In Stitches Page 6

  The effects of drinking continued. Luckily, as it got later in the evening, the patients generally got a little older. Unfortunately, they also got a little more abusive as their waits to see me increased. There was a lot of drinking going on–mostly on empty stomachs but largely on empty heads as well–a particularly dangerous combination. The only difference from New Year’s Eve in the days before liberal drinking laws is that now cases of alcohol intoxication continue from 8 p.m. to 6 a.m.

  The thing to remember is that these patients do need proper medical care–in fact they often need even better attention than sober patients as it is easy to miss injuries when someone is drunk. More seriously, it is easy to misdiagnose an unconscious patient as someone being drunk, when in fact they have had a serious head injury. I left work absolutely exhausted, but with a thought. If only we could videotape these patients and then show them what fools they made of themselves…

  Why bother coming?

  It’s a Sunday. The weather is beautiful. There are hills to walk up, football matches to watch, women/men to chat up, beer to drink and the seaside is only an hour’s drive away. You are young and healthy, with money in your back pocket–the world is your oyster. Lastminute.com is offering you 12 hours in New York for £3, the cinema has a new movie on; you have a new horny girlfriend who has lost her rabbit. You could do anything. So why on earth do you sit in A&E for 5 hours (sorry, Mrs Hewitt, 3 hours and 59 minutes on the computer), for me to see you and say there is nothing wrong with you? Look, go to your GP if you are worried about non-urgent things and next time you come, read the sign outside–ACCIDENT AND EMERGENCY DEPARTMENT.

  Some examples from the last few days:

  1. 8-year-old kid at school. Fell over and grazed his knee. Played football for 30 minutes after injury before the bleeding became too noticeable. His school was not happy to take the responsibility to wash the graze and give him a paracetamol. So the poor kid waited 4 hours and 30 minutes (whoops…3 hours and 59 minutes to you, Mrs Secretary of State for Health) to see a nurse to have it cleaned and bandaged. If the kid had just had a teacher who was legally allowed to show common sense, he could have been at school having fun and perhaps learning something, as opposed to sitting in the waiting room all day.

  2. 50-year-old man: ‘Doctor, I went to bed and woke up and felt scared and so called an ambulance.’ He was having a nightmare. Now, I am not annoyed with him, just the lack of mental health support in the community, which can look after patients with his type of condition.

  3. Man with chronic hip pain–no worse–had it for two years. The GP he likes is on holiday, so came to us instead. Needs a new hip, but doesn’t need to come to A&E. Poor bloke, not annoyed with him, but more at the system for allowing waiting lists of eight months for hip operations. (N.B. Clever statistics would show that he has only been waiting four months for the hip, but he waited four months to see the orthopaedic surgeon to tell him that he needs an operation. In the real world that is an eight-month wait. In NHS world, it is four months. However, that is still much better than in the days of the Tories ruining the NHS. Now at least the waiting lists are coming down quickly–even if they have done it in a very expensive and divisive way.)

  4. 28-year-old man–pain in his foot for three days after playing football. No obvious injury and has been able to run on it but as it was still sore this morning, he called an ambulance. Not taken any analgesia. Well, if he had, it might not hurt so much. He demanded an X-ray; I asked why he had called an ambulance. He said he paid his ‘f**king taxes to get X-rays when he wanted one’, but didn’t answer my ambulance question. I reminded him that he paid his taxes so that I could decide if I would X-ray him. He went on about patient choice to call an ambulance and choice of getting an X-ray. I had to listen to his twaddle and be polite. It was hard. I wish there was a campaign for doctor choice as well as patient choice. I would have chosen to tell him where to go. Instead, I was polite and moaned about him when I got home from work.

  There are loads more. People will not take responsibility for themselves or others. Some are just selfish, others just have mental health issues and the community services are not in place. Some just don’t go to their GP for one reason or another. In the end, there is no inappropriate A&E attendee, just someone who doesn’t know what the alternatives are (and when they should be used), or who lives in an area where the alternatives are not properly resourced.

  I am so glad I am tired

  Last night I went to bed at 10 p.m. My wife was not well at all, high temperature, coughing and sneezing and lethargy–Man ’flu, I diagnosed, and so I agreed to look after our non-sleeping child all night. I was nervous and the anticipation of being awakened stopped me falling asleep. I resorted to desperate measures–I started reading the British Medical Journal: 30 seconds later, I was out like a light.

  Two hours later the crying started. Back to sleep, and then up again at 2 a.m., then 4 a.m. and then 5.30 a.m. I wish I could invent a cure for colic and teething–something more ethical than ear plugs. But alas no…So, off to work at 7.30 a.m. and I was exhausted. I believe that the bastard who invented the term ‘sleeps like a baby’ never met anyone under five.

  I arrived as the red phone went off. Information from the ambulance crew–paediatric arrest. Patient, six months, mottled and blue on arrival. The senior nurse called the paediatric resuscitation team down, but we all knew the probable outcome: this was a cot death and we were going to be going through the motions just in case and also to help the long-term grieving process.

