by Nick Edwards
‘There we go, sir,’ I said. ‘Not a bad job if I may say so myself.’
He looked at it in a satisfied way. ‘Should I go to my practice nurse to get the stitches removed?’ he asked.
‘Yes, in seven days. Take care now…’
He picked up his stuff and then took five steps away and came back to me. ‘Is it normal to not use local anaesthetic nowadays?’ he asked.
I thought he was joking and then I realised that I had completely forgot to use it. WHAT THE HELL! I had forgotten to put in local anaesthetic, and he had been too polite to tell me. Oh my God! I’ll get the sack. The pain he must have felt! I went white and then nearly cried.
‘I am so, so sorry…’ I started to confide in him.‘I have been so stressed recently. It’s my first A&E job and I just seem to find it all so stressful. I don’t know what I was thinking. I am so sorry.’
My eyes started to well up and my bottom lip quivered.
‘Don’t worry. It didn’t hurt that much. It was nothing when you have been fired at on the Normandy beaches. You’re a good doctor–don’t get stressed by one mistake.’
He was so nice.
‘I only asked because I wanted to know if it had become normal practice.’
He left and I went to cry for a minute or two. I don’t know why this encounter had made me cry–perhaps it was just the stress of the last four months coming out.
Two weeks letter he sent a letter to the hospital. He thanked me personally for a ‘pleasant and pain-free visit to the A&E department’. Thank God for patients like him.
More inefficiencies of hospital care
Despite what you see on TV, most cases coming to A&E are what are termed ‘medical’ cases, such as chest infections, chest pain and little old ladies with a ‘collapse–?cause’.
Last night I had a large number of medical cases come to A&E. Some I sent home, but quite a few needed admission into hospital for in-patient care. These patients are called ‘medical referrals’. Although they are seen and stabilised by the A&E doctors, they need to be referred to the medical doctors for admission and continuing care. The medical team of doctors is generally the busiest specialty in the hospital and in a medium-sized hospital will often admit over 30 patients in a 24-hour period.
As it routinely takes over an hour to properly sort out a new sick patient and write up their notes, not to mention catch up on the routine day-to-day jobs, you can see why they are so busy. Once I have referred a patient to them, it can often take several hours before the patient is reviewed by a member of the medical team and a final plan of action made. This means that the more I can do in A&E to diagnose, treat and manage the patient, the better and faster it is for everyone concerned. However with the 4-hour target and the lack of staff compared with patients, this is often very difficult to do.
Last night the A&E SHO and I were working flat out all night. So were the medical team of doctors. Because we were so busy, sick patients were waiting about 2 hours to see us (the A&E team) and then about another 3 hours to see the medical team (if they needed to). Despite everyone’s best efforts, I don’t think that as a hospital we provided that good a service that night.
Many of the patients I saw had quite simple problems that, although needing admission, were very easy to treat and construct a management plan for. However, once they had seen me and been referred to the medical team, the hospital policy is that they are then ‘reclerked’ by the medical team. Re-clerking means that all the same questions that I had already asked are repeated and a full examination is performed again. The results of this re-clerking are then written down on hospital paper as opposed to the separate A&E notes where I had written the exact same things several hours earlier. For the busy medics, this is a complete waste of time. Especially so as one of the medical doctors reviewing the patients that I had referred used to work with me as one of my juniors and has a lot less medical experience than I do.
Now, I do agree that it is good for patients to be reviewed by the team they are coming in under, and it is vital that important questions are clarified and important parts of the examination rechecked. But why do they need to do a time-consuming rewriting of their notes? Sometimes it is necessary if the A&E team have been so busy that the patient might not have been properly sorted out before referral, but often this is not the case. Because of pointless hospital rules, the notes are simply copied out by the medical specialists from the A&E doctors’ notes. Haven’t we heard of a photocopier and then writing: ‘In addition:… ? ’
As well as being inefficient, the system is demoralising. The medical doctors have not trained as doctors simply to repeat someone else’s work and the A&E doctors get annoyed as they think, ‘What is the point of me writing all those notes if they are just going to get re-written?’. What is needed is a single ‘tier’ of care. Who that initial doctor is, is not that important. The only thing that is important is that the doctor treating the patient has had sufficient skills and supervision. The skills to treat ‘medically’ ill patients are something both A&E and medical doctors should have. There should then be a system in place for handing over the care of the patient to the inpatient team, who then appropriately review them closely.
There are two ways of bringing about changes that I believe are needed to improve care and improve efficiency. The first route is what some smaller hospitals are starting to do when they are ‘down grading’ their A&E department. Instead of having A&E doctors see patients, a triage nurse sees them and then asks the appropriate specialist doctor to see them straight off. In principle, this is fine. It gets rid of the inefficiencies of ‘double clerking’. It is also a model that can be used in areas of the country where there is not a large cohort of experience emergency doctors. However, I think that this is a poor solution. The A&E doctors have a specific interest, training and skills in emergency medicine. If you come in with an acute problem then we are the right people to see you initially and give you immediate care–especially if the cause of why you are unwell is not easily identifiable by the triage nurse (e.g. being unconscious could have a surgical cause, medical cause or be the result of trauma). Also, properly trained A&E doctors are particularly good at preventing patients who do not need admission from being admitted unnecessarily. They are also very good at treating the sickest of patients who do need admission.
