by Nick Edwards
‘I am afraid that I will have to make a small incision and get the pus out.’
He started to laugh, ‘I am the biggest wimp in the world. Please no! I can’t stand needles; I’d rather lose my finger,’ he pleaded.
I told him that he very well might lose his finger and again offered him the option of an ‘incision and drainage’ of the abscess. He pondered, thought about a life with a nose full of bogies and opted to be brave.
I had just started to inject a tiny bit of local anaesthetic into the finger when the screaming started. Oh my God! I had never heard anything like it. But he was so embarrassed and apologetic and so nice about it, I didn’t mind. I got the emergency supply of gas and air.
For simple procedures like this, gas and air (laughing gas) is hardly needed. But he needed it and boy did it work. What the gas does is to provide a small level of anaesthetic with a large amount of hysteria. You can still feel the pain, but it is no longer upsetting. You can also get the giggles. If the patient gets the giggles, then the drug is working. As long as they stay still, you can perform your operation to your heart’s content. But as we all know, the giggles can become infectious. Unfortunately, once they get the giggles, then so may you. That’s when the fun/difficulties start.
But you need to start the ball rolling. I started with my favourite joke for wimpish men who are having a procedure done on their arm.
I started, ‘Did you hear about the patient who went to the doctor with pains in his arm? “Do you want the good news or the bad news?” the doctor inquired.
“The bad news please,” said the patient.
“Well, I am afraid that we are going to have to amputate your arm.”
“And the good news?” enquired the poor patient.
“The bloke in bed two wants to buy your gloves.” ’
Well, that got him started. The nurses groaned as they had heard it many times before. He was giggling a little at this point, but still thinking about his finger. ‘Breathe more of the gas,’ I said.
I went through my memory bank of shit doctor jokes. Luckily, I know a lot of them.
A patient went to his GP, ‘Doctor, I don’t know what the matter with me is, but I can’t stop singing in a sexy Welsh accent.’
‘Ah’ said the doctor, ‘You have Tom Jones syndrome.’
‘Tom Jones syndrome?’ said the patient. ‘Is that common?’
The doctor responded with a little sexy dance and sang ‘It’s not unusual…’
The jokes were coming thick and fast. I was starting to win. The room was filling with laughter. I went for the kill. The classic man with pain everywhere he touches–he has a broken finger; the old man who has a bit of lettuce in his ear, who the doctor wants to investigate as he thinks it’s a sign of something serious–the tip of the iceberg. Then my favourite: the bloke who goes to the doctor and the doctor says, ‘I am afraid to tell you that you have got cancer and Alzheimer’s.’ ‘Oh well,’ the patient says. ‘It could be worse–I could have cancer.’
He was in fits and it was perfect timing; with one more whoosh of the gas and air, the scalpel went in and pus upon pus upon pus came out…it was like a teenager’s dream. A bandage and some antibiotics and he was on his way…all of us contented.
Closing your A&E, are they?
I work in an A&E department that the government is thinking about closing–it adds to the stress of working. The government thinks that we don’t need so many A&Es and district general hospitals. It says this because:
1. Fewer people should attend A&E.
2. Most attendances are things GPs/community nurses could cope with.
3. Many conditions need home care and not hospital admission.
4. With reductions in doctors’ hours, we can’t have so many hospitals
5. Centralised care is better for the sickest 1–2 percent, so sod the rest of you.
I am going to try and persuade you (just in case you needed it) why closing your local A&Es isn’t such a good idea. At the same time I am going to explain why many of the problems A&Es are facing are partly caused by policies carried out by New Labour and the Tories before them.
