In Stitches Read online

  1. Have an accident.

  2. …or an emergency.

  3. Always, always, unless you fulfil criteria 1 or 2, go to your GP first. They get paid a lot more than me.

  4. …Even if you don’t like bothering them.

  5. …Even if you have to wait 2 hours for an appointment.

  6. See point 3 again just to make sure you remember it.

  7. Don’t come just because your no-win, no-fee, no self-respect lawyer has told you to come.

  8. If you have had a bad back/knee/ankle for more than 2 days, try pain killers before coming to see me.

  9. Please bring a list of the pills you take. Ridiculously, we haven’t got access to GPs’ computer records and so, no, I don’t know what you are on. It also takes about 4 hours to get your hospital records, so don’t say ‘You must have a list in the files.’ Also, please note that there are thousands of little white pills and even if it does taste bitter, it doesn’t help me pinpoint exactly what you are taking.

  10. Don’t just come for a chat because you are lonely. Go to the pub or your GP.

  11. Don’t call an ambulance because you don’t want to spend money on a taxi (they are there for people who need them).

  12. …or because you think it will get you seen quicker–it doesn’t.

  13. Don’t remind me that you have to be seen and discharged within 4 hours–I know, but I am not sitting on my arse, I might just be seeing someone sicker than you who met the criteria in points 1 and 2.

  14. If you must mention the ‘4-hour rule’ (see point 13) at least get the facts right and don’t make up rights that don’t exist.

  15. Be polite to the doctors/nurses/receptionists, etc. Don’t doubt my parentage because I won’t see you before the really sick bloke in Resus. A thank you and a compliment can really make a difference to our day and might get you further along than complaining.

  16. Don’t be racist. Ever. The NHS would collapse if it were not for foreign and non-Caucasian staff. The phrase ‘I ain’t seeing no Paki doctor’ will end up with you ‘ain’t seeing no doctor’.

  17. Don’t be homophobic. I am told that 96.7 percentof all male A&E nurses are gay (and they are working hard to convert the other 3.3 percent). Please note that this is not an accurate figure, just a joke…the true figure is much, much higher.

  18. If you are from a nursing home and confused, please bring a carer who cares about you and knows why the matron has sent you to A&E.

  19. If you think we have been nice to you, please write in to say thanks. It really does make our day worthwhile–genuinely.

  20. Make jokes with us, but please make them funny.

  21. Don’t flirt with the nurses or female doctors–that’s my job.

  22. When you see us at the desk, don’t moan loudly that we are sitting having a chat–we are writing notes and getting advice from specialist doctors. We are only occasionally just having a chat.

  23. When asked what happened, try to get to the point in under 10 minutes.

  24. Similarly, if describing an assault, don’t explain in detail why it ‘weren’t your fault’.

  25. Don’t ask female doctors ‘When am I going to see the doctor please, nurse?’.

  26. When I introduce myself as the Registrar don’t ever say ‘I came here for my chest and not to get married! ha-ha-ha.’

  27. If I make a joke–please laugh.

  28. Understand I am allowed to yawn at 4 a.m. in the middle of a 12-hour shift so don’t say ‘Am I keeping you up?’

  29. When the speciality team I have referred you to asks you the same questions I did earlier, try and answer with the same answers.

  30. If you don’t agree with what I am doing let me know ASAP–I am not a policeman, or a prison warden. I can’t keep you in hospital against your will. So tell me you are going to self-discharge before I have organised expensive tests and a bed.

  31. Have a condition we can treat in less than 4 hours to the point of discharge or to admission. Don’t come with complicated problems which might mean time-consuming tests–we can’t have you breaking our precious 4-hour rule, now can we?

  32. Understand that we have emotions too. We may have just seen a child die, or had to break bad news to a relative. It may be our sixth night in a row, and we might be missing our family. We may be carrying emotional baggage with us which our professional façade does not allow us to expose to the outside world. Have patience with us, be polite and friendly and don’t moan too much if you have to wait to be seen.

