by Nick Edwards
It hasn’t been easy for my wife. We now have two kids under 4 and it has been hard for her with me having long commutes to work, studying for exams and having to change jobs every 6 to 12 months. (She was also qualifying and working as a GP.) However, with the hope that in 6 months’ time I will be a consultant with a fixed job and settled working pattern, things should be easier.
Things in A&E have changed for the better in the last 4 years. There have been more resources given to the NHS and emergency departments in particular. Through a dynamic and effective College of Emergency Medicine, the importance of A&E as a speciality is rapidly being accepted by hospital managers and politicians. There are more consultants than there were 4 years ago and more senior supervision of junior doctors – especially at the weekends and in the evening. Care has also improved. There is better treatment for strokes, heart attacks and trauma victims, more intensive care beds and a realisation that in conditions like septic shock it is the quality of the treatment we give in the first few hours that really affects patients’ outcomes.
But over the last few years despite all the initiatives to reduce demands on A&E, more and more patients attend, expecting higher and higher levels of service. The pressures for the doctors and nurses on the shop floor have continued to rise. If I hadn’t adapted my outlook, then there was no way I could have continued with the stress that this creates. I used to get so wound up by what I perceived as unnecessary micro-management, personal slights by other doctors or patients being rude and ungrateful. I used to come home angry after nearly every shift, but now I think my skin has thickened and I have realised what is truly important at work: how we care for our patients.
I have chosen a few stories to highlight what working in A&E during these last few years has been like. The important bits: working with colleagues, the satisfaction you can have from treating patients and the despair when our care doesn’t work. It is not just a barrage of moans. Most importantly I have tried to show the amusement that work can bring and why there is no other job that I could do.
The problem with French
‘Je m’appelle Nick. Je suis votre docteur. Vous êtes à l’hôpital.’ The basic French that my mum had fastidiously taught me was at last becoming advantageous. The patient I was currently talking to was a Frenchman in his 20s. He currently had a tube in his windpipe which was helping him to breathe following a drug overdose of GHB.
GHB doesn’t often hit the headlines but can very dangerous; a small bit makes you horny, a bit more euphoric, and just a tiny bit more completely unconscious and unable to breath unaided. This was what happened to this particular gentleman at a local nightclub a couple of hours previously.
But now the drug was starting to wear off. He was starting to wake up and the breathing tube needed removing. For it to be done safely, it needs to be done with full cooperation of the patient and without them being stressed. I had found a French ID card in his wallet and thought speaking in his native tongue would help calm him down, especially as he couldn’t talk to us with the tube in. But it just seemed to make him more stressed.
When we had taken out the tube he started to scream in French: ‘What the hell am I doing in France? I went away for a weekend party in England and now I am here. What the hell has happened?’
My French wasn’t good enough to translate that I was just trying to help, and so I spoke in English from then on. He was much happier after that.
Not good enough for some people
With the increasing use of the internet and such wide-ranging reporting of medical issues, I sometimes feel in competition with the patients as to who has the most medical knowledge. This was exemplified by two slightly tipsy patients who had got into a fight. One of them had sustained a nasty forearm laceration which needed exploring in theatre under anaesthetic to check in case there were tendon injuries. His friend entered into the room – uninvited, I may add – voice first. I took an instant dislike to them – it saved time.
‘Just stitch his wound and we’ll be off,’ the friend slurred. I looked at the patient and was trying to explain what I needed to do when his friend butted in and proffered more advice. ‘He’ll need some ice an’ all.’
‘Oi love,’ he bellowed to the nurse. ‘Fetch us some ice will, ya?’
Turning to me he gave some more scientific explanation to his advice. ‘Slows down blood clotting, you see. He don’t need an op, just stitches or a bit of glue.’ At this point he fell off his stool. He sat there and continued to slur, and mumble general advice at me.
The only thing worse than a patient talking crap, is a patient’s friend speaking utter crap. I tried to explain why just stitching up the wound would be a very bad idea. Neither listened. They both continued to talk drunken gibberish and irritate me.
The next question really blew me away.
‘Anyway who are you to tell me what I need to do with my arm?’
I took a big breath about to list my many years’ study, various letters after my name and degrees I have, when he rendered it all moot by declaring: ‘My mate has a first aid at work certificate and he says stitch it and so stitch it.’
Again I tried convince him this was not the best course of action when he proudly announced he was off home to stitch it himself so he could get back to the pub. With that he self-discharged, although he did accept a bandage to stop it bleeding. A village was about to get their idiot back but only for a few hours.
Five hours later and a bit more sober, and after a good telling off from his mum, he came back and apologised. Exploring the wound showed a severed tendon which needed a plastic surgeon to repair the next day.
Two important things to remember here – just because a patient wants something, doesn’t mean that we should and must do it. They are patients and not customers. Customers may always be right, but patients certainly aren’t. But far more importantly I realised that if you find these types of interactions stressful, then you can’t do A&E for a career. Luckily I enjoyed every minute of my time with this man.