Attendances at A&E departments are on the rise–both appropriate attendance and the inappropriate stuff we see that is neither an accident nor emergency. The fact is that people do attend…and they need treatment or reassurance or whatever. There are a number of reasons why there are increasing demands on our service. These include:
1. Alcohol–as a nation, we are getting pissed more and coming to A&E with the problems.
2. Drugs–the nation is getting higher, and when people fall they present to A&E.
3. Increasing violence in society–often resulting from factors (1) and (2).
4. Obesity–only since Jamie Oliver kicked up a fuss has Labour started doing something about it. We see more and more obese patients with the complications that ensue.
5. Privatisation of social care–some care homes are there to make a profit and so might not always have the patient’s best interests at heart. If a patient becomes a little tricky to look after, they are sometimes sent to hospital. The same goes for the privatisation of home care.
6. Encouraging (or at least not dissuading) the blame culture–the number of patients who come in because their ‘no-win, no-fee,’ no self-respect lawyer has told them to do so is excessive.
7. Lack of responsibility-taking–for example, I now see kids that have had a fall at school. A few years ago the school first-aider would have dealt with the scraped knee, now they are too afraid that the parents will complain.
8. The ageing society–even I can’t blame that on New Labour.
There is also the problem of patients attending with GP-type problems. Yes, they should go to their GP and let me concentrate on treating the sicker patients but it is not always as simple as that. So why do they come to A&E more nowadays?
1. Loss of good-quality out-of-hours GP provision.
2. NHS Direct–it costs a lot of money and gives good advice, but at the end of the day cannot physically see patients and so takes a low-risk approach, which often means saying, ‘Go to A&E’.
3. Patient choice has been encouraged–many patients now come with primary care problems, as they seem to think they can choose to come to us instead of their GP.
4. The massive influx of eastern European workers–there seems to have been no active plans to encourage them to register with GPs and so they come to A&E with their minor ailments.
With more and more people using A&E as their first point of call for many medical non-urgent problems, is it the right time to talk about closing down A&Es, without having organised the infrastructure of local community-based care? I think not.
Many conditions could be treated at home. However, we have to admit patients because support structures are not available –especially if we are trying to organise them out of ‘working hours’. Admission to hospital is then the safest option. So, until a proper system of community care is sorted out, it is dangerous and unfair to local populations to close the local hospital. The other factor I think the government has forgotten, is that these patients still need to come to A&E when they are acutely ill to have their diagnosis made and then to be risk-stratified before being sent home for community care. We need a local A&E, staffed 24 hours a day for this to happen.
The government also argues that it needs to shut A&Es and local hospitals to comply with the European Working Time Directive and doctor training requirements. However, there are lots more medical students than there used to be–they will need jobs and will be happy to do shift work when they qualify. Also, all doctors are meant to have generic skills and so can cross cover. Very rarely do you need a senior orthopaedic doctor/ENT/ophthalmologist, etc., in the hospital after midnight…and if you do, then call in the consultant if you are worried. Whatever is done, it should not be used as an excuse to close hospitals, but as another reason to make junior doctors’ time more efficient and relevant to training requirements.
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br /> Finally, the government’s main argument is that centralising care for the most serious of cases is a good idea. I completely agree. Heart attacks and major trauma would do better in large centres where there is expertise and experience. The ambulance could take these patients directly to the most appropriate place. Consultants could work in regional teams rotating around the major centre and so those working at smaller A&E, would not become deskilled. For it to work, we would need to overcome the problem of how we are going to look after these sick patients on their long journey to regional centres, especially when our roads are so clogged up…and, remember, traffic jams are often worse when the roads have had an accident on it. The government hasn’t yet got the answers in place. It seems to me that it needs a massive increase in funding for the infrastructure of pre-hospital medicine, such as having specialist doctors in ambulances and using more helicopters, before thinking about closing hospitals.
The other thing to remember is that centralising care should only affect the outcome of the sickest 1–2 percent. So what about the other 99 percentof patients? Centralising their care will not improve their outcome. The government should not use the centralising argument as an excuse to close local A&Es and district general hospitals (DGHs).
