In Stitches

by Nick Edwards

  Dr means: ‘I still haven’t got a clue.’

  However, the ones I love the most are when patients actually tell the truth. Some recent examples:

  ‘I have a carrot stuck up my arse. It helped me come and I like the feeling of it, but my wife is getting back from holiday tomorrow and Jason wants his carrot back.’

  ‘My GP is shit and not giving me the answer I want, so I came to you instead.’

  ‘I was lost so I called an ambulance as I live near the hospital. There is nothing wrong with me but I thought I’d come in for a check up as I am here already.’

  The best honest comment I have ever heard was from one of our sisters who is slightly disillusioned by British culture…

  Chaviest/ugliest girl ever: ‘My drink has been spiked.’

  Senior sister: ‘I doubt it. People only spike your drink if they want to sleep with you.’

  A typical day

  So what is my average day like? Some people joke that it is same shit, different day–but the wonder of A&E is that the same shit comes in different colours and textures. I have chosen a random date to describe a typical day–my birthday.

  I was doing a day shift, 8–6. Great, as it meant I that would see my wife and child in the evening, but shit because of rush-hour traffic on the way to work. The alarm went off at 6 a.m. and then turned onto Snooze a couple too many times. Quick shower and into the car–with a breakfast bar en route.

  7.40 a.m.–arrive for the extraordinarily ridiculous hunt for the car park space. Find a spot and celebrate only to see that it is reserved for the hospital Chaplain (who rides a bike anyway).

  7.55 a.m.–decide to park illegally by the back of A&E reserved for police and ambulance crews. Again, no spaces there as all my colleagues have done the same thing. Eventually, I park at the local DIY shop–I’ll buy some screws on the way home from work, promise. Arrive 10 minutes late and stressed.

  The first part of the registrar’s morning job is to get a handover from the night doctor. After a quick assessment of the priorities in A&E, I delegate one of the junior doctors I have with me to see the two sicker patients. I then review the patients who were admitted to the A&E overnight ward–a combination of suicidal patients waiting to see the psychiatrist once they have sobered up, head injuries needing observations, little old ladies who have had a fall and need an occupational therapy assessment and the homeless alcoholic who was given a bed for the night.

  Then it is off to see the minor patients–or patients that the triage nurse has deemed to be minor. You are expected to breeze through these patients and they usually require quick fixes such as a plaster cast or a few stitches. Unfortunately, some are far from minor and can take ages to sort out.

  9.30 a.m.–the consultant emerges from his office, wondering why there are patients waiting: you either answer in a short-term view –that you have been caught up with a complicated patient–or you answer in a more socio-political way, i.e. there are increasing numbers of patients attending A&E without reciprocal resources, etc. Neither answer pleases the consultant and you are told to get on with it.

  10.30 a.m.–have seen more minor cases and I am frustrated for a number of reasons:

  1. When the emergency nurse practitioner is away on a course, why isn’t there cover built into the rota and why am I just expected to cover the workload?

  2. Why has the triage nurse let some of these patients through? A typical example is the toothache that has not been sent to the emergency dentist. So they wait for 2 hours for me to say, ‘I am not a dentist–here is the number of the emergency dentist.’

  3. Why have some patients come? Typical example–lump on leg for four years; have you not heard of a GP?

  11.30 a.m.–just about to get a coffee and the ‘red phone’ goes off. This is the phone which is meant to tell us when sick patients are coming in, so we can get prepared. This time it was used for a patient who had had chest pain but now had resolved and who had a normal ECG. I got ready by drinking my coffee and taking the time to flirt with the nurse I will be working with. The nurse flirts back and flicks her hair back and smiles at me.

  1.00 p.m.–lunch. Shit food. Not that cheap. Jamie Oliver, please come and look after us.

  1.20 p.m.–get asked out by the student nurse, aged 21, 34B, size 10.

  2–4.50 p.m.–see a few major and minor cases. Nothing that exciting happens, but what I do notice is the number of freaks that are coming in to see me. Too many freaks and not enough circuses I think. There are also lots of people who genuinely need my help and are appreciative. I like it when people say thank you.

