In Stitches

by Nick Edwards

  Other factors lowering the political interest are the heterogeneity of trauma cases: it is very hard to try and get meaningful trauma survival rates for each hospital as opposed to say, cancer mortality rates. This lack of a target means that the government is not as interested in the quality of care. It wants a target to show off to the voters, so for A&E it has produced a 4-hour waiting target, rather than a quality of care one, which ends up distorting priorities. However, politically it makes sense as there are a lot more voters who have had to wait to get their stubbed toe seen to than have been in a near-fatal accident.

  The lack of political interest in trauma outcomes also means there is only a tiny amount of public investment into trauma research. Where there is investment in research, it is often heavily restricted into what can and cannot be researched. Politicians are concerned about not doing trials on people without their express consent (which is very hard to get from an unconscious trauma patient), which means that research into how best to care for these people is very difficult to do in this country. There is currently a worldwide research trial into whether a particular drug that stops bleeding would be of benefit in patients such as the one described. But the UK is one of the lowest contributors to the data because of the complexities of taking part in the trial. We didn’t enter the patient into the trial purely because the amount of bureaucracy involved would have made it very difficult. He potentially didn’t get a beneficial drug and neither will future patients because of difficulties constructed by research committees in this country.

  Added to this are the budgetary constraints being instituted across the NHS. Two things that have been cut, and no-one seems to have noticed, will soon affect the care of trauma patients. First, there is a Trauma Audit Research Network which hospitals pay to join. For their money, researchers look at the patient notes, collate data and look at how well they are managing their trauma patients, then recommend how they can improve their care. Some hospitals are saving money by not joining this network and thus are not getting the vital feedback they need.

  Second, the study budgets for nurses and doctors are being cut. These study budgets, in the past, have been used to pay for high-quality trauma training–Advanced Trauma Life Support (ATLS) courses. Less funding means fewer staff being able to attend the courses, which means less well trained doctors and nurses looking after you, which means you may have a worse outcome. These cuts have not even entered anyone’s political debate but then I suppose we shouldn’t complain about the NHS not having enough money. The government needs the money for other vital things such as paying for a war in Iraq and renewing the Trident missile system…

  As I thought about this, I got more and more annoyed–why do I mull over things so much after work and why do all my thoughts end up with me becoming angry, ranting and usually getting political? It must really drive my family and friends mad as this is all I think about. So, one of my New Year’s resolutions must be to not think about work on my drive home, otherwise I’ll send myself mad.

  I decided to start my New Year’s resolution early. I put on the radio and listened to some inane presenter encouraging me to sing along to ‘Rocking around the Christmas Tree’ and then ‘Mistletoe and Wine’. For the first time ever, I found Cliff Richard relaxing and enjoyable. That is something else I better hide from my friends and family.

  The joys of shift work

  One of the lows of workings as an A&E doctor is the effect shift work has on your body clock. I notice a number of problems. First, I just can’t wake up easily before going to work and second, my bowels go crazy. Things got bad last night before work.

  My wife tried the normal tactic of gently kissing me at first, then nudging me and then pulling off the covers, before resorting to pouring cold water over me–all with no effect. She has learned that she needs to start getting me up quite early as I take a while to rouse. Her latest tactic has been to start a countdown until I have to leave, with increasing levels of threats of violence if I don’t get up. Tonight, however, was worse than usual. The routine shouting soon started.

  ‘Nick it is eight-fifteen. Get up’–no response from me

  ‘Nick it is EIGHT-THIRTY. GET UP NOW!!!’ Again, no response.

  ‘NICK. GET UP NOW. IT IS EIGHT-FORTY. GET UP NOW!!!’ She bellowed up the stairs.

  It was only when my mobile went off and I saw a text message from my next door neighbour that I realised that I need to get in to a better routine before work. It read ‘Nick. Apparently it is 8.40. I think you need get up and go to work!’ Oh, the joys of shift work and terraced housing.

  The other main problem is what shift work does to your bowels at night. I have nicknamed it SWAC (shift worker’s anal conditions) as a main term and I suffer from two subtypes–nocturnal SACS (sweaty arse-crack syndrome) and nocturnal CATED (constipation and then excessive diarrhoea). Luckily, it all goes back to normal once I am on day shifts. I am so looking forward to the coming stretch of six weeks of days before my wife loses her voice and my arse becomes an issue again.

  Careful with your notes and coffee room

  chats

  In the last couple of months, I have listened to two of the most amusing talks. One by the hospital solicitors and one by the Medical Protection Society–a doctor’s legal advice service. Both were about how to write in notes and not get sued. Two main bits of advice were given. First, write what you have done. If it is not in the notes, then it hasn’t happened. Second, be careful about what is written. Do not use acronyms–especially TLAs–three letter acronyms–it leads to confusion. Do not insult people (they can now get hold of your notes) and don’t use insulting acronyms (it is the worst of both worlds).

  With this on board, and knowing that I was a new breed of doctor who was too scared of being struck off to do any of this (and also someone who believes patients should automatically get a copy of their attendance letter from A&E), all I could do was sit back and enjoy what some others had written in the past…and you thought that all doctors were angelic creatures. (Please note that although I think that the following comments may be potentially amusing, they are insulting and should never be used.)