If anything, it will harm the health of the nation. Patients will put off travelling miles and miles to get treatment, so will get worse until they are compelled to call an ambulance. It would also be cruel to send elderly people miles and miles for non-life-threatening medical conditions such as pneumonia. The same argument goes for surgical procedures which don’t need to be done at specialist centres–for example, mending broken hips. Saying that ambulances should take heart attack victims to regional centres is NOT an argument for closing your local DGH.
What really pisses me off is that Blair made a recent speech saying that he is upset that doctors are not on the streets campaigning for his reforms to be brought in more quickly. Mr Blair, I am not on the streets demonstrating because they are ill thought out and community services are not ready to take over the role of DGHs. Your successor needs to go back to the drawing board. Although your reforms may benefit the sickest of patients, it will not be beneficial to the other 99 percentof patients.
Also, why didn’t you tell us about it before the last election?
So, sign that petition and write to your MP. Pray that our new Prime Minister changes Blair’s plans. Go on the streets and campaign to keep your local hospital A&E department. But just understand why it may be good for the ambulance to take you a bit further afield when you are having a heart attack.
Nasty walls
Many people think that there are a lot of nasty people in my town and that is why there are so many people who turn up with hand injuries from punching. I believe not. In my town, we have some really nasty walls. These walls piss people off, antagonise the good young men, shag their birds and probably their mums, and generally create trouble. That’s why these walls get punched and that’s why these walls need to be stopped.
I hereby pledge to campaign for the Home Secretary to introduce a wall ASBO. Lock up these evil collections of bricks which so upset these fine examples of upstanding members of the community. Make their parent ceilings pay for the damage they do to the 5th metacarpal (little finger knuckle) bone of these young upstanding members of the community. WALLS MUST BE STOPPED! WE MUST BAN WALLS FROM CITY CENTRES. This is especially so on a Friday and Saturday night when walls become especially antagonistic.
If this ban came into force, then we could virtually eradicate the broken hand problem and its victims would have no reason to come to see me at 4 a.m. It has been getting worse–yesterday I saw evidence of a wall that had teeth. This shows how nasty the walls have become.
On a serious note, if you have given someone a good punching, don’t say you punched a wall. The truth is obvious and we like to know all the details…and it makes my job more interesting. If you do say that you have punched a wall, beware. You may face a sarcastic response from the doctor treating you. For example:
Dr says: ‘Did the wall have teeth?’
Dr thinks: ‘Tell me the truth so I know whether you need antibiotics or not.’
Dr says: ‘This will hurt a little.’
Dr thinks: ‘Stitching up your cut with only homoeopathic levels of local anesthetic will hopefully teach you a lesson.’
Dr says: ‘You’ll still have to wait for another 3 hours until I see your hand.’
Dr thinks: ‘Please self-discharge.’
Dr says: ‘When I get angry I say oh fiddle-dee-sticks and count to 10. Have you ever thought of that as a way of controlling your anger?’
Dr thinks: ‘There are two very hard coppers with us, and you are nicked and I can joke as much as I want.’
This is just a brief synopsis of a ridiculously common injury. Let’s get this wall ASBO campaign up and running. Please write to Dr Nick Edwards c/o The Friday Project.
P.S. On a serious note, even if you have got into a fight and then lied, you will still get properly treated in a non-judgmental way. The doctor just might smirk a bit behind your back. Also, if you have genuinely punched a wall then I apologise.
Tired again
It was 5 a.m. on night six of seven consecutive 12-hour shifts and I was exhausted. The last patient came in with heart failure. I examined and treated her, but her condition was nothing to get an adrenaline rush for. I think that I treated her well, but on reflection I am not sure. Did I give the right dose of morphine and frusemide? Did she really need that GTN infusion? Would I have treated her the same way if I had not been exhausted? If not, would it have been my fault?
Well, in this case I think I did do the right thing–she improved and was well enough to leave the resuscitation room and go to the ward within one and a half hours. However, I feel that there are loads of other patients that I have treated at this time of night when I may not have treated this well because I have been so tired.
