by Nick Edwards
Cannabis use is widespread in teenagers and the young adult population–40 percentof people under 20 have taken it. When I was a teenager, the cannabis on the street was relatively mild but now the dealers are selling stronger and stronger stuff.
There are two options. One is keep it illegal and punish people more severely for using it. However, that is never going to work–you can’t arrest 40 percentof the population. Prohibition doesn’t work. Anyway, in some cases the police don’t actively encourage it, but do turn a blind eye. For example, during the last World Cup the foreign police didn’t seem to mind our football fans smoking it, as it calmed them down and stopped them beating the shit out of the opposing supporters. Medically it is, I believe, much safer to go on a one-night bender getting stoned rather than a drinking binge. I would also feel much safer walking past a group of stoned teenagers than a group of drunken ones.
The alternative is to legalise it. Then you do two things. You can control the quality and power of the drug–the weaker stuff still has the same instant relaxing effect people use it for, but is probably less likely to cause the longer term decline in function and psychosis. You then create very high sentences for dealing with other stronger forms of cannabis.
Users then have a standardised and controlled drug, which is cheaper than the dealers can sell it for and also much safer. Market forces reduce the number of dealers; fewer people go to them and so fewer people are introduced to more dangerous drugs. The cannabis can be taxed and the money spent on treating those that are addicted to drugs, while the rest of the population can make a judgment call about whether they take the drug, knowing the risks and benefits (as we all do when drinking alcohol).
Unfortunately, the government’s half-way house is the worst of both worlds and is a ridiculous compromise. It has encouraged the rise of dealers selling very strong and dangerous cannabis. Please reverse this decision, and go back to the drawing board. Get a Royal Commission on how to deal with cannabis and generally tackle drugs in society–but please get some A&E doctors’ advice because we deal with it and its consequences every day.
For fit’s sake
There are two explanations for the events of last night. First, the organiser of the event was a complete idiot or, second, he was just sick and twisted. I hope the latter, but rather think it’s the former. Imagine you were in charge of an Alcoholics Anonymous summer party. Would you take them drinking? No! Or a vegetarian community group, would you take them to a slaughter house? No! Or a nudist group, would you take them clothes shopping? No…but why not? Because it would probably upset them and make them ill.
So why on earth did a local epileptic support group on a summer weekend away organise a disco with strobe lighting? You couldn’t make it up. It was epilepsy city in my A&E. Two fitters, one pseudo fitter–he made it up ’cos he was feeling left out. (You can tell if a fitter is making it up by dropping their arm on their face: if it hits the face, they are not making it up but if they move the arm so that it doesn’t hit them, then they are making it up.) Two people also attended A&E because they thought they might have a fit, one carer came with chest pain and one with stress. Luckily, it wasn’t too busy an evening otherwise, so I saw the funny side.
The best bit came when a druggie was in and saw these two people fitting, and when they woke up, asked where they got their E from as they were really moving with the beat!
The state of some nursing homes
Today I had a 78-year-old confused and scared lady come in from a residential home. The ambulance form said she came in because she was short of breath. The home didn’t send anyone with her and there was no accompanying letter. I phoned the home and there had been a change of shift since she had been admitted. No-one really knew what had happened or why she was sent in. I then asked for some details about her past medical history. No-one seemed to know much about that either.
This is a problem that is becoming far too frequent. It is a sad indictment of how we care for our elderly population, where homes are often run for profit and not necessarily to provide as good a service as possible. As always, when there is a problem, it gets dumped on A&E and the ambulance service. I couldn’t find any new problems with her and ended up sending her back home with no change in her medications.
Why aren’t GPs called out more often for these types of problems? They know their patients and know what is normal for them. Why can’t homes give us a clue to the problem and send a letter or carer? Why does this happen so often? Why isn’t there a word in the English language to describe me gripping my fingers and making angry facial expressions, which I could use to describe my frustrations?
The best year for the NHS?
I read with interest that Patricia Hewitt, Secretary of State for Health, claimed that 2006 was the best year ever for the NHS. I really think she has lost her last marble. Yes, money has been poured in to the NHS, but in such a bad way that it has antagonised the NHS workers. For those of us who love the concept of the NHS, it has been one of the most miserable of years, not the best ever.
In 2006 we have seen plans for haphazard reorganisation lead to hospital closures without alternative options being in place. We have seen various trusts go virtually bankrupt and having to call in ridiculously expensive management consultants. There has been a loss of nursing and vital ancillary staff jobs and some trusts have seen posts for doctors frozen to save money. Meanwhile, the benefits of being an NHS hospital doctor have been eroded (e.g. by plans to reduce study budgets).
Some private finance companies are making a fortune from poorly negotiated PFI (private finance initiative) contracts and Private Treatment Centres are milking in the profits from guaranteed payments for operations that may or may not happen. The waste drives hospital doctors mad. Meanwhile, in GP land, despite their pay increases, doctors are feeling less and less motivated and more disillusioned with a centrally directed NHS and erosion of their autonomy.
