by Nick Edwards
‘You’ll know him. He is a regular. He’s completely well and a bit of a pain in the rear (he may have been slightly more fruity in his description). Get rid of him…Oh, and he has just pissed all over the floor and is swearing at us.’
The nurse was right. I knew him very well. He was an alcoholic (not a particularly pleasant alcoholic either) who had turned down help dozens of times. He usually came in when a member of the public saw him comatose and called an ambulance.
‘Hello sir. You seemed to have urinated all over the floor. Is everything OK?’ I enquired.
‘I couldn’t be bothered to walk to the toilet,’ he slurred.
‘A pleasure to see you, sir. Always a pleasure. Do you want to sit in the chair?’ I asked (he was standing and looking a little threatening).
The nurse interjected: ‘He has pissed on that as well.’
‘Well, sir, I suggest we do this consultation somewhere else…why don’t you move away from the pool of urine beneath your legs and come with me to the next cubicle? Why are you here?’
‘Don’t know. I was having a kip and them bastards in green brought me in.’
‘They are ambulance men, sir. Not in any way do you know their parentage. And please don’t swear.’ I was losing my patience but also quite enjoying the amusement this patient was giving me. I added, ‘Are you unwell? Have you banged your head?’
He showed me his arm. He needed to be here because he had a laceration that needed suturing. I explained that to him, went into the theatre to open up all the expensive suturing packs and called for him. But he had left–probably back to the pub or the nearest park bench to finish the kip that had been so rudely interrupted. Oh well…on to the next patient. I’m sure he’ll be back.
Off on holiday
Yipeee…I am off on holiday! No work for two weeks. I can leave it all behind and not have to think about anything but sun, sea, sand and trying to persuade my wife to have sex.
We were flying in economy class to Dubai–to sample everyone’s favourite new tourist destination. In an attempt to impress my wife, I hadn’t bought a paper and had planned to try and charm her en route and therefore guarantee the fourth ‘s’.
‘Stop boring me. I am trying to sleep,’ she responded, with no flick of the hair or any sign that I was guaranteed a holiday shag on arrival. She fell asleep and I had no paper to read on the journey. I was shit bored.
An hour later she was still asleep and I was still bored.
Two hours later she was still asleep and I was trying to play noughts and crosses with myself.
Then relief! The scariest thing you can hear if you are a doctor on a plane (except perhaps ‘We have hijacked your plane, etc.’–that is probably scarier): ‘Is there a doctor on board?’ I was so bored that I jumped up and went running. I wasn’t thinking what could be wrong, I was thinking, ‘Will I get an upgrade with some better films to watch?’
I got there and saw a woman in her 50s totally unconscious. Oh shit! I couldn’t wake her. I was no longer concerned about the upgrade–as long as they could give me change of pants at the end of this I would be OK. I went through basic first aid –ABC. A for airway–that was OK. She was still breathing and she still had a pulse. OK, she is safe for a minute–but what do I do now? I asked questions, getting more frantic.
‘Does anyone know her? Who is with her? Did she fit?’ No one knew her. Shit! It is easy in a resuscitation department, but at 12 000 feet a little less so.
Think, Edwards, think. The algorithm that all emergency doctors remember is ABCDEFG and the DEFG, stands for don’t ever forget glucose. I turned round and said, ‘Can anyone do a BM?’ (sugar level test).
What the hell was I saying–we were in aeroplane aisle and not an A&E. Why didn’t I ask for a CT scan, a ‘chem. 20’ or an ECG? I obviously got blank looks from the passengers around me that I had hoped had mysteriously turned into nurses.
I asked to see what was in their emergency bag. At the same time, the pilot asked if he should divert. I had one lady’s well-being in my hands and 300 people’s holiday at stake, including my own. This was not part of the relaxing holiday plan.
Bingo! In the emergency drug box, I saw they had glucagon. It reverses the effects of insulin and can increase your sugar level. I might as well give it a go, I thought. I opened the pack and then realised that in the last five years of medicine I hadn’t given an injection. I was on my own and so gave it a go.
