In Stitches

by Nick Edwards

  Another patient came with an attempted suicide. He was very distressed and he needed to see a psychiatrist. However, the psychiatrist was doing a 24-hour shift and was on ‘protected sleep’ except for dire emergencies. He could wait to see the psychiatrist on our observation ward, but this only added to his distress.

  There are numerous other examples of the problems of out-of-hours care. The NHS should be planned so that you can expect the same level of care whatever time of day you are ill. People should do only a maximum of 12-hour shifts so that there is no such thing as ‘protected sleep’, and so we can get specialist doctors down to A&E at all hours of the night even if the patient’s condition is not life threatening.

  Whatever the problems are, surely A&E needs to be able to get specialist help 24 hours a day? The resources need to be made available so that this happens. Specialist help is available for life-threatening conditions 24 hours a day, 7 days a week. But perhaps it also needs to be available 24 hours a day for less important, but still potentially treatment-altering reasons, if only to speed up patient care and reduce the number of unnecessary admissions (and hence also save money). We live in a 24/7 society–surely it is time the NHS joined the twenty-first century.

  A sick man

  His pulse was getting weaker and weaker. Shit, I had given him too much of the sedative drug. Shit! Shit! Shit! I got an ECG. His rhythm had changed into an irregular one. I started another drug. It didn’t work. He was starting to become unconscious. I tried to call out to the nurses to get the consultant in to help me, but nothing came out. I had to take over this patient’s breathing. I tried to intubate him, but I just kept on getting the tube in the gullet and not the windpipe. His oxygen levels were falling. My pulse was racing. I called for an anaesthetist and finally someone came running to help. But he was dressed as Pudsey Bear. I begged my wife to help. Hang on…What the hell was my wife doing at work, holding my hand? Why was the anaesthetist dressed as Pudsey Bear? What the hell was going on? I breathed a sigh of relief. I was dreaming again. There was no sick man and I could get back to sleep, knowing that I hadn’t been party to anyone’s demise in the last few hours.

  But there was one sick man. Me. Why can’t I sleep well at night? Why do I ruminate about problems? Why do I worry so much about how I treat patients? And, what is worse, spending all my time worrying and driving my wife mad, or not worrying at all?

  Why I love A&E

  The wonder of A&E is that you never know what is going to happen and who or what is going to walk through the doors. It is not like being a specialist doctor, where you will only see packaged patients who fit a certain criterion. That would drive me crazy. I love the unknown.

  It was 4 a.m. when the ambulance brought us an 86-year-old man from a nursing home. He was unconscious. As he arrived, I directed the ambulance into the Resus area. I grabbed my junior colleague and went through the set pattern of treating people when they are sick and you haven’t got a clue what is going on. It’s the ABCDE approach. Basically, you treat the things that could kill them first and then move on.

  A is for airway Check the airway. This gentleman couldn’t keep his airway open because he was unconscious. He was at risk of dying from a lack of oxygen. To solve this problem, I inserted a naso-pharyngeal airway–a small tube that goes through the nose to the back of the throat. It means that even if the patient is unconscious, they cannot block their windpipe with their tongue. It can appear a bit barbaric to do, and it’s not particularly nice for relatives to see–but it is simple and life saving.

  B is for breathing Check the breathing. He wasn’t breathing well enough and so I gave him oxygen–again ridiculously easy and cheap and a life saver. You then move on to C.

  C is for circulation His blood pressure was low, so we inserted a cannula and gave him intravenous fluids. This brought up his blood pressure, thereby improving his circulation. We then moved on.

  D is for disability Find out how unconscious he is and then look for a cause. He was very unconscious and it soon became obvious on examination that he had had a major stroke.

  E is for exposure Examine the rest of him–is anything else going on, for example hidden injuries, etc.

  At this point his respiration became more and more erratic. I thought that it was because of the swelling from the stroke pressing on the brain. I thought he might ‘arrest’ (i.e. his heart and breathing stop). I then had to make a very quick decision as to whether trying to restart his heart would be a good idea.

