by Nick Edwards
‘I need morphine now, you c***,’ he explained to me.
I explained that there was a seven-year-old in the department and she did not need her vocabulary expanding. I also advised him why paracetamol would be a preferable analgesic to morphine, considering his objective pain-level and both drugs’ side-effect profiles. He then started becoming very aggressive and swearing and putting other patients at risk.
At this point I asked the police to take him away. However, he collapsed and started to fit, arms and legs shaking rigorously, but still flinching when I brushed against his eyelashes. It was really bad acting. I got down to him on the floor and whispered, ‘Stop it. I know what you are playing at.’
He continued pretending to fit.
I tried to respond to the humanitarian part of his personality. ‘Look mate, there are some really sick people here. I need to go and check on the man in cubicle four with a heart attack and there is a seven-year-old girl in cubicle fifteen who now knows a lot more swear words and has a dislocated finger. I need to fix it for her.’ Still no response. I started to get annoyed. Real patients were here and he was wasting my time.
‘Please stop, sir. Stop being selfish.’ (I may not have used those exact words–my memory fails me). He continued and so I decided to go into true bullshit mode.
‘Sister,’ I called out. ‘I think he really is fitting. Quick, come. Can you get the largest catheter possible? We haven’t got time for local anaesthetic; we need to know his urine function now. Quick, sister, quick!’
All of a sudden he started to wake up and stop fitting. Considering he had been ‘fitting’ for 5 minutes, he made a very quick recovery.
‘I don’t know what happened there,’ he said, ‘and my pain’s gone completely. Can I go now please?’
‘Yes. I think it was a severe case of AAS, which has resolved. Take care. Goodbye, sir. Always a pleasure, never a chore.’ (AAS–arrest avoidance syndrome)
As an aside, I know the police sometimes come in for a lot of flak. But I want to say that all the police I have ever worked with in A&E have been fantastic. How they keep happy and don’t show their anger that often when dealing with people like him, I will never know.
Smoking yourself to death
It is not easy giving up smoking. However, it is a lot easier than being told you are going to die of lung cancer.
A gentleman came to A&E after his wife had forced him to. He had had weeks of problems before succumbing to her pressure.
‘So what’s up?’ I enquired.
The typical hesitant-male-being-encouraged-to-talk-by-his-wife conversation ensued. Eventually I found out what had been bothering him–and it wasn’t just his wife’s nagging.
‘I have been losing weight and coughing a lot. But I had to come today because I have coughed up a lot of blood the last two days.’ He didn’t make direct eye contact, but looked at me as if he was feeling guilty.
I took some more information and asked if I could examine him. The first things that I noticed were his tar-stained hands from years of smoking (he thought that because the cigarettes were low tar, they weren’t that dangerous–he believed a myth not denied by the smoking companies). The next thing I noticed was indeed the amount of weight he had lost. His collar was at least two sizes too large and his trousers were falling off him. I examined his chest and while I was doing that, another coughing stint started. I looked at what he was coughing and it was bright red…and there was a lot of it–at least an eggcup-full of bright-red blood. The sight of this made me feel sick.
I stopped my examination to get a line into his veins in case he needed an urgent blood transfusion. I then went back to examining him. Listening to the base of his lungs, I heard odd noises, which just didn’t seem right. I asked him to say ‘99’, but only because that is what patients expect us to say–all the information I was going to need, I was going to get from a chest X-ray. (Also, I am not as clever as the respiratory doctors who actually listen back when you whisper 99.) I then moved on to his abdomen. I laid him down flat and started feeling his abdomen. I felt his liver. It was hard and craggy. I felt sick. He probably had a metastatic lung cancer (i.e. a cancer that had spread and that he was going to die from). He must have noted my unconscious facial expression.
‘What is it, Doc? What is going on?’