For all those reasons, I think that A&E doctors are the ones who should see the patients initially. But we need sufficient resources so that we can spend time with our sick patients and we need to not be constrained by targets of getting them out of A&E ASAP. Once referred to the medical team they should be reviewed by medical doctors with a specific interest in acute problems–called acute physicians. In the UK we have started to increase the number of acute physicians, which is fantastic for patient care as they have the specialist skills in caring for very sick patients in the first 48 hours of their admission and, if appropriate, organizing speedy discharge.
There is a system in Australia where patients stay under the A&E team for a lot longer and it works very well. However, they have a greater number of A&E doctors than we do in the UK and so have the manpower to properly sort out their patients before passing them on to the specialist doctors. We are not going to suddenly triple the number of A&E doctors overnight so we need to think about how things can be improved currently.
What we need to do is improve the integration of the A&E teams and medical teams. For example, an A&E doctor could assess the patient and, if necessary, admit them to the acute ward with a management plan and drug chart written up. This would happen without the need for a medical doctor to repeat the whole process. They would then be handed over to the medical team on call who could review the patient without repeating all the notes. The medics would therefore have a lot more time available and could come down to A&E and see patients directly (i.e. instead of their being seen by A&E doctors first) as well as the other admissions such as those that are referred directly from GPs. This would also mea
n that A&E doctors would have more time to sort out their patients properly and do a ‘good clerking’ which doesn’t need redoing by the medical doctors.
To bring in this mind-set of changes of managing acute medical patients would require doctors of different specialties (A&E, Acute Medics and ‘General Medics’) to work together and trust each other. People then need to realise that what is important is how well the patient is being treated and not which particular specialty the doctor seeing them works for.
I hope that these changes get brought in and that I can just get on with my job–looking after sick patients who have not had to endure long waits to see me. I don’t want to have to move to Australia to get job satisfaction. I want things to change over here.
P.S. Mum, if you are reading this, don’t worry, I wouldn’t really move to Australia–I’ll stay here and just rant after work instead.
Sad request for a MAP
The computer showed that the next patient was ‘requesting MAP’. The medical student shadowing me believed me when I told him that as we were becoming a ‘foundation hospital’, one of our hospital’s money-making mechanisms was giving out directions to lost people. I explained that we were in partnership with the AA and charged only £1.50 per direction. I was baffled when he muttered that he thought it was a good idea and could he come and watch how to give out appropriate advice. I shook my head, distressed that sarcasm had been taken off the medical school curriculum and replaced with bum licking. I went in the cubicle and started to ask the patient about her request for the morning-after pill–MAP.
She came with her husband and three-year-old child. She told me that the condom had split and therefore she needed the morning-after pill. They were holding hands and looked like a perfect couple. As I was going through how to take the pill, she burst into tears.
‘But I want another baby. And I want to give my little one a brother or sister,’ she said tearfully.
I asked why she had come for a morning-after pill then. I was being stupid and naive and she quite rightly told me so.
‘It’s all right for you. What with your good salary and three-bed semi. But we are struggling to pay the mortgage on our two-bedroom flat. My hubby is a Postie and we rely on my wage to pay the bills. I can’t afford to go on maternity. We can’t afford another baby. I want one, but can’t have one. Give me the pill and don’t ask questions please.’
I gave her the MAP and all the advice it entails. I couldn’t really respond to her distress. I have the benefits of a good job and decent pay-packet (a terraced house though not semidetached). For me, poverty and how people cope or don’t with it, is something I see at work, but which doesn’t ever enter my private life. I am so lucky and this encounter made me realise that.
P.S. I don’t want this book to be burdened with patient advice, but please realise that the morning-after pill is a truly shit name. It is best used asap, but is still effective for up to three days. End of lecture.
Teaching
I love teaching medical students and medical students usually love coming to A&E as there is much to see and learn. But today I hated it. I had a third-year shadow me for a taster day in A&E. He was the most arrogant, pompous little shit I have ever met. He was rude to the patients and just tried to question my management in front of them. He had no ability to empathise with patients and viewed them solely as an illness entity and not a patient with an illness. I know he is only a third-year, but I would hate to be his patient if these personality traits are not knocked out of him.
I know when I first started medical school, not everyone was interviewed–some places were offered on the basis of exams alone. It is becoming academically harder and harder to get into medical school. However, you don’t have to be a brain surgeon to be a doctor (you do have to be a doctor to be a brain surgeon though). What is needed is common sense and courtesy, not four As at A-level. I don’t know what the interview process is like nowadays but I have some worries after trying to teach my student today.
Sorry, there was no real point to this story, I was just expressing my frustration.
