In Stitches

by Nick Edwards

  Oh, and one more thing on nights and sleeping: the seventh night of my week was very quiet–luckily. The nurses knew I had had a crap day and not slept that well and so I slept for an hour or two when it was very quiet. I slept in the side room where we often put patients when they are going to die, to give relatives some privacy. It was a little spooky–but needs must, especially when you are working a dangerous rota.

  Changing emotions

  It had been a very pleasant day at work. We were well staffed and everyone was in a good mood as someone had bought some Nescafé Gold in to replace the Happy Shopper coffee. How easily pleased we all are.

  I picked up the next card: 28-year-old male. He hadn’t been triaged yet so the only information I had was from the receptionist, who wrote ‘not feeling right’. (I also knew his religion–for some reason they always find out the patient’s religion. Maybe it is just in case we need some extra special help and it helps us to know who to call?)

  I started chatting to him. He was a delightful man. He was there with his pregnant wife of seven months who had forced him to come. He started to tell me his symptoms. They were all a bit non-specific. He had felt tired and a bit sick for the last few days. I was about to advise him that he should have seen his GP instead when he added that he had tried to play the piano and it just didn’t seem right. His hands didn’t seem to touch the keys properly (he was a good jazz pianist apparently).

  This concerned me. This shouldn’t happen to 28-year-olds. I examined him and he had a neurological sign that concerned me –he couldn’t tap his hands together properly. It worried me, first because it implied that he might actually have a brain tumour, and second because I had to write down such a long word in the notes that I would invariably spell wrongly–dysdiadokinesis. (Many doctors love medical jargon and long words because they think they are clever when they say them. I don’t, partly because patients don’t know what you are talking about, but mainly because I am shit at spelling.)

  I left him for a moment to plead with the radiologists for a scan. After being told that I was probably wasting their time/ making up symptoms/exposing my patients to unnecessary radiation, they eventually agreed to the scan after I promised to sacrifice my first born child in their honour.

  I explained to the patient that although the signs were probably caused by ‘something minor’ we had to rule out ‘something more serious’ going on inside his brain. He seemed satisfied by my explanations and went for his scan.

  While he was in the scanner, all my colleagues were taking the piss out of me for organising another ‘unnecessary’ test and just looking for something dramatic to excite my day. I explained to them all why I believed he might have a brain tumour and went into detail about the anatomy of the damaged bit of brain. They explained to me that I needed to get out more and realise that most people’s symptoms are caused by stress.

  Just as I was saying ‘I bet you he has got a tumour’ and my colleagues were saying ‘I bet you he hasn’t’, the radiologists called. ‘You’d better come down and have a look at the scans.’

  ‘Oh f**k’, I thought, as I looked at the scan. But I am a professional and so collected my thoughts before contributing to the academic discussion about the scan results. ‘Oh f**k’, I said.

  He had an obvious tumour. Not only that, but he had swelling of the brain and he would need immediate transfer to a specialist centre. This was the worst possible scenario that I could have imagined, but, strangely, from a purely academic point of view, I was pleased.

  I was pleased that I had been proved right. Pleased that I had worked out his diagnosis from a weird set of signs and symptoms. But de facto I was therefore pleased that this man had a brain tumour with a possible death sentence. This is surely not right. I went to speak to my colleagues/doubters. A ‘told you so look’ went across my face as I told them what the scan had shown. However, as the glow of academic satisfaction dimmed, the reality struck. He had a brain tumour and would need an urgent operation tonight. He was seriously sick and might not see his child grow up…and I had to go and tell him.

  It didn’t go well. I told them what the scan had shown. He was stoical. His partner was hysterical. It was awful.

  I left the conversation feeling sick. It had been a day of weird emotions: pleasure from an academic viewpoint and heartbreak from a personal one. It can be a very interesting job this one…but also very upsetting.

  Career stresses

  There is a lot of uncertainty about working in A&E at the moment. In the past, to become a registrar, you had the stress of passing exams and having to move around the country for different jobs, but at least you knew that once you had finished your training, you could settle down as a consultant and help run an A&E department.

  However, for the registrars of today’s A&E, it is very different. More exams and constant revalidation, are things all specialist doctors should expect, but it is the uncertainty of what our role will actually be that is worrying.

  Emergency nurse practitioners see a lot of the minor cases that doctors used to see. This was supposed to give us time to see the sickest patients. However, the government’s 4-hour target is taking away our role in their ongoing emergency care (which is often beyond 4 hours) and it is being taken over by a new creed of doctors–acute medics.

  Then there is the question of whether there will be jobs in the future for us once we have finished our training and are consultants. Hospitals are cash-strapped at the moment and there seems to be a reluctance to take on new consultants. Even the government has said that it anticipates that there will be too many consultants in a few years’ time. Also, how many A&E consultants will we need in the future, if the government has closed all the smaller units?

  So, if you see your A&E doctor looking stressed, it may be because of career worries on top of the other expected ones.

  Bloody Jobsworth

  Your job is hard enough and then you get twats making your job harder. They read protocols and policies, and then think they have power. I have had quite a few examples during my time as an A&E doctor. Here are a couple–the first one happened a couple of years ago.