  There are three main questions that must be asked at times like this: first, what was his quality of life like before?; second, what are his chances of surviving the cardiac arrest and then the subsequent treatment?; and third, what are his wishes, either expressed by him or by his relatives?

  There are two common misconceptions here. First, the decision whether to restart a heart is ultimately the doctors’ and not the relatives’. I know some doctors make patients’ relatives feel that they are making the decision–well, they are not. It leads to relatives feeling guilty and that is not fair. Consult them and take their opinions into account. But do not let them decide.

  Second, ‘not for Resus’ does not mean not for treatment. You can have full, active treatment to try and prevent a cardiac arrest, but not resuscitation–basically if the treatment has not stopped you having a terminal event (i.e. a cardiac arrest) then nothing we do as doctors will change that. To proceed with a resuscitation attempt under these conditions is fruitless and cruel. The same applies (and a lot of doctors don’t get this one–and it is also only my opinion and not necessarily medical gospel) if your underlying condition means that any treatment in intensive care would ultimately be futile. You can survive a prolonged resuscitation only if you go to intensive care afterwards. If that is not appropriate, then what is the point in trying to stop you dying now, only to die 2 hours later but with multiple rib fractures?

  I spoke to the nursing home. The patient had a poor quality of life, didn’t get out of his wheelchair and had multiple medical problems. If he did arrest, his medical problems might hinder any resuscitation attempt and his quality of life was such that we might be making things worse rather than better. Therefore, he was a patient whom I indicated not for Resus (or intensive care) but for active treatment–we gave him fluids and oxygen. I called his son in.

  By then I thought he was going to die. I explained to the son what had happened and what we were doing. Although we couldn’t save his life, I think we made the inevitable death easier for his son to bear. We then handed over care of the patient to the medical doctors who would provide ongoing care. He died the next day with his family around him.

  Patients’ wrong priorities

  Part of the fun of working in A&E is that you get to work with challenging patients who are accompanied by the police. A lot of doctors hate working with this subsection of the community, but I find it…interesting.

  Last night I saw a patient who had strong personality traits that other people might find offensive, but which I, as a doctor, couldn’t possibly comment on. He had nicked a car, then been chased by the police. He crashed at about 90 m.p.h. and was thrown about 20 metres along the ground. He tried to run away, but with one leg at a completely unnatural angle to the rest of his body; he only managed to get as far as a waiting ambulance.

  The ambulance service called us up to let us know what was coming in. A trauma call was put out. When he arrived he was in a bad state. His leg was mangled, but it was important to not just focus on the obvious injury and ensure that the rest of him was not in trouble, especially his lungs, heart and abdomen. We went through the usual treatment of my colleagues assessing him while I explained to him what was happening and getting relevant information.

  ‘How old are you, what medical problems have you got, any allergies, do you take any medications?’ I asked.

  His answers were not that helpful. ‘Get the f**k off me and get those f**king stupid things off my neck.’

  I t
ried to explain that those things were neck blocks, which were protecting his neck in case he had damaged his cervical vertebrae and possibly his spinal cord. I again explained what we were going to do to him–give him fluids and pain relief, take blood tests, examine him and organise some scans if necessary. He seemed a little bit quieter for 10 seconds, but then he started again.

  ‘Who the f**k is cutting my f**king T-shirt? That cost a thousand pounds. I am going to sue you, you bastard.’

  The nurse apologised and explained why she had cut it–so that I could examine his chest easily–and said we had spares he could have afterwards. He thanked her by spitting in her face and accusing her of being a lady of loose morals. For A&E doctors at this stage, it can be very difficult. Is the patient acting this way because this is their normal behaviour pattern –or are they acting in that way due to pain, fright, lack of oxygen and/or brain damage? And if you treat them against their will, are you doing it in their best interest because they are not in a rational state or are you assaulting them? These are all judgment calls, with no right or wrong answers, which makes A&E doctors’ and nurses’ jobs interesting but frequently difficult.

