In Stitches_ The Highs And Lows Of Life As An A And E Doctor Part 3

Why bother coming?

It's a Sunday. The weather is beautiful. There are hills to walk up, football matches to watch, women/men to chat up, beer to drink and the seaside is only an hour's drive away. You are young and healthy, with money in your back pocketthe world is your oyster. Lastminute.com is offering you 12 hours in New York for 3, the cinema has a new movie on; you have a new h.o.r.n.y girlfriend who has lost her rabbit. You could do anything. So why on earth do you sit in A&E for 5 hours (sorry, Mrs Hewitt, 3 hours and 59 minutes on the computer), for me to see you and say there is nothing wrong with you? Look, go to your GP if you are worried about non-urgent things and next time you come, read the sign outsideACCIDENT AND EMERGENCY DEPARTMENT.

Some examples from the last few days: 1. 8-year-old kid at school. Fell over and grazed his knee. Played football for 30 minutes after injury before the bleeding became too noticeable. His school was not happy to take the responsibility to wash the graze and give him a paracetamol. So the poor kid waited 4 hours and 30 minutes (whoops...3 hours and 59 minutes to you, Mrs Secretary of State for Health) to see a nurse to have it cleaned and bandaged. If the kid had just had a teacher who was legally allowed to show common sense, he could have been at school having fun and perhaps learning something, as opposed to sitting in the waiting room all day. 2. 50-year-old man: 'Doctor, I went to bed and woke up and felt scared and so called an ambulance.' He was having a nightmare. Now, I am not annoyed with him, just the lack of mental health support in the community, which can look after patients with his type of condition. 2. 50-year-old man: 'Doctor, I went to bed and woke up and felt scared and so called an ambulance.' He was having a nightmare. Now, I am not annoyed with him, just the lack of mental health support in the community, which can look after patients with his type of condition. 3. Man with chronic hip painno worsehad it for two years. The GP he likes is on holiday, so came to us instead. Needs a new hip, but doesn't need to come to A&E. Poor bloke, not annoyed with him, but more at the system for allowing waiting lists of eight months for hip operations. (N.B. Clever statistics would show that he has only been waiting four months for the hip, but he waited four months to see the orthopaedic surgeon to tell him that he needs an operation. In the real world that is an eight-month wait. In NHS world, it is four months. However, that is still much better than in the days of the Tories ruining the NHS. Now at least the waiting lists are coming down quicklyeven if they have done it in a very expensive and divisive way.) 3. Man with chronic hip painno worsehad it for two years. The GP he likes is on holiday, so came to us instead. Needs a new hip, but doesn't need to come to A&E. Poor bloke, not annoyed with him, but more at the system for allowing waiting lists of eight months for hip operations. (N.B. Clever statistics would show that he has only been waiting four months for the hip, but he waited four months to see the orthopaedic surgeon to tell him that he needs an operation. In the real world that is an eight-month wait. In NHS world, it is four months. However, that is still much better than in the days of the Tories ruining the NHS. Now at least the waiting lists are coming down quicklyeven if they have done it in a very expensive and divisive way.) 4. 28-year-old manpain in his foot for three days after playing football. No obvious injury and has been able to run on it but as it was still sore this morning, he called an ambulance. Not taken any a.n.a.lgesia. Well, if he had, it might not hurt so much. He demanded an X-ray; I asked why he had called an ambulance. He said he paid his 'f**king taxes to get X-rays when he wanted one', but didn't answer my ambulance question. I reminded him that he paid his taxes so that I could decide if I would X-ray him. He went on about patient choice to call an ambulance and choice of getting an X-ray. I had to listen to his twaddle and be polite. It was hard. I wish there was a campaign for doctor choice as well as patient choice. I would have chosen to tell him where to go. Instead, I was polite and moaned about him when I got home from work. 4. 28-year-old manpain in his foot for three days after playing football. No obvious injury and has been able to run on it but as it was still sore this morning, he called an ambulance. Not taken any a.n.a.lgesia. Well, if he had, it might not hurt so much. He demanded an X-ray; I asked why he had called an ambulance. He said he paid his 'f**king taxes to get X-rays when he wanted one', but didn't answer my ambulance question. I reminded him that he paid his taxes so that I could decide if I would X-ray him. He went on about patient choice to call an ambulance and choice of getting an X-ray. I had to listen to his twaddle and be polite. It was hard. I wish there was a campaign for doctor choice as well as patient choice. I would have chosen to tell him where to go. Instead, I was polite and moaned about him when I got home from work.

There are loads more. People will not take responsibility for themselves or others. Some are just selfish, others just have mental health issues and the community services are not in place. Some just don't go to their GP for one reason or another. In the end, there is no inappropriate A&E attendee, just someone who doesn't know what the alternatives are (and when they should be used), or who lives in an area where the alternatives are not properly resourced.

I am so glad I am tired

Last night I went to bed at 10 p.m. My wife was not well at all, high temperature, coughing and sneezing and lethargyMan 'flu, I diagnosed, and so I agreed to look after our non-sleeping child all night. I was nervous and the antic.i.p.ation of being awakened stopped me falling asleep. I resorted to desperate measuresI started reading the British Medical Journal British Medical Journal: 30 seconds later, I was out like a light.

Two hours later the crying started. Back to sleep, and then up again at 2 a.m., then 4 a.m. and then 5.30 a.m. I wish I could invent a cure for colic and teethingsomething more ethical than ear plugs. But alas no...So, off to work at 7.30 a.m. and I was exhausted. I believe that the b.a.s.t.a.r.d who invented the term 'sleeps like a baby' never met anyone under five.

I arrived as the red phone went off. Information from the ambulance crewpaediatric arrest. Patient, six months, mottled and blue on arrival. The senior nurse called the paediatric resuscitation team down, but we all knew the probable outcome: this was a cot death and we were going to be going through the motions just in case and also to help the long-term grieving process.

