In Stitches

by Nick Edwards

  While I am on the case about managers, it is important to realise that there are a massive number of excellent ones working in the NHS. But they have to implement politicians’ plans and with limited resources and skewed targets. I need to remember that when I get frustrated with them.

  Unexpected laughter

  Today, I had a tragedy turn into a comedic episode. I had to certify a patient’s death and the family ended up in fits of giggles. It was a very odd experience and just shows that people cope with grief in different ways. The patient, who eventually died, came in from the ambulance in ‘cardiac arrest’. She had no heartbeat and the ambulance personnel were doing chest compressions.

  During the cardiac arrest, I was supervising one of the junior doctors on how to ‘run’ a cardiac arrest–she was doing very well. However, cardiac arrests are not like you see them on TV. Only rarely are they successful–this is partly because we have all forgotten the importance of actually compressing the chest properly when the heart stops, as opposed to giving fancy drugs–for which there is little evidence that they make any difference. Patients also rarely wake up and say thank you and walk out. They go to ICU and three days later they may or may not wake up with some brain damage. After 15 minutes we realised that this case was ‘futile’. We couldn’t save her. My junior colleague quite rightly asked if we all agreed to stop her chest compressions. Everyone nodded.

  She was placed into the ‘quiet room’ ready to transfer to the 7th floor (we have only six floors and it is a euphemism for the mortuary). The family was by her side–her daughter and three grandchildren. Before she could be moved to the chapel of rest, she had to be formally certified. This was the first ‘cardiac arrest’ my junior colleague had been in charge of. I therefore offered to certify on her behalf while she composed herself.

  I had already met the family and explained what had happened to their mother, and so had no problems speaking to them again. I explained what I needed to do, and asked if they wished to stay. They did. I then asked if they had any questions. They did. The youngest of the grandchildren spoke.

  ‘Did you used to live in Stanford Drive?’

  ‘Why?’ I asked.

  ‘A few years ago?’ he asked.

  I nodded and again asked why.

  ‘See, I told you all,’ he said to his family. Looking back at me, he continued, ‘Did you used to have a dodgy “kung fu fighting” dressing gown?’ he asked.

  ‘Yes, when I was a student. As soon as I went out with my wife, she chucked out all my clothes and I became well dressed. Why?’ I really wasn’t expecting this type of questioning and was becoming a bit perturbed. I think my facial expression was showing that now.

  ‘And did you used to have your milk delivered?’ he continued.

  In a rather shocked way, not expecting my retail preferences to being the main points discussed in this meeting, I nodded. He seemed to take glee from this and said to his family once again.‘Told you so!’

  He turned to me.

  ‘I used to be your milkman mate…Tony. Do you remember?’

  I smiled and everyone burst into laughter. Had he more to say?

  ‘Word of advice mate. Wear boxers with that dressing gown. It was a bit too see-through if you know what I mean.’

  He burst out in tears of laughter and I couldn’t stop myself smiling and nervously joined in with the laughing. All the time his grandma lay dead between us. It was a very surreal experience and his mother could obviously tell my unease.

  ‘Don’t worry, love. She liked a good joke and tease. It’s a tribute to her that we can still laugh about things.’

  As I walked out of the room still laughing my junior colleague walked past.

  ‘Why are you laughing?’ she asked.

  ‘I’ve just certified the death of our last patient and I haven’t been so amused for days.’

  I needed to do some explaining before I was thought of as the most insensitive doctor ever to have existed…

  Repeat attenders

  Some patients I love treating–others I don’t. I have just finished a set of seven nights and seen the same bloke five times. Each time he has come in drunk, with nothing wrong. Each night he makes up a symptom. He is homeless and there is nothing wrong with him except that when it is raining he wants a bed for the night. He can’t get a hostel because he won’t stop drinking. It is a very difficult situation and very hard to discharge people into the cold outside. We can’t give in to his demands because otherwise it would set a precedent and we wouldn’t have the beds to look after people who genuinely needed them for medical reasons. His problems need to be sorted out by society.

  On the fourth night it was very cold and raining and he refused to leave. He started getting loud and swearing and began upsetting the children in the department. We had to get security to escort him off the premises. As soon as he left he called an ambulance from the nearest phone box and complained of suicidal tendencies and came back. Eventually, we had to call the police. I explained to him that I couldn’t let him stay for the night. He asked the police if they could take him for the night. They shook their heads and tried to escort him off the premises again.

  ‘You can only get a bed if you get nicked mate,’ they informed him, much to our cost. He then kicked the window of our A&E and smashed it. They nicked him and he got what he wanted. What a sad reflection on society.

  While I don’t blame him for wanting somewhere warm for the night, it was very frustrating for all concerned.

  This job is hard

  As an A&E doctor, you sometimes have to develop a barrier where you don’t let emotion get to you. It is important, because only by being rational can you deliver good quality care. But sometimes little things get to you and however hardened you are your emotions can buckle. This morning I buckled.