  33. If you follow 1–32, you can (hopefully) expect good quality, timely treatment from A&E staff.

  The effects of bloody accounting rules

  It’s not just me who gets annoyed with how accounting rules forget about patients. I went to a conference last week and heard a story about a patient from a fellow A&E doctor. He was 45 and fed up (the patient not the doctor–she was 33 and fed up) and came in because he didn’t know what else to do. He had tingling in his thumb, index and middle finger–its called carpel tunnel syndrome. The irritation was so bad that he was having trouble sleeping. He had had it seen by his GP and had been referred to the local surgeon, who, with a couple of minor cuts to the structures in his wrist, could resolve his problem. However, he hadn’t seen the surgeon yet or had the operation. The surgeon had available time, there were some brand spanking new theatres to do the operation in and the day ward had a lot of free space because the local private treatment centre had nicked most of their patients. The actual additional costs for the NHS (sutures, scalpels, bandages, etc.) would have been very minimal–the fixed costs (surgeon, nurses and theatre) had already been met. The problem was that new budget rules mean the PCT pays for each individual operation and his local trust was much overspent. He had had his referral delayed until after April as it would then be in the new financial year. As he had waited less than 18 weeks, the PCT still met its targets. The manager was happy as the cost was delayed for the local PCT until after April, and the government could say that it had fulfilled its targets.

  The people who weren’t happy were the surgeon and theatre staff, who were bored with twiddling their thumbs, and the A&E doctor who had to give out strong pain killers at 2 a.m., for a problem that could have been sorted out weeks ago. And let’s not forget, most importantly, the patient.

  I don’t profess to understand the details of accounting and I have limited financial management skills (hence my excessive credit card bills) but surely this is madness. When NHS finances and organisations are not cooperative, but competitive, then middle managers cannot see the wood for the trees. In this case they couldn’t see that saving a small amount of money for the PCT would cost the hospital a lot of money, cause resentment in the hospital workers and piss off a patient. Well done, Mr Blair, on producing such a ridiculously managed NHS.

  Please come to A&E

  You may have noticed that I frequently moan about people who come to A&E unnecessarily. However, today I had a patient that I just couldn’t believe didn’t want to ‘bother us’. He was a 55-year-old builder. Six days previously he had spilt molten hot tarmac on his arm. He didn’t want to bother anyone, so he put some cream and a dressing on it. It was still painful, but he still didn’t want to be a nuisance so he just took more and more analgesia. It was only when he took off his shirt and a work colleague saw his burn that he was persuaded to come to A&E.

  He had a small, full-thickness burn, with surrounding partial thickness burn and damage to his nerves. He must have been in agony. I just don’t understand how he could have had such a stiff upper lip or not have died already from infection. We sent him straight to the local burns unit where he will stay in for skin grafts but he could very possibly lose the arm.

  I have seen many similar cases of people putting up with problems and not seeing a doctor. The most common are chest pain and acute shortness of breath. If you get either of these, come and see us please, and come now. The same advice applies if you pour molten tarmac over your arms.
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  We have gone drug crazy

  I live in a ‘high’ town. Not in an altitude sense, but in a drug-taking sense. I saw three interesting patients today, all of whom were in because of drug complications.

  The first one came in because he was starting to feel very anxious after taking ecstasy–it was his first night on ‘E’. I initially tried to calm him down verbally and explain that it was a consequence of the drug, but that didn’t work. He just kept on shouting ‘I need a beat’. I tried some diazepam but that didn’t seem to work either. ‘I need to move,’ he cried out.

  Being a holistic doctor, I decided to go for another tactic. I asked one of my nursing colleagues to come and join me. I instructed her to be a human beat-box. Bemused but compliant, she started going ‘boom, boom, boom, boom’ to a typical R&B beat. I then added ‘oooooooohhhhhh, ooooohhhhh’ as an off-beat addition. The patient nodded and started to move to the impromptu performance. Three minutes later he started to feel better and was now calm and compliant. I gave him some more diazepam. He quickly stopped moving, we stopped our beat-box routine and he fell asleep on the trolley. He was discharged relaxed and happy 5 hours later (or 4 hours as was probably put on the computer.)