The child came in with mother screaming. The thing I noticed was that he had the cutest little blue socks on which were the same colour as his skin. Our initial expectations were correct. We had all agreed our jobs, with the paediatric registrar being in charge of us all. My job was to get an interosseous line in (this is where a needle is quickly inserted into baby's leg bone as a very quick way to give fluid and drugsyou do this when they are so ill they have no visible blood vessels). I got on with my job, but felt sick. I wasn't in charge and could just concentrate on my job. Somehow I felt very detached from the whole situation. All the voices seemed distant. The mum's cry was audible, as was the counting of the cardiac compressions, but it all felt surreal. I can't explain why I felt like this but I did. I pushed the needle a little harder and felt the pop of the needle going through the baby's bone. It was a huge sense of relief that I had done the part I was supposed to do. I attached the needle to fluids and gave drugs that others had drawn up.

The drugs were not helpingnothing was. We were keeping his blood pumping with the compressions and the anaesthetist was breathing for himbut he was dead and had been for a long time. We all knew it but n.o.body wanted to give up. n.o.body wanted to stay 'Stop' in front of mum.

It felt like fruitless cruelty, but I rationalised it by knowing that the child would feel nothing and the grief would perhaps be easier in the long run for mum and dad if they knew we had tried everything.

I wanted to say 'Stop' but my colleague in charge murmured a suggestion of doubling the usual adrenaline doseno-one really thought it would work, but no one said so. It is much easier to stop resuscitating an elderly adult than a child. No one wants to be the first to say stop. After about 15 minutes, one of the senior nurses first brought up stopping. No-one really responded but a general agreement was made to continue for another cycle (2 minutes) But then, thankfully, the (right) decision was taken out of our hands. 'Please stop...Stop, STOP. STOP. He's dead...My baby is dead.' We all looked at each other, nodded and stopped. The barbaric-looking lines and tubes were removed and the senior nurse wrapped him in a blanket. He picked him up and took him to mum. She held him and sobbed, and sobbed and sobbed...and then started speaking to him, 'I am so sorry I let you down today. I'll make it up to you. Tomorrow, we can go to the zoo and see all those animals you like.'

At this point I couldn't stay in the resuscitation room any longer. The consultant paediatrician was coming in from home to talk with the mother about what had happened. I was so glad it wasn't my job, because all I wanted to do was cry and have a cup of tea.

I made the tea and went to calm my nerves for a few minutes. I was soon interrupted by one of the new nurse managers who came and found me and barked an order, 'The bloke in cubicle three needs to be seen now or he is going to breach his 4-hour target,' he said. I couldn't believe it. I had just been part of a failed resuscitation of a child and all he cared about was some poxy figure. 'I couldn't care less,' I wanted to scream. Unfortunately, all I ended up muttering was 'I'll be there in a minute.' How I hate myself when that happens.

The senior nurse, who had been at the failed resuscitation, came and found me, gave me a hug and said, 'Have your tea. Sod the pointless figures...someone can always fiddle them.'

I smiled, happy that the vast majority of nurses have kept their sanity despite the government interference, and went to my next job: a man who had called an ambulance for a painful shoulder which he had for 4 years...ah, the joys of working in A&E...

By the end of my s.h.i.+ft, I was exhausted. But I was so, so glad I was tiredmy child had kept me up all night. That other kid's mum and dad had had an undisturbed night's sleep. That little boy wouldn't have made a sound for the last few hours.

...What a s.h.i.+t start to the day.

People we refer to

The A&E doctors often refer to specialist doctors and other health-care professionals. Listed below are a few of the people we work with and what they do. (This is all tongue-in-cheek and if I offend anyone, then I am truly sorry.) Radiologists Radiologistsdoctors who specialise in looking at X-rays and scans. Older ones specialise in explaining why the test you want to do is not justified, younger ones specialise in not only doing the test, but then putting various tubes in to the patient while they are having the test. Never call them radiographersapparently they get upset. Plastic surgeons Plastic surgeonsas consultants they spend a lot of their time making money out of people with low self-esteem. As trainees they spend a lot of their time treating burn victims and nasty hand injuries. Respiratory specialists Respiratory specialistsknow a lot about chests, tuberculosis (TB) and asthma. Like to t.i.tter when they say to patients 'big breaths'. (If anyone says this to you, do NOT say 'well thank you doctor!' and play with your hair.) Cardiologists Cardiologists.e.xperts on knowing lots about the heart. They are also experts on making sure that you know that they know a lot about the heart. They like the phrase 'A stent in time, saves nine!' The last breed of doctors to not realise that wearing a bow tie makes them look like an idiot. Junior surgeons Junior surgeonscavalier with their approach to cutting. Senior surgeons Senior surgeonscavalier with their approach to putting. Gynaecologists Gynaecologiststhe Heineken of all doctors. Can reach the parts that others can't. Acute medical doctors Acute medical doctorslook after a very similar type of patients to A&E doctors with a similar approach; but have got longer than 4 hours to play with. General medical doctors General medical doctorslook after patients with 'medical' conditions (e.g. heart attacks, strokes, heart failure, pneumonia). Like to organise a lot of teststhe more expensive the better. Paediatricians Paediatricianslook after little kids. Always happy. Colourful ties. Generally nice. Orthopaedic surgeons (orthopods) Orthopaedic surgeons (orthopods)known as the carpenters of the medical world through their mending of bones and replacing of joints. They take pride in knowing as little medicine as possible. They are the b.u.t.t of medical doctors' jokesreplace the word 'blonde/Irish' with the word 'orthopod' and the joke is usually funny to doctors. Favourite ortho jokes include: How many orthopods does it take to change a light bulb? One: referral to the medics, 'darkness, query cause?' How many orthopods does it take to change a light bulb? One: referral to the medics, 'darkness, query cause?'What is the definition of a double-blind trial? Two orthopods looking at an ECG.What is the difference between an orthopaedic surgeon and a carpenter? The carpenter knows more than one antibiotic, etc., etc. Rheumatologists Rheumatologistsgive you tablets for your arthritis. When they stop working, send you to the orthopods. Psychiatrists Psychiatristsdon't like people saying 'You should have your head examining if you want to see a psychiatrist.' A lot of their time in A&E is for risk a.s.sessment for depressed patients; a small proportion of their time is for truly floridly psychotic patients. Generally poor taste in clothessandals and tweed. Use phrases such as 'erotic counter transference', when trying to explain that they thought their last patient was quite fit (in the attractive, not necessarily athletic sense). Anaesthetists Anaesthetistsput people to sleep for surgery, usually by drugs but sometimes by conversation. Very useful when we have very sick patients as they can put in central lines (large intravenous lines through which fluids, blood and drugs can be given quickly) and take over their breathing when patients are struggling. More and more A&E doctors are learning these skills too. So, in the future, we may have to call for these doctors' help less and less. They can therefore spend more time concentrating on their specialist subjectssudoku and crosswords at the local independent treatment centre. Renal doctors Renal doctorslook after patients who have damaged kidneys. Highly intelligent, but can be a little dull. Understand glomerulonephritis and cANCA. (see Glossary, p.256). Be wary of dialysis specialists. They get offended easily, so don't take the p.i.s.s out of them. It's their job to do that to their patients Geriatricians Geriatriciansunsung heroes of the NHS. See ma.s.sive amounts of patients and act in pragmatic wayby not treating each sign and symptom but the patient. Sometimes difficult to tell the doctor from the patient. Oncologists Oncologistssung heroes of the NHS. Fair enough, though, they do a good job. Palliative care doctors Palliative care doctorstreat terminal patients. Aviation doctors Aviation doctorstreat patients in terminals. Midwives Midwivesthey deliver babies and us from evil. Don't mess or answer back. Ever! Dermatologists DermatologistsIf you are able to refer to one of these as an emergency, you work in a big teaching hospital. They look at rashes and give them a Latin name to look clever and then prescribe steroids Ophthalmologists Ophthalmologistseye specialists. Could replace their on-call service with an automated answer message. 'Press 1 for me to say give chloramphenicol ointment and I will see them in the morning', press 2 for me to say give chloramphenicol and review in two days time', etc. Urologists Urologistswillie doctors. They love themshort ones, big ones, thin ones, long ones, fractured ones, infected ones, bent ones, lacerated ones...any typethey will have them. Also look after kidney stones and the prostate gland and erectile dysfunction which isn't an A&E condition. Please remember that I do not give v.i.a.g.r.a from A&E, so don't come and ask for it...even if she is really fit and you haven't had any for years. And no, I will not call a urologist to prescribe it for you either. Not getting a hard-on is not an accident or emergency condition. Go to your GP...Sorry, I just remembered a patient who made me irate about six months ago.

