by Nick Edwards
Initially I was annoyed, this doctor had to learn, but then I realised that the patient had a great point and that simulation is something we should do as students before being let loose on patients. However, nothing makes up for the real thing and we are all eternally grateful for those patients that do let us hone our skills on them.
Being honest with patients
I used to get flustered seeing patients with whom I didn’t know what was wrong. But after one encounter I learned to realise that being totally honest is the best way. I didn’t know what was wrong with this 45-year-old lady and tried to tell her, but was failing badly.
‘Be honest, you haven’t got a clue what is wrong with me,’ she said. I meekly nodded. ‘Which is bad because I still don’t know what is going on with me, but must be good as you know all about life-threatening conditions and I assume this is not one of them?’ ‘Yes,’ I replied. I now use a variation on what she said and I think patients appreciate the honesty.
Being personal
I was having a discussion with a dad about what to do about his child who had fallen off a horse, sustained a head injury and who had vomited twice. I explained that we could scan his head and see if there was any injury but this would mean exposing him to potentially unnecessary radiation, or we could watch him on the ward and see if he started to deteriorate, scan him then but risk delaying treatment if he did actually have a brain bleed. The discussion seemed to go on for ever, even printing out a copy of the national guidelines for him to read, didn’t seem to help.
‘What would you do if it were your son?’ he eventually asked.
‘I would watch him and not scan,’ I replied.
‘Why didn’t you tell me that ages ago then? We would have saved the last 20-minute discussion.’
From now on, I do.
Keeping patients up to date with what is going on
I was a patient for a couple of weeks, two years ago. There is nothing as scary and annoying as not knowing what is going. I keep this in mind with all my patients now.
Learning to communicate better with my team
I was treating a lady who worked at the local Chinese takeaway restaurant. She was having an exacerbation of her chronic respiratory condition and I made of series of requests to the junior doctor I was working with. I checked that my colleague knew what I wanted by saying ‘Happy?’ and her response was a nod, which I took to mean yes. On review 30 minutes later, I saw that 2 of the things requested hadn’t happened – this could compromise care. I felt annoyed with her, for not listening and, I thought, not working as a team.
Then the patient said to me: ‘How could you know she knew what you wanted. You didn’t check with her. I have never got an order wrong in our restaurant as I always read back to the customer what I think they said. That way there is no confusion and no errors.’ I paused and thought what a genius she was and what a fool I was. Now I practise the ‘Chinese takeaway’ style of communication whenever I am issuing or following treatment plans. I may sound like a man suffering from a compulsive disorder, but it has lead to less errors and better care.
Oh shit I am pregnant
Miss S was an 18-year-old Korean girl, on holiday with her family when a sudden bout of abdominal pain had diverted her from her sightseeing fun to A&E.
She presented with all the classical signs of appendicitis: pain in the right lower abdomen, no appetite and inability to do anything that increased the pressure in her stomach, e.g. coughing etc. She also had a negative Croydon triad. (The Croydon triad is the rule that if three of the following are present, then the chances of right lower-sided pain being due to a sexually transmitted disease leading to pelvic inflammatory disease are greater than the chances of appendicitis: large hooped earrings, toe ring, ankle bracelet and small dolphin tattoo on the side of their belly/backside.)
Luckily this girl had none of these signs and I was pretty confident in my diagnosis of appendicitis. I assessed her and took blood and asked for a urine sample. It is routine procedure for any woman between 13 and 60 to have a pregnancy test if they come in with abdominal pain.
The results came back as positive. This threw my appendicitis diagnosis into question and threw up a new possibility of the pain being caused by an ectopic pregnancy. I needed to tell her the result as it meant more investigations and some of these might require an intimate examination. We hadn’t actually told her that we would be doing a pregnancy test as part of the routine assessment so there was no lead in to telling her the result. I asked to have a word with her alone, without her parents, at which she looked very frightened and I realised how young for her age she seemed. I asked her gently if she thought she might be pregnant but I was met with a flat denial and an explanation that she had never even had sex as she was unmarried. She was very adamant about this. I wanted to believe her but the fact was that the test had come back positive. Falsely positive tests can happen but are very rare. I believed the test more than I believed her. Tests generally don’t lie but frequently teenagers do. I told her about the results of the test. Naturally she was very shocked and upset and worried about her parents. She still denied having had sex.
Suddenly she came up with a possible explanation.
A few weeks ago her boyfriend had touched her ‘down below’. She had liked the feelings but asked him to stop it as she wanted to wait till she was married. But she told me this is how she must have got pregnant. He had never actually penetrated her with anything other than his finger and that his fingers had been nowhere near his manhood before then. So I thought this was unlikely. She also asked if she could have got pregnant by giving her boyfriend a blow job, which is as far as she goes with him. I explained no and was a bit short with her. Why was she lying to me? I’d already told her I wouldn’t tell her parents but she still stuck to her story that she had never had sex.