Even more hospital inefficiencies
We are massively in debt as a hospital and there are plans for a freeze on recruitment. It is not just redundancies in the NHS we have to worry about, but newly qualified nurses and physiotherapists, etc., not getting jobs. Apparently, this is because as a ‘Trust’ we are short of pennies.
I was feeling in a reflective mood, so on my break I went for a walk around the hospital. Through every corridor loads of the windows were open but below these windows were radiators pumping out hot air paid for by our taxes. I then went to see a friend on a ward. After meal time, plate upon plate of food was thrown away. Not necessarily because it was no good, but because there was no-one there feeding the patients; what a waste of money. I then wandered to the car park, and there were two parking attendants just sitting there, chatting, not really doing much–at our expense.
I walked past theatres and there were surgeons doing bugger all, because there were no beds for their patients to go to after surgery, and so their lists were cancelled. I walked back to the wards and saw that tests were being repeated because results had got lost through not being stored electronically.
I then saw patients being unnecessarily admitted to wards because of targets…and other patients who were sicker and costing the NHS more because they didn’t get ‘gold standard’ treatment from the NHS earlier in their hospital stay. Then I went to A&E and saw doctors repeating each other’s work.
I then carried on my wanderings. I accidentally went to the management suite. It was late in the evening and no-one was working there–but all the lights were on. Couldn’t anyone turn them off? What are all these offices for? We need managers, but this many?
NHS money is being wasted left, right and centre. The NHS needs a bigger pot (especially emergency services), but the pot needs to be used a bit more sensibly. Quite rightly, the government wants to improve efficiency. It is just a shame they are doing it in such a bad way.
A weird rash
Last week I saw something I have never seen before. A child came in with a weird-looking rash that I didn’t recognise. I asked my colleagues–they had no idea either. Then the paediatric doctor had a look, she was clueless. Finally, the senior consultant came to review.
‘Do you read the newspapers?’ he asked the mother.
‘No. Why?’ she responded, a bit perplexed.
‘Your child has measles. You may have believed the stuff they said about MMR (measles, mumps and rubella). That’s why I asked. Did he have the MMR?’
He hadn’t. Mum had listened to some ridiculous stories perpetuated by the headline-seeking gutter press. As a result he hadn’t been immunised. But he was lucky and OK to go home.
Today, I saw a much sadder case; a little girl who had also got measles. I recognised it now. But she was much sicker. She had to go to the paediatric intensive care ward. Her life was at risk as the virus had caused infection to the brain and she might suffer brain damage as a result. Her mum had also stopped her from having MMR, and was paying privately for single-injection immunisations, but her daughter hadn’t had the measles one yet.
Measles is a serious killer (mumps and rubella aren’t so good either). The MMR vaccination is not this evil autism-inducing injection that the media sometimes make us think. There is no evidence that it causes autism. However, there is evidence that if your child doesn’t have the injection, they are at higher risk of getting these illnesses. Today I saw a child I shouldn’t have. Have a proper think before you refuse your health visitor’s advice.
Feeling guilty
Have you ever felt that you have contributed inadvertently to someone’s demise? I have and I can’t stop feeling guilty about it. It happened two days ago, and I have felt really shit since. He was a 45-year-old–a lovely bloke who came in reluctantly with his wife. Quite poignantly he explained that he didn’t want to come in as ‘you never get out of hospita
ls ok’.
He had had some chest discomfort after dinner. He thought it was indigestion. His wife wasn’t so sure. She had seen posters advising you to call an ambulance if you had odd chest pains and this pain seemed to be getting worse. She (very sensibly) called 999. He was having a heart attack. The ambulance blue lighted him in, and I met him in the Resus department.
His ECG confirmed the diagnosis. The treatment for this (in our hospital, out of working hours) is a clot-busting drug. It is a very effective drug in these situations and opens up the artery that has become blocked. I have given it successfully many times in the past but there can be some rare but serious side-effects. One is bleeding in the brain. I took him and his wife through the risks and benefits in his case. I said it was low risk and that I had personally never had a problem.
We started the drug. Very quickly his speech became slurred. I stopped the drug straight away. Then he couldn’t move the right side of his body and then he became unconscious. The drug had caused a bleed in his brain and he will suffer severe lifelong side-effects from the drug we injected. Although, medically, I did nothing wrong, and know that it was the right drug for his condition, I still feel guilty that I may have inadvertently contributed to his demise by giving him a drug that should have saved his life, not left him disabled for life. I find that hard to deal with.
Being called at home
I got a call from one of the nurses at home today. She sounded worried.
‘I just thought I’d call you before one of the bosses. I think you need to know.’ She sounded worried. ‘Do you remember the old lady you treated yesterday? The lady with the very fast heart rate?’
I did. I was really pleased about how I had treated her. I had taken her and her son into the resuscitation bay and spent about 1 hour sorting her out properly. I had spent the whole time explaining to her and her son what we were doing and why. They commented on how nice we had been and how she was pleased that nowadays doctors aren’t ‘stuffy’ and take the time to explain to them what we were doing. She also said how much more comfortable she felt that I had introduced myself as Nick as opposed to Dr Edwards.