Dealing with death
Some things I find very hard to cope with at work. It had been a fairly boring and standard Saturday afternoon shift. Then the ‘red phone’ went off and the horror call came in.
‘Twenty-two-year old male. Cardiac arrest. CPR in progress. No return of rhythm.’
A call was put out and the team arrived. A friend of mine, Mike, came down from anaesthetics to help in case there was a problem with the patient’s airway. He started to make jokes. This is quite normal when waiting for a patient – it helps relieve some tension. But this occasion was different. I told the story and he shut up.
The patient was a semi-professional Afro-Caribbean rugby player. He had suddenly collapsed in a cardiac arrest mid game, in front of a couple of thousand spectators. The team physio had rushed on and immediately started heart massage. When the paramedics arrived they told us that they could hear a pin drop in the stadium. They had been working on him for 40 minutes but nothing they had tried had managed to restart the heart.
The waiting arrest team descended on him as he came through the doors to resus. Drug after drug was given to try to kick start the heart back to life. Everything we could think of: more adrenaline, some atropine and calcium gluconate to help correct possible electrolyte imbalances. I did a scan of his heart, but there was no obvious cause for the arrest. It just wasn’t beating. Emergency blood tests called a ‘blood gas’ showed the situation was a dire as it looked – the results were incompatible with life.
Just then his girlfriend arrived. One of the nurses led her into the corner of resus as she wanted to watch what was happening. She calmly stood back, saying nothing, but with tears rolling from her eyes. This man, her boyfriend and father to her child, was clearly dead but we continued on as we wanted to show her that all was being done to try to save him. It was all an act as everything proved futile. Eventually I think she realised this too.
I told her we were going to stop. She just nodded. Ev
eryone was in agreement and resus went from a hive of noise and frantic activity to complete silence as we stopped. This poor man in the prime of his life was dead.
I had seen death many times, and been affected by it before, but this time it was surreal. It was like I was watching down on myself being in charge, detached but still focused. I knew there wasn’t anything more that the team could have done.
I did what was necessary. Called the coroner, certified the body and had another chat with his girlfriend. I soon learned that his parents hadn’t been told and that a colleague was trying desperately to contact them. In the waiting room was an anxious rugby team desperate to find out what had happened to their friend and teammate. I asked to speak to the manager alone, but he wanted me to tell all of them together what had happened. Oh boy, I thought, and took a deep breath.
I cleared out our coffee room of staff and rubbish and lead them in. A few burst into tears. One asked if he could see the body. Then another and then another. Then they all decided they wanted to see him and so they were shown into resus in pairs.
Meanwhile my colleague had got through to his parents and informed them; they were due to arrive in about half an hour. I wrote up my notes and started to see another patient as the department had become so busy. As much as I wanted to stop and collect my thoughts, life went on and there were patients to see. A nurse came to get me when the parents arrived.
Walking back into resus I was astounded by the sight that greeted me. His mum was screaming at his lifeless body, wailing and slapping his face and jumping up and down. It was almost a chant and unlike any form of expression of grief I had ever seen up until now. I am used to a western type of mourning, which is often rather quiet and reserved as relatives sit in stunned silence.
‘Wake up. Wake up. Wake up.’ She seemed to scream this for ages and ages. With the pitch getting louder and louder and her voice more and more frantic I had to interrupt and try to calm her down. I introduced myself. I explained what had happened and that there was nothing more we could have done.
She looked at me with anger and pushed my chest before starting to scream again, but this time it was: ‘You killed my son. You killed my son. You killed my son.’ The screaming at me, the screaming at her son and the physicality of her mourning seemed to go on for ever. I felt helpless at even beginning to aid to her cope with her grief. As more of the patient’s family arrived, similar chanting and wailing echoed though the department. As uncomfortable as I felt and as unused to this form of grief as I was, my discomfort was nothing compared to what his family went through. I led them back to the staff coffee-room and let them get it out of their systems. Everyone and every culture have a different way to deal with grief.
A guide to A&E sisters and charge nurses
If you are ever in the ‘majors’ part of A&E, I am sure you will agree that it looks like organised chaos. But I assure you, there is method in the madness. This attempt at order is usually down to the senior nurses who run the department. They take the handover from the ambulance crew, they coordinate their staff, liaise with the senior doctor about what is happening to various patients, make sure patients are being seen on time and keep managers abreast of what is happening and often have to fend off irate relatives who feel they are being left too long to wait. It is a thankless task.
I have now worked in many hospitals and with many senior A&E nurses and have come to realise that there are a few stereotypical types of A&E nurse with various management styles. They usually conform to these stereotypes except for one mad sister who managed to encompass all styles in a single shift. Sometimes in a single sentence.
The Fat Controller – like in Thomas the Tank Engine, the Fat Controller reigns supreme. They are fat because they have a chair with wheels. They rule with an iron fist and control everything including the chocolates and biscuits. They bark orders and manage well, but don’t seem to be able to get off the chair. Often they get on very well with the registrar doctor – we also like to sit in a chair and ‘direct’. But they are tough and when the going gets tough, they sit and tell you their tales from how much worse it was when they worked in another inner city A&E.