  I then saw the effects of a cocktail of drugs including ketamine (on an unconscious teenager, with very worried parents). Because of his level of unconsciousness he needed to be intubated and his airway protected so that he didn’t choke on his own vomit. He ended up in the ITU for three days at a large cost to you and me as tax payers.

  The next patient I saw was a 29-year-old who had given himself chest pains by taking too much cocaine. Cocaine is thought of as a safe, ‘trendy’ drug. It is not. It is powerfully psychologically addictive and can cause spasm of the coronary arteries. This is what had happened to this patient and he was soon sent to the CCU, where he was the youngest patient by about 40 years. He soon came down from his high, but his cardiac damage is permanent.

  It is fascinating working in A&E as you see such weird and wonderful side-effects of drugs. It is also very scary. All three patients had responsible jobs and when at work had others in their care.

  Coming home for Christmas

  I was really pissed off I was working this Xmas Day. I really wanted it off, so I could spend it with my family. But, unfortunately, people get ill outside 9–5 Monday to Friday and so I suppose it is something that you sign up to when you choose this job… until you are a boss and you can get your juniors to do most of the unsocial shifts.

  My mild annoyance soon dissipated very quickly, however, with the arrival of the shift’s first ‘major’. A young lad in his 20s had been involved in a road traffic accident and he was arriving in 10 minutes. (The new term is apparently ‘road traffic incident’ as the traffic police say the word ‘accident’ implies that nobody was at fault and it was a random occurrence. This is hardly ever the case.)

  As the classic song goes, he had been ‘driving home for Christmas’. What isn’t in the song was that he was driving home for Christmas very fast, as he was going to be late for his festivities. He had also been out late, enjoying a Christmas Eve piss up. We found out later, that even though it was 10 a.m., he was still over the limit despite finishing his partying 8 hours before.

  We got the call from the ambulance team at 10 a.m. He had been travelling at 90 mph. No other car was involved, but he seemed to have flipped his car and it skidded 50 metres upside down. He was the only passenger. Luckily, he had been wearing a seat belt and the air bags had been deployed. I called for the trauma team, which is made up of anaesthetists, surgeons and orthopaedic surgeons who are ‘on-call’ but during the day are based on the wards and in operating theatres, doing day-to-day work. They come down to A&E when we need their additional help and expertise to manage a trauma. Usually, the trauma is led by an A&E doctor like me, who is in overall charge of the situation while the casualties are in the department. My job is to coordinate everyone, to get a ‘wide-angled lens’ view of what needs to be done (as opposed to just concentrating on a specific part of the body), to organise definite care and scans and to explain to the patient what is happening.

  As soon as the patient came in, I realised that he needed no explanations. His head was bleeding and he was unconscious. After an initial examination, we realised that both his legs were broken. Fortunately, initial examinations showed that his chest and abdomen were not badly damaged.

  The main problem was his head. There are two immediate risks in this type of situation. First, that he might vomit and inhale, and then the vomit would clog his lungs and hamper his breathing. Second, if he had a bleed in his brain, then the pressure in his brain would grow and eventually crush the area of the brain responsible for breathing–also not so good.

  Both of these are managed by intubating the patient (i.e. putting him to sleep and taking over his breathing). While the anaesthetists were doing this, the orthopaedic surgeons and I tried to stop some of the bleeding from the broken legs. This generally involves pulling the fractured bones back into alignment. There is no great science to it. Just pull it to the angle that looks right. They can be sorted out properly at a later date; he had more pressing issues.

  He was intubated and we phoned the radiology consultant to come in to do a full-body scan and then interpret if for us. Amazingly, there was no argument and the radiologist was in the hospital within 10 minutes–grumpy, as usual, but at least he was here.