So there you have it. Now when you hear a doctor say that they are going to refer you to a so-and-so doctor, you will know what to expect.

Why patients are more important than budgets

I saw a 76-year-old gentleman yesterday. The poor man had had a stroke. He had very severe weakness down his left side. Once the stroke has already occurred, there is little that can be done initially for the patient (although at some hospitals, strokes are being treated like heart attacks and clot-busting drugs are given). Generally, though, it is more about long-term rehabilitation and preventing further strokes.

When I looked at the A&E notes from exactly four weeks ago, I noticed that he had come in with a TIA (transient ischaemic attack)often called a 'mini' or 'warning' stroke. He had had 10 minutes of arm weakness which had resolved. Quite rightly, the doctor who had examined him had ascertained that it had resolved and he could go home. The A&E doctor wanted to refer him to a rapid access 'TIA/stroke prevention' clinic. In these clinics, a specialist tries to reduce the chance of a stroke happening. Patients get an urgent CT (computed tomography) brain scan and a scan on the neck (in case there is a blocked artery which may need an operation), not to mention getting started on the necessary drugs to prevent further strokes such as aspirin. If he had been referred, this would have been excellent A&E treatment. A letter to the GP would have let them know what was going on. The problem was that he was not referred to the clinic. Owing to the financing arrangements of hospitals and GPs, we are encouraged not to make direct referrals but to refer the patient back to their GP for them to make the referral to the clinic. The reason for this is purely arbitrary accounting rules. Although the cost is all borne by the NHS, if the referral comes from the GP, it comes from a different pot and the hospital can then be paid by the PCT (primary care trust). Dull accountancy facts, but important for this patient.

The waste of time is the thing that annoys me (for the patient, not just the GP). The patient couldn't see the GP over the weekend and then, when he booked an appointment, he didn't tell the receptionist it was urgent and asked to see his regular GP who only worked two days a week and was on holiday. As a result, he had to wait till the following Tuesdaya delay of 10 days so far. The referral was then promptly made, but he had not yet been seen in clinic by the time he came back to A&E. This is despite evidence-based medicine advocating that these patients are seen in clinic within two weeks of a warning stroke. It is upsetting that at courses and medical school we learn the gold standard of care but then often end up only being able to provide a silver or bronze quality of care because of local guidelines, management structures or rationing of resources.

I am not saying that this delay in being seen in clinic was the cause of his stroke, but if A&E could have referred him to the clinic, he might have had an operation and the stroke could possibly have been prevented. But no, the NHS has become disjointed, with separate parts working independently of each other without the cooperation that used to be present. Accountancy rules ruled over clinical care.

Sadly, this is just one example. So that hospitals can earn money when patients are seen in clinic, A&E doctors refer fewer and fewer patients to specialist clinics. Everything must go through GPs now. This is sensible for conditions that may be chronic and for which the GPs may have already organised various tests, but for new conditions these rules are madness. It is an inefficient use of GP time and a waste of resources.

Accountancy rules run the NHS and not common sense. In some hospitals, even consultants, who see patients in outpatient departments at the GP's request and want an opinion from another specialist before making final treatment judgments, have to refer them back to their GP for the GP to refer on. If this isn't done, then apparently the hospital won't get paid for the cost of the second opinion.