  The child came in with mother screaming. The thing I noticed was that he had the cutest little blue socks on which were the same colour as his skin. Our initial expectations were correct. We had all agreed our jobs, with the paediatric registrar being in charge of us all. My job was to get an interosseous line in (this is where a needle is quickly inserted into baby’s leg bone as a very quick way to give fluid and drugs–you do this when they are so ill they have no visible blood vessels). I got on with my job, but felt sick. I wasn’t in charge and could just concentrate on my job. Somehow I felt very detached from the whole situation. All the voices seemed distant. The mum’s cry was audible, as was the counting of the cardiac compressions, but it all felt surreal. I can’t explain why I felt like this but I did. I pushed the needle a little harder and felt the pop of the needle going through the baby’s bone. It was a huge sense of relief that I had done the part I was supposed to do. I attached the needle to fluids and gave drugs that others had drawn up.

  The drugs were not helping–nothing was. We were keeping his blood pumping with the compressions and the anaesthetist was breathing for him–but he was dead and had been for a long time. We all knew it but nobody wanted to give up. Nobody wanted to stay ‘Stop’ in front of mum.

  It felt like fruitless cruelty, but I rationalised it by knowing that the child would feel nothing and the grief would perhaps be easier in the long run for mum and dad if they knew we had tried everything.

  I wanted to say ‘Stop’ but my colleague in charge murmured a suggestion of doubling the usual adrenaline dose–no-one really thought it would work, but no one said so. It is much easier to stop resuscitating an elderly adult than a child. No one wants to be the first to say stop. After about 15 minutes, one of the senior nurses first brought up stopping. No-one really responded –but a general agreement was made to continue for another cycle (2 minutes)

  But then, thankfully, the (right) decision was taken out of our hands. ‘Please stop…Stop, STOP. STOP. He’s dead…My baby is dead.’ We all looked at each other, nodded and stopped. The barbaric-looking lines and tubes were removed and the senior nurse wrapped him in a blanket. He picked him up and took him to mum. She held him and sobbed, and sobbed and sobbed…and then started speaking to him, ‘I am so sorry I let you down today. I’ll make it up to you. Tomorrow, we can go to the zoo and see all those animals you like.’

  At this point I couldn’t stay in the resuscitation room any longer. The cons
ultant paediatrician was coming in from home to talk with the mother about what had happened. I was so glad it wasn’t my job, because all I wanted to do was cry and have a cup of tea.

  I made the tea and went to calm my nerves for a few minutes. I was soon interrupted by one of the new nurse managers who came and found me and barked an order, ‘The bloke in cubicle three needs to be seen now or he is going to breach his 4-hour target,’ he said. I couldn’t believe it. I had just been part of a failed resuscitation of a child and all he cared about was some poxy figure. ‘I couldn’t care less,’ I wanted to scream. Unfortunately, all I ended up muttering was ‘I’ll be there in a minute.’ How I hate myself when that happens.

  The senior nurse, who had been at the failed resuscitation, came and found me, gave me a hug and said, ‘Have your tea. Sod the pointless figures…someone can always fiddle them.’

  I smiled, happy that the vast majority of nurses have kept their sanity despite the government interference, and went to my next job: a man who had called an ambulance for a painful shoulder which he had for 4 years…ah, the joys of working in A&E…

  By the end of my shift, I was exhausted. But I was so, so glad I was tired–my child had kept me up all night. That other kid’s mum and dad had had an undisturbed night’s sleep. That little boy wouldn’t have made a sound for the last few hours.

  …What a shit start to the day.

  People we refer to

  The A&E doctors often refer to specialist doctors and other health-care professionals. Listed below are a few of the people we work with and what they do. (This is all tongue-in-cheek and if I offend anyone, then I am truly sorry.)

  Radiologists–doctors who specialise in looking at X-rays and scans. Older ones specialise in explaining why the test you want to do is not justified, younger ones specialise in not only doing the test, but then putting various tubes in to the patient while they are having the test. Never call them radiographers–apparently they get upset.

  Plastic surgeons–as consultants they spend a lot of their time making money out of people with low self-esteem. As trainees they spend a lot of their time treating burn victims and nasty hand injuries.

  Respiratory specialists–know a lot about chests, tuberculosis (TB) and asthma. Like to titter when they say to patients ‘big breaths’. (If anyone says this to you, do NOT say ‘well thank you doctor!’ and play with your hair.)

  Cardiologists–experts on knowing lots about the heart. They are also experts on making sure that you know that they know a lot about the heart. They like the phrase ‘A stent in time, saves nine!’ The last breed of doctors to not realise that wearing a bow tie makes them look like an idiot.

  Junior surgeons–cavalier with their approach to cutting.

  Senior surgeons–cavalier with their approach to putting.

  Gynaecologists–the Heineken of all doctors. Can reach the parts that others can’t.

  Acute medical doctors–look after a very similar type of patients to A&E doctors with a similar approach; but have got longer than 4 hours to play with.

  General medical doctors–look after patients with ‘medical’ conditions (e.g. heart attacks, strokes, heart failure, pneumonia). Like to organise a lot of tests–the more expensive the better.