Shit, I need to think of something to say and quickly. ‘Erm…well…we need…’ Where had my bullshit ability gone? Where was it when I needed it? Shit! Then a great idea came to me. I put my stethoscope on his chest again. ‘Can you say ninety-nine, please?’ He did as requested and I had some breathing space. I repeated the request a few more times, pretended to listen, and I collected my thoughts.
‘I am not sure what’s going on,’ I lied. ‘I need to do some tests on you. I need to do an X-ray of your chest and some blood tests. When we get those results, I’ll have more of an idea.’
‘Have I got cancer, sir?’ he asked.
I was honest this time. ‘I don’t know. I suspect you may, but I can’t really say much until I have got some test results back.’ He seemed satisfied with that response, and then from nowhere I said, ‘I hope not though’. Where that came from, or why, I had no idea. What a stupid thing to say. I meant it though; he was a genuinely nice bloke. He was polite, unassuming and obviously doted on his family.
‘Me too,’ his wife responded.
I sent off a battery of blood tests and sent him for his chest X-ray. I looked at the X-ray when it came back. There was a large mass in the lower part of his left lung. His blood tests came back. He was anaemic from coughing up blood. I then looked at his liver test. The counts were very deranged. Finally, his calcium level was very high–probably from the cancer spreading to the bones. You didn’t need to be that skilled to come to the obvious diagnosis (you rarely do in medicine). My suspicions were right. All the evidence was pointing to lung cancer. However, you do need to be skilled at how you tell someone they have cancer. That is something that comes from your personality and is hard to teach. It is also something I rarely do in A&E as a diagnosis of cancer is rarely this obvious. I went into the cubicle where he was and asked him if he wanted to go somewhere more private. He declined my offer, but knew what my opening gambit meant.
‘I’ve got it, ain’t I? I’ve got cancer. Tell me. I need to know. Tell me.’
‘The tests so far show you may have a lesion on your chest. You also have some blood tests which show that the liver may be damaged. Although I can’t confirm you have lung cancer, I think that you might have it. We need to do some more tests.’
His wife was silent. He strangely seemed relieved.
‘At least I know what is going on. What happens now?’ He said it in a matter of fact way. I felt that he already knew his diagnosis and I had only confirmed his suspicions. It was odd.
‘I have to refer you to the medical team who will take over your care from now on. They will organise various special tests where they try and get some of the tissue and send it to the pathologists to confirm if it is a cancer and what type. They will also do scans to see if it has spread anywhere else. Until those other tests come back, I can’t say any more.’
I also explained that as the A&E doctor I would not be involved in their care anymore and that any future questions would best be discussed with the specialist team.
As I spoke, I soon realised that he was listening but his wife was not taking it in. They both spoke at the same time.
‘How long have I got?’ he said.
‘He won’t die, will he?’ she said.
I was honest. I told them that I didn’t know what was going to happen. She started to cry and he told her off for crying.
‘I need to tell the kids…what do I say?’
If I had thought telling him he had lung cancer was hard, him telling his kids would be a lot harder than what I just faced. I left the cubicle and made them a cup of tea.
Ironically, it is at times like this when I wish I smoked and had an excus
e to go outside for 10 minutes to collect my thoughts. Luckily, I don’t. One coughing fit when I was 14 put me off for ever.
The next patient I saw was a 60-year-old smoker who had just had a stroke…
Patient choice or patient confusion?
In the past if you were ill, you would go to your GP. If you were very ill, you would go to A&E. Now you have many other options: NHS Direct, your pharmacist, out-of-hours GPs, acute care centres, walk-in centres, urgent care centres, walk-in GPs, minor injuries units, major trauma centres, private treatment centres and private diagnostic and treatment centres (which is in essence what a hospital is). All of these are designed to give you, the patient, greater choice.
Did you want all this choice, or would you choose to have a functioning, open, good-quality local district general hospital and a GP that you can see when you need to? I know what I would go for.
Putting yourself at risk
There isn’t much risk working in A&E compared with other jobs such as the police, fire brigade or army. However, one of the risks you do have is catching diseases from patients.