So why are these rules in place? Part of the logic of this is also to do with the new concept of patient choice and the involvement of the private sector. The government thinks that it can drive up standards and save money by making GPs the purse holders to the NHS. 'Payment by results' is the term it is using to mean that primary care trusts via your GP pay for 'episodes of care'. This is why the referrals need to come from from your GP and not a hospital doctor (who in fact may know a lot more about your current problem because they have been dealing with you.) The GPs can now refer you to your local hospital or a local private treatment centre, depending on patient preference. This is OK in principle but most patients, if they had the choice, would choose a local well-run hospital where profit was not a concern. What is happening is that money is being taken out of hospitals and spent on private companies. The hospitals are suffering as a result and are starting to have to compete against these private treatment centres. your GP and not a hospital doctor (who in fact may know a lot more about your current problem because they have been dealing with you.) The GPs can now refer you to your local hospital or a local private treatment centre, depending on patient preference. This is OK in principle but most patients, if they had the choice, would choose a local well-run hospital where profit was not a concern. What is happening is that money is being taken out of hospitals and spent on private companies. The hospitals are suffering as a result and are starting to have to compete against these private treatment centres.

Some hospitals will be good at one thing and charge a cheaper rate and get the business. Others will not be so good and then lose business. So, in the future, your local hospital may not have all the necessary services. For example, your local knee surgeon may have been made redundant and had to move 70 miles away to the local 'knee specialist hospital'. This is fine for elective operations but what happens if you are in a car accident and your knee is damaged? Now that there is no longer an experienced knee surgeon working at your local hospital you either have to travel miles to a 'centre of excellence' or possibly receive substandard care locally. This is the logical end result of current government thinking.

When the government was implementing these changes I don't think that they thought through the effects that these changes would have on emergency-care patients. An unintended consequence of payment by results and patient choice is services being damaged at the local hospitals as well as referrals to clinics being delayed. If the government truly wants patient choice then let patients have what they are asking for: properly run local hospitals where care comes before accountancy rules and regulations.

An occupational hazard

A teenager would sometimes love my job, but there are hazards. It was 7.30 a.m. and the last patient before I finished, and I was looking forward to some scrambled eggs in the canteen. He had come in with a nasty abscess on his b.u.t.tock. He needed it incised and drained. I put a scalpel in the abscess and squeezed. Pus upon pus squeezed out. I gave it one last squeeze and then disaster struck. The pus squirted straight in my face. Egg-like Staph. infection all over my right cheek and gla.s.ses. I remained professional, finished the minor operation, then left my nurse colleague to finish off dressing the wound and went to wash my face thoroughly. As I found the sink and disinfectant, my colleague, who was starting his s.h.i.+ft, saw what had had happened and reminded me of the time when this happened to him about a month ago. Except that his mouth was open at the time and he wasn't wearing any gla.s.ses.

Feeling a bit sick, I decided to give scrambled eggs a miss this morning and went to sleep without breakfast, but after a very long shower.

I don't understand some patients

Last night I saw a patient who was having unstable angina. He needed drugs to relieve the pain and treat the condition, but despite about an hour of persuasion he refused to let me put a needle into his arm, and give him the drugs. He explained that he did not believe in western medicine and therefore refused my drugs. Why he came to A&E in that case was beyond me, but it was really difficult seeing a man whom I could have so easily helped sit there in agony. However, patients (quite rightly) have a right to decide what treatment they will or will not accept. It's just that I did not understand why he came if he was going to refuse treatment.

The case reminded me of another man I had seen a few weeks ago with a dislocated shoulder. I needed to give him morphine for pain relief but he refused an intravenous cannula because he was scared of needles. Normally, a couple of minutes persuasion and they will agree to it; but not him. The thing that confused me on this occasion was, if he was so scared of needles, how come he had so many tattoos?

A trip round A&E

When patients come to A&E, they only see the small bit of A&E that they are in. This quick guide tells you a little about what is in an A&E department so, if you can't see things going on, then at least you may know where the doctors and nurses are and what they might be doing.

Let's start the tour at the front entrance. It is often a very flash and expensively done-up area of the A&E department. You may find a 'mission statement' on the wall. These are usually 'management speak' rubbish about striving for optimal health in a holistic way, while encompa.s.sing your disabilities and understanding your cultural sensitivities, blah, blah, blah. If you have a half-hour wait read it. If you have a 3-hour wait to be seen, kill some time and try and translate it into English. Alternative things you could read are adverts for 'no-win, no-fee' solicitors and the in-house hospital glossy magazine: reading either is bad for your blood pressure.

So, you walk in and get to the reception area. Depending on where you live, there will either be a security guard near by and bullet-proof gla.s.s, or a vase and some flowers.

After you have booked in, you go to the triage nurse. They have a nice room, with lots of bandages and splints, etc., and they decide how sick you actually are and therefore who you are going to see and where. You can become a 'majors patient', because they think that you may need a bed to lie on, or a 'minors patient', where you will get a seat in a waiting room, or, if they think you might die because you are so unwell, you will get sent to the resuscitation room. The same process of triage happens if you come by ambulance but is not done in the triage room, but in the main part of the A&E. Unless you have been sent direct by your GP to one of the specialist doctors you will see an A&E doctor in one of those three areas. However, in a few cases the triage nurse may think it appropriate for a specialist doctor to see you straight away (e.g. if you are very pregnant) and may send you straight to the ward.

Recently, changes have meant that if your condition is minor, the triage nurse may redirect you to your GP or get an emergency nurse pract.i.tioner (ENP) to see you. They may even discharge you themselves. These triage nurses have done extra training to be called SMINTS (senior minor injury nurse triage). They are also called 'See and Treat', often nicknamed 'See, Treat and Street' them.

Minors is a less high-tech part of A&E. There are plaster trolleys lying around and lots of bandages. Minors is a very poor name. It may be a minor injury that you have, but it could be very significant to your quality of life. It is also quite demeaning to patients to say they are a minor case. But anyway...

Down the corridor from minors is usually the Radiology department, where they do X-rays, etc. In minors, you can often hear screams as minor fractures are relocated here and local anaesthetic injected. Not that exciting.