However, it is not just me who believes that 2006 has been a disaster for the NHS. As the BMA (British Medical Association) council chair James Johnson said, ‘Health workers and patients are paying the price for ill-thought-out government policies such as PFI and for poor NHS management that has led to job cuts and clinic closures…’ (for more information see http://www.bma.org.uk/ap.nsf/Content/pr141206).
Fortunately, it is not just doctors and nurses who realise that the fundamentals of the NHS are being eroded. The campaign to keep the NHS public has seen phenomenal growth this year and the number of petitions and demonstrations about ill-planned closures has increased dramatically.
What is really amazing is that it is not just me that disagrees with the NHS reform plans as they are at present. At a hospital close to my heart, there was Hazel Blears, the chairman of the Labour Party, campaigning against the effects of her party’s policies–in this case the closure of the maternity unit in Salford. Reading on the BBC website, I also learned that in April John Reid (a senior Labour politician) campaigned against closures at his local hospital (for further information see http://news.bbc.co.uk/1/hi/uk_politics/6213445.stm).
But, Mrs Blears and co.–stop being so hypocritical and NIMBYish. If you don’t support these hospital closure programmes you have only got yourselves to blame. It is the effect of sofa-style government without proper scrutiny that leads to the effects of the unintended consequences. So, Blears and co., since you obviously agree with me that that these NHS reforms (which are needed) have been very badly organised and damaged the NHS, then surely you must resign from your positions and campaign for a properly run NHS. If you did this, then I would imagine that Nye Bevan might be turning that bit less in his grave.
Hoping that the ground will swallow you up
It is an easy mistake to make. You are seeing lots of patients, all of whom are new to you, and sometimes you make an assumption about a patient and the person with them. When this is wrong, it can be very embarrassing. Some of the assumptions I have made, have made me want the earth to swa
llow me up:
Me: ‘…And you are his mother.’
Patient’s relative: ‘Wife. Not mother’.
Me: ‘Ah, yes. Oops’.
To a patient and relative holding hands: ‘And you are her partner?’.
Relative: ‘No. Brother.’
To a male relative who was there with his unconscious partner in a blond wig: ‘So what happened to her tonight?’
The friend replies: ‘He has been drinking. He is pre-op, darling. Pre-op. “She” is still a he. Read the name on the card. Stephen is hardly a female name is it?’.
The list goes on and on. However, I also find that some people automatically go out of their way to tell me their significance to each other.
To an elderly lady accompanying her friend: ‘And you are her friend?’
‘No, we are lesbian partners. We have been together now 45 years. We first met when I was only 25 and then we bought our first house together in Stockton-on-Tees. Her family never approved, but mine didn’t really understand what lesbians were so just accepted that we were friends. But we are not. We are, but first and foremost we are a couple. A lesbian couple. And don’t get embarrassed, it is beautiful.’
I wasn’t embarrassed. I was just a little bored with the life story and felt as if I was on the set of Little Britain.
One of the things I tried after a spate of faux pas was to not ask what the relationship of the friend/relative is. After one experience I will not make that mistake again. There I was, asking this lady of 65 all about her abdominal problems and her regularity down below, etc., and then I said, ‘I need to examine your abdomen. Would you like it if your friend was here or would you prefer me to ask him to leave?’ As I said this, I looked at the slightly dishevelled man who had been standing inside the curtains throughout the whole of our consultation and who had even said ‘hello’ as I walked in.
‘I don’t really mind. But he is nothing to do with me. I thought he was with you.’
‘Oh’, I replied as I could hear nurses looking for the elderly patient who had been brought in for new onset confusion and had gone missing…behind my curtains.
As my experience has grown, I have decided that the easiest way is either to flatter every relative (e.g. say to a mum with her child, ‘And are you her big sister?’) or just put my hand out to a relative and say, ‘And you are…?’ and wait for them to reply. I just wish they taught us simple tactics like that at medical school so I wouldn’t have had to be so embarrassed over the last few years.
Two similar patients, but two different
outcomes
You may think that wherever and whenever you go to A&E, you will get a similar standard of treatment. This is far from the truth. As well as medical expertise, it is the process of how emergency patients are cared for that really affects their outcome. I was at a recent training day when two cases were discussed that really showed this to be true.
The first was a 65-year-old man with severe pneumonia. The junior A&E doctor saw him after a wait of a couple of hours. After various tests, she had noticed how unwell he was and discussed it with her senior A&E colleague. The senior doctor advised that this patient needed a central line, and should then be transferred to ICU. Despite this, protocol in his hospital dictated that the patient be referred to the medical team first and they would have to arrange ICU admission. The senior A&E doctor couldn’t sort the patient out as there was a very long wait of minors patients to see.