  4.50 p.m.–have to remind another nurse that I am married and she shouldn’t try and snog me in the linen cupboard.

  5.00 p.m.–see an overdose. Fortunately, not that serious and I don’t get that emotionally involved.

  5.25 p.m.–turn down a come-on from one of the fit nurses.

  5.30 p.m.–department quite quiet, so I write a police assault form.

  5.50 p.m.–persuade a heroin user that he shouldn’t self-discharge after my colleague has reversed the effects of their smack, in order to help them breathe. Get told to f**k off.

  6.00 p.m.–home time! Buy some screws in the DIY store and say I got lost in the timber section. Get the clamps removed from my wheels and go home as four ambulances rush by with major traumas that my colleague has to see.

  So, while it can sometimes be a case of ‘same shit, different day’, it is a fact that no shit is like another and you never quite know what is going to happen next, which keeps my interest in my patients and my job. It is stressful, but time just flies past and at the end of the day I usually feel as if I’ve done something useful.

  So all in all, a normal day with no major incidents, a few moans and a few pleasant patients.

  P.S. Sadly, the bits in italics were all made up to boost my ego. The exciting, sexy things that you see on TV A&E dramas don’t actually happen in reality. Sorry to destroy the illusion.

  JFWDI

  Contrary to what may come across in a lot of my rants at the pub/writings, I do not hanker after the good old days where the doctor knew best. They were bad old days. It led to arrogance in the medical profession and unaccountability. It is a very good thing that doctors have to justify their actions not only to themselves but also to the public and other professionals allied to health care–radiographers, biomedical scientists, etc.

  Having to justify our actions to other health-care professionals, especially when we are organising tests, makes us think more about exactly what we are looking for and why. When we write request forms or phone up for an urgent test, we, quite rightly, always have to justify it.

  Most other professionals know that sometimes the information you have can be sketchy, owing to the nature of A&E work, and 99 percentof staff are very helpful and get test results done as quickly as possible. Sometimes, however, that 1 percent feels like 99 percent. You feel that they have no inkling of the stresses of working in the A&E department when they are stuck in their fume-filled laboratories. You feel they sometimes follow protocol just to get out of work–and it can drive you mad. Here is a recent example of this.

  I had a 43-year-old man come in to A&E. He looked dreadful, he had vomited blood and his heart rate was up but blood pressure hadn’t fallen yet. My gut instinct was he needed blood–and quick. I fast bleeped the haematology technician, who slow responded. Five minutes later we got into a discussion on why I wanted blood when I hadn’t got a result of his haemoglobin. (A pointless argument as, regardless of the result, he was going to need blood, or at the very least some standing by ready to be given just in case.)

  Apparently the scientist in his lab knew exactly what was going to happen–even though he hadn’t seen the patient. An unsuccessful discussion ensued and I was only successful in my argument when I asked for his name so I could write it in the notes and move the clinical responsibility to him. My blood then arrived quicker than you can say a short sentence quite quickl
y.

  Why did I have to have a fight? I didn’t ask for the blood just to piss him off, my patient needed it. I didn’t want a stressful battle but I had to have one. Yes, he can question why I need the blood but in an emergency repeating an argument 10 times is not helpful to the patient or to me.

  A few days previously to that, I had a patient who had been in a fight (a case of nasty walls again!). I wanted both the hand he had used to punch with and the elbow he fell onto X-rayed. Both were tender on palpation. An hour later, the hand X-ray came back–broken–but there was no elbow X-ray. I enquired as to why. Apparently, the radiographer didn’t think it was broken and so didn’t bother to X-ray it. However, I did think it might be broken and didn’t want to miss a fracture. I take clinical responsibility for the patient and not the radiographer.

  Again, I had to have a 10-minute argument about why I wanted to X-ray this man’s arm. I didn’t have the time for this. I tried to explain that the point of my being at work wasn’t to upset diagnostic staff by getting them to do unnecessary tests, but to look after patients wanting (and occasionally needing) our help. Again, only by resorting to the ‘What’s your name so I can put it down in the notes, etc.’ tactic, did I get my X-ray…which turned out to be entirely normal. I then got an episode of ‘I told you so,’ but at the end of the day it is my responsibility, so don’t moan at me for being cautious and not wanting to end up in court for missing a fracture.