  All his observations were so far normal, and he had no obvious head injury of note. I therefore decided that he was acting in this manner because he wasn’t the most pleasant of people. He started to swear about the neck brace and collar again.

  ‘Look mate. We are cutting off your T-shirt because we want to examine your chest and I do not think the T-shirt cost a grand –even if it is a real Ralph Lauren one. As for your neck brace, we will take it off as soon as we have X-rayed your neck.’

  He didn’t seem satisfied.

  ‘F**k the lot of you. I am out of here.’

  He ripped the collar off, put the nurses at risk by pulling out his cannula and somehow stormed as far as the end of the resuscitation room, where he was nicked for stealing cars and dangerous driving. This was quite a feat with a broken leg, but it is amazing what the power of the mind and the thought of being nicked (oh, and a temporary plaster cast) will do. After he realised his fate, he accepted treatment and was in theatre later that night to have his leg fixed properly.

  How to be seen quickly

  Ever gone to A&E and been frustrated at having to wait 3 hours and 59 minutes to be seen and sorted out? Over the years, I have observed various methods of how to get seen quickly. Some of these methods are very inappropriate and have been used by some quite naughty patients to speed up their care at the expense of more needy patients. Please remember that by lying about symptoms, you are putting your and other people’s health at risk. Don’t do it please.

  1. Have a genuine emergency. Best is probably your heart stopping. The ambulance will call us to tell you are coming in and you will be seen straight away. During the day, you may even see a consultant, unless they are doing something that management have deemed more urgent, such as responding to a complaint letter, filling in a compensation form or going to a meeting with a silly title such as ‘Introducing a Patient Centred Care Flow Pathway: Interim Discussions’.

  2. Similarly, have a serious trauma and you will have a team of doctors waiting to see you on arrival.

  3. Be a child and cry a lot. If that doesn’t work, cry loudly, then start to scream.

  4. If you are pregnant, say you think you are having your baby. This scares A&E staff shitless and we get you a swift transfer to the maternity unit.

  5. Say you have chest pain as soon as you book in with reception. Clutch your chest and say you feel sick and the pain is going down your left arm. This guarantees going to the front of the queue. Only do this if it is true. About a year ago, I had a bloke who said all this to the receptionist. I was called away from the patient I was seeing and went to see him. The pain had gone (it had never been there) and he had injured his foot playing rugby. He admitted to making it up, as he had a date that night and didn’t want to be stuck in A&E.

  6. If you have a minor injury, make it a really simple one such as a broken wrist that emergency nurse practitioners can treat. You don’t want to have to wait to have to see a doctor.

  7. Have a condition that an A&E doctor can treat and doesn’t have to get specialists to see you. It is bad enough having to wait to see us, but if you have two waits then that is doubly bad. You may even get admitted to a ward unnecessarily, just so that you don’t breach the government’s 4-hour target.

  8. Be a doctor or nurse at the hospital where you go. Or be a friend or relative of theirs and take them with you to A&E.

  9. If you are a policeman, fireman or ambulance man, come in wearing your uniform so that the triage nurse knows you are 999. There are some very minor perks to serving the public.

  10. Come in with police. It is not that we want to see you that quickly, but we know that the police are needed back on the streets and they don’t want to be here.

  11. Please note that calling an ambulance will not speed up how quickly you get seen.

  12. …Neither will saying ‘NHS Direct told me to come straight away.’

  13. …Neither will saying, ‘My father is a big contributor to the local area and paid for your new scanner, you know. I want to be seen now.’

  14. The best one I have found, which never fails to work, is simple. Be a politician or an important hospital manager. Not only will you be seen straight away, but you will be seen by a consultant. As well as being seen straight away, you will get immediate access to any form of investigation and if you need to see a specialist, then this will happen immediately. No wonder the politicians and managers don’t really know what is happening in emergency care.Please note that this is only my prejudiced opinion and sarcastic sense of humour and not really NHS policy.