Majors is where you see elderly patients who have collapsed due to an unknown cause. You also see patient with chest pains. Apparently, other patients get seen there, but I don't seem to see many others. We do blood tests here and send them for scans and X-rays if necessary. From here we can send our patients to one of five places. 'Home' and the 'mortuary' are self explanatory (although should never be mixed up). If they have a condition which just needs observationi.e. a head injurythey can be sent to the A&E overnight ward, if your hospital is lucky enough to have one, which is usually situated somewhere near the A&E department. If your condition means that you will need longer than 4 hours before we can decide whether you need admission or not you may get sent to a CDU ward (CDU stands for clinical decision unitnot the 'can't decide unit'). Please note, if you need hospital admission you shouldn't be sent to the A&E ward or CDU wardyou may go there only if there is nowhere else to send you. Lastly, you can be sent to a normal ward, if the doctors think you need admission. Very rarely do you get sent from A&E to the appropriate specialist ward. More often, you go to the MAU (Medical Admissions Unit), where they might send you for a short stay to be further a.s.sessed before going to the appropriate specialist ward.

At any stage, the A&E doctor may ask a specialist doctor to review the patient, who may or may not admit them to a hospital bed. The doctor who decides if you need admission is initially the A&E doctor but that plan may be changed by the specialist doctor. It is confusing, but trust me when I say I am trying to simplify it!

The final place you may go is the resuscitation roomResus. This is the high-tech bit of A&E. Lots of machines go beep here. There is the equipment to put people to sleep and defibrillators to restart their hearts. I find this the most relaxing part of A&E as you don't get constantly disturbed by trivia and you always get a nurse allocated to work with you. From here, the very sickest patients often go direct to the mortuary, via the viewing/grieving room. However, if they are lucky they also can go to ICU from here, or, once stabilised, back into A&E and then to a ward. The traumas and cardiac arrests are all seen here and there are often many doctors involved in these patients' care as we call the Resus and trauma teams down from the wards to help the A&E doctors (teams are composed of the on-call doctors for that day from specialties such as Anaesthetics, Medicine, Surgery and Orthopaedicsdepending on the type of call put out. Again, don't get the calls mixed up as you really don't want an orthopaedic doctor at a cardiac arrest call).

There are lots of other bits to A&E that you probably won't see: the officesusually far too many of them; the store rooms (where, contrary to popular belief, there is very little 'action'); stock cupboards and the utility rooms where bodily fluids are cleared away. Finally there is a coffee room and a seminar room. To me it all feels strangely like home.

A&E Room 101

I don't know if you have heard of Room 101 Room 101. It is a vaguely amusing programme with Paul Merton as the host, where guests come along and say what they would eradicate from society to make their life a better placefor example, parking attendants, men wearing sarongs, Simon Cowell-inspired boy bands, Simon Cowell, etc.

I have been thinking that if I could, I would like to be able to go on Room 101 Room 101. I would pick the things I could get rid of in society to make my life at work easier (i.e. make there be fewer accidents), so I can spend less time seeing patients and more time flirting with the nurses.