A minute or two later, she started to wake up. Yes, it was working. ‘Get her some sugar,’ I called out. About five stewardesses came running forward (which was a beautiful, wonderful vision). I got more sugar than you could wish for. I gave it to her and she became coherent. It turned out she was a diabetic, had taken her insulin and then got drunk as she was scared of flying. She then felt sick and so didn’t eat any dinner. Her glucose level had dropped dangerously low and she had therefore become unconscious. The treatment had taken about 30 minutes of my time, broken up the journey, stopped her getting sick and prevented my holiday plane being diverted.
The senior steward approached me. ‘Thank you so much–please let me upgrade you for the rest of the journey’ Lovely jubbly –I thought. I’ll be mixing with millionaires. I went and got my wife, who was a little embarrassed at the fuss.
With free drinks flowing, I got horny and she got…tired and fell back to sleep. At least I now had a free paper to read while she was asleep. Being the aeroplane saviour also got me appreciated by her when we finally arrived in a hotel.
You can’t escape from the job of being a doctor, but it does have its advantages…
Hospital inefficiencies
It was 1 a.m. in the morning and I was knackered. It was ridiculously busy. It had been non-stop for the last 5 hours. I was examining a little old lady who had fallen and broken her wrist and it needed manipulation (pulling back into a better position). This is a very common A&E procedure and I was getting ready to manipulate this woman’s arm when the ‘red phone’ went off. A heart attack was coming in, in 3 minutes’ time.
I had no option but to postpone the woman’s manipulation and make her wait at least another hour. I apologised that there were only two doctors for the whole of A&E and that she would have to wait. I also explained to the other people waiting how busy we were. There were a few moans and groans, a couple of patients self-discharged but no-one seemed that annoyed and most seemed to understand.
However, it didn’t need to be that way. There were only two A&E doctors working, but there were lots of other doctors in the hospital who could have come and helped. However, there isn’t always the cooperation between A&E and the specialist doctors based in the rest of the hospital. If A&E is busy, then there is no arrangement for them to come down just when we need an extra pair of hands (as opposed to see an admission or give specialist advice).
So there I am, slogging my guts out, while others are sitting in the doctors’ mess less than 200 metres away. It doesn’t often happen that we are the only doctors working (in addition to the medical doctors–they are always as busy as us), but it does happen frequently enough to warrant making plans on how to utilise all the doctors at night. Being honest, the problem is that there are no expectations for the specialists to help out. When I was working as a specialist junior doctor, I would sit in the mess (even though I had A&E experience) while patients would wait to see an A&E doctor, because that is the way hospitals work.
It may seem a crazy reality, but it is how hospitals function at night. You wait 3 hours with a broken bone to see an A&E doctor, when there may have been an orthopaedic doctor sitting there doing nothing.
I think the reason that there is a tradition for specialist doctors to not come down and help ‘just to lend a pair of hands’ is because of the tradition of 24-to 48-hour shifts when these doctors needed to sleep. But this is no longer the case. Nowadays, the vast majority of doctors only do 12-hour shifts and so can work through the whole of the shift.
There can also be a
‘them and us’ attitude between A&E and specialist doctors. Just because we are the ones who provide the rest of the hospital with a lot of their workload, this shouldn’t make us the enemy. The other reason for this lack of collaboration is that some A&E doctors don’t want other specialist doctors ‘stepping on our toes’ and coming in and managing the cases that we can deal with. Surely, what is important is not which part of the hospital micromanagement the doctor works for, but what their skills are and whether they are appropriately trained to see the patient.
Reforms are a necessity for the NHS. Hospitals are starting to introduce a hospital-at-night scheme, where doctors cooperate more, but it doesn’t usually involve the A&E doctors–what madness. We need better reforms which break the inertia of senior management and improve the cooperation between A&E doctors and specialists. This is one example where I think real change to practice would make a massive difference. (And it did.)