  The dangers of cannabis

  It was 4 p.m. on a Thursday. I picked up the next card out of the box–a 19-year-old with personal problems, who was accompanied by his mother. No. No. No! Not another attempted suicide. It drives me mad. With people who have suicidal ideation, my sole job is to check they are medically OK and then determine if they are very suicidal and need to see the psychiatrist today or if it can wait for a GP review in a few days’ time. I looked around to see if anyone would notice if I put the card back and picked up something less soul-destroying. No luck.

  ‘What are you seeing next?’ asked my consultant.

  ‘Nineteen-year-old. Personal problem.’

  ‘Easy,’ he said. ‘Just determine if they need to see a psychiatrist today or their GP in a few days time’.

  ‘Thanks for the advice,’ I said sarcastically.

  ‘It’s a bit boring, though. I’m about to see a bloke with something where it shouldn’t be,’ he retorted and laughed in a quite inappropriate way.

  I had no idea what he was on but I smiled and answered something about how I thought psychiatry patients got a raw deal and how I was quite interested in them. It was one of those comments that you couldn’t tell if you meant it sarcastically or not.

  I went to the private interview room nicknamed WD40 (it is called the ‘Want to Die’ room and the hinges need some oil, hence the name). There I saw this very posh-looking mother and her son, who also looked very posh, except that he had an eyebrow ring, dreadlocks and was playing with a packet of Rizlas. (He was a true Trustafarian–attempting to be a hippie, but with Daddy’s trust fund to support him.)

  ‘So what’s the matter?’ I asked.

  ‘What are those?’ He pointed at a smoke detector. ‘Turn them off; I don’t want people to know what is going on.’

  ‘They are smoke detectors. Don’t worry. What’s the matter?’

  ‘Who are you?’ he asked without making eye contact.

  ‘I’m a doctor.’ I turned to his mother. ‘Did you bring him here?’ I asked.

  ‘Yar. I just don’t know what is going on. He is not himself. He is normally so polite and nice. All he does is scream and say they are after him. I do not know who they are.’

  ‘There is a battle of good and e
vil and they need me dead,’ he interjected. ‘She doesn’t understand.’

  The conversation continued in a similar vein and it became quite obvious that this was a not a case of suicidal ideation, but an acute psychotic paranoia episode. Not only would he need a psychiatrist to review him, but he would probably need to be admitted to a psychiatric hospital.

  As I continued my questioning, it transpired that he had recently been using cannabis. It had started a year ago at his boarding school. He was destined for four As at A-level–and probably a place at Oxbridge that our class system had predetermined for him–but he started to smoke dope and lost interest in most things except weed. He passed his A levels but only just. He and his parents had planned for him to go on a gap year travelling to find himself and the true meaning to life, or study pottery at St Martin’s College of Art or something like that. He never found himself. All he found was a harder dealer. Over the last few weeks he had been buying skunk–stronger cannabis than what he was used to. That was when the paranoia started. He slowly changed from a fast-food ordering, ambivalent and stoned teenager into a psychotically paranoid man.

  As it was within working hours, it wasn’t a fight to get a psychiatrist. Psychosis is the interesting part of psychiatry. Most of their work in A&E is now personality disorders and attempted suicides/cries for help/attention-seeking behaviour. This was good old proper psychosis, but with a new cause–very strong cannabis.

  I cannot be 100 percentsure that this lad was psychotic because of the cannabis. However, there is a correlation between cannabis use and psychosis and schizophrenia. Whether it is a cause or a correlation, no-one can be sure, but both are on the rise in society and so I reckon that cannabis is at least a causative factor.

  So, despite the evidence of this, the government confused the law and people thought that cannabis had been decriminalised. What folly. People like this lad were not scared of the consequences of taking this very strong hallucinogenic drug and so built up an addiction. So what’s my solution? I think the answer is legalising the drug. These two facts are not contradictory. Let me explain.