by Nick Edwards
‘Yes I do. What’s the matter?’ I asked.
‘Her son has sent a formal letter to the chief executive and as I was the nurse working with you I have been asked to comment.’
‘What the hell. I thought…’
‘The letter went on about your informal style and relaxed attitude. It talked about letting relatives into Resus and being present the whole time during a difficult and scary time.’
‘But I thought they were happy with us,’ I responded as I started to panic about such a formal complaint.
‘I have got to go now. There is a long wait in minors. Bye. I’ll phone back soon.’
She hung up before I could find out who I needed to speak to.
Oh my God! Why had they complained? What had I done? What was going to happen to me? I felt faint with anxiety. Very soon I was going to need A&E treatment for my own fast heart rate. Five minutes later she phoned back.
‘As I was saying, the letter praised the entire department for being so wonderful and the family has given us a case of wine to say thank you! Well done.’
Getting thank you letters really does make work a pleasure. So does practical jokes and being wound up…but only after the event. If she is reading this, then I just want you to know that he who laughs last laughs loudest. Watch out…
Complaint letters
One of the most upsetting things for a doctor or a nurse is getting a complaint letter. We are human and sometimes we fall below the expected standard–then a complaint is justified. However, many complaints are preventable and caused by poor communication. The complaints which are upsetting are the unjustified ones and the ones sent out of a desire to seek compensation. The stresses of complaints are enormous. Your clinical skills are brought into question. Your name can appear in the local press, where everyone assumes you are guilty. Then there is the concern that it may affect your career as well as the personal feeling that you may have let people down.
Some legal complaints are utter bollocks, but often the hospital ‘pays up’ because the cost of the claim is cheaper than going to court against a ‘no-win, no-fee’ company.
What prompted me to write about complaints is one I received last week and I have been fuming about it ever since. I had seen a really sick and unwell asthmatic mother of three. She was 38. She had been into ICU twice in the past with breathing difficulties. She came in very unwell. I was really pleased with my very swift and good treatment. After the treatment in A&E, she was well enough to go to a normal ward as opposed to ICU. I really felt that we had saved her life.
When she was a bit better, I went and had a longer chat with her. She told me she that still smoked. I couldn’t believe it. She had a life-threatening respiratory problem and still smoked. I told her, in no uncertain terms, that she was putting her children at risk of losing their mother. I told her it was easier for her to give up smoking than for her partner to bring up their children alone. The whole time I was being polite and had her interests at heart. It would have been much easier to not give out advice.
I thought I had done the right thing. Apparently, I hadn’t. She left hospital a week later and two months later she contacted the hospital. It wasn’t to send us a thank you letter. She had called up the patient advocacy team. They had written a complaint on her behalf. I had apparently caused psychological trauma and upset her so much that she had not been able to work since she had left hospital. (As far as I remember, she hadn’t worked before coming into hospital.) She was also threatening to claim compensation via ‘no-win, no-fee’ lawyers (I doubted that they would take her case on, but she was threatening none the less).
Instead of this patient’s complaint being filed under W for waste of time, my bosses had to do an investigation. My integrity was called into question, along with my patient manner–something which I am particularly proud of. A grovelling letter was sent back which I fundamentally disagreed with. Money and time were wasted. I am now constantly worried that I will get more letters and more investigations even though all I was trying to do was help her.
I completely agree that doctors should be investigated and complaints looked at if their personal or clinical skills are lacking. But I think the complaining society is spreading too far. If we worry that every bit of advice given may lead to a complaint, then doctors will act in a way to stop themselves getting in trouble and perhaps not always act in the patient’s best interest.
If this ‘no-win, no-fee’ culture continues not only will the NHS be bankrupt from payments but it will also be bankrupt from doctors ordering too many investigations as they will treat people in a ‘defensive way’ (i.e. not in the patient’s best interest but in a way that no one could ever complain about, as they will have carried out every possible test–even unnecessary ones). These worries pervade us as we work. Quite rightly the ‘doctor knows best’ culture is leaving medicine. But when we live in constant fear of litigation and worry excessively about every decision, then no wonder doctors and nurses are leaving the profession.
Why I am glad I am an A&E doctor
Today I saw a lady who was really unhappy with herself and the world. However, she made me realise why I am suited to being an A&E doctor. She was 59, depressed and had had chronic abdominal, back and head aches. She had come to A&E as she was feeling a bit worse than normal. I went to chat to her and within minutes I too became depressed and had a headache.
There was nothing really wrong with her at all. I did some blood tests to appease her and reassure myself that I wasn’t missing anything. They were all normal. I told her so, and said that I didn’t know what was causing her problems. I explained that she didn’t need admission to hospital as there was no acute problem. All I could do was give her pain killers and get her to see her GP. I left feeling very miserable and depressed–I hadn’t really helped her and both of us left feeling a bit dissatisfied.