Anyway, 8 a.m. came and I left for my drive home, luckily only 20 minutes away. I don’t know how, but despite two strong coffees before leaving, I was driving on the main road home and then suddenly I wasn’t. As the road was curling left I was sleeping. I had crossed the hard shoulder and hit the grass hill on the other side. Luckily, no-one else was involved. However, the car was destroyed, the air bags were brilliant and the police very sympathetic. An embarrassing trip back by ambulance to work, for my neck to be checked out, ensued. I was furious with myself. But again, was it all my fault or were the people who designed my rota (medical staffing) partly to blame?
While waiting for my X-ray I started to think–we are told by managers all about patient safety and how to stop causing harm to our patients. It feels (even in this no-blame culture) that doctors and nurses are taking all the blame, but the managers who design our rotas are escaping scot-free. Do airlines let their pilots work seven consecutive nights? No, it is dangerous. Are train drivers protected? Yes. Lorry drivers have maximum times they can drive for. Why? To protect you, the public. The police, ambulance and fireman–as far as I know–have had research done into night working and know that it is dangerous to do so many consecutive nights. They only do a maximum of three or four at a time. Again, safer for them and safer for the public. But doctors…sod them–let them do seven consecutive nights and let’s just hope they don’t kill anyone at work or on a drive home. Anyway, if they do kill someone, we can blame the doctor–we can say it is because they haven’t taken part in a patient safety course, or been keen enough on continuing professional development. We can refer them to the GMC, smash their confidence and wash our hands and just say, ‘Oh well, it shows that the problems in the NHS are all caused by useless doctors.’
But seriously, it is not right–it is dangerous and it does affect you. I wouldn’t want to be seen by a colleague who had just done six straight nights. In the days when I first qualified, specialist junior doctors (i.e. not ones who worked in A&E–but to whom A&E referred to for ad
mission and advice) often did 24-hour and 48-hour shifts. That was wrong but at least you got a bed and then were not on call for a few days after that. You never had to do seven consecutive nights.
The government rightly changed it, but delayed the implementation of the full working time directive and made (sorry…allowed) doctors to opt out of it. This allowed managers to devise the most dangerous working patterns–who cares if it damaged doctors and patients? What makes matters worse is that junior doctors often rotate around hospitals on training schemes. We often live 1–2 hours away, and often not near public transport. There also used to be rooms where specialist junior doctors could sleep when it wasn’t busy (this was even more important for them since, unlike A&E doctors who can go home after their 12-hour shift, they often had to stay longer on the ward round telling the consultant about the patients admitted overnight). Admittedly the beds were used only occasionally–but a half-hour nap really can refresh. Now they have generally been taken away and in most cases turned into vital managers’ officers–the room once referred to as ‘Medical SHO On-Call Room’ is now often called ‘Patient Liaison Facilitator Deputy Manager’s Sub-office’ and the surgical SHO on-call room you can find under ‘Patient Pathway Discharge Facilitator Deputy Coordinator’s Deputy Assistant Manager’s Officer’.
Is this just my view? No. In October 2006 the Royal College of Physicians published a study ‘Designing Safer Rotas for Junior Doctors in the 48-hour Week’ Its main conclusion was, ‘Most junior doctors work night shifts, many of them are doing seven consecutive nights, each lasting 13 hours. That has been shown to be potentially the most dangerous type of rota that could be devised, in terms of risks to both patients and staff.’ For futher information, please go to http://www.rcplondon.ac.uk/pubs/brochure.aspx?e=180.
Now that we know that the politicians have the evidence we shouldn’t allow them to let hospitals arrange such dangerous rotas. The Labour government has brought about good changes to our working life styles but it needs to do more and do it faster– for the patients’ sake. Change rotas now. It won’t necessarily cost anything, it will just mean that medical staffing managers will have to think about things a little bit harder.