  When the next pub opportunity arrived, I ranted about these episodes in a more and more manic way as the beer flowed (OK, I’ll be honest, as the alcopops trickled). A friend of mine–also a doctor but much older and with years of experience– told me how he and his colleagues used to deal with these problems. They just wrote on the form JFWDI–it stood for ‘Just f**king well do it.’ This was before people questioned doctors. Few knew what JFWDI meant and so nobody would dare question the doctor. It is an amusing thing to write, but totally inappropriate. As I said earlier, I am so glad that times have changed–99 percentof the time.

  At this point I want to say how totally reliant A&E doctors are on the other staff working in the labs/X-ray departments. They are usually highly skilled and, on the whole, highly efficient, helpful, frequently friendly and generally a pleasure to work with. It is just a small minority that drive me mad.

  What these people lack is the respect and recognition for what they do–especially lab technicians and scientists. They have fallen behind the doctors’ and nurses’ pay scales and work hours that are often much worse than ours. However, unlike nurses–who are all apparently angels with a seat in heaven waiting for them–they don’t get recognition and respect from the public, or politicians. An example I read in the paper was that a pop star wanted to say thank you for the care his mother had received in hospital. He was going to put on a free concert for NHS nurses. Great, but he didn’t mention all the other NHS staff vital to making the place tick–lab scientists, physios, OTs, radiographers, secretaries, etc. And before you ask, doctors don’t really need free tickets for pop concerts. Whatever anyone says, we are quite well paid and can buy our own tickets. I know very few really poor doctors. Lots of pissed off and stressed ones, but not many poor ones.

  Male menstrual syndrome

  I got really fed up at work this week. I tried to rationalise why and realise that my wife is probably right and I have got ‘Male Menstrual Tension’–a little known condition but with symptoms far worse than PMT. It is often exacerbated by a lack of sleep, beer, sex and football–but nearly always induced by stress. It was the stresses and annoyances at work which set it off. These include:

  1. The 4-hour rule–don’t get me started.

  2. The frequently rude patients that I have to treat.

  3. The chav night club where the chavs go to for their chavy fights and then come to see me. N.B. When I go to the club, I tell people it is retro chic and not chavy.

  4. Toffs with excessive expectations–there is only one little me.

  5. People trying to kill themselves.

  6. People trying to kill themselves but not very effectively–five vitamin pills will not do it but it will get you a bed for the night while we wait until the psychiatrist can see you in the morning.

  7. Medical doctors. They moan a lot, can be arrogant and condescending, copy our clerking, complain that unnecessary tests have not been done and then say, ‘Well I wouldn’t have referred it.’ Well then, you can send them home, professor. Please note usually I don’t think this of medical doctors and they are usually good colleagues–I am just having a bad week.

  8. Cardiologists who arrogantly say–‘So I suppose you want an unnecessary echo to make yourself feel better.’

  9. Ophthalmologists who answer ‘chloramphenicol’ to every question.

  10. Respiratory doctors who always ask if you have excluded TB. No! The test takes weeks. I only have 4 hours!

  11. Out-of-hours GPs–don’t get me started.

  12. NHS Direct having no choice but to advise people to go to A&E to cover their own backs.

  13. People coming in saying, ‘I just wanted to get a second opinion.’

  14. Drunk teenagers–when I was young I went home to sober up, not to A&E.

  As I said, I am having a bad week. Normally I love my job but at the moment I am fed up. Sorry to be moody.

  Delivering oranges

  The next patient’s card I picked up was an elderly lady, in her mid-70s with ‘abdominal pain’. I quite enjoy seeing elderly patients. They are usually really grateful and undemanding, and you can always try and charm them. My favourite tactic is pretending that they must have given the wrong details to the nurse as their date of birth must be at least 10 years out. It always gets a smile and then the patient gets more relaxed. This didn’t quite work with this patient. She gave a faint ‘Don’t be a patronising twat’ smile and asked me if we could go into a private cubicle. I walked with her into the gynaecological room which has a door and some privacy. She started the conversation.