  It was 7 a.m. Only 2 hours before home time. A fry-up and a pint of beer with the 9.30 a.m. regulars at my local Wetherspoon’s (the shift workers and enthusiastic drinkers) beckoned. But then the red phone went off: 14-year-old girl, overdose, unconscious.

  We called down the anaesthetic team, in case we had to take over the care of her breathing, and also called the paediatricians. She came in and I went into autopilot. You learn a set routine. Check her airway, give oxygen and check her breathing, check her pulse rate and blood pressure and then give fluids. Basically, stabilise the patient and then think. She was soon stabilised and not in any immediate danger. I soon realised that the mum was standing near us. Out of autopilot, I went to comfort her and explain what had happened.

  ‘Nick’, the senior sister called out. ‘Her blood pressure has fallen.’ Some of then drugs she had taken had caused that. Back onto autopilot. No emotions. More venous access obtained and another drip put up.

  Soon her condition had turned from serious to stable and I was able to get some history about what had happened from her mum. I asked her if she knew why her daughter had taken the drugs. She cried and handed me a suicide note as she muttered about bullying.

  The letter was heartbreaking; it described the feelings of hopelessness that she felt and how she saw no other option to stop the endless cycle of bullying and self loathing. It was the saddest thing I have ever read. She apologised to her parents and asked them to carry on looking after her guinea pig.

  I read it and the experience of reading her thoughts made me shudder and think. It put my concerns into perspective. I couldn’t stop thinking of her parents. How will they cope if she dies? Then I had a selfish thought. Why do I put myself through this? Am I strong enough to cope with experiences like this? I should be in bed by now, cuddling my own child and telling them how much I love them. It is always hard in situations like this, not to let them affect you personally, but this is often very hard to do. So why do I put myself through this stuff? The answer is simple. Because of all the work we all did, her mum got a chance to tell her she loves her too. I couldn’t swap this job for another even if it costs me lots in Kleenex tissues– which y
ou can’t even claim for against tax.

  P.S. She was transferred to the regional centre of paediatric intensive care and made a good recovery.

  Another sad case

  I saw an 82-year-old gentleman today. His wife had died earlier that month. He was brought in after he was spotted at a local beauty spot with a hose going into his car from his exhaust. The fire brigade broke into the car and the ambulance brought him in.

  This was a genuine attempted suicide case. He told me that he had lived for his wife. He had no children and few friends. All he wanted to do was join her in the ‘afterlife’. He couldn’t cope with the loneliness. He told me that his decision was a logical one, made by a man who had full faculties of mind. He told me that as soon as I had discharged him, he would try and kill himself again. He told me that that was the right thing for him to do, so that he could join her in heaven. He was lonely and missing her.

  I sympathised greatly, but still asked the psychiatrist to see him, knowing that they would admit him to a psychiatric hospital. I have no idea if I did the right thing but I was sure that if he left then he would kill himself. I just didn’t know if that was the best thing for him. In all honesty, I referred him to the psychiatrist because I had to. I didn’t want to feel the guilt if he did kill himself and I didn’t want to face a coroner’s court case where I admitted discharging someone who had an acute depressive episode.

  The importance of banter at work

  The department got a complaint letter today. It said that the doctors writing their notes seemed to be chatting too much with the nurses and there was too much ‘fun’ going on. We then all got told by our bosses to ‘cut out the banter’.

  Doctors and nurses do need to be careful about how we act in areas where the public can see us. But we need to be careful not to lose the camaraderie that a bit of banter can bring about. It helps keep up morale and can therefore improve patient care. Please just remember that when you see doctors and nurses having a chat (we may even be discussing important clinical information).

  One of the best things about working nights is that there is more opportunity for banter–or team building as I like to call it. There are no bosses, fewer patients and the ones who are there are usually pissed as a fart. In some A&Es doctors and nurses have been known to play ‘games’ with the patients–although this is only done if they are drunk and never if anyone is distressed, ill or sober enough to know what they are doing.

  There is the game of seeing how many song titles from various albums you can get into one short consultation. There is the very similar and somewhat more amusing game of trying to get a bizarre but relevant fact into a consultation. These games are only possible because of the fact that all A&E consultations occur behind curtains–which are not soundproof, and so an independent adjudicator can mark you. Again, just because I am talking about these things doesn’t necessarily mean that I approve.

  Only when it gets quiet and the A&E department is left empty can the fun really begin. Most times an empty A&E leads to the staff trying to get a bit of rest or people surfing the net. However, if you are on duty with a ‘good bunch’ of doctors and nurses, then an empty A&E can lead to some great fun and games. Unfortunately, anything you might have thought about such as ‘the key game’ or ‘spin the bottle’ is purely for the imaginary letter pages of Fiesta or Escort: the stock cupboard is usually full of stock and the sluice is probably the least erotic place I can imagine. The A&E games can be much more fun: crutch races, wheelchair races, gloves turned into balloons and then volley ball matches. There are also the practical, slightly macabre, practical jokes to play on the more junior staff. Then there is the routine of drenching with water anyone that has managed to nod off to sleep. These types of things help us cope with the stresses of A&E work at night and also keep us alert in case an emergency comes in.

