In Stitches Page 7

  The waste of time is the thing that annoys me (for the patient, not just the GP). The patient couldn’t see the GP over the weekend and then, when he booked an appointment, he didn’t tell the receptionist it was urgent and asked to see his regular GP who only worked two days a week and was on holiday. As a result, he had to wait till the following Tuesday–a delay of 10 days so far. The referral was then promptly made, but he had not yet been seen in clinic by the time he came back to A&E. This is despite evidence-based medicine advocating that these patients are seen in clinic within two weeks of a warning stroke. It is upsetting that at courses and medical school we learn the gold standard of care but then often end up only being able to provide a silver or bronze quality of care because of local guidelines, management structures or rationing of resources.

  I am not saying that this delay in being seen in clinic was the cause of his stroke, but if A&E could have referred him to the clinic, he might have had an operation and the stroke could possibly have been prevented. But no, the NHS has become disjointed, with separate parts working independently of each other without the cooperation that used to be present. Accountancy rules ruled over clinical care.

  Sadly, this is just one example. So that hospitals can earn money when patients are seen in clinic, A&E doctors refer fewer and fewer patients to specialist clinics. Everything must go through GPs now. This is sensible for conditions that may be chronic and for which the GPs may have already organised various tests, but for new conditions these rules are madness. It is an inefficient use of GP time and a waste of resources.

  Accountancy rules run the NHS and not common sense. In some hospitals, even consultants, who see patients in outpatient departments at the GP’s request and want an opinion from another specialist before making final treatment judgments, have to refer them back to their GP for the GP to refer on. If this isn’t done, then apparently the hospital won’t get paid for the cost of the second opinion.

  So why are these rules in place? Part of the logic of this is also to do with the new concept of patient choice and the involvement of the private sector. The government thinks that it can drive up standards and save money by making GPs the purse holders to the NHS. ‘Payment by results’ is the term it is using to mean that primary care trusts via your GP pay for ‘episodes of care’. This is why the referrals need to come from your GP and not a hospital doctor (who in fact may know a lot more about your current problem because they have been dealing with you.) The GPs can now refer you to your local hospital or a local private treatment centre, depending on patient preference. This is OK in principle but most patients, if they had the choice, would choose a local well-run hospital where profit was not a concern. What is happening is that money is being taken out of hospitals and spent on private companies. The hospitals are suffering as a result and are starting to have to compete against these private treatment centres.

  Some hospitals will be good at one thing and charge a cheaper rate and get the business. Others will not be so good and then lose business. So, in the future, your local hospital may not have all the necessary services. For example, your local knee surgeon may have been made redundant and had to move 70 miles away to the local ‘knee specialist hospital’. This is fine for elective operations but what happens if you are in a car accident and your knee is damaged? Now that there is no longer an experienced knee surgeon working at your local hospital you either have to travel miles to a ‘centre of excellence’ or possibly receive substandard care locally. This is the logical end result of current government thinking.

  When the government was implementing these changes I don’t think that they thought through the effects that these changes would have on emergency-care patients. An unintended consequence of payment by results and patient choice is services being damaged at the local hospitals as well as referrals to clinics being delayed. If the government truly wants patient choice then let patients have what they are asking for: properly run local hospitals where care comes before accountancy rules and regulations.

  An occupational hazard

  A teenager would sometimes love my job, but there are hazards. It was 7.30 a.m. and the last patient before I finished, and I was looking forward to some scrambled eggs in the canteen. He had come in with a nasty abscess on his buttock. He needed it incised and drained. I put a scalpel in the abscess and squeezed. Pus upon pus squeezed out. I gave it one last squeeze and then disaster struck. The pus squirted straight in my face. Egg-like Staph. infection all over my right cheek and glasses. I remained professional, finished the minor operation, then left my nurse colleague to finish off dressing the wound and went to wash my face thoroughly. As I found the sink and disinfectant, my colleague, who was starting his shift, saw what had had happened and reminded me of the time when this happened to him about a month ago. Except that his mouth was open at the time and he wasn’t wearing any glasses.