  It was a quiet night and I was the only doctor in a small A&E where everyone knew everyone else. At about 3 a.m. the knob of a security officer came over on his rounds. He was the type of security officer who instilled no confidence in either his fighting abilities or his conflict resolution skills. He was fat, greying and very sweaty and all he looked good for was making the tea for the post-fight analysis.

  ‘Evening, Edwards,’ he said in his quite irritating Birmingham accent. He walked off to check a door or something and then came back. ‘Have you got your ID badge on you?’

  ‘No.’

  ‘Well, have you seen the new trust memo section 4, paragraph 6.2 section 3, line 7 on improving patient safety. It says if you have not got your ID badge, then you can’t see patients and so I can ask you to leave.’

  ‘Oh well…bureaucracy etc.’ I responded.

  ‘No, seriously, I could ask you to leave and I’ll escort you off the premises if I want to,’ he said.

  ‘Look, just let me get on with my job and stop being pedantic,’ I responded.

  He retorted, ‘I am just doing my job. I am not padantic.’

  ‘Pedantic. Not padantic,’ I responded, in what I thought was a witty way, but he didn’t get. ‘I would be delighted if you escorted me off the premises. But who is going to see the patients?’

  ‘Not my problem…section 4, paragraph 6.2, etc., etc.’ He went on and on.

  Now, I wouldn’t have minded this conversation if he was joking, but he wasn’t. He was deadly serious. I fought back in this game of verbal judo.

  ‘Actually, please escort me off the premises, and you can explain why all the patients had to wait until the morning to see a doctor.’

  He backed down, but then a week later I got a letter advising me about my section 4, paragraph 6 from the personnel manager and copied to my bosses. What
a waste of NHS money and time.

  But this wasn’t as bad as the Jobsworth a colleague of mine got told off by. You may not have noticed, but recently the NHS has gone ‘smoke free’. A great idea–no smoking in the building or grounds but a blanket ban lacks common sense. It is a fact of life that in A&E stressful things happen, and some people smoke for a bit of urgent stress relief.

  A colleague of mine had been telling a dad about his 20-year-old son who had had a serious motorbike accident and had to go to ICU. The dad asked him if they could talk outside as he needed a cigarette. They went outside and carried on the discussion and my colleague explained in detail what was going to happen when his son was on ICU.

  As they were talking, a health and safety manager, or something like that, walked past. ‘You are not allowed to smoke in the trust grounds,’ he said, while pointing to a ridiculously expensive, large banner draped across the outside wall of the hospital. My friend said he was trying to tell his patient’s dad about his son’s critical illness and asked him to leave them alone.

  ‘Well, you can tell him without him smoking. We are a smoke-free site,’ he said in a completely dispassionate way.

  Ten minutes later the safety officer came back to tell off my colleague for encouraging members of the public to break health and safety regulations and advise him that if he did it again, it was a disciplinary offence. What a cock. People need to think about the problems people face when they come to A&E and think outside their own small box.

  While I would never encourage smoking, in very stressful situations nicotine withdrawal can make the stress a hundred times worse. Don’t make life harder for staff and patients/relatives. Rules need to be bent where appropriate.

  Lack of staff

  One way A&Es have adapted to the 4-hour rule is to bring in A&E-run observation units/clinical decision units (CDUs) for patients who are waiting for test results before they can go home or who only need a very short admission. They are not intended for people who are going to need admission regardless of the blood results. However, some hospitals don’t have these wards, or perhaps only have a few beds, so patients are still needlessly admitted to the main hospital for a few hours.

  Yesterday I found out how frustrating it must be to work in an A&E without these wards and with the government 4-hour targets. I was working on a day when our ‘CDU’ ward was closed because of staff shortages. I had a gentleman who had walked in from the street 10 minutes after taking 16 paracetamol tablets. The medical management for this is to measure the levels of the drug after 4 hours to see the level of paracetamol in the blood and then, depending on the level, to treat the patient with a drug to protect the liver. Absorption varies from person to person, so not everyone will need this treatment. It was unlikely that this man would need the treatment, but he would need to see a psychiatrist for his suicidal intention.

  I wanted to admit him to our ward for the test so he wouldn’t breach but I was unable to. He had to be admitted to the main hospital. He would then be seen again by the medical doctors, who would then take the blood and sort him out. Six hours after admission to A&E, they had his blood results and knew that, medically, there was nothing for them to do. However, he ended up staying the night as the medical team was unable to get a psychiatrist to come and see him as quickly as we generally can in A&E.

  It was a waste of a bed, a waste of time for the medical doctors as they had to ‘clerk him’ (take a history and examine the patient) and a huge waste of money. The patient got the right treatment but was confused as to why he was being shipped around the hospital.

  For me, it made me feel that my job was pointless. I am not on a training scheme to become a consultant in triaging patients. I am a specialist in emergency care. I didn’t need to refer this patient to the medical doctors for their expert advice– it is my area of expertise. It really pissed me off.

  Am I becoming sick?