I have compiled a listI have called it the A&E Room 101: 1. Lawn bowlsa surprise choice coming at number 1. The number of little old ladies coming in with a fractured hip after tripping on a bowls ball is ridiculous...And the stress of the game! I have seen two heart attacks induced by the high-pressure situations of the inter-village summer lawn compet.i.tion. Why can't these people play a less dangerous sport? I have never seen anyone over 70 with a rugby injury or a hang-gliding injury. So come on you health and safety managers. Let's ban bowls. 2. Wonderbra advertsin at 2 this is possibly another surprise choices.e.xy roadside advertisingespecially those 'h.e.l.lo boys!' Wonderbra adverts with the fit girl. When that advert was around, I used to dread coming to work. I would have a number of conversations similar to this one: 'Yeah. I was just driving to work and I got distracted by that advert of the fit bird with her big t.i.ts covered by a Wonderbra. Anyway I had to have a look, know what I mean. Just as my head was in the opposite direction to the way my car was going, I crashed into a wall. So here I ammy arm is broke.' 2. Wonderbra advertsin at 2 this is possibly another surprise choices.e.xy roadside advertisingespecially those 'h.e.l.lo boys!' Wonderbra adverts with the fit girl. When that advert was around, I used to dread coming to work. I would have a number of conversations similar to this one: 'Yeah. I was just driving to work and I got distracted by that advert of the fit bird with her big t.i.ts covered by a Wonderbra. Anyway I had to have a look, know what I mean. Just as my head was in the opposite direction to the way my car was going, I crashed into a wall. So here I ammy arm is broke.' 3. 4 4 (Chelsea tractors), especially the ones with bull bars4 x 4s are designed for muddy terrains; bull bars are designed for hitting bulls. However, these eco-friendly 'Chelsea-ites' don't realise this. They drive in areas that are surfaced with tarmac, with lots of kids running aroundthere are very few bulls. So when the car hits a kid (instead of a bull), it does what it is designed for and injures the kid (instead of a bull) while protecting the car from being damaged. If you need a 4 x 4 because of where you live, then fair enough. But otherwise think about other people's safety before going out on the school run. 3. 4 4 (Chelsea tractors), especially the ones with bull bars4 x 4s are designed for muddy terrains; bull bars are designed for hitting bulls. However, these eco-friendly 'Chelsea-ites' don't realise this. They drive in areas that are surfaced with tarmac, with lots of kids running aroundthere are very few bulls. So when the car hits a kid (instead of a bull), it does what it is designed for and injures the kid (instead of a bull) while protecting the car from being damaged. If you need a 4 x 4 because of where you live, then fair enough. But otherwise think about other people's safety before going out on the school run. 4. Motorised mini scooterswhy are they on our streets and estates? They are possibly the most dangerous things I have ever seen. They are tiny bikes that go very fast and you crouch on them. A lot of people fall off. Quite a few get really nasty injuries. They were sold with the proviso that they were not toys and were only to be used in private estates. The people that sold them knew that the people who bought them would live on estates where ponies are trainers and butlers are a type of cigarette. Were they more interested in profit than public safety? I wonder. Please don't buy one for your kids. They really are dangerous. 4. Motorised mini scooterswhy are they on our streets and estates? They are possibly the most dangerous things I have ever seen. They are tiny bikes that go very fast and you crouch on them. A lot of people fall off. Quite a few get really nasty injuries. They were sold with the proviso that they were not toys and were only to be used in private estates. The people that sold them knew that the people who bought them would live on estates where ponies are trainers and butlers are a type of cigarette. Were they more interested in profit than public safety? I wonder. Please don't buy one for your kids. They really are dangerous. 5. Excessive outdoor Christmas decorationsapart from being aesthetically Chavy, they cause problems for two reasons: (a) people fall off roofs and get electrocuted while putting them up and (b) people drive past them and look at them saying 'what is that Chavy monstrosity?', and fail to notice the car in front until it too late. 5. Excessive outdoor Christmas decorationsapart from being aesthetically Chavy, they cause problems for two reasons: (a) people fall off roofs and get electrocuted while putting them up and (b) people drive past them and look at them saying 'what is that Chavy monstrosity?', and fail to notice the car in front until it too late. 6. Skateboardsbut only in the over-18s. When I was at junior school, I used to play on one and would occasionally fall off. I once broke my wrist because of it, but it was an accepted occupational hazard of being a kid. However, there is no excuse for anyone over 18 to play with a skateboard. Do you know how stupid you look doing it, especially when you fall off and have to come to A&E? Leave adults to drink and smoke, and leave kids to play on skateboards. The same applies to BMX bikes. As a public education measure, even if it is not cool, please get your kids to wear a helmet and knee and elbow pads. It would mean I would dread working the school holiday days that little bit less. 6. Skateboardsbut only in the over-18s. When I was at junior school, I used to play on one and would occasionally fall off. I once broke my wrist because of it, but it was an accepted occupational hazard of being a kid. However, there is no excuse for anyone over 18 to play with a skateboard. Do you know how stupid you look doing it, especially when you fall off and have to come to A&E? Leave adults to drink and smoke, and leave kids to play on skateboards. The same applies to BMX bikes. As a public education measure, even if it is not cool, please get your kids to wear a helmet and knee and elbow pads. It would mean I would dread working the school holiday days that little bit less. 7. 7. Jacka.s.s Jacka.s.sthe hit TV show and film. A group of pain-resistant Americans do stupidly dangerous stuff and then film it. Luckily, they say at the beginning that these are performed by stunt actors and that kids shouldn't copy themwell, that works, doesn't it? That'll stop themthey think 'Oh no I won't try and imitate these cool people; I'll go and play chess with Tarquin now.' A couple of years ago I had a spate of kids dive-bombing out of a tree while screaming 'JACKa.s.s'. They often went through a bush onto the ground below, into A&E via an ambulance and then onto theatre via the CT scanner. I am dreading the new film coming out. 8. Ineffective safety warningscompanies are so worried that they are going to get sued nowadays that they put ridiculous disclaimers everywhere. So many, in fact, that they start to become ineffective. For example, last week I had a patient with an anaphylactic reaction to nuts. She had a known allergy, but says she now ignores all disclaimers for 'may contain nuts or nut extracts or made in a factory where nuts are used or once been within a 50-mile radius of a nut' otherwise she would have nothing to eat. They are now put on everything for fear of being sued and it is completely uninformative, so she ignores them all. One thing I don't object to, and others do, are stupid warnings. For example: KP nuts, WARNING. MAY CONTAIN NUTS. McDonalds coffee, WARNING. CONTENTS ARE HOT AND MAY SCALD. I think these signs save the lives of a particular subgroup of people who often attend A&E and I thank the companies for their corporate responsibility. 8. Ineffective safety warningscompanies are so worried that they are going to get sued nowadays that they put ridiculous disclaimers everywhere. So many, in fact, that they start to become ineffective. For example, last week I had a patient with an anaphylactic reaction to nuts. She had a known allergy, but says she now ignores all disclaimers for 'may contain nuts or nut extracts or made in a factory where nuts are used or once been within a 50-mile radius of a nut' otherwise she would have nothing to eat. They are now put on everything for fear of being sued and it is completely uninformative, so she ignores them all. One thing I don't object to, and others do, are stupid warnings. For example: KP nuts, WARNING. MAY CONTAIN NUTS. McDonalds coffee, WARNING. CONTENTS ARE HOT AND MAY SCALD. I think these signs save the lives of a particular subgroup of people who often attend A&E and I thank the companies for their corporate responsibility. 9. The new ethos of excessive risk management and risk avoidanceschools and clubs are scared to take their kids on trips for fear of the consequences of an accident. Things have become so rigid in society that people are going against the excessive bureaucracy and doing the most bizarre and dangerous sports and challengeskite surfing, gra.s.s tobogganing and such like. It is two fingers to the no-risk culture and gets their adrenaline pumping...and when they have their horrendous accident and come to A&E, it gets me injecting adrenaline into them. 9. The new ethos of excessive risk management and risk avoidanceschools and clubs are scared to take their kids on trips for fear of the consequences of an accident. Things have become so rigid in society that people are going against the excessive bureaucracy and doing the most bizarre and dangerous sports and challengeskite surfing, gra.s.s tobogganing and such like. It is two fingers to the no-risk culture and gets their adrenaline pumping...and when they have their horrendous accident and come to A&E, it gets me injecting adrenaline into them.

How to be a good patient

The government wants to increase patient choice. I want to increase doctor choice. I want a system where we choose and book and decide which patients we are going to see; depending on how 'good' they will be as a patient. It will never happen. Instead, just for my own amus.e.m.e.nt, I have compiled a list of qualities that make you a good patient to see in A&E.

