitted by computer to an A&E ward (and not breach) but physically not move because there are a lot more beds on the computer than there are in real life.

  5. The time it takes from the ambulance bringing a patient in to being logged onto the computer can take up to 30 minutes longer if there are no nurses to meet the ambulance. The clock starts ticking when we are ready and when the receptionist has had her cup of tea, NOT when you arrive.

  6. If a patient has been referred by a GP, they don’t come to A&E anymore, but to an admission ward. As they are technically admitted, there is no target for how quickly they get seen and so they can often languish for hours before seeing a doctor.

  7. Patients for whom A&E doctors have asked for a review by a specialist can get admitted to a ward regardless of whether the specialist has seen them or not and regardless of whether they actually need to come in or not. Once admitted to a ward they can stay there for ages without being seen by the specialist as they are no longer in A&E and so cannot breach.

  8. Originally, there were specific days when the 4-hour rules were being assessed. On that day, the hospitals would cancel elective operations so that there were spare beds and employed loads of extra locum doctors and nurses to make it look as if the hospital was more efficient than it really was.

  So, as you can see, hospitals feel compelled to massage their figures. The target was brought in for the right reason and initially did a very good job. But we need clinicians to make the priorities, not politicians. If the government is going to insist on targets, then let’s make some sensible ones such as all urgently triaged patients to be seen within 5 minutes of arrival. Or how about patients being able to expect a bed 30 minutes after they have been fully treated in A&E, etc? These targets may not be as glamorous to tell voters about, but they might actually improve care without distorting priorities.

  The reason I moan so much about this is that what was once a tool to improve A&E is now damaging patient care and doctors’ and nurses’ sanities. I just hope a politician or two reads these words and does something about it other than claim that what we are saying is just ‘nonsense’.

  At work on New Year’s Eve

  I am writing this on New Years Day. Last night I was at work and it was absolute hell. The A&E looked like a war zone–police restraining aggressive drunks, teenagers vomiting and crying and overworked staff acting as bouncers. I can only assume that the managers thought that someone might fiddle figures for the night and so didn’t bother to employ any extra staff despite knowing how busy it was going to be. I was knackered by the end of the shift and was pissed off with some of the patients’ attitudes, but in all honesty, I quite enjoyed myself.

  But I can hardly blame the new drinking laws. I started my shift at 9 p.m. and the drunks were already there. The first was quite a nice lad of about 17. He had fallen asleep in the street and someone had called an ambulance because he had wet himself and was vomiting.

  ‘So what happened?’ I asked.

  ‘You tell me,’ he retorted.

  ‘No. I asked first. What happened?’ I countered.

  ‘Don’t know mate. Been larging it,’ he said in his irritatingly pretend street speak accent–posh but with a touch of Estuary English.

  ‘It says on the notes from the nurse that you have been drinking. That can’t be true as you are under 18 and so surely can’t have been drinking. What actually happened?’ I mocked.

  ‘Nah mate, I gone massive. I am quality,’ he retorted in Mockney.

  Luckily, I listen to Radio One, so I sort of understood what he had said.

  ‘So how have you gone massive mate?’ I enquired.

  ‘Vodka mate. Bottle of vodka–down in 1 hour. Larging it. So what I am doing here?’

  I explained that an ambulance had been called for him as he was so drunk.

  ‘That is quality. Coming to hospital ’cos so drunk. Quality.’

  I asked some questions to check that he was OK and had suffered no ill-effects from his night’s drinking. I asked him if he thought a bottle of vodka was really that sensible for a 17-year-old’s liver.

  ‘I can do it because I am so f**king hard. I am hard as nails me.’

  ‘Right…so hard you end up vomiting all night and pissing yourself so that your mummy had to collect you at 10 p.m.? Yep, hard, aren’t you? Well done mate.’

  I called in his mother, and as soon as he was able to walk without falling over, he went home. Except that that wasn’t all he had to say for himself. While waiting for his mum, every couple of minutes he would call out to one of the nurses.

  ’Oi! Beautiful! I am quality–do you want to come home with me?’