  Feeling a bit sick, I decided to give scrambled eggs a miss this morning and went to sleep without breakfast, but after a very long shower.

  I don’t understand some patients

  Last night I saw a patient who was having unstable angina. He needed drugs to relieve the pain and treat the condition, but despite about an hour of persuasion he refused to let me put a needle into his arm, and give him the drugs. He explained that he did not believe in western medicine and therefore refused my drugs. Why he came to A&E in that case was beyond me, but it was really difficult seeing a man whom I could have so easily helped sit there in agony. However, patients (quite rightly) have a right to decide what treatment they will or will not accept. It’s just that I did not understand why he came if he was going to refuse treatment.

  The case reminded me of another man I had seen a few weeks ago with a dislocated shoulder. I needed to give him morphine for pain relief but he refused an intravenous cannula because he was scared of needles. Normally, a couple of minutes persuasion and they will agree to it; but not him. The thing that confused me on this occasion was, if he was so scared of needles, how come he had so many tattoos?

  A trip round A&E

  When patients come to A&E, they only see the small bit of A&E that they are in. This quick guide tells you a little about what is in an A&E department so, if you can’t see things going on, then at least you may know where the doctors and nurses are and what they might be doing.

  Let’s start the tour at the front entrance. It is often a very flash and expensively done-up area of the A&E department. You may find a ‘mission statement’ on the wall. These are usually ‘management speak’ rubbish about striving for optimal health in a holistic way, while encompassing your disabilities and understanding your cultural sensitivities, blah, blah, blah. If you have a half-hour wait read it. If you have a 3-hour wait to be seen, kill some time and try and translate it into English. Alternative things you could read are adverts for ‘no-win, no-fee’ solicitors and the in-house hospital glossy magazine: reading either is bad for your blood pressure.

  So, you walk in and get to the reception area. Depending on where you live, there will either be a security guard near by and bullet-proof glass, or a vase and some flowers.

  After you have booked in, you go to the triage nurse. They have a nice room, with lots of bandages and splints, etc., and they decide how sick you actually are and therefore who you are going to see and where. You can become a ‘majors patient’, because they think that you may need a bed to lie on, or a ‘minors patient’, where you will get a seat in a waiting room, or, if they think you might die because you are so unwell, you will get sent to the resuscitation room. The same process of triage happens if you come by ambulance but is not done in the triage room, but in the main part of the A&E. Unless you have been sent direct by your GP to one of the specialist doctors you will see an A&E doctor in one of those three areas. However, in a few cases the triage nurse may think it appropriate for a specialist doctor to see you straight away (e.g. if you are very pregnant) and may send you straight to the ward.

  R
ecently, changes have meant that if your condition is minor, the triage nurse may redirect you to your GP or get an emergency nurse practitioner (ENP) to see you. They may even discharge you themselves. These triage nurses have done extra training to be called SMINTS (senior minor injury nurse triage). They are also called ‘See and Treat’, often nicknamed ‘See, Treat and Street’ them.

  Minors is a less high-tech part of A&E. There are plaster trolleys lying around and lots of bandages. Minors is a very poor name. It may be a minor injury that you have, but it could be very significant to your quality of life. It is also quite demeaning to patients to say they are a minor case. But anyway…

  Down the corridor from minors is usually the Radiology department, where they do X-rays, etc. In minors, you can often hear screams as minor fractures are relocated here and local anaesthetic injected. Not that exciting.