  Paediatricians–look after little kids. Always happy. Colourful ties. Generally nice.

  Orthopaedic surgeons (orthopods)–known as the carpenters of the medical world through their mending of bones and replacing of joints. They take pride in knowing as little medicine as possible. They are the butt of medical doctors’ jokes–replace the word ‘blonde/Irish’ with the word ‘orthopod’ and the joke is usually funny to doctors. Favourite ortho jokes include:

  –How many orthopods does it take to change a light bulb? One: referral to the medics, ‘darkness, query cause?’

  –What is the definition of a double-blind trial? Two orthopods looking at an ECG.

  –What is the difference between an orthopaedic surgeon and a carpenter? The carpenter knows more than one antibiotic, etc., etc.

  Rheumatologists–give you tablets for your arthritis. When they stop working, send you to the orthopods.

  Psychiatrists–don’t like people saying ‘You should have your head examining if you want to see a psychiatrist.’ A lot of their time in A&E is for risk assessment for depressed patients; a small proportion of their time is for truly floridly psychotic patients. Generally poor taste in clothes–sandals and tweed. Use phrases such as ‘erotic counter transference’, when trying to explain that they thought their last patient was quite fit (in the attractive, not necessarily athletic sense).

  Anaesthetists–put people to sleep for surgery, usually by drugs but sometimes by conversation. Very useful when we have very sick patients as they can put in central lines (large intravenous lines through which fluids, blood and drugs can be given quickly) and take over their breathing when patients are struggling. More and more A&E doctors are learning these skills too. So, in the future, we may have to call for these doctors’ help less and less. They can therefore spend more time concentrating on their specialist subjects–sudoku and crosswords at the local independent treatment centre.

  Renal doctors–look after patients who have damaged kidneys. Highly intelligent, but can be a little dull. Understand glomerulonephritis and cANCA. (see Glossary, p.256). Be wary of dialysis specialists. They get offended easily, so don’t take the piss out of them. It’s their job to do that to their patients

  Geriatricians–unsung heroes of the NHS. See massive amounts of patients and act in pragmatic way–by not treating each sign and symptom but the patient. Sometimes difficult to tell the doctor from the patient.

  Oncologists–sung heroes of the NHS. Fair enough, though, they do a good job.

  Palliative care doctors–treat terminal patients.

  Aviation doctors–treat patients in terminals.

  Midwives–they deliver babies and us from evil. Don’t mess or answer back. Ever!

  Dermatologists–If you are able to refer to one of these as an emergency, you work in a big teaching hospital. They look at rashes and give them a Latin name to look clever and then prescribe steroids

  Ophthalmologists–eye specialists. Could replace their on-call service with an automated answer message. ‘Press 1 for me to say give chloramphenicol ointment and I will see them in the morning’, press 2 for me to say give chloramphenicol and review in two days time’, etc.

  Urologists–willie doctors. They love them–short ones, big ones, thin ones, long ones, fractured ones, infected ones, bent ones, lacerated ones…any type–they will have them. Also look after kidney stones and the prostate gland and erectile dysfunction –which isn’t an A&E condition. Please remember that I do not give Viagra from A&E, so don’t come and ask for it…even if she is really fit and you haven’t had any for years. And no, I will not call a urologist to prescribe it for you either. Not getting a hard-on is not an accident or emergency condition. Go to your GP…Sorry, I just remembered a patient who made me irate about six months ago.

  So there you have it. Now when you hear a doctor say that they are going to refer you to a so-and-so doctor, you will know what to expect.

  Why patients are more important than

  budgets

  I saw a 76-year-old gentleman yesterday. The poor man had had a stroke. He had very severe weakness down his left side. Once the stroke has already occurred, there is little that can be done initially for the patient (although at some hospitals, strokes are being treated like heart attacks and clot-busting drugs are given). Generally, though, it is more about long-term rehabilitation and preventing further strokes.

  When I looked at the A&E notes from exactly four weeks ago, I noticed that he had come in with a TIA (transient ischaemic attack)–often called a ‘mini’ or ‘warning’ stroke. He had had 10 minutes of arm weakness which had resolved. Quite rightly, the doctor who had examined him had ascertained that it had resolved and he could go home. The A&E doctor wanted
to refer him to a rapid access ‘TIA/stroke prevention’ clinic. In these clinics, a specialist tries to reduce the chance of a stroke happening. Patients get an urgent CT (computed tomography) brain scan and a scan on the neck (in case there is a blocked artery which may need an operation), not to mention getting started on the necessary drugs to prevent further strokes such as aspirin. If he had been referred, this would have been excellent A&E treatment. A letter to the GP would have let them know what was going on. The problem was that he was not referred to the clinic. Owing to the financing arrangements of hospitals and GPs, we are encouraged not to make direct referrals but to refer the patient back to their GP for them to make the referral to the clinic. The reason for this is purely arbitrary accounting rules. Although the cost is all borne by the NHS, if the referral comes from the GP, it comes from a different pot and the hospital can then be paid by the PCT (primary care trust). Dull accountancy facts, but important for this patient.