She was in tears, scared witless, I imagine. I left her for a time to have a think while I arranged her admission. I was hoping the truth would be remembered soon, otherwise I had been talking to the twenty-first-century Virgin Mary. I went to write my notes when one of the doctors was joking to one of the nurses that she had done a pregnancy test on the lady in the opposite cubicle even though she had had a hysterectomy (removal of the uterus.) two months previously.
‘But it had come back positive’ she exclaimed.
‘Blooming heck!’ I thought. What an amazing time the obstetricians are going to have for the next few months; A Virgin birth – the first one in over 2,000 years – and a pregnant woman without a uterus… What the…? Bloody hell, I thought, as it clicked into place.
I got the packet of pregnancy sticks and picked up three at random.
I went to the toilet and pissed on the first one. The pink line came up. I’m pregnant.
I tried the second. I was having twins.
We urgently needed some new testing strips. We repeated the test and it was negative. Which was fantastic for her and not so good for me. I had to tell her that all the upset and worry I had put her through was all unnecessary, it was just that our bloody pregnancy tests were faulty.
I went in humble as possible and she was there with her mum. I apologised profusely.
She was so kind about it. ‘I wasn’t worried for one moment as I have only ever held hands with my boyfriend.’
I smiled as I organised for the surgeons to come and review her. I had two more things to do. I wrote an incident form about the pregnancy test batch and then went to the toilet. I peed on one of the new ones. I wasn’t pregnant. Phew! I had no idea how I would have explained that one away to my wife.
So pleased he broke his ankle
One of the patients who has made me really happy came in with an injured ankle. He was in his 50s, a builder by trade and an absolutely delightful man. He had come in after playing football with his 3-year-old grandson. He slipped on the grass and got a small break to his fibula. An easy to treat fracture, which I was delighted he got.
The reason I was s
o happy was that he looked very familiar. I had been part of a team that treated him about 4 months previously. He had had an out of hospital cardiac arrest caused by a heart attack, his heart had stopped for 13 minutes and in essence he had died. A member of the public saw him collapse and immediately started chest compressions. The ambulance arrived and started his heart again using a defibrillator. When he arrived in the emergency department, I was in charge of his care. We gave special drugs to keep up his blood pressure, and we used special ice packs to cool down his body temperature to protect his brain from the damage that had occurred to his body during the arrest. He went from us in A&E to the cardiac catheter lab and had a stent placed to open up the blocked vessels. A bit like a plumber unblocking your drain. He went on to have a balloon pump placed in his aorta (largest blood vessel coming from the heart) to help keep up his blood pressure. He went from there to the ICU, where he was kept alive by dialysis despite his kidneys failing. From there he went back to the cardiology unit where he had a pacemaker fitted which not only sensed if his heart missed beats, but also controlled how frequently it beat and could also shock his heart back into a normal rhythm if he were to have another cardiac arrest.
After discharge a team of rehabilitation physios worked on him to get him up to working again and playing football with his grandson. His GP provided ongoing care, reassurance and a point of contact where all the specialists he needed could feed in.
Ten years ago, he would have died. Now he can live a full life, thanks to the advances in technology and increased funding for the NHS. At no point in this scenario did we stop to question if he had insurance or if he could pay for the treatment he received. We did not care if he was a millionaire or on the dole. All we wanted was to give him the best possible chance to walk out of the hospital, not only alive but in good enough shape to live a normal life again. This is possible because of the way the NHS works – it is free to whoever needs it regardless of ability to pay and with cooperation and not competition between the many different health care professionals and services. Thanks to the NHS he lives to fight another day. It was great to be a small cog in his care 4 months ago. It is great he has been well enough to go out and break his ankle.
The future of the NHS
I firmly believe that the last patient is alive today because of the health service we have in the UK. In the USA, he wouldn’t have been able to afford the costs of this expensive state of the art treatment. The ambulance service, GPs, A&E, cardiologists and intensive care team all worked together thinking about how best to care for the patient without considering how we could make a profit out of our patient. He got excellent but also efficient care because there was no incentive to do unnecessary tests to create extra profits. Health care isn’t appropriate to be run like a business, where cutting costs and removing competition lead to more profits. Working together, improving quality and cooperating with local hospitals and GPs is the best way to run health services and we are lucky that we in the UK have the NHS which in essence does this.
Yes, it has it problems, but they are solvable by good management. Despite the extra resources, there has been money wasted, excessive micro-management and sledge hammers to crack nuts. This has led some doctors and nurses, and a large section of the press, to not appreciate what we do have.
Recently there has been an appreciation that the government needs to let clinicians take the lead on how to improve care. For instance, in A&E the government worked with A&E doctors and nurses about implementing new standards of quality of care and not just a time standard – the old 4-hour rule. The debacle of modernising medical careers, where good doctors were left without jobs, has largely been resolved as have reforms about improving accountability of doctors and learning from mistakes.