  Majors is where you see elderly patients who have collapsed due to an unknown cause. You also see patient with chest pains. Apparently, other patients get seen there, but I don’t seem to see many others. We do blood tests here and send them for scans and X-rays if necessary. From here we can send our patients to one of five places. ‘Home’ and the ‘mortuary’ are self explanatory (although should never be mixed up). If they have a condition which just needs observation–i.e. a head injury–they can be sent to the A&E overnight ward, if your hospital is lucky enough to have one, which is usually situated somewhere near the A&E department. If your condition means that you will need longer than 4 hours before we can decide whether you need admission or not you may get sent to a CDU ward (CDU stands for clinical decision unit–not the ‘can’t decide unit’). Please note, if you need hospital admission you shouldn’t be sent to the A&E ward or CDU ward–you may go there only if there is nowhere else to send you. Lastly, you can be sent to a normal ward, if the doctors think you need admission. Very rarely do you get sent from A&E to the appropriate specialist ward. More often, you go to the MAU (Medical Admissions Unit), where they might send you for a short stay to be further assessed before going to the appropriate specialist ward.

  At any stage, the A&E doctor may ask a specialist doctor to review the patient, who may or may not admit them to a hospital bed. The doctor who decides if you need admission is initially the A&E doctor but that plan may be changed by the specialist doctor. It is confusing, but trust me when I say I am trying to simplify it!

  The final place you may go is the resuscitation room–Resus. This is the high-tech bit of A&E. Lots of machines go beep here. There is the equipment to put people to sleep and defibrillators to restart their hearts. I find this the most relaxing part of A&E as you don’t get constantly disturbed by trivia and you always get a nurse allocated to work with you. From here, the very sickest patients often go direct to the mortuary, via the viewing/grieving room. However, if they are lucky they also can go to ICU from here, or, once stabilised, back into A&E and then to a ward. The traumas and cardiac arrests are all seen here and there are often many doctors involved in these patients’ care as we call the Resus and trauma teams down from the wards to help the A&E doctors (teams are composed of the on-call doctors for that day from specialties such as Anaesthetics, Medicine, Surgery and Orthopaedics–depending on the type of call put out. Again, don’t get the calls mixed up as you really don’t want an orthopaedic doctor at a cardiac arrest call).

  There are lots of other bits to A&E that you probably won’t see: the offices–usually far too many of them; the store rooms (where, contrary to popular belief, there is very little ‘action’); stock cupboards and the utility rooms where bodily fluids are cleared away. Finally there is a coffee room and a seminar room. To me it all feels strangely like home.

  A&E Room 101

  I don’t know if you have heard of Room 101. It is a vaguely amusing programme with Paul Merton as the host, where guests come along and say what they would eradicate from society to make their life a better place–for example, parking attendants, men wearing sarongs, Simon Cowell-inspired boy bands, Simon Cowell, etc.

  I have been thinking that if I could, I would like to be able to go on Room 101. I would pick the things I could get rid of in society to make my life at work easier (i.e. make there be fewer accidents), so I can spend less time seeing patients and more time flirting with the nurses.

  I have compiled a list–I have called it the A&E Room 101:

  1. Lawn bowls–a surprise choice coming at number 1. The number of little old ladies coming in with a fractured hip after tripping on a bowls ball is ridiculous…And the stress of the game! I have seen two heart attacks induced by the high-pressure situations of the inter-village summer lawn competition. Why can’t these people play a less dangerous sport? I have never seen anyone over 70 with a rugby injury or a hang-gliding injury. So come on you health and safety managers. Let’s ban bowls.

  2. Wonderbra adverts–in at 2 this is possibly another surprise choice–sexy roadside advertising–especially those ‘Hello boys!’ Wonderbra adverts with the fit girl. When that advert was around, I used to dread coming to work. I would have a number of conversations similar to this one: ‘Yeah. I was just driving to work and I got distracted by that advert of the fit bird with her big tits covered by a Wonderbra. Anyway I had to have a look, know what I mean. Just as my head was in the opposite direction to the way my car was going, I crashed into a wall. So here I am–my arm is broke.’