The doctor nurse – known as a noctor –‘Doctor, will you go and see the bloke in cubicle 3. He has got heart failure. I have given him GTN, morphine and frusemide. You need to sign for them. I have bleeped the medics for you… Oh here you are, they are on the phone.’ That is one way of dealing with a very junior doctor, but I have heard the same conversation with consultants. Their management style can be loved by managers as it means patients are processed out of A&E very quickly, but sometimes patients present with symptoms out of the box where a set recipe is not the best treatment.
The coercive – somehow with their personality they make people do things for them. A busy ambulance team arrives. They have handed over the patient. The Coercive flicks her hair back. ‘Oh you wouldn’t mind just taking them to cubicle 3 and attaching them to the monitor. We are all one seamless team, you know. I hear you are wonderful at doing bloods – you couldn’t just do a quick set on him could you? Tea, white and one sugar please – my cup is the blue one. Thanks darling.’ It’s those two words – thanks darling – which help them get away with it. ‘Can you just work that bit harder, stay an extra couple of hours and not have any breaks… Thanks darling.’
The rude ones – they just bark orders. Never smile. Slag off everyone and everything. They often combine their personality with a desire to be seen as above board as possible and so spend hours writing copious notes and incident forms in case they get in trouble.
The manager’s pet – desire to fulfil targets is greater than desire to care for patients. These are the type of lead nurses who can really wind you up. You are half way through looking after your patient when nature calls. You return to the patient, but they have already taken over and referred them to the medical team and moved them to the ward. They also put unreasonable demands on the junior doctors – ‘They have been waiting nearly 4 hours and so you have only 10 minutes to see them, make a plan and either admit or discharge them. I don’t want them hanging around in my department. And before you ask – no, no one can do your bloods for you.’ They love to use the word ‘escalate’. Doing a night shift with this type of lead nurse is often a harrowing experience.
The generally lovely – nice, kind and warm to everyone. Helpful to the doctors but not dictatorial. Oozes experience and compassion. Manages their team well. Makes sure the department and patients are safe. Thinks about the patients first. Comes in various forms – some are more laid back than others, some are a bit obsessive and others might get a bit stressed, but they all have the same essential qualities. Luckily, the vast majority of senior A&E nurses are like this. Just a shame that they are underpaid, overworked and underappreciated. To the scores of top quality A&E nurses, thank you for making my job that bit easier. Now can I have the last choccie biscuit please?? Darling?
Abnormal observations
It happens every other Tuesday and one weekend in seven. If I refer a patient to the medical team with bradycardia (low heart rate) or hypotension (low blood pressure), and if they are then seen by a particular medical junior doctor, then, within a couple of minutes, the patients’ observations miraculously improve. Heart rate and blood pressure up and I look like a fool who can’t do simple patient observations. A sub-analysis of the patients who respond this way show it is 96 per cent of male patients and about 3 per cent of female ones.
The explanation for this is wonderful but wrong. This particular house officer (now called a Foundation One doctor: FY1) is dressed more in keeping with being a foundation one stripper. She is pretty, very pretty – 5 foot 9, long blonde hair, beautifully made-up face, manicured nails and a size 8. That is fine, but it’s what she is wearing that causes such dramatic improvements in some patients’ observations. She dresses very professionally. Well… professionally for an escort perhaps. Usually black high heels, or perhaps knee high stiletto b
oots, a short skirt which finishes a few inches below her knickers and the tightest of T -shirts. To top the look off, there is a stethoscope swinging gently across her overexposed breasts.
Now, don’t get me wrong. I love this look and it makes my day when she comes down to A&E. All the boys’ eyes just follow her around for a couple of minutes and we all enter a slight trance as our daydreams run away with us. As lovely as she looks, it is completely distracting and very unprofessional for a doctor. As much as all the ladies would enjoy it if I were to see patients in a tight T shirt, with my six pack bulging, wearing only tight Armani underwear, showing my perfectly formed posterior and my more than ample manhood, it would not be right. It gives the wrong impression and completely undermines what she is trying to do as a doctor.
I and most of my colleagues wear scrubs, which in the days of hospital acquired infection are more hygienic, they easily identify who I am and what job I do and allow patients and colleagues concentrate on the job in hand. I know it would make my days less enjoyable but I really think it is time all doctors working in the wards or in A&E started wearing a uniform like the nurses do.
But going back to our heroine of the day – I might ask her to keep her preferred attire close by, just in case we have a very sick patient whose blood pressure doesn’t respond to the usual dose of fluids and drugs and needs an urgent extra tonic.
Good form of pre-op anxiolytic
It was a Friday evening when I saw a young lad who had crashed his motorbike. He was a bit upset generally, rather unhappy that we had to cut his clothes off and apoplectic that he was in hospital. He kept announcing that he was ‘Outa here.’ Sadly he wasn’t going anywhere. Not for a long while.