1. Have an accident. 1. Have an accident.2. ...or an emergency.3. Always, always, unless you fulfil criteria 1 or 2, go to your GP first. They get paid a lot more than me.4. ...Even if you don't like bothering them.5. ...Even if you have to wait 2 hours for an appointment.6. See point 3 again just to make sure you remember it.7. Don't come just because your no-win, no-fee, no self-respect lawyer has told you to come.8. If you have had a bad back/knee/ankle for more than 2 days, try pain killers before coming to see me.9. Please bring a list of the pills you take. Ridiculously, we haven't got access to GPs' computer records and so, no, I don't know what you are on. It also takes about 4 hours to get your hospital records, so don't say 'You must have a list in the files.' Also, please note that there are thousands of little white pills and even if it does taste bitter, it doesn't help me pinpoint exactly what you are taking. 10. Don't just come for a chat because you are lonely. Go to the pub or your GP. 10. Don't just come for a chat because you are lonely. Go to the pub or your GP.11. Don't call an ambulance because you don't want to spend money on a taxi (they are there for people who need them).12. ...or because you think it will get you seen quickerit doesn't.13. Don't remind me that you have to be seen and discharged within 4 hoursI know, but I am not sitting on my a.r.s.e, I might just be seeing someone sicker than you who met the criteria in points 1 and 2. 14. If you must mention the '4-hour rule' (see point 13) at least get the facts right and don't make up rights that don't exist. 14. If you must mention the '4-hour rule' (see point 13) at least get the facts right and don't make up rights that don't exist. 15. Be polite to the doctors/nurses/receptionists, etc. Don't doubt my parentage because I won't see you before the really sick bloke in Resus. A thank you and a compliment can really make a difference to our day and might get you further along than complaining. 15. Be polite to the doctors/nurses/receptionists, etc. Don't doubt my parentage because I won't see you before the really sick bloke in Resus. A thank you and a compliment can really make a difference to our day and might get you further along than complaining. 16. Don't be racist. Ever. The NHS would collapse if it were not for foreign and non-Caucasian staff. The phrase 'I ain't seeing no Paki doctor' will end up with you 'ain't seeing no doctor'. 16. Don't be racist. Ever. The NHS would collapse if it were not for foreign and non-Caucasian staff. The phrase 'I ain't seeing no Paki doctor' will end up with you 'ain't seeing no doctor'. 17. Don't be h.o.m.ophobic. I am told that 96.7 percentof all male A&E nurses are gay (and they are working hard to convert the other 3.3 percent). 17. Don't be h.o.m.ophobic. I am told that 96.7 percentof all male A&E nurses are gay (and they are working hard to convert the other 3.3 percent). Please note that this is not an accurate figure, just a joke...the true figure is much, much higher Please note that this is not an accurate figure, just a joke...the true figure is much, much higher. 18. If you are from a nursing home and confused, please bring a carer who cares about you and knows why the matron has sent you to A&E. 18. If you are from a nursing home and confused, please bring a carer who cares about you and knows why the matron has sent you to A&E. 19. If you think we have been nice to you, please write in to say thanks. It really does make our day worthwhilegenuinely. 19. If you think we have been nice to you, please write in to say thanks. It really does make our day worthwhilegenuinely.20. Make jokes with us, but please make them funny.21. Don't flirt with the nurses or female doctorsthat's my job.22. When you see us at the desk, don't moan loudly that we are sitting having a chatwe are writing notes and getting advice from specialist doctors. We are only occasionally just having a chat. 23. When asked what happened, try to get to the point in under 10 minutes. 23. When asked what happened, try to get to the point in under 10 minutes.24. Similarly, if describing an a.s.sault, don't explain in detail why it 'weren't your fault'.25. Don't ask female doctors 'When am I going to see the doctor please, nurse?'.26. When I introduce myself as the Registrar don't ever say 'I came here for my chest and not to get married! ha-ha-ha.'27. If I make a jokeplease laugh.28. Understand I am allowed to yawn at 4 a.m. in the middle of a 12-hour s.h.i.+ft so don't say 'Am I keeping you up?'29. When the speciality team I have referred you to asks you the same questions I did earlier, try and answer with the same answers. 30. If you don't agree with what I am doing let me know ASAPI am not a policeman, or a prison warden. I can't keep you in hospital against your will. So tell me you are going to self-discharge before I have organised expensive tests and a bed. 30. If you don't agree with what I am doing let me know ASAPI am not a policeman, or a prison warden. I can't keep you in hospital against your will. So tell me you are going to self-discharge before I have organised expensive tests and a bed. 31. Have a condition we can treat in less than 4 hours to the point of discharge or to admission. Don't come with complicated problems which might mean time-consuming testswe can't have you breaking our precious 4-hour rule, now can we? 31. Have a condition we can treat in less than 4 hours to the point of discharge or to admission. Don't come with complicated problems which might mean time-consuming testswe can't have you breaking our precious 4-hour rule, now can we? 32. Understand that we have emotions too. We may have just seen a child die, or had to break bad news to a relative. It may be our sixth night in a row, and we might be missing our family. We may be carrying emotional baggage with us which our professional facade does not allow us to expose to the outside world. Have patience with us, be polite and friendly and don't moan too much if you have to wait to be seen. 32. Understand that we have emotions too. We may have just seen a child die, or had to break bad news to a relative. It may be our sixth night in a row, and we might be missing our family. We may be carrying emotional baggage with us which our professional facade does not allow us to expose to the outside world. Have patience with us, be polite and friendly and don't moan too much if you have to wait to be seen. 33. If you follow 132, you can (hopefully) expect good quality, timely treatment from A&E staff. 33. If you follow 132, you can (hopefully) expect good quality, timely treatment from A&E staff.

The effects of b.l.o.o.d.y accounting rules

It's not just me who gets annoyed with how accounting rules forget about patients. I went to a conference last week and heard a story about a patient from a fellow A&E doctor. He was 45 and fed up (the patient not the doctorshe was 33 and fed up) and came in because he didn't know what else to do. He had tingling in his thumb, index and middle fingerits called carpel tunnel syndrome. The irritation was so bad that he was having trouble sleeping. He had had it seen by his GP and had been referred to the local surgeon, who, with a couple of minor cuts to the structures in his wrist, could resolve his problem. However, he hadn't seen the surgeon yet or had the operation. The surgeon had available time, there were some brand spanking new theatres to do the operation in and the day ward had a lot of free s.p.a.ce because the local private treatment centre had nicked most of their patients. The actual additional costs for the NHS (sutures, scalpels, bandages, etc.) would have been very minimalthe fixed costs (surgeon, nurses and theatre) had already been met. The problem was that new budget rules mean the PCT pays for each individual operation and his local trust was much overspent. He had had his referral delayed until after April as it would then be in the new financial year. As he had waited less than 18 weeks, the PCT still met its targets. The manager was happy as the cost was delayed for the local PCT until after April, and the government could say that it had fulfilled its targets.