At 4 a.m. in came a 32-year-old male. He was a heroin user and had cut his arm on a bottle. He needed suturing. I was doing this when I got a ‘nick’ through my glove and into my hand. It was nobody’s fault–a pure accident. I went through the procedure of washing my hand very thoroughly. My colleague then asked him if he would consent to an HIV (human immunodeficiency virus) and hepatitis test. He said he was ‘clean’ and refused another test. I couldn’t force him to have one and so I was in the lurch not knowing what his HIV status was and therefore what my risk was. I discussed it at length with the specialists and was told that the risk of catching HIV were minuscule.
However, it is hard to rationalise your own risk. It is much easier telling other people than telling yourself. I refused their advice and went on post-exposure prophylaxis (anti-HIV drugs) just in case. I felt sick every time I had a tablet. I also had to wait six long, sex-free weeks until I found out that I did not have HIV. That was a real low of working in A&E –especially the sex-free bit.
I know I have mentioned it before, but shouldn’t NHS workers have rights as well? Shouldn’t we have the right to do blood tests on high-risk patients when we have sustained an injury helping them? If they don’t want the results and don’t want anything doing then that is their decision, but to not let health-care workers know the risks they are facing is a bit unfair.
The anger of chess
Sometimes I find myself in some truly bizarre conversations with patients, but this is often one of the funniest bits of working in A&E. Last night the police bought in two rather large, scary-looking, biker types who had gotten into a fight at the local pub.
‘So what happened?’ I asked in a slightly disinterested, my department is very busy, could you not have kissed and made up and not kicked the shit out of each other? type of way.
‘He cheated!’ my patient said, getting fired up again and pointing to the man opposite handcuffed by two large coppers.
‘Right…but what actually happened?’ I repeated.
‘I moved my king to D4. He thought I had cheated.’
Slightly bemused, I tried to be not too surprised that not only had he heard of chess but that he was so passionate about it he that he had lost two teeth in its honour.
I went on. ‘OK. But how did you get your cut? Was it from a punch, a glass? What happened?’
‘Well, he moved his queen illegally. He jumped a pawn and anyone should know you just can’t have that.’
‘And…?’ I enquired.
‘So that’s cheating. I retaliated by moving my pawn across.’
It didn’t get any better. Eventually, he admitted that he had gotten so drunk that he couldn’t remember what happened but that the fight was definitely over chess. It is stories like this that provide the much-needed, light-hearted relief to stressful days at work.
Training to be a consultant
Many registrars are like me, on a training scheme to become a consultant. It involves two mains bits of education. First, there are training days. These are days of lectures where you are taught how things should be done (the gold standard) as opposed to how things are done in reality. They are also a good chance to meet up with friends and be reassured that you are not the only one a bit pissed off at the moment. However, the vast majority of training is done on the shop floor in an apprentice type of way. The quality of this can vary somewhat, but it sometimes opens your eyes to how the experience of consultants really shows when there are real emergencies. It makes you appreciate them and realise that your skills are in need of improvement.
This weekend I experienced a two-day course of intensive medical education. It was powerfully lectured. They were wide-ranging topics and, best of all, the course was free and included all food and accommodation. Yes, I went home to my mum, who not only knows nothing about medicine but even failed her first-aid at work course. However, she still thinks she knows more than me about health and tries to give me her advice.
I had a nose bleed–according to her you must pinch near the forehead and then go to A&E. I had years of nosebleeds that didn’t stop before I learned to pinch the soft bit of the nose for 5 minutes and wait until it stops instead. Then my cousin came to see me as he had hurt himself playing football. I advised paracetamol and ibuprofen, but no, apparently my mother knows better. Pain killers hide the true injury and you always need an X-ray. The other incident was my dad complaining about his bad back. I advised losing some weight and taking pain killers. But again I was wrong. There is apparently a fantastic herbal remedy, for only £69.99 from gulliblemiddleagedhousewife.com.