The ethos of the NHS – cooperation and not competition and putting patients before profits – has served us well, despite years of underfunding which has only partially been rectified in the last decade. The new reforms to the NHS in England (the NHS in Wales and Scotland are not following these reforms) are essentially following Blair’s reforms but at breakneck speed, and I believe are very risky.
Although I agree that GPs should be central to commissioning health care for their patients, it is the future of hospitals that concerns me. GPs will be able to buy services from any provider; hospitals will be able compete against each other on price and as standalone institutions. The ethos of cooperation will be eroded and the NHS could just become a kite mark for an umbrella of organisations which are providing health care independently, often with the aim to make as much money as possible, rather than working together for the health of the local area.
It doesn’t really matter if your local hospital stopped doing elective hip operations as the private treatment sector undercut them, but what happens at 2 a.m. when your nan has broken her leg and there is no orthopaedic doctor available in an emergency as they no longer work for the NHS? Or worse still, they are available but so inexperienced at what should be the bread and butter of their job that poor care is given in the end?
I don’t honestly believe that the government wants to dismantle the NHS. I do, however, have concerns that a blind acceptance of market forces in health care could lead to the unintended consequence of a dismantling of the ethos and structures of the NHS. It is these that have served us well, from cradle to grave, regardless of ability to pay.
So to round up…
This book has no firm end. The last story and the one I have chosen to end the book on wasn’t special, wasn’t particularly fascinating and wasn’t a particularly exciting case for me – a simple fractured ankle. But for the patient it was. For him it was special; he was so anxious about his injury, the effects it would have on his job and livelihood, worried about if he would survive an anaesthetic and worried that he might never run again.
I knew he was going to be okay, but he didn’t, he was scared. The words I spoke did matter and were unique for him. And he reacted differently to how other patients did and so his similar condition became a unique encounter.
I have learned a lot in the last few years. Not facts or new drugs – they can be looked up on ‘Google’ anyhow – but the importance of how we speak to our colleagues and our patients, how we implement what is already known about best patient care so that all our patients can get top notch treatment, and most importantly how we look after ourselves.
Medicine is an art as well as a science. Only by thinking about what we do, can we appreciate that art. This book in essence has been one long reflective practice essay. What I used to mock that medical schools taught as an unnecessary piece of political correctness, I have come to use, to help me enjoy my job and care as best I can for my patients. I go on looking forward to another 30 years of this.
Glossary
ASBO–antisocial behavioural order. I believe over 90 percentof people coming to A&E after midnight on a Saturday night have or should have one of these.
Blair, Tony–icon of revolutionary socialist ideology or Thatcher’s love-child who acts as a tree for George Bush’s poodle. You choose.
BMA–British Medical Association (the doctors union) but not the type that calls each other comrade and organises meat raffles. A GP’s best friend.
BMJ–British Medical Journal (the Sun of medical journals). You can understand most of the words, it keeps you vaguely interested and there is often an interesting picture or two.
Brown, Gordon–icon of revolutionary Scottish socialism or a boring and impolite version of Tony Blair. I am not sure which one yet.
Cannula–a plastic tube that goes in the back of your hand and from which we can take blood tests and give you fluids and drugs. Not really something to make a joke out of, as it has no amusing properties.
Charge nurse–nurse in charge. It is what we call male sisters. They object to the term ‘brother’.
Chav–English equivalent of trailer trash. Spend money on crap food, fags and on Burberry gear.
Choose and boo
k–to make the NHS look good we now let you choose if you want to go to your local hospital or one 50 miles away.
Copper–policeman; precious metal.
CPR–cardiopulmonary resuscitation.
Cross matching–finding out what batch of donated blood is compatible with the patient’s.
Dowie, Iain–footballer (very, very good in his time) and manager (not so good). Like all the best sportsmen he has got a big, ugly bent nose.
DGH–district general hospital. Your local hospital. Apparently our affection for them is the problem for the NHS and they must be destroyed. Personally, I think they do a good job for the populations they serve.
Diagnostic and treatment centres–New Labour term for hospitals. So we close down NHS DGHs and open these ‘for profit’ diagnostic and treatment centres instead. Makes sense to me. Same as independent treatment centres/private treatment centres.
DVT–deep vein thrombosis.
ECHO–echocardiogram. Takes an ultrasound picture of your heart. It looks like a fuzzy black and white TV screen. I have no idea how people can actually interpret these things.
Fast bleeped–called quickly. Response is often variable.
Frusemide–a drug that makes you pass urine. The Americans keep trying to get us to change the way we spell it, but I won’t succumb to the pressure.
Fracture–exactly the same as a break.
Glomerulonephritis and cANCA–something to do with the kidneys but the subject went way over my head at medical school. Only properly understood by renal specialists and perhaps Einstein.