  Diagnosis

  NFB–normal for Birmingham.

  FLK syndrome–funny-looking kid

  FLP with a FLK–funny-looking parent with a funny-looking kid (the condition is often hereditary).

  FLKBOFB–funny-looking kid, but OK for Birmingham.

  FLKNLP–funny-looking kid, normal-looking parents (the kid’s condition has not been inherited).

  GOMER–get out of my emergency room. Used for old patient who is ill and you need to admit them to a ward before they become really ill and become your problem.

  RIP–rest in peace. Nothing rude about that, except beneath the notes certifying the death, a doctor had drawn a grave stone with some flowers around it and then written RIP on the gravestone.

  TFTB–too fat to breathe.

  WNL (as in ‘observations were all WNL’)–within normal limits/we never looked.

  ECG (heart tracing), NAD–no abnormalities detected/ not actually done.

  COPD–chronic obstructive respiratory disorder/chronic old person disorder.

  PEP–pharmacologically enhanced personality (pissed or stoned).

  CRAFT–can’t remember a f**king thing.

  NPS–new parent syndrome. Parent anxious. Child well.

  Oligoneuronal–not many brain cells (similarly used is pneumocranial–air head, literally air in the head).

  LPT–low pain threshold.

  PFO/DFO–pissed fell over/drunk fell over.

  ASS–arrest avoidance syndrome. Similar to PAS (prison avoidance syndrome) and PDSD (pre-detention stress disorder).

  PTSD–post truncheon stress disorder. Similar to above but also involves trying to make up symptoms or blame previous injuries on the police.

  TATT–tired all the time.

  TTT ratio–teeth to tattoo ratio. A low ratio implies a difficult upbringing with all the c
osmetic effects that has on people.

  ONF–overall nick factor.

  As I said earlier, these terms are rightly consigned to the history books. I always write notes knowing that patients can read them and I don’t want to cause upset. However, one place where they are still used is A&E coffee rooms. There are also a lot of slang terms used in these rooms, and since I am trying to show what it is like to work in A&E, understanding some of these terms is quite important.

  Can’t Decide Unit–other name for Clinical Decision Unit. The bit of A&E where we put all the patients in who have been there for more than 4 hours so they don’t break the 4-hour target.

  Meet, treat and street nurses–triage nurses who can now put on a sticky plaster and then say goodbye.

  Code blue–a really non-urgent ambulance that should never have been called.

  Smurf positive–blue colour of patient owing to hypoxia/ lack of oxygen.

  Simpson positive–a patient with jaundice.

  Homer Simpson positive–a gay patient with jaundice.

  Rooney fracture–fracture of the fourth metatarsal.

  Beckham fracture–fracture of the fifth metatarsal.

  An Owen knee–knee pointing in the wrong direction (as per Michael Owen in the 2006 World Cup).

  Ear ring sign–the larger the hooped earring, the more likely she is to have pelvic inflammatory disease as opposed to appendicitis. Similar to the toe ring and ankle bracelet sign.

  Granny dumped–happens on Christmas Eve, when family want to go on holiday. Speaks for itself.

  Gomergram–GOMER who you do a battery of tests on if you have no idea what is going on (ECG, chest X-ray, blood tests and in America a CT scan).

  Buff–make the patient easier to refer to another team (i.e. moderate chest pain, gets exaggerated to excruciating chest pain).

  Turf–send to another team so it is not our problem.

  Fluttering eye syndrome–a patient who fakes unconsciousness, but we know they are making it up as they flutter their eyelids when you stroke them.

  O sign–old person dying with their mouth open.

  Q sign–old person dying with their mouth open and tongue out.

  Dotted Q sign–old person dying with their mouth open and tongue out and fly on the tongue.

  Chav–English equivalent of trailer trash. Not really sure what it stands for. A policeman friend of mine claims that it means ‘Council Housing and Violent’.

  Chavet–female chav.

  Chavlett–young chav.

  Ash cash–money for signing cremation forms. Personally, I think that the amount of money people pay for us to sign a form, so that they can cremate their relatives, is disgusting. However, I am hypocritical and happily spend the money. In quite a sick way lots of junior doctors buy rounds and then toast the person whose family has just paid for the drinks.

  Ash machine–a doctor’s cash machine.

  A part 2 slimer–a doctor who makes friends with the morticians, purely so they can get to fill in parts of the cremation forms and make lots of money.

  Bash cash–money the police give us for describing the beating that we treated in A&E.

  To an outsider, these may seem sick and cruel words, but they are used away from patients and are part of the black humour that keeps A&E staff sane. So, be wary of going into a staff room in any hospital and, please note, my describing these terms does not mean that in any way do I approve of them.

  An embarrassed husband

  Working in A&E you always get to see a few patients with rectal foreign bodies–things placed where they shouldn’t be. It’s an occupational hazard of anal play, but it’s not my cup of tea. However, it really doesn’t bother me at all if that’s how you like to get your kicks. I don’t get embarrassed by it (much) and I often feel genuinely sorry for the patients. They are very embarrassed and doctors and nurses can only make it worse by asking too many questions or taking a moralistic view.

