by Nick Edwards
If the resources were put into employing more senior doctors on the shop floor 24 hours a day, then patients would receive better care. The NHS would also save money in the long run as there would be fewer unnecessary admissions and good initial treatment is cheaper than expensive long-term care and lawsuits. The argument that there are not enough senior A&E doctors to provide 24-hour care is folly. If the specialty was made more attractive, and training jobs increased, then there would be enough to go round.
Harming yourself
I asked a psychiatrist to come down and see a patient who had taken 10 paracetamol and told me that if they were discharged from hospital they were going to kill themselves. This was her 15th attempted suicide in the last six months. She didn’t seem too distressed by what she was saying, but I had to refer her.
The psychiatrist came down to see her. Luckily he knew her very well. Despite what she was saying he discharged her and said to me, ‘She has got a personality disorder. By referring her to me you are encouraging her behaviour.’ He then muttered quietly, ‘Between you and me, she needs more friends and not more prescribed drugs–but I can’t prescribe friends. But, hey, that’s my job. I just hope I am right and she doesn’t kill herself.’ I chuckled as he went about writing his notes. It also made me think…
A great deal of the A&E workload is now seeing patients with suicide attempts. It is one of the most common reasons for youngsters (and the not so young) to be admitted to hospital. I don’t know what it is–the increased stress of modern living? more and more stresses at school? or the prevalence of drugs?–but the numbers of attempted suicides seem to be rising.
Seeing a genuinely depressed patient is upsetting. They deserve your full attention and care as they are just as ill as anyone with a heart attack or broken bone but, as described above, a section of patients do take minor overdoses as a way of getting attention. Instead of being recognised as such they are now labelled as having a personality disorder. It can be very hard to make the distinction between people genuinely in need of help and those with a personality disorder (who also need help –but not by being referred as an emergency since that just gives positive feedback to their behaviour). I am just glad that I have got access to psychiatrists who can make that assessment for me.
There is also a large cohort of patients that comes in repeatedly after having self-harmed by cutting. It is hard to not be infuriated with them, especially when it is very busy, knowing that they caused their own problem. It is also hard to understand how someone could inflict so much pain and damage on themselves. However, they too need our attention and to dismiss them as time wasters is unfair. My eyes were opened to the problem last week, when a frequent cutter came back. As we were very quiet, I had time to chat with her, while suturing her wounds. She told me that she cut as a way of giving herself the control over her life that she had never had and that she had become addicted to it. She had been abused when younger and this was her way of coping. Again, A&E can only solve the acute problem. People like her need more help from other services.
Factitious behaviour
Some people come to A&E for bizarre reasons. I have seen two recently who have made up symptoms to get morphine or sympathy. The first I saw was a fantastic actress. She said that she had fallen off her bike. She was carrying her arm and wouldn’t let me go near it, saying that she gets recurrent dislocations. She just kept on asking me for painkillers.
Dislocated shoulders can be agony, so I gave her some morphine and sent her for an X-ray. I asked her to wait while I arranged for someone to escort her to X-ray; however, as soon as my back was turned she got up and walked out of the hospital, ready for a night high on the morphine. Clever girl! She fooled me and made me feel like a right prat.
The next case was of a woman who pretended that she had HIV (human immunodeficiency virus) and had stopped taking her anti-retrovirals because of the side-effects. At the time I didn’t realise she was lying because her story was so convincing. She claimed she was very short of breath and so I referred her to the medical team for treatment of an AIDS (acquired immunodeficiency syndrome)-related pneumonia. They were fooled as well. She was kept in and given expensive drugs for three days, by which time no-one could trace any old notes and her HIV test was negative. It’s a weird world working in A&E.
People who work in the A&E department
There are lots of people who work in A&E–not just doctors and nurses. Here is a quick review of the people I spend my days with.
Emergency nurse practitioners (ENPs)–specially trained nurses who can treat minor injuries independently. They have taken a lot of the pressure off A&E doctors and done more for reducing waits in A&E than any other development. They write a lot of notes for each patient and can see fractures on X-rays (which I need a magnifying glass for) from 10 metres.
Pharmacists–go round improving doctors’ spelling with green pens. Often save the arses of junior (and senior) doctors.
Receptionists–run the whole show. Know how to do everything. Massive amounts of common sense. I often think that if we sacked all the doctors and gave the receptionists a stethoscope, the NHS would be a better place. They keep the waiting masses in order with flair and frequently an iron rod.
Consultants–the senior doctors. Have years of experience and when they are on the shop floor, they make the place so much more efficient and patients get excellent treatment. Unfortunately, they are often in their offices answering complaints, or at meetings explaining why patients have ‘breached’ their 4-hour rule (probably because the consultants were in a meeting explaining why other patients ‘breached’ as opposed to seeing patients)
Registrars/staff grade doctors/SpR doctors–below the consultants, more experienced than the SHOs. We are the ones who, when asked a question, will take off our glasses and put them in our mouths to look as if we have some intelligence and knowledge when really we are just playing for time.