  ‘I have an orange in my vagina, and I can’t get it out.’

  ‘OK. That’s fine; I’ll need to examine you to see if I can get it out. I’ll go and get a nurse so that she can chaperone me. Don’t worry, it’s quite a common problem.’

  What the hell was I saying? No, it wasn’t a common problem, and what the hell was she doing with an orange in her fanny…and what was she doing not looking in the slightest bit embarrassed? She would have had the same facial expression if she had said she had slipped and fallen and hurt her wrist. I wanted to know how it got there, but I just couldn’t ask. I just stood there pretending I was unfazed and unembarrassed. I always have to remember my medical ethics of being nonjudgmental. I found a nurse, who was free to chaperone me.

  ‘Don’t ask any questions. Just stay with me in the room. I need a chaperone and some psychological support.’

  She looked at me strangely but came with me into the room. I examined her and there was this large orange. There was no way I could get it out. If it had been a Clementine, or even possibly a Satsuma, I could have ‘delivered’ it. I explained to her that I couldn’t get it out, but that it needed to come out, otherwise she could get a nasty infection. I told her that I was going to refer her to the gynaecologists, who were going to have to retrieve it under a general anaesthetic. She just nodded and said ‘Thank you, doctor’.

  I have never before written in the notes ‘Diagnosis: orange in vagina’. But then in A&E you get to see lots of strange things.

  The problems of alcohol

  I am writing this after a Thursday night shift. There was a common theme running through most of the patients I saw–alcohol. Now I am not self-righteous or pious–I love a good drink and I am grateful to that drug for helping me flirt vaguely successfully over the years. However, what most people don’t seem to realise, both the general public and law-makers, is that alcohol is a drug, and an incredibly powerful drug at that. It is addictive and a depressant, and it can really bugger u
p your body if used excessively. The reason people like it is that its depressant effects depress the inhibitory areas of the frontal lobe. In other words, it makes you think that you have actually got a chance with that really fit blonde, but unfortunately also makes you think that you should beat up her boyfriend to win her affections.

  It needs to be used with caution…and then it can be brilliant. Unfortunately, people forget about the caution bit and the consequences end up at A&E. The short-term consequences are the fights, accidents and deliberate self-harm, and the long-term consequences are liver failures, the dementias and the suicides.

  My shift started at 10 p.m. The first person I saw was a man who had come in after being forced to by his wife. He was in his 40s and had combined a career in business with a social life in the pub. He was the nicest man you could ever wish to meet. He was like Homer Simpson–funny, caring, devoted to his wife and children, and yellow. It was obvious that he was in acute liver failure–caused by the drink. Blood tests revealed his kidneys were not working either and that his liver was so damaged that as well as making him yellow, his blood couldn’t clot properly.

  The medical treatment isn’t that complicated–once you have a diagnosis and a cause, you try and stabilise him, stop him drinking and send him to the ICU where they do expensive and clever stuff. Once patients go to ICU, it really is touch and go whether they survive, but the prognosis is usually very bad, especially if their kidneys are not working. I don’t actually know what happened to this patient–one of the worst things about A&E is you don’t get to follow up your patients. However, from experience, I wouldn’t give him much of a chance. What a waste of life: a man in his 40s who should be spending time with his kids won’t be because he spent too much time drinking.

  The next patient I saw was a typical Friday night injury (I think Thursday is becoming the new Friday). He came in with a punch to his face and an injured little finger (known as a Boxer’s fracture). I am not sure exactly what happened, but he mumbled something like: he went to the pub, got pissed, knocked into someone and spilt their pint. A ‘What you looking at?’ type of conversation started up. His mother was insulted and he questioned the other person’s parentage. The final straw was that his sister’s celibacy wasn’t accepted as gospel by the person he bumped into. He had to defend the family’s traditions and honour. He punched the bloke, who then punched him back, and, being a lot less pissed, the other bloke won the fight and left. My patient got the silver prize of an ambulance ride to A&E.