However, I am so glad that I saw her as she made me realise what is the beautiful part of being an A&E doctor. There are so many ‘heart sink’ patients that we can’t really sort out. They keep coming back to their GP and clinics and it is depressing for the doctor and the patient (who has often got underlying problems–though not necessarily medical ones). In my line of work, I only have to see these ‘heart sink’ patients once, whereas their GP has to try and work with them over and over to get to the root of their problems. I admire GPs who can deal with these patients over and over and still remain objective –I’m just glad I’m not one of them.
Not enough beds
Today, yet again, there were patients lying in A&E trolleys as there were not enough beds to go to. The hospital ‘bed’ manager even had to call up the local GPs requesting that they refer as few patients as possible as the hospital couldn’t cope. He also came round to me and was basically pleading with me to not refer any patients for admission. What a ridiculous thing for a bed manager to be forced to do. What a wonderful NHS we have at present. I need to treat my patients in the best possible way, not with the pressure of knowing that there is a ‘bed crisis’ all the time.
It drives me mad when I read that the problem with the NHS is that there are too many hospital beds and that the NHS would improve if we closed beds and got patients cared for in the community. Our wards are swamped with well patients awaiting social services placement and, sadly, also awaiting a hospital-acquired pneumonia. Until adequate community care is in place, we shouldn’t be closing any beds. However, at my hospital we have. A ward has been closed to save money. To house the extra patients, the medical assessment ward has become a traditional ward with one patient staying over four weeks on a supposedly short-stay emergency ward.
This means that, when A&E have stabilised the patients and referred them for hospital treatment, there is an unnecessary extended wait before they go to the ward. It has become a bit reminiscent of the A&Es of 10 years ago, with patients waiting for hours for a hospital bed. The A&E nurses have to act as ward nurses and the new patients that are arriving are given less
than perfect care. It is bollocks that we need fewer beds.
Cutting bed numbers truly buggers up the quality of care that patients receive and has a damaging effect on the efficiency of the hospital. It is sad that the notification of the death of a patient on a ward is received with gratitude by the bed manager as it means that one of the A&E patients could get a bed…and I thought this was meant to be the best year ever for the NHS.
Satisfied doctor and patient
There was nothing particularly unusual today at work. It was just quite a satisfying day. No-one was particularly ill, but those that were all had readily treatable conditions. My treatments resulted in instant improvements, gratitude from the patients and satisfaction for me. They made me feel that I sometimes do useful things as opposed to practising ‘defensive medicine’, getting stressed by targets and doing audits showing up problems that I know will not change.
The first patient was 26 and had a dislocated shoulder. He had fallen off his skateboard. I gave him some sedation and pulled the shoulder back into place. (Sedation relaxes your muscles and also has the added benefit of making the patient amnesic so they don’t remember the pain of the relocation. If you were so inclined, you could take the piss out him still skateboarding at 26, without him remembering the conversation.) When the shoulder went back in, the release of pain was enormous.
The next patient had fluid on the lungs and was really short of breath. A couple of drugs and some oxygen and within 1 hour she was a different patient. I felt quite happy.
Then a child came in with a ‘pulled elbow’. It is a condition where the elbow slips from its ligaments, often when they have been ‘yanked’ up. They just don’t use the arm. Some gentle manipulation and within 15 minutes they are back to normal.
Later in the evening we had a diabetic patient brought in unconscious by her panicking friend. A simple sugar test told us that she needed an injection of a drug to reverse the insulin she had taken without eating. Within minutes the patient was back to normal and the friend was impressed by our quick actions and calm attitude (as were the patient’s parents)–and told us so.
Just before I was about to leave for home, I was asked to see a man in excruciating abdominal pain. A quick assessment and I realised that his bladder was blocked. I inserted a catheter and his pain vanished within minutes.
I drove home and thought that work is quite good fun; I am lucky I do what I do. I didn’t moan once in the pub that night.
Mad bureaucracy
There are some rules in the NHS that I just don’t understand. Today, I had a patient who needed blood tests. I asked one of the nurses, who wasn’t busy, to take them for me and she was very happy to do so.
She was an experienced nurse, and had just got promotion to become a sister. She normally takes blood without any problems, having had the appropriate training by her last hospital trust. However, since she had moved hospitals, she apparently is not allowed to do it until she has been on a course and had 10 patients signed off. This is ridiculous. Junior doctors, who have only seen blood being taken a couple of times, are let loose to do their best as soon as they qualify. But here was an experienced nurse not being allowed to do a job she was perfectly capable of, because of bureaucracy. Let nurses’ skills transfer between hospitals and let’s have less form-filling and more caring.
NHS Direct…to A&E
Two patients I saw today had been told by NHS Direct to call an ambulance and come straight away. The first was a sore throat and the second a case of long-standing arthritis. They were fine and didn’t need to be in A&E. I was initially annoyed, but after speaking to a friend who works at NHS Direct, my annoyance left and was replaced by pity for their difficult working environment.