SHOs/F2–the junior rank of doctors working in A&E. Some are excellent. All are hard working–or forced to work hard by their appalling rotas which often mean that they work mostly unsocial shifts so that the more senior doctors can have a life. However, they only work for 4–6 months in the A&E department, so medical staffing planners can get away with it without too many complaints.
A&E secretary–she knows everything and everybody, does everything, finds everything and without her the place would fall apart. The most amazing organisational skills I have seen. This is not being sexist, but I don’t think a man could ever replace our secretary –we can’t multitask and she can.
Sisters–the lynchpins of A&E. They make sure that a ‘shift’ is run properly, coordinate the department along with the senior doctors, run the show, get paid bugger all and if they want promotion get pushed into management.
Charge nurses–male sisters. I call them brothers. They don’t find it amusing except the vegetarian communist one, who keeps on trying to get me to join his commune.
Staff nurses–the work horses of the A&E. Usually excellent, but there are a few disgruntled and eccentric ones, especially the breed known as ‘agency staff nurses’.
Health-care assistants–do the jobs nurses used to do, except give out drugs. Get paid a criminally small amount for such a vital job. It’s a disgrace.
Physiotherapists–specialists in musculoskeletal problems. Female ones are usually very fit and male ones good at sport.
Occupational therapists–a cross between a social worker and a physiotherapist. Vital in helping elderly patients get out of A&E.
Radiographer–the person who does your X-rays. Not a doctor, but highly skilled and valuable members of the A&E team. Spend 3–4 years at university learning about human anatomy, physics and how to read doctors’ writing.
Too posh to wash?
I was struggling at work today. The nurses on the ‘shop floor’ were flat out. I needed observations doing and drugs given, and neither was happening quickly. A patient had been calling out for 15 min
utes for a commode before they got one. A patient needed changing from their wet incontinence pad, but it was left on for long enough to make the patient cry. Admittedly, we were busy, but the nursing care the patients were getting was not adequate, although there were nurses around. There were two ENPs, who now treat minor injuries. There was a specialist DVT (deep vein thrombosis) nurse seeing a patient as well. The urology nurse specialist had been asked to chat to a patient about their catheter and the cardiac specialist nurse was looking at an ECG and deciding if a patient needed to go to the coronary care unit.
I think all these jobs are valuable, and A&E would be lost without the input of specialist nurses, especially in the days of reduced doctor’s hours. But is it right that we have so many nurse specialists when simple nursing procedures such as washing, doing observations, etc., are being left to a handful of overworked and underpaid junior nurses and nursing auxiliaries who have not got the time to do it properly.
You may think that it is the job of the senior sisters to organise the caring of the patients better. However, so much of their time is spent on managerial matters, planning meetings and worrying about targets, etc., that they have less and less clinical time to spend looking after patients and mentoring the junior nurses.
Often, the basic nursing tasks are performed by the nursing auxiliaries (health-care assistants). They, I believe, are the least appreciated and most valuable members of the A&E team. They do all the basic nursing tasks except give drugs. They take bloods, insert cannulas, do ECGs and, when time allows, they care for the patients. Last week I went to the leaving do of a health-care assistant of 10 years’ experience. She had got a job at Tesco on the tills–earning more than her present job. But it wasn’t just her leaving do: it was a joint one with an excellent senior A&E nurse who, because she wanted promotion and a pay rise, was pushed into a managerial role as a ‘patient pathway coordinator’ as opposed to nursing.
We need more nurses in nursing care. I am not saying we should cut the specialist nurses. I am just saying that we need more nurses employed to nurse…and they need better pay, both junior and senior, otherwise they will continue to leave the NHS or move into management and we need their skills where it really matters–on the shop floor.
How to lose a friend
I am good friends with some of the nurses at work, but I think that I have lost a friend today. She was chaperoning me doing a rectal examination. The patient had diarrhoea–I was checking that she (the patient not the nurse) didn’t have something called overflow diarrhoea, where severe constipation only lets liquid faeces pass the blockage. I examined her and my suspicions were confirmed. As I withdrew my gloved finger, I examined it and saw lots of diarrhoea. As I took the gloves off, the elastic of the gloves acquired a life of their own. It then all happened in slow motion. I saw particles of faeces fly off my glove straight onto my colleague’s uniform, leaving a brown splatter pattern right over her left breast. ‘Ooops! I am sorry’ didn’t appear to be sufficient and I found myself cleaning a lot of commodes that night.
Hero to heroin
The ambulance call came through; ‘21-year-old male. Unconscious, respiration rate 5. Having to be bagged (artificially ventilated) by the paramedics. IVDU–intravenous drug user’.