One month later, I was doing another set of nights when a friend of mine was the orthopaedic doctor on for the hospital for a week of nights. She realised how busy we were and spent the whole night (when she could have been asleep) helping out by seeing patients who obviously had an orthopaedic problem directly–as opposed to them seeing an A&E doctor first. It made a massive difference, but led to complaints from her colleagues that it set a ‘precedent’. How sad that working together can be frowned upon by some of our colleagues.
Crying wolf
All A&Es get their ‘regulars’. Often they are homeless people, or drunks or drug addicts. They attend frequently, as their life styles mean that they are prone to getting ill. Also, they don’t know how to access primary care resources, or perhaps choose not to. Some staff can get quite close to these patients. It leads to a dangerous relationship, whereby whenever they want shelter or food they attend A&E, as opposed to going through other more appropriate channels.
My colleague saw one of our regulars yesterday. It was his 145th attendance in three years. He comes when he needs a wash or food and shelter. He always puts on a fake abdominal pain and trades getting his needs catered for in return for not making a fuss and leaving soon after dinner. He came in again with abdominal pain, this time after a supposed fight. A brief examination resulted in the usual general tenderness in the stomach. My colleague told him that A&E was not the right place for him to go to when he wanted food and he was discharged without being given dinner. He protested but everyone assumed it was because of the lack of food.
The next day he came back with a ruptured spleen from the fight. He was rushed to theatre and, thankfully, is making a good recovery after two days in the high-dependency ward. My colleague feels awful. But I think some of the blame lies with the patient for crying wolf and with all of the A&E staff for in the past positively reinforcing his wolf-crying behaviour.
P.S. Three weeks after he was discharged he was back in A&E with abdominal pain. He was given food and left. However, for the last few months he has not been to A&E. Apparently he is currently in jail. As soon as he is out, he will be back. He needs social services, police and A&E to come up with a joined-up plan for him. He also needs to stop crying wolf.
Blind to the problems
It was 4 p.m. and a panicked 29-year-old builder walked in. He had had a sudden clouding of vision over his left eye. The other thing I also noticed was that he was overweight…very overweight. He made John Prescott seem svelte. I examined him and took a history from him. He was reasonably well, but admitted to a poor diet and little exercise. I looked in his eye and there was evidence of damage done to the back of the eye by diabetes. I then did a sugar test–18–very high, virtually confirming a diagnosis of diabetes. I explained what I thought was going on, and referred him urgently to the eye clinic and then via his GP to the diabetologists. For me, it was a simple case. But for him, it is the start of a life with the miserable potential complications of diabetes: eye problems, heart disease, nerve damage and kidney disease. What was interesting in this case was his age.
There are two types of diabetes mellitus. Type 1 is the type children get when (possibly) an autoimmune disease damages the pancreas, which then stops the production of insulin. Insulin is a hormone that is produced after eating to lower the blood sugar level and store this ingested energy. Too high a level of sugar in the bloodstream damages fragile tissues such as in the back of the eyes, the kidneys and the body’s blood vessels. Type 2 diabetes is a problem with the body’s metabolism and sensitivity to insulin and usually occurs in the later part of life (if you have a genetic predisposition for it). However, if by overeating you have already had a lifetime’s metabolism when you are young, then you can actually get it at a young age.
This is what had happened to this patient of mine. Overeating and under-exercising had caused him to have a much older person’s illness. Unless he massively changes his lifestyle, he will get all the consequences described above, retire early and get his money’s worth (and yours) from the NHS.
However, he isn’t unique. The text books I first had when studying said you couldn’t make the diagnosis below the age of 40, but I have seen him and three other people in their late 20s/early 30s with type 2 diabetes, and so have my colleagues. Amazingly, paediatric colleagues have seen this condition in teenagers. All of them have the disease at so young an age as a result of obesity.