The man was admitted to the medical admissions unit after 3 hours and 49 minutes in A&E. After another 90-minute wait, he then saw one of the medical doctors. At this point the patient was deteriorating rapidly. His breathing was getting worse and his blood pressure was falling. The junior medical doctor, who was only in his second year of training (as a GP not an emergency physician), did not have the same grasp of the urgency of the problem as did the senior A&E doctor. They didn’t see the problem of spending a long time asking detailed questions about past medical history instead of getting on and treating the life-threatening condition.
After another hour, the medical registrar came to review. He soon realised that the patient was very sick and needed this central line. However, he didn’t feel confident in putting one in as it wasn’t part of his routine work–he was training to be a rheumatologist and had just had a year out to do research. He asked the anaesthetist to do it for him.
After another 30-minute wait the anaesthetist came and put in the central line and treatment was started, as well as closer monitoring of his vital signs. At the same time the medical doctor referred him to ICU. The ICU doctor came down and accepted him immediately to ICU. However, they had not been prewarned to expect this patient, so spent 2 hours discharging another patient from the ICU to the ward to create a free bed. Finally, some considerable time after first coming into A&E, the patient went to ICU, where proper treatment started. However, by this time his kidneys had stopped working and he needed dialysis until he was well again. His breathing had got even worse and he had to be intubated. After a two-week stay in ICU, he died from multi-organ failure induced by the chest infection.
In this case, no individual did anything wrong, but the system was at fault, in not allowing the patient to get speedy ICU treatment. As a whole, the care was not perfect and possibly contributed to his death. As a government statistic it was great –he was seen and admitted within 4 hours of arrival in A&E. There are no stars for the quality of his care.
The second case was very similar and happened at a hospital 50 miles away from the first one (and it wasn’t a centralised teaching hospital, but a bog-standard district general–the type the government don’t seem to like). The difference was that they had better processes in place and had invested money in emergency nurse practitioners (ENPs).
A sick man, 68, was brought in with a very nasty chest infection. The A&E senior specialist doctor in this hospital was not busy seeing minor patients, as that was the ENP’s job, and so was free to see the patient with her junior colleague. She realised immediately how sick he was.
Also, in this hospital there are very close links between ICU and A&E, which were not there in the first hospital. When the A&E doctor called, the ICU doctor took down all the information and got the unit ready to accept the patient. The unit didn’t insist that the patient be seen by a medical doctor (who, remember, may not have a specialisation in acute/ emergency care) but just wanted the name of the medical consultant on that day so that when the patient left ICU they had a set of doctors they could liaise with.
The A&E doctor (who is experienced in putting in central lines) inserted one into this patient while they were in the safe environment of the resuscitation room. She taught her junior doctor how to do it and so he also got training while at work. She started fluids and antibiotics. She also set up the equipment needed to monitor this man’s blood pressure beat-to-beat, so they could tell exactly how he was doing. A catheter was inserted and the urine output monitored. Very soon the patient improved. After 4 hours and 30 minutes, the patient made his way up to ICU with the proper treatment well under way. He did very well and was discharged back to the ward after five days. He was home after 12 days.
While all that was happening, the ENPs were seeing the minor patients and the medical doctors were looking after their sick patients on the ward without having to be bothered by the acutely sick patient, who was being well-managed by the A&E doctor. In this case, the patient did very well but since he was in A&E for more than 4 hours the case was probably not regarded as a success in terms of targets, but was placed in the exceptions to the 4-hour rule category. There are no stars for quality of care.
Unfortunately, the process of care that the first patient got is far more common. If the money was put into acute care and the processes of delivery of care were changed, so that they were all like the second example, it would cost a bit at the beginning, but in the end would save a fortune.
One of the main reasons that these situations are so common is t
hat the doctors working in A&E are often not experienced enough and have not had the right training to decide if the patient needs to go to ICU with the result that they are referred to the medical team. The senior doctors, who are capable of making those decisions, are often too busy trying to stop more minor cases breaching their 4-hour rule. This is a crazy situation. We should work closely with the medical doctors and make it a rule that the sickest patients should be seen by the most senior people straight away–A&E physicians or acute physicians, whoever is available at the time (it doesn’t matter, as long as we are all working together).
As an aside, to get improved health care, we don’t necessarily need centralised care and we certainly don’t need your local district general hospital to close. There is nothing high tech about the treatment the second patient received; it was just more efficiently delivered and thus that patient had a better outcome. As my gran used to say, ‘A stitch in time saves nine’; she could teach our managers a thing or two, I reckon.
An amusing patient
I couldn’t swap my job for any other. Sometimes I just love being at work–especially so when you can have pleasant and amusing patients. Today I had one such patient.
Six-foot-five, built like a brick shithouse and tattoos aplenty. When he came in he was all smiles and jokes. He had an infection at the end of his finger. He had been to his GP, who had given him antibiotics, but they hadn’t worked. The pus needed to come out.