The people who weren't happy were the surgeon and theatre staff, who were bored with twiddling their thumbs, and the A&E doctor who had to give out strong pain killers at 2 a.m., for a problem that could have been sorted out weeks ago. And let's not forget, most importantly, the patient.

I don't profess to understand the details of accounting and I have limited financial management skills (hence my excessive credit card bills) but surely this is madness. When NHS finances and organisations are not cooperative, but compet.i.tive, then middle managers cannot see the wood for the trees. In this case they couldn't see that saving a small amount of money for the PCT would cost the hospital a lot of money, cause resentment in the hospital workers and p.i.s.s off a patient. Well done, Mr Blair, on producing such a ridiculously managed NHS.

Please come to A&E

You may have noticed that I frequently moan about people who come to A&E unnecessarily. However, today I had a patient that I just couldn't believe didn't want to 'bother us'. He was a 55-year-old builder. Six days previously he had spilt molten hot tarmac on his arm. He didn't want to bother anyone, so he put some cream and a dressing on it. It was still painful, but he still didn't want to be a nuisance so he just took more and more a.n.a.lgesia. It was only when he took off his s.h.i.+rt and a work colleague saw his burn that he was persuaded to come to A&E.

He had a small, full-thickness burn, with surrounding partial thickness burn and damage to his nerves. He must have been in agony. I just don't understand how he could have had such a stiff upper lip or not have died already from infection. We sent him straight to the local burns unit where he will stay in for skin grafts but he could very possibly lose the arm.

I have seen many similar cases of people putting up with problems and not seeing a doctor. The most common are chest pain and acute shortness of breath. If you get either of these, come and see us please, and come now. The same advice applies if you pour molten tarmac over your arms.

We have gone drug crazy

I live in a 'high' town. Not in an alt.i.tude sense, but in a drug-taking sense. I saw three interesting patients today, all of whom were in because of drug complications.

The first one came in because he was starting to feel very anxious after taking ecstasyit was his first night on 'E'. I initially tried to calm him down verbally and explain that it was a consequence of the drug, but that didn't work. He just kept on shouting 'I need a beat'. I tried some diazepam but that didn't seem to work either. 'I need to move,' he cried out.

Being a holistic doctor, I decided to go for another tactic. I asked one of my nursing colleagues to come and join me. I instructed her to be a human beat-box. Bemused but compliant, she started going 'boom, boom, boom, boom' to a typical R&B beat. I then added 'oooooooohhhhhh, ooooohhhhh' as an off-beat addition. The patient nodded and started to move to the impromptu performance. Three minutes later he started to feel better and was now calm and compliant. I gave him some more diazepam. He quickly stopped moving, we stopped our beat-box routine and he fell asleep on the trolley. He was discharged relaxed and happy 5 hours later (or 4 hours as was probably put on the computer.) I then saw the effects of a c.o.c.ktail of drugs including ketamine (on an unconscious teenager, with very worried parents). Because of his level of unconsciousness he needed to be intubated and his airway protected so that he didn't choke on his own vomit. He ended up in the ITU for three days at a large cost to you and me as tax payers.

The next patient I saw was a 29-year-old who had given himself chest pains by taking too much cocaine. Cocaine is thought of as a safe, 'trendy' drug. It is not. It is powerfully psychologically addictive and can cause spasm of the coronary arteries. This is what had happened to this patient and he was soon sent to the CCU, where he was the youngest patient by about 40 years. He soon came down from his high, but his cardiac damage is permanent.

It is fascinating working in A&E as you see such weird and wonderful side-effects of drugs. It is also very scary. All three patients had responsible jobs and when at work had others in their care.

Coming home for Christmas

I was really p.i.s.sed off I was working this Xmas Day. I really wanted it off, so I could spend it with my family. But, unfortunately, people get ill outside 95 Monday to Friday and so I suppose it is something that you sign up to when you choose this job... until you are a boss and you can get your juniors to do most of the unsocial s.h.i.+fts.

My mild annoyance soon dissipated very quickly, however, with the arrival of the s.h.i.+ft's first 'major'. A young lad in his 20s had been involved in a road traffic accident and he was arriving in 10 minutes. (The new term is apparently 'road traffic incident' as the traffic police say the word 'accident' implies that n.o.body was at fault and it was a random occurrence. This is hardly ever the case.) As the cla.s.sic song goes, he had been 'driving home for Christmas'. What isn't in the song was that he was driving home for Christmas very fast, as he was going to be late for his festivities. He had also been out late, enjoying a Christmas Eve p.i.s.s up. We found out later, that even though it was 10 a.m., he was still over the limit despite finis.h.i.+ng his partying 8 hours before.

We got the call from the ambulance team at 10 a.m. He had been travelling at 90 mph. No other car was involved, but he seemed to have flipped his car and it skidded 50 metres upside down. He was the only pa.s.senger. Luckily, he had been wearing a seat belt and the air bags had been deployed. I called for the trauma team, which is made up of anaesthetists, surgeons and orthopaedic surgeons who are 'on-call' but during the day are based on the wards and in operating theatres, doing day-to-day work. They come down to A&E when we need their additional help and expertise to manage a trauma. Usually, the trauma is led by an A&E doctor like me, who is in overall charge of the situation while the casualties are in the department. My job is to coordinate everyone, to get a 'wide-angled lens' view of what needs to be done (as opposed to just concentrating on a specific part of the body), to organise definite care and scans and to explain to the patient what is happening.

As soon as the patient came in, I realised that he needed no explanations. His head was bleeding and he was unconscious. After an initial examination, we realised that both his legs were broken. Fortunately, initial examinations showed that his chest and abdomen were not badly damaged.