  The best part of nights nowadays is that you can actually have a drink after a night at work. One of the best ‘nights’ out I have had recently was when all of us had just finished our last night (of a run of seven) and went out ‘morning’ drinking. After a change of clothes, we went for a fry-up, and then hit the pub at 9 a.m.; eight of us drinking and playing silly pub games till lunchtime. We were then ready for a club and a kebab, but as it was only noon we went home to our beds instead. Sadly, it is not a truly 24-hour city that I reside in.

  The wonders of the Internet

  Have you ever been to A&E and for some bizarre reason the doctor has said ‘I’ll just be a minute’ then disappears for 20 minutes? That used to be because the doctor was off to ask someone’s advice or look something up in a book. While we know many things, often we get stumped.

  Now we have the Internet and it has revolutionised things. We can look up symptoms or rare conditions or sometimes just refresh our memories of long-forgotten diseases last heard about in medical school. Often we say ‘I’ll just be a minute’ to go and look up the latest treatment guidelines on the ‘net’. One of my favourite (A&E) sites is called Best-Bets, which basically goes through the evidence for what is the best treatment for various conditions. It is a fantastic site and helps enormously; it is one I use very often.

  That is until this afternoon, when I ‘logged’ on to the net with my password and typed in the site details. All I got was a screen saying, ‘You have tried to access an inappropriate site. Your manager will be informed. You are reminded that breaches of the computer use code may result in disciplinary dealings.’ What an idiot of a computer person; not letting a vital site be used because it has the word ‘bets’ in it. I am very much looking forward to my disciplinary meeting. Meanwhile, I had to phone up a friend at another hospital to look up what exactly to do on my behalf. Thankfully, my friend is an ophthalmologist and has plenty of free time to help me out when he is at work.

  Just a little small moan

  Today a son brought his mother into A&E. She had bled from a varicose vein. This was cleaned and bandaged up, but I wanted to a do a blood test on her before we let her go to check that she was OK. I asked him if he could stay for a couple of hours till the blood results were back. He said he couldn’t afford to. I enquired why. He showed me the parking prices. I soon realised… the charges are horrendous. It is a tax on being ill or visiting ill relatives. They justify the prices by saying that they are used to pay for NHS services. But isn’t that what our taxes are for?

  The joys of A&E

  Most people, even ones you really don’t like, have some redeeming features: someone I met today most people would describe as having not one. They might go on to describe him as the type of person you could only wish to become better strangers with. However, at work I can’t jump to those conclusions and am obliged (quite rightly) to treat him in a non-judgmental way and provide appropriate care regardless of the way he treats me or the NHS. Being non-judgmental is sometimes the hardest–but an essential–part of the job.

  The person in question is a man in his 30s and is very well known to the police. Every time he gets arrested, he says his chest hurts and so he gets sent to hospital to stop him having to go to the cells (he has done this over 10 times now, at vast expense to the NHS/police/me and you as taxpayers). This time he got arrested for something vaguely serious. So instead of just saying his chest hurt, he said his chest and stomach hurt. He was initially triaged by an Asian nurse and he responded that he would prefer to be seen by a Caucasian member of staff (he put it in a slightly less polite way).

  As the senior doctor, I was asked to see him. None of his symptoms fitted any pathology known to me. Despite his belief that he was going to ‘die in the next hour’ I felt there were few grounds for concern. When I started to examine him, he started screaming out in pain. All his observations were normal. However, everywhere I touched him was ‘f**king agony’; again, not fitting any known pathology. I tried to distract him, and when I did, he became pain free. The best way to do this, I find, is to listen to their abdomen/chest with your stethoscope and press down quite hard. The
y don’t realise that you are trying to elicit pain, so stop acting. I assured him that he didn’t need any blood tests and that he could go back with the police. I don’t think he agreed with my provisional management plan.

  ‘I am telling you I need some f**king blood tests to prove I’m going to die,’ he said.

  Now, I know that these are the days of patient choice, but I declined to take his advice and act upon his choice of management plan. I advised him of this. Unfortunately, in this litigious and complaint-led society many doctors sometimes succumb to doing unnecessary blood tests due to patient pressure, and just in case there is a problem, as opposed to trusting their clinical skills. I am one of those doctors. However, in this case I was as sure as sure can be that there was nothing wrong.

  ‘I need some tests, or I’ll die. Then you’ll be sorry. Do you want to come to my funeral?’ he enquired. I advised him that I try to avoid my patients’ funerals (it doesn’t fill me or the mourners with great confidence). I again reiterated my management plan, which also involved his apologising to the nurse that he had sworn at and then kindly leaving.

  ‘You can go now, sir,’ I advised him, content that my management had been appropriate.