  Is it right that I am hoping patients have various ailments to make my job easier or more interesting? Surely the humanitarian side of me should want everyone I see to be pain-and illness-free? I don’t and I am worried I should, but at least I know my thoughts aren’t right…

  Today I saw a little old lady who had a fall. She was living at home, and her carer had found her on the floor. She was confused and it was very hard to understand what had happened. On examination, I could tell that she had a painful hip. I sent her for X-ray and thought, ‘I hope it is broken, because if it is, then she will be an easy referral to the orthopaedic doctors. If it is not, then I will have to do some thinking and sorting out.’

  How wrong is that thought? I wanted to condemn the poor woman to an operation, weeks of hospital stay and a 30 percentchance of dying in six months, just to make my job easier?

  A couple of nights ago, I was getting quite tired and bored when I saw someone and sent them for a chest X-ray. I was concerned that they might have a pneumothorax (hole in the lungs). I was disappointed that they didn’t. I wanted them to have that condition purely so I could get out of seeing another patient and put in a chest drain, which I enjoy doing. That surely isn’t a right thought.

  A few day before that, I was sure that I had seen a patient with a brain tumour. I was really proud of my clinical examination and history-taking skills. I sent her for an emergency CT scan and was disappointed to find out that she didn’t have anything wrong with her brain at all. How wrong is that? (How can I be disappointed that someone hasn’t got a cancer, just because it’s lowered my confidence in my doctoring abilities?)

  Do all doctors think that? Am I unusual? Am I an uncaring bastard? My fears were relieved at the pub when an anaesthetic colleague told me about her day at work. The ICU was full and there was a cardiac arrest on one of the wards. She ran down and during the resuscitation attempt, she kept on thinking, ‘I hope she doesn’t make it, otherwise I’ll be up all night taking her to ICU. I want to go back to bed.’ She then said how relieved she was that the resuscitation attempt had failed (although it had been conducted properly). She was relieved that a 60-year-old lady about to embark on her well-earned retirement had died, just so that she could get back to bed?

  To someone who doesn’t work in the NHS, these thoughts may seem very sick. But as long as you treat your patients to the best of your ability, regardless of any feelings, do not let patients know what you are thinking and realise that the thoughts are wrong, then what you are thinking deep down shouldn’t really matter…I hope.

  Why do we all lie?

  One of the things that I have noticed working in A&E is the lies patients tell us. Perhaps ‘lies’ is too strong a word–I mean the things they say when they mean something else. Here are some examples I’ve had in the last few nights:

  Patient says: ‘I didn’t mean to bother you.’

  Patient means: ‘I did mean to bother you.’

  Patient says: ‘I had a car accident two days ago and my neck hurts.’

  Patient means: ‘My unemployed mate who watches lots of daytime TV told me about “no-win, no-fee”, no self-respect lawyersforyou.com and I think I am in for a fortune.’

  Patient says: ‘How do you spell your name?’

  Patient means: ‘You are getting a thank you letter.’

  Patient says: ‘How do you spell your surname?’

  Patient means: ‘You are getting a complaint letter.’

  Patient says: ‘I have got a personality disorder.’

  Patient means: ‘I used to be known as an attention seeker. Now I am medicalised by a hippy psychiatrist and you have got to be nice to me and treat my time-wasting seriously.’

  Patient says: ‘My drink has been spiked.’

  Patient means: ‘I got so drunk I need an excuse for my behaviour.’

  Patient says: ‘The GP told me to come/I tried for 2 hours to get a GP/The GP couldn’t see me for two weeks.’

  Patient means: ‘I didn’t bother to try and see my GP as I knew you would see me anyway.’

  Patient says:
‘I am an ex-smoker.’

  Patient means: ‘I gave up an hour ago.’

  Patient says: ‘You f**ker. You f**king f**ker. Why did you get me off my high you f**ker.’

  Patient means: ‘Thank you so very much for saving my life by giving me naloxone and letting me breathe on my own and stopping me being in a coma all my life after I overdosed on heroine.’

  Patient says: ‘I have been waiting over 2 hours.’

  Patient means: ‘I have been waiting 20 minutes but am in a rush.’

  Patient says: ‘I don’t drink much.’

  Patient means: ‘I drink less than my doctor.’

  Patient says: ‘You won’t break confidentiality with the police, will you?’

  Patient means: ‘I have been very naughty.’

  However, there is not just patient to doctor lies; it’s the other way round that I like best. Here are some things that I have heard some doctors say when I am sure that they might mean something else.

  Dr says: ‘This won’t hurt.’

  Dr means: ‘This will hurt.’

  Dr says: ‘Don’t worry, I have done this procedure loads of times.’

  Dr means: ‘Don’t worry, I read about this procedure earlier today.’

  Dr says: ‘Emmm…I’ll just be a minute.’

  Dr means: ‘I haven’t got a clue. I’ll have a look on the Internet for some medical inspiration.’

  Dr says: ‘So what accident or emergency do you have?’

  Dr means: ‘Why are you wasting my time?’

  Dr says: ‘I’ll get a second opinion.’