Mum, thank you for putting me through medical school but please let me be the household advisor on medical matters and you can stick to your specialist subject: knowing when I do or do not need a coat to go out in.
The last straw
It is not just me who gets annoyed about events at work. A friend of mine who works in another region told me about an event at work. He had been seeing a really sick 24-year-old asthmatic. My friend started giving him nebulisers and various drug infusions. However, he soon realised that the patient would need his breathing taken over by an anaesthetist otherwise he would die. He ‘fast bleeped’ the anaesthetist and medical team to come down. They arrived shortly after. Between them, they stabilised the patient and while the anaesthetist was transferring the patient to ICU, he was letting the distraught family know what was going on. One week later the patient was discharged. I have no doubt that my friend saved this man’s life. He then went back to the main section of A&E, to sort out the wait that had ensued while he had been busy. He did not expect any praise for what had happened, but didn’t expect the criticism he got from his seniors and from management about the number of ‘4-hour breaches’ that ensued on his shift. No wonder he is planning on leaving A&E medicine and becoming a GP–I think this was the last straw. At least when he is a GP, he might feel valued.
Missed fractures
Part of a consultant’s job is to call patients back who have had a fracture, but it was missed by the A&E doctor. Today that task was delegated to me.
The first report I got was from a lady of 65. She had fallen 10 days before, and had had an X-ray that showed a subtle but significant fracture. The junior doctor had missed it and told her that all was well. It was only today that the radiologist had reported it. I phoned her up and explained our mistake and got her to come back and get it plastered.
Far from being angry, she was apologetic about the trouble she had caused. Some people are just too nice for their own good. She explained that she had not come back as she didn’t want to bother anyone. So she sat there, in obvious pain for 10 days, until she got my call.
Luckily, she didn’t put a complaint in. If she had, I think the fault would not have been with the junior doctor but the system for taking so long for a radiologist to report an X-ray. We are soon having X-rays put on computers�
��why can’t there be a radiologist on to do ‘hot reporting’ on the X-rays as soon as the X-ray is done? They wouldn’t even need to leave their office to do this. At night, couldn’t we have one radiologist up for a whole area hot reporting all the X-rays and CT scans done? (Or even sending the scan off to the other side of the world, where the time difference means it can be reported on immediately without having to wake up the radiologist?) This seems to me to be an efficient way of reporting urgent scans: it is safer for the patient and it is good education for all doctors.
Let’s bring in reforms to the NHS; but sensible ones, ones that will help and make a difference. I think that this one might be a good idea.
Things have improved…but they need to
be better still
For all the moans I have about A&E, some things have got better. Last night I was working and a patient came in with a dislocated shoulder. My junior colleague had never dealt with one before and had only seen them put back twice. I asked them to see the patient with me supervising the procedure. I asked my colleague how much sedation he wanted to give. The answer given was about three times as much as the patient should have received. If she had received that dose of analgesia, she could have had a respiratory complication (i.e. stopped breathing).
The answer given, though, was the dose I gave for a very similar patient about four years ago. Then I had little night supervision and the junior doctors just got on with it. We would be the ones seeing the sickest patients. There was a ‘see one, do one, teach one’ attitude. There was no senior A&E doctor on the ‘shop floor’ supervising me when I was doing nights. I don’t know if any patients came to harm, but without senior supervision they could have.
Thankfully, because of the extra resources, there is more and more supervision of very junior doctors by middle-grade doctors like me. (We still could do with a bit more supervision from our bosses though.) However, some of my colleagues work in hospitals where it is not the case that there is always a middle-grade A&E doctor present on the shop floor. I think that this just isn’t safe–if you are acutely unwell an experienced doctor, or a supervised junior one, not someone who is new to the job, should see you immediately. It is barmy that in this country that the sickest patients are frequently seen first by the most junior doctors, especially out of working hours.