  There a few cases that spring to mind. However, there is only one that is truly memorable, but mostly for the reaction of a fellow doctor to the patient. The gentleman in question came in with a ‘personal problem’, and he had asked to be seen somewhere private. I asked what had happened. He started to lie–it was obvious.

  ‘I was lying on the couch and fell asleep. I had taken my trousers off because I spilt wine on them. Then my phone went. I went to pick it up off the sofa and I slipped and it sort of…’

  ‘Is there a phone up your rectum sir?’ I asked. He nodded nervously. ‘Don’t worry. It doesn’t bother me. I am only here to help you.’ I didn’t ask what make, or if it was on vibrate mode. I X-rayed his abdomen and there it was–from the look of it probably a Nokia 6250i or something similar. I just hoped that it wouldn’t ring. There was no way that it would come out without a general anaesthetic and the skills of a good surgeon. Some foreign bodies even need a cut to be made in the abdomen so that they can be pushed out from the inside so to speak. I explained all this to him.

  ‘But you must get it out now; my wife can’t know…she doesn’t know about that side of me and I don’t want to lose my kids.’ He started to panic.

  I explained that there was no alternative. Leaving it there was a definite no-no as it might perforate the bowel and cause septicaemia and death.

  He continued to panic. He explained to me that his wife was a medical secretary at a local GP practice and would have access to any notes sent to his GP about the episode. I assured him that no notes would be made available to his wife and that we wouldn’t tell her anything. However, that didn’t satisfy him.

  ‘I can’t have the operation or my marriage is over. I am leaving,’ he whispered. I tried to stop him leave and then offered him a solution.

  ‘You could lie. We can’t lie for you, but you could say you have an anal fissure that has started to bleed and they need to do an examination under anaesthetic.’

  He seemed a little calmer now. I phoned the surgical team on call and explained to them what had happened and his embarrassing predicament. I explained to them the explanation I had given him to offer to his wife, so that they would know what he was going to say so they didn’t put their foot in it. The response I got shocked me.

  ‘You can lie if you want, but it’s his sin and his problem. I am not taking part in your deceit.’

  I didn’t see the patient after that. I hope the surgeon was a little bit more understanding of his predicament face to face, otherwise, if it ever happened again, then the patient would be too embarrassed to come back to A&E and could end up with the complications of foreign bodies where they shouldn’t be–septicaemia and death. It is not our job to moralise but we often do and sometimes you can’t help it. However, part of the job is hiding your own views from the patients.

  The human effect of reconfiguration and

  lack of beds

  Just in case you thought that the NHS emergency care reconfiguration was a utopia of improved health, I want to remind you of the reality.

  A 19-year-old patient had been involved in a massive car accident. He needed his breathing taken over for him and for that he needed to go to ICU. The only problem was that there were no ICU beds available. This was not a new problem but had been exacerbated by an increase in serious cases coming to our hospital as the other local A&E had, in all but name, been closed. However, the genius planners had not considered the fact that the only hospital in the region with a fully functioning A&E would now have a busier ICU. Consequently, there had been not enough increase in funding and not enough new beds were funded for all the extra patients.

  The problem of a lack of ICU beds existed before the reconfiguration, but now in my hospital it is a lot worse. In this case the patient, instead of going to ICU, stayed in A&E till they could ‘create’ a bed. This involved waiting for a ward patient to die, a high-dependency patient going into their bed, a patient from ICU going to the high-dependency unit (HDU) ward and then quickly cleaning the spare ICU bed.

  This meant
that an anaesthetist had to stay with the patient for 6 hours until they were on ICU. This in turn meant that the appendicitis case that I referred 4 hours ago, and the patient who needed a ‘ERPC’–removal of an embryo after a miscarriage –who both were due for an operation that night, were delayed. Those patients were unduly put at psychological, if not a serious medical, risk. Not knowing this, they did not make a fuss.

  Another patient who suffered was a gentleman needing his oesophagus removed for cancer. His surgery was booked for the next day. However, it is a very large operation and he would need an ICU bed post-op. As there now were none, the operation was postponed. All these patients were told it was an exceptionally busy night, no-one could have predicted it, etc., etc. They were not told that the root cause was poor managerial planning.

  So, the inpatients had their length of stay increased and their cost to the NHS rose. The cancer patient had another few days’ wait for the operation and the surgeon and his team sat frustrated that they couldn’t operate.

  Reconfigurations without proper planning have made our hospital ICU run at close to 100 percentbed occupancy. What managers must realise is that this leads to decreased efficiency and care. It is not just ICUs running at close to 100 percentoccupancy, but the whole hospital. Surely the managers have got to realise that the point about emergency care is that it is unpredictable and you need to have spare capacity to cope with minor surges in need. Even the Department of Health in 2002 said that the optimum bed occupancy rate is 82 percent. However, week-in, week-out we go above this and patients do suffer. That’s why you need clinical advisors when a hospital needs a ‘hit squad’ to come and improve things, not some city kids in suits, who are called management consultants, charge a grand a day and know bugger-all about patient care.