  3. 4 × 4 (Chelsea tractors), especially the ones with bull bars–4 x 4s are designed for muddy terrains; bull bars are designed for hitting bulls. However, these eco-friendly ‘Chelsea-ites’ don’t realise this. They drive in areas that are surfaced with tarmac, with lots of kids running around–there are very few bulls. So when the car hits a kid (instead of a bull), it does what it is designed for and injures the kid (instead of a bull) while protecting the car from being damaged. If you need a 4 x 4 because of where you live, then fair enough. But otherwise think about other people’s safety before going out on the school run.

  4. Motorised mini scooters–why are they on our streets and estates? They are possibly the most dangerous things I have ever seen. They are tiny bikes that go very fast and you crouch on them. A lot of people fall off. Quite a few get really nasty injuries. They were sold with the proviso that they were not toys and were only to be used in private estates. The people that sold them knew that the people who bought them would live on estates where ponies are trainers and butlers are a type of cigarette. Were they more interested in profit than public safety? I wonder. Please don’t buy one for your kids. They really are dangerous.

  5. Excessive outdoor Christmas decorations–apart from being aesthetically Chavy, they cause problems for two reasons: (a) people fall off roofs and get electrocuted while putting them up and (b) people drive past them and look at them saying ‘what is that Chavy monstrosity?’, and fail to notice the car in front until it too late.

  6. Skateboards–but only in the over-18s. When I was at junior school, I used to play on one and would occasionally fall off. I once broke my wrist because of it, but it was an accepted occupational hazard of being a kid. However, there is no excuse for anyone over 18 to play with a skateboard. Do you know how stupid you look doing it, especially when you fall off and have to come to A&E? Leave adults to drink and smoke, and leave kids to play on skateboards. The same applies to BMX bikes. As a public education measure, even if it is not cool, please get your kids to wear a helmet and knee and elbow pads. It would mean I would dread working the school holiday days that little bit less.

  7. JackAss–the hit TV show and film. A group of pain-resistant Americans do stupidly dangerous stuff and then film it. Luckily, they say at the beginning that these are performed by stunt actors and that kids shouldn’t copy them–well, that works, doesn’t it? That’ll stop them–they think ‘Oh no I won’t try and imitate these cool people; I’ll go and play chess with Tarquin now.’ A couple of years ago I had a spate of kids dive-bombing out of a tree while screaming ‘JACKASS’. They often w
ent through a bush onto the ground below, into A&E via an ambulance and then onto theatre via the CT scanner. I am dreading the new film coming out.

  8. Ineffective safety warnings–companies are so worried that they are going to get sued nowadays that they put ridiculous disclaimers everywhere. So many, in fact, that they start to become ineffective. For example, last week I had a patient with an anaphylactic reaction to nuts. She had a known allergy, but says she now ignores all disclaimers for ‘may contain nuts or nut extracts or made in a factory where nuts are used or once been within a 50-mile radius of a nut’ otherwise she would have nothing to eat. They are now put on everything for fear of being sued and it is completely uninformative, so she ignores them all. One thing I don’t object to, and others do, are stupid warnings. For example: KP nuts, WARNING. MAY CONTAIN NUTS. McDonalds coffee, WARNING. CONTENTS ARE HOT AND MAY SCALD. I think these signs save the lives of a particular subgroup of people who often attend A&E and I thank the companies for their corporate responsibility.

  9. The new ethos of excessive risk management and risk avoidance–schools and clubs are scared to take their kids on trips for fear of the consequences of an accident. Things have become so rigid in society that people are going against the excessive bureaucracy and doing the most bizarre and dangerous sports and challenges–kite surfing, grass tobogganing and such like. It is two fingers to the no-risk culture and gets their adrenaline pumping…and when they have their horrendous accident and come to A&E, it gets me injecting adrenaline into them.

  How to be a good patient

  The government wants to increase patient choice. I want to increase doctor choice. I want a system where we choose and book and decide which patients we are going to see; depending on how ‘good’ they will be as a patient. It will never happen. Instead, just for my own amusement, I have compiled a list of qualities that make you a good patient to see in A&E.