Obesity not only contributes to the diabetic epidemic, being overweight makes one more likely to get cancer, heart disease, stroke, breathing difficulties and osteoarthritis. It is a ticking time bomb for health. The fact that one in three youngsters are overweight makes it an epidemic waiting to happen–an epidemic that I believe could be a real threat to the viability of the NHS.
When I was at school, nobody seemed to care. Maggie Thatcher sold off my school’s playing field and privatised the school canteen and then they sold shit food for a profit. Also, I wasn’t taught cooking, and if it wasn’t for my wife (a wonderful cook), then the local curry house owner (also a wonderful cook) and ‘pizza a go-go’ would have much larger profits. Up until Jamie Oliver kicked up a fuss, Blair didn’t seem that bothered. However, things are changing, but not really quickly enough.
Why not slap on a 20 percentshit food tax (with qualified nutritionists deciding what is unhealthy) and use the money to give out healthy food vouchers with child support benefit? Why not ban junk food advertising before the 9 p.m. watershed and not just around kids’ TV programmes? Why not stop kids leaving schools at lunchtime so they can’t eat crap from the local newsagent? Why not put proper amounts of money into a cycling network as opposed to painting a bit of pavement and then producing leaflets saying how much you have done? Whatever the arguments are against these proposals, then surely the fact that if we don’t do something our nation’s health will be buggered in the future is a decent enough counter argument.
It needs a change of mind-set from the government, not just tweaking around the edges. Prevention is much better than cure and in the long run cheaper, but until they do something then we are faced with the problem. Individually, people must make an effort and medical staff must encourage them to make an effort.
Finally, if we did as a nation lose weight, then it would not be so embarrassing when I go abroad and see a group of men sunbathing on the beach, where the Spanish life guards and World Wildlife Federation volunteers try to roll them back into the sea…
It is also a sobering thought, that however many years I work in A&E, I will never make as much impact on people’s health as Jamie Oliver will…and I don’t even cook as well as him…or earn as much…or sell as many books…or say ‘pukka’ as authentically.
When patients make jokes
The last few days at work, I have noticed an increasing number of very poor jokes coming from patients. It is getting to epidemic proportions. Please stop. I have heard them all before. I like new jokes, so learn some before coming to A&E but please don’t use any of the ones below that I have heard in the last two days.
Dr: ‘
What brought you in?’.
Patient: ‘An ambulance’.
Dr: ‘How do you feel?’.
Patient: ‘With my hands. How do you feel?’
When taking blood. Patient: ‘Ho-ho-ho it’s the vampires.’
Yesterday, a woman who works in Asda came in with the worst possible dress sense and one of the worst jokes:
‘Any allergies?’
‘Only hospitals…ha ha ha’.
‘So’, I thought, ‘I have heard that joke a thousand times. Let me laugh, if I find it funny, but please don’t laugh on my behalf.’
However, I got her back. I went shopping to Asda that evening. I paid with a large note, put the change in my back pocket and tapped my back pocket twice. How I laughed. She thought: ‘I have heard that joke a thousand times. Let me laugh, if I find it funny, but please don’t laugh on my behalf’.
Seriously though, there is nothing better than having a bit of banter with your patients at work. It makes my day so much more enjoyable. So although I have heard those jokes before, on second thoughts keep them coming.
Ooops again
Blaming tiredness was no excuse. Blaming lack of experience was also not an excuse. I genuinely mucked up but luckily the patient didn’t complain. He was a 90-year-old war hero–he had won a VC in WW2. He had tripped and got a cut to his forearm which needed stitching.
It was at the beginning of my working life and I was still keen to suture. Now I find it very time-consuming and usually delegate it to the nurses, but at that point in my training I found it really satisfying. I cleaned the area thoroughly. I then sterilised the wound with some Betadine (antiseptic wash) then opened my sutures and slowly and methodically put in 10 stitches. The wound closed easily and I was proud of the cosmetic appearance.