I can see why the government has promoted NHS Direct. It is a great shiny thing to show off to the voters. And it is good in some respects–it is good for non-urgent advice (for example, it gave my friend fantastic advice on their non-sleeping newborn). However, for emergencies it is not so good. First of all they take a long time to get through to and second, they can’t see the patient or get a general feel for how they are. Third, the treatments and advice are very protocol-driven and the staff that man the phones have got to be safe.
Hence, when there is something confusing going on, their frequent conclusion is to advise people to go to A&E…and we see some spectacularly inappropriate attendances. The sore throat clearly went down an ‘airway obstruction’ protocol (why else was an ambulance called?) and the hip pain must have gone down a ‘fractured leg’ pathway. It is not the nurse advisors’ fault, they are just doing their job. People often cannot describe their symptoms clearly and when someone can’t see the patient, they have to err on the side of caution. Anyway, we never hear about the ones that they prevent from coming in. Last but not least, I am sure that people lie and say NHS Direct told them to come, to lay the blame on someone other than themselves once they realise that maybe A&E is not quite where they should be.
While I think NHS Direct has its uses, I can’t help but think that there may be a more efficient and safer way to help potential patients. How about more triage nurses in A&E who can give out advice? Because the patient is right in front of them they can evaluate the problem safely. Or how about taking a step back in time and paying for an out-of-hours GP service where these patients in distress would actually get a home visit at night as opposed to a protocol telling them to call an ambulance?
In the meantime, it looks as if NHS Direct is here to stay and will continue to be nicknamed NHS direct to A&E.
Why I hate laziness
I hate lazy people. Whether they work in and around A&E and delay treatment, or whether their actions force someone to come unnecessarily to A&E. All in all, laziness is not good for patient care. Last night I had three cases that really upset me.
A psychiatric patient was sent in from the local unit by ambulance. It was 3 a.m. and the nurses had called the psychiatric doctor to go and see the patient but he couldn’t be bothered. The patient was short of breath so the psychiatric doctor, instead of getting off his lazy arse to assess the situation, just told him to call an ambulance. When the patient arrived, there was a very distraught family. The patient had severe dementia, and had recently developed a chest infection. Documented in the notes was a plan not to transfer the patient to hospital if she deteriorated, but let her slip away peacefully. But as no one could be bothered to properly assess the patient she was sent to the dumping ground known as A&E.
I also saw a lady with a sore throat. I explained that she didn’t need to come to A&E. She told me that the GP had told her to come as he was too busy. I phoned the out-of-hours GP receptionist who confirmed that the GP was ‘surfing’ the net and I informed him that I was sending the patient to him. When I asked the GP why he had told this lady to come to A&E, I was told that he was there for emergencies only. Hang on…Wasn’t that my job? What a lazy (but no doubt well paid) colleague.
Then I saw a badly injured motorcyclist (otherwise known as an organ donor). His neck was painful and he needed a CT scan of the neck and head to rule out injury. The head was normal and we got a report for that (it is whizzed across to the radiologist’s phone line and down their computer so they don’t need to get out of bed to report it). However, to report the CT scan of the neck, the radiologist needed to come into the hospital. Instead of coming in at 1 a.m., he told us to keep the patient’s neck immobilised and he would report it in the morning when he was coming in anyway. So this poor fellow had to stay strapped down all night and not move. The nurses had to log-roll him whenever he needed to vomit and I had to make up a pathetic lie of why we couldn’t get the CT results straight away. Amazingly, he thought his treatment had been brilliant. It is fantastic how a few half-truths can placate most patients and hide them from the real cause of their delays and difficulties.
All I can say is that the vast majority of my colleagues are not like this. It is only a very select few. The only downside is that I only wri
te when I am angry and so you rarely get to hear about when people have put themselves out and been helpful. But then that’s life really–no-one ever praises the good guys, they just moan about the baddies. Sorry.
MRSA: the good, bad and ugly
The bad and ugly
A little known fact: one in three of us have MRSA (methicillin-resistant Staphylococcus aureus). It is a nasty bug that cannot be killed by the common antibiotics. Normally, it lives up your nose, getting on with its own little life and never bothering you. However, if you are vulnerable (i.e. elderly or have open wounds, etc.) it does cause problems.
A well known fact: MRSA can be transferred from patient to patient by poor hygiene and lack of proper hand washing. If you are unlucky enough to get it, then its consequences can be devastating
A little known fact: it’s not all doctors’ fault. There are things all of us need do, such as hand washing. It is also true that some doctors don’t help at all, but there are other causes.
I was at work today and went to clean my hands with alcohol gel between seeing patients. I squeezed at the dispenser and nothing came out. I went to the next one and again nothing came out. It was a real effort to get anything to clean my hands with.
Later on, I went to the toilet. There was no soap, so I went to another toilet. There were no hand towels left either, so now my hands were left to dry in the air (a great way to encourage MRSA). I saw another patient and, as can often happen, I got some vomit on my clothes. I would have to take them home myself and wash somebody else’s bodily fluids off in my washing machine. I don’t particularly like doing that and, anyway, my machine is not specifically designed to be a sterilising washer. When I wear that top, how can I be sure it won’t be harbouring any bugs?