  The CT scan showed a large bleed in the brain, which meant he was probably going to be badly disabled for life–either that or die in the next 48 hours. Which one is worse, I am not sure. Plans were made for transferring him to the local specialist neurosurgical (brain surgery) hospital, so they could operate to drain the blood and relieve the pressure on his brain. In the meantime, the anaesthetists were giving drugs to reduce the pressure in the brain and prevent further damage. It was my job was to talk to the family.

  Even though most of my best medical practice is done with my mouth rather than my stethoscope, and even though I have broken bad news countless times, I was dreading this. I hate it, but someone has got to do it, and I feel that I am as good as any of the other doctors on the team at this job. I took one of the nurses in with me as support, both for me and the family.

  As I started to talk to them, I felt the slight depersonalisation that I often get. I found myself looking down on myself speaking to them. It doesn’t stop me being compassionate, but it does protect my mental health.

  I felt awful. There was I talking them through what had and was going to happen. At the same time I found myself holding the mother’s hand as it felt the right thing to do–reassuring and comforting. But at the same time, I also felt that it was like an episode of EastEnders–his mum was blaming herself for having a go at him earlier as he might be late for lunch. He had even told her that he would drive like the wind so that he wouldn’t be late. Meanwhile, the dad wanted to know if he had been over the limit from last night’s festivities. Apparently, he had been with his cousin, who apparently was a ‘good-for-nothing little shit’, who always made his son drink to excess and who ‘was going to pay for this’.

  His sister brought some sensibility to the discussion.

  ‘Is he going to…?’ she didn’t say the word die, but I knew what she was asking.

  ‘I don’t know. We are doing everything we can but he has been seriously injured.’

  ‘Don’t let him die,’ pleaded his mum.

  I didn’t know what to do so I just frowned. She gave me a hug and begged me to save him.

  ‘We will do our best,’ I said. That was the truth, but I wasn’t sure if it was going to be good enough.

  It was a shit start to my Christmas but it stopped me moaning about being at work. I looked at the box of the next few patients who were waiting–two chest pains, an asthmatic having an attack, an injured finger, a sore throat and tooth ache. Thank God that these are the normal type of patients we see in A&E. Thankfully, the trauma case is a rarity, othe
rwise I am not sure that I could handle this job.

  It came to home time, and I called my mother-in-law’s house to say I was going to be a bit late for Christmas dinner. My wife was a bit miffed, but after I told her what had happened she certainly didn’t moan or ask me to speed home.

  On the way home, I had a few thoughts. What if he dies? Not just from a ‘what a catastrophe for his family’ point, but from a professional perspective. If he dies, the family will not blame the medical staff. If he survives, however, we will get the credit and praise. This is very different from most doctors–if a GP misses a diagnosis then they can be vilified. If someone dies in a routine operation, the surgeon will be investigated and their career damaged. But in cases like this we very rarely get blamed as the cause of the injuries are out of everyone’s control.

  The downside to this is that people very rarely realise that the quality of care affects the outcome–they just blame the initial injury. They believe it was an inevitable outcome from the accident, not one that might have had an alternative ending in a different hospital with different resources and differently trained staff. I am not saying we are responsible for everyone who dies from a trauma. Cases like this involve everyone working their hardest to provide the best possible care. However, we are limited by our resources and the skills and experience of the members of the team, and this can affect the outcome in these types of patients.

  What the lack of public awareness of this means is that there is a lack of public pressure to improve the care for emergency patients. There are thousands of cancer charities, but very few that promote ‘pre-hospital care’ and even fewer campaigning for the improved care of trauma victims. This is despite trauma being the leading cause of death in the young adult population. It has been shown that better care and facilities lead to better outcomes. Greater investment in A&E care would massively alter the outcomes of many of these patients. Of course, in many cases even the best care in the world could not alter some outcomes, but in many, simply improving research funding and resources could save many lives and decrease morbidity. The decreased morbidity would soon save millions in not having to pay sick benefit and having people back at work and paying taxes. Even government accountants should agree with that spending increase.