  He was harmless but irritating after a while.

  The next case was a 14-year-old girl. The ambulance called ahead to say they were blue lighting her in as she was completely unconscious. The nurse and junior doctor tried to wake her up and couldn’t. I got a call on the intercom.

  I walked in and initially failed as well. If she was truly unconscious then we might have to intubate her (i.e. put her to sleep and take over her breathing) so that she wouldn’t choke to death on her own vomit, which I was currently sucking out of her mouth (with a suction tube). Then I tried a ‘registrar’s trapezius squeeze’. (Basically, you squeeze as hard as possible on the bit of muscle between the neck and shoulder, then carry on squeezing until they wake up.) She did wake up–very quickly. I checked that she hadn’t hit her head or taken any drugs, asked the senior nurse to put in an intravenous cannula, watch for more vomiting, and give her some fluids.

  Giving fluids to someone who is drunk is a little controversial. We spend tax-payers’ money helping them to sober up and not get as bad a hangover which may positively reinforce their A&E-seeking behaviour after drinking. This can’t be good, but I am still a believer in giving them lots of fluids when people are drunk because it helps to get rid of them more quickly. It helps them sober up, and also they soon wake up needing to go to the toilet. Sometimes it backfires and they end up losing full control of their now full bladder–but the risk is worth taking as it is so effective in aiding appropriate discharges.

  I explained to the girl’s mum what was happening and why we were giving her daughter fluids. We put the girl on her side and left her where we could watch her closely. We also gave her little
sister, who had to enjoy her New Year’s Eve watching her big sister vomit, a chair and a blanket to cuddle into.

  After 3 hours and 59 minutes the girl was sober enough to go home with her mum, who was furious with her daughter. As I came to see her, her mum was in the middle of telling her off.

  ‘This is the second time you have done this now. You have ruined your New Year and everyone’s else’s, you selfish girl,’ I heard her say. I introduced myself to the young girl and checked she was OK. I then said she was free to go but before that I wanted give her some useful patient education.

  ‘You could have died you know–you are only 14. Don’t be so dangerous in future.’

  She looked at the floor.

  ‘Do you want me to tell her off?’ I asked her mum.

  ‘Please do,’ she said.

  ‘I have seen loads of people ruin their lives by binge drinking. You have been so stupid. We had to suck out the vomit from your mouth. Do you realise that? Do you? You could have had the vomit go into your lungs and then you wouldn’t have been able to breathe properly. You could have died, and in that state anybody could have done anything to you and you wouldn’t have known. Don’t be so stupid again and drink with some self respect.’

  Her mother seemed suitably pleased with me. But I hadn’t yet finished.

  ‘You have also stopped me seeing really sick people who needed my help. The elderly lady in cubicle 5 had to wait an extra 30 minutes for me to give her pain killers for her broken leg because of your selfish stupidity.’

  Her mum seemed very pleased with my chastising abilities, but then said, through gritted teeth, ‘You wait till you get home and then you’ll get a proper telling off.’ I felt sorry for the girl: I obviously had not been stern enough!

  There are probably some trust guidelines saying that my attitude to this patient was probably not appropriate–I didn’t treat her in a holistic way and I didn’t communicate in a way appropriate to understanding her cultural needs (i.e. she was an Anglo-Saxon who culturally needed to binge drink). A lot of doctors, who are worried about having to be politically correct, may not have acted in that way for fear of being complained about. But I think that we should be complained about if we don’t try and educate patients on harm prevention. We need them to know the danger of their behaviour and it has been shown that short blasts from A&E doctors can make a difference. It is also quite enjoyable for us, but that is not the point. If I really wanted to go into a job so I could tell off teenagers, I would have gone into teaching. But then all my teacher friends say that if they really wanted to go into a job where they could tell off teenagers, then they would have been A&E doctors. Anyway my fears that I had gone a bit over the top subsided when in the morning, her mum brought round a thank you letter and a box of chocolates. I have never been thanked so kindly for being so forthright to someone’s offspring before.