It was the third similar patient this week. I met the ambulance as it arrived and we wheeled him into Resus. Behind came a distraught mother and father. We went through the basic treatment of the unconscious patient. The ambulance man continued to keep him alive by giving him oxygen. I examined him and tried to get a cannula in. It was virtually impossible: all his veins had scarred up from excessive use in injecting drugs. I eventually managed to find one in his neck.
I could now give him the reversal for heroin–naloxone. I was only a relatively naive junior doctor at this stage, with a limited experience of heroin overdoses. I gave him the full dose of reversal medication. It blocks the morphine receptors, and means that the patient quickly wakes up, starts to breathe for himself and comes down off his high.…And he did. In about 3 minutes he had woken up, pulled his Guedel airway (piece of equipment used to keep the airway open in an unconscious patient and let them breathe) out of his mouth and started to shout and curse.
‘What the f**k did you do that for, you bastard?’
I tried to explain that his mum had called an ambulance and he had needed the paramedics to keep him alive. I expected him to be grateful. As I said, I was naive to the gratitude of some patients.
‘You can f**k off. I am out of here.’ He pulled off his ECG monitor and cannula and stormed out, looking for another fix.
Heroin has powerful qualities. It makes the user fixate only on the drug and nothing else matters. They ignore all else in the search for the ultimate ‘nirvana’ high. No need, therefore, for the social niceties of being pleasant to hospital staff and the paramedics who saved his life. No need to show love to his parents. No need to conform to accepted social standards and so it is no wonder many steal from grannies or take excessive risks as prostitutes to pay for the drug. There is just the need to get that high and so he left looking for a hit again.
The danger of what I did was that the reversal wears off quicker than the heroin, so he may have gone back to his unconscious state. Also, with him in the plucking/cold turkey state he could be a danger to himself and staff. I learned my lesson: give very small doses of the reversal slowly over time, so they are too drowsy to up and leave.
As he left I had a word with his distraught parents. They had been loving parents but he had got in with the wrong crowd. He used to be a footballer–apparently quite promising. He was a hero for his school’s team, being top scorer for three years, but then the wrong crowd came along. He had started with cannabis and then moved onto ecstasy, cocaine and then heroin. He was in and out of prison and then either on the streets or kipping at various friends’ houses. He paid for his fixes with petty crime. He had been on a methadone treatment programme (methadone is a heroin substitute, but does not give the same high) but it hadn’t worked. He had been loving as a child and now they described him as a monster that they didn’t recognise. They loved him, but hated who he had become.
At this point in my career, I was new to drug abusers and the thing that I found most strange (which shows that I obviously have deep middle-class misconceptions and prejudices) was that they seemed a normal loving middle-class parents. His mother was a nursery nurse and his father was a taxi driver. They were not alcoholics and they had not abused him or neglected him. It just shows that drugs can affect anyone, no matter what their upbringing.
They asked what they could do. I didn’t have the answer. The police were failing him. The social services were failing and so were the methadone programmes–he still went out and took methadone. He might die soon after another overdose, and they and I felt helpless. That week, three similar patients had come in. The police also said that another had died before an ambulance had been called. Apparently, a new drug dealer was on the street and was selling a stronger version of heroin. It was getting people more and more addicted and killing some of them because of overdoses as a result of its strength. The policeman told me that they needed to catch this dealer quickly or there would be more deaths. His colleague joked that at least the crime rate would go down if he wasn’t caught…but it wasn’t funny. These addicts are people’s sons, daughters, fathers and mothers. They also have potential to be reintegrated into society and to become assets to the country. We are failing them as much as they are failing themselves and their families.
So could anything be done? Well, possibly. A couple of years after I saw this patient, the government brought in some pilot schemes, some of which are using the experience of the Swiss authorities, who have made heroin free and available to use on prescription in special clinics run by specialists. The patients can go twice a day and get their normal fix, but with a standardised drug so that they don’t overdose. It is a clean and safe environment. The users no longer go to the dealers
as free heroin is available from the clinics. Crime is down, as they no longer need to mug grannies to pay for their fixes. Dealers have left because of market forces and so fewer kids are starting heroin. The users are medicalised, the glamour of drug-taking is reduced and their lives have been stabilised. They can start to get jobs and when they are ready they can be transferred to methadone and slowly weaned off the drug.
It is a possible solution. But it is controversial because the government is, in effect, saying to people that taking heroin is no longer a crime–come round and have some of our free stuff. However, initial results show that this approach works. I think it is controversial not to consider this scheme. It is just a shame for the user I saw and his family that he does not live in one of the trial areas.
Taking the piss
Life can be a bit unfair for patients. If you sit quietly, then you usually don’t get pushed to the front of the queue, but if you make a fuss sometimes your care is speeded up. Today I learned that if you piss on the floor you’ll get seen straight away.
The ‘minors’ nurse asked if I could see a patient because he wanted him out of the department ASAP. He explained: