In Stitches_ The Highs And Lows Of Life As An A And E Doctor Part 7

Yipeee...I am off on holiday! No work for two weeks. I can leave it all behind and not have to think about anything but sun, sea, sand and trying to persuade my wife to have s.e.x.

We were flying in economy cla.s.s to Dubaito sample everyone's favourite new tourist destination. In an attempt to impress my wife, I hadn't bought a paper and had planned to try and charm her en route and therefore guarantee the fourth 's'.

'Stop boring me. I am trying to sleep,' she responded, with no flick of the hair or any sign that I was guaranteed a holiday s.h.a.g on arrival. She fell asleep and I had no paper to read on the journey. I was s.h.i.+t bored.

An hour later she was still asleep and I was still bored.

Two hours later she was still asleep and I was trying to play noughts and crosses with myself.

Then relief! The scariest thing you can hear if you are a doctor on a plane (except perhaps 'We have hijacked your plane, etc.'that is probably scarier): 'Is there a doctor on board?' I was so bored that I jumped up and went running. I wasn't thinking what could be wrong, I was thinking, 'Will I get an upgrade with some better films to watch?'

I got there and saw a woman in her 50s totally unconscious. Oh s.h.i.+t! I couldn't wake her. I was no longer concerned about the upgradeas long as they could give me change of pants at the end of this I would be OK. I went through basic first aid ABC. A for airwaythat was OK. She was still breathing and she still had a pulse. OK, she is safe for a minutebut what do I do now? I asked questions, getting more frantic.

'Does anyone know her? Who is with her? Did she fit?' No one knew her. s.h.i.+t! It is easy in a resuscitation department, but at 12 000 feet a little less so.

Think, Edwards, think. The algorithm that all emergency doctors remember is ABCDEFG and the DEFG, stands for don't ever forget glucose. I turned round and said, 'Can anyone do a BM?' (sugar level test).

What the h.e.l.l was I sayingwe were in aeroplane aisle and not an A&E. Why didn't I ask for a CT scan, a 'chem. 20' or an ECG? I obviously got blank looks from the pa.s.sengers around me that I had hoped had mysteriously turned into nurses.

I asked to see what was in their emergency bag. At the same time, the pilot asked if he should divert. I had one lady's well-being in my hands and 300 people's holiday at stake, including my own. This was not part of the relaxing holiday plan.

Bingo! In the emergency drug box, I saw they had glucagon. It reverses the effects of insulin and can increase your sugar level. I might as well give it a go, I thought. I opened the pack and then realised that in the last five years of medicine I hadn't given an injection. I was on my own and so gave it a go.

A minute or two later, she started to wake up. Yes, it was working. 'Get her some sugar,' I called out. About five stewardesses came running forward (which was a beautiful, wonderful vision). I got more sugar than you could wish for. I gave it to her and she became coherent. It turned out she was a diabetic, had taken her insulin and then got drunk as she was scared of flying. She then felt sick and so didn't eat any dinner. Her glucose level had dropped dangerously low and she had therefore become unconscious. The treatment had taken about 30 minutes of my time, broken up the journey, stopped her getting sick and prevented my holiday plane being diverted.

The senior steward approached me. 'Thank you so muchplease let me upgrade you for the rest of the journey' Lovely jubbly I thought. I'll be mixing with millionaires. I went and got my wife, who was a little embarra.s.sed at the fuss.

With free drinks flowing, I got h.o.r.n.y and she got...tired and fell back to sleep. At least I now had a free paper to read while she was asleep. Being the aeroplane saviour also got me appreciated by her when we finally arrived in a hotel.

You can't escape from the job of being a doctor, but it does have its advantages...

Hospital inefficiencies

It was 1 a.m. in the morning and I was knackered. It was ridiculously busy. It had been non-stop for the last 5 hours. I was examining a little old lady who had fallen and broken her wrist and it needed manipulation (pulling back into a better position). This is a very common A&E procedure and I was getting ready to manipulate this woman's arm when the 'red phone' went off. A heart attack was coming in, in 3 minutes' time.

I had no option but to postpone the woman's manipulation and make her wait at least another hour. I apologised that there were only two doctors for the whole of A&E and that she would have to wait. I also explained to the other people waiting how busy we were. There were a few moans and groans, a couple of patients self-discharged but no-one seemed that annoyed and most seemed to understand.

However, it didn't need to be that way. There were only two A&E doctors working, but there were lots of other doctors in the hospital who could have come and helped. However, there isn't always the cooperation between A&E and the specialist doctors based in the rest of the hospital. If A&E is busy, then there is no arrangement for them to come down just when we need an extra pair of hands (as opposed to see an admission or give specialist advice).

So there I am, slogging my guts out, while others are sitting in the doctors' mess less than 200 metres away. It doesn't often happen that we are the only doctors working (in addition to the medical doctorsthey are always as busy as us), but it does happen frequently enough to warrant making plans on how to utilise all the doctors at night. Being honest, the problem is that there are no expectations for the specialists to help out. When I was working as a specialist junior doctor, I would sit in the mess (even though I had A&E experience) while patients would wait to see an A&E doctor, because that is the way hospitals work.

It may seem a crazy reality, but it is how hospitals function at night. You wait 3 hours with a broken bone to see an A&E doctor, when there may have been an orthopaedic doctor sitting there doing nothing.

I think the reason that there is a tradition for specialist doctors to not come down and help 'just to lend a pair of hands' is because of the tradition of 24-to 48-hour s.h.i.+fts when these doctors needed to sleep. But this is no longer the case. Nowadays, the vast majority of doctors only do 12-hour s.h.i.+fts and so can work through the whole of the s.h.i.+ft.

There can also be a 'them and us' att.i.tude between A&E and specialist doctors. Just because we are the ones who provide the rest of the hospital with a lot of their workload, this shouldn't make us the enemy. The other reason for this lack of collaboration is that some A&E doctors don't want other specialist doctors 'stepping on our toes' and coming in and managing the cases that we can deal with. Surely, what is important is not which part of the hospital micromanagement the doctor works for, but what their skills are and whether they are appropriately trained to see the patient.

Reforms are a necessity for the NHS. Hospitals are starting to introduce a hospital-at-night scheme, where doctors cooperate more, but it doesn't usually involve the A&E doctorswhat madness. We need better reforms which break the inertia of senior management and improve the cooperation between A&E doctors and specialists. This is one example where I think real change to practice would make a ma.s.sive difference. (And it did.) One month later, I was doing another set of nights when a friend of mine was the orthopaedic doctor on for the hospital for a week of nights. She realised how busy we were and spent the whole night (when she could have been asleep) helping out by seeing patients who obviously had an orthopaedic problem directlyas opposed to them seeing an A&E doctor first. It made a ma.s.sive difference, but led to complaints from her colleagues that it set a 'precedent'. How sad that working together can be frowned upon by some of our colleagues.

Crying wolf

All A&Es get their 'regulars'. Often they are homeless people, or drunks or drug addicts. They attend frequently, as their life styles mean that they are p.r.o.ne to getting ill. Also, they don't know how to access primary care resources, or perhaps choose not to. Some staff can get quite close to these patients. It leads to a dangerous relations.h.i.+p, whereby whenever they want shelter or food they attend A&E, as opposed to going through other more appropriate channels.

My colleague saw one of our regulars yesterday. It was his 145th attendance in three years. He comes when he needs a wash or food and shelter. He always puts on a fake abdominal pain and trades getting his needs catered for in return for not making a fuss and leaving soon after dinner. He came in again with abdominal pain, this time after a supposed fight. A brief examination resulted in the usual general tenderness in the stomach. My colleague told him that A&E was not the right place for him to go to when he wanted food and he was discharged without being given dinner. He protested but everyone a.s.sumed it was because of the lack of food.

The next day he came back with a ruptured spleen from the fight. He was rushed to theatre and, thankfully, is making a good recovery after two days in the high-dependency ward. My colleague feels awful. But I think some of the blame lies with the patient for crying wolf and with all of the A&E staff for in the past positively reinforcing his wolf-crying behaviour.

P.S. Three weeks after he was discharged he was back in A&E with abdominal pain. He was given food and left. However, for the last few months he has not been to A&E. Apparently he is currently in jail. As soon as he is out, he will be back. He needs social services, police and A&E to come up with a joined-up plan for him. He also needs to stop crying wolf.

Blind to the problems

It was 4 p.m. and a panicked 29-year-old builder walked in. He had had a sudden clouding of vision over his left eye. The other thing I also noticed was that he was overweight...very overweight. He made John Prescott seem svelte. I examined him and took a history from him. He was reasonably well, but admitted to a poor diet and little exercise. I looked in his eye and there was evidence of damage done to the back of the eye by diabetes. I then did a sugar test18very high, virtually confirming a diagnosis of diabetes. I explained what I thought was going on, and referred him urgently to the eye clinic and then via his GP to the diabetologists. For me, it was a simple case. But for him, it is the start of a life with the miserable potential complications of diabetes: eye problems, heart disease, nerve damage and kidney disease. What was interesting in this case was his age.

There are two types of diabetes mellitus. Type 1 is the type children get when (possibly) an autoimmune disease damages the pancreas, which then stops the production of insulin. Insulin is a hormone that is produced after eating to lower the blood sugar level and store this ingested energy. Too high a level of sugar in the bloodstream damages fragile tissues such as in the back of the eyes, the kidneys and the body's blood vessels. Type 2 diabetes is a problem with the body's metabolism and sensitivity to insulin and usually occurs in the later part of life (if you have a genetic predisposition for it). However, if by overeating you have already had a lifetime's metabolism when you are young, then you can actually get it at a young age.

This is what had happened to this patient of mine. Overeating and under-exercising had caused him to have a much older person's illness. Unless he ma.s.sively changes his lifestyle, he will get all the consequences described above, retire early and get his money's worth (and yours) from the NHS.

However, he isn't unique. The text books I first had when studying said you couldn't make the diagnosis below the age of 40, but I have seen him and three other people in their late 20s/early 30s with type 2 diabetes, and so have my colleagues. Amazingly, paediatric colleagues have seen this condition in teenagers. All of them have the disease at so young an age as a result of obesity.

Obesity not only contributes to the diabetic epidemic, being overweight makes one more likely to get cancer, heart disease, stroke, breathing difficulties and osteoarthritis. It is a ticking time bomb for health. The fact that one in three youngsters are overweight makes it an epidemic waiting to happenan epidemic that I believe could be a real threat to the viability of the NHS.

When I was at school, n.o.body seemed to care. Maggie Thatcher sold off my school's playing field and privatised the school canteen and then they sold s.h.i.+t food for a profit. Also, I wasn't taught cooking, and if it wasn't for my wife (a wonderful cook), then the local curry house owner (also a wonderful cook) and 'pizza a go-go' would have much larger profits. Up until Jamie Oliver kicked up a fuss, Blair didn't seem that bothered. However, things are changing, but not really quickly enough.

Why not slap on a 20 percents.h.i.+t food tax (with qualified nutritionists deciding what is unhealthy) and use the money to give out healthy food vouchers with child support benefit? Why not ban junk food advertising before the 9 p.m. watershed and not just around kids' TV programmes? Why not stop kids leaving schools at lunchtime so they can't eat c.r.a.p from the local newsagent? Why not put proper amounts of money into a cycling network as opposed to painting a bit of pavement and then producing leaflets saying how much you have done? Whatever the arguments are against these proposals, then surely the fact that if we don't do something our nation's health will be b.u.g.g.e.red in the future is a decent enough counter argument.

It needs a change of mind-set from the government, not just tweaking around the edges. Prevention is much better than cure and in the long run cheaper, but until they do something then we are faced with the problem. Individually, people must make an effort and medical staff must encourage them to make an effort.

Finally, if we did as a nation lose weight, then it would not be so embarra.s.sing when I go abroad and see a group of men sunbathing on the beach, where the Spanish life guards and World Wildlife Federation volunteers try to roll them back into the sea...

It is also a sobering thought, that however many years I work in A&E, I will never make as much impact on people's health as Jamie Oliver will...and I don't even cook as well as him...or earn as much...or sell as many books...or say 'pukka' as authentically.

When patients make jokes

The last few days at work, I have noticed an increasing number of very poor jokes coming from patients. It is getting to epidemic proportions. Please stop. I have heard them all before. I like new jokes, so learn some before coming to A&E but please don't use any of the ones below that I have heard in the last two days.

Dr Dr: 'What brought you in?'. Patient Patient: 'An ambulance'. Dr Dr: 'How do you feel?'. Patient Patient: 'With my hands. How do you feel?' When taking blood. When taking blood. Patient Patient: 'Ho-ho-ho it's the vampires.'

Yesterday, a woman who works in Asda came in with the worst possible dress sense and one of the worst jokes: 'Any allergies?''Only hospitals...ha ha ha'.

'So', I thought, 'I have heard that joke a thousand times. Let me laugh, if I find it funny, but please don't laugh on my behalf.'

However, I got her back. I went shopping to Asda that evening. I paid with a large note, put the change in my back pocket and tapped my back pocket twice. How I laughed. She thought: 'I have heard that joke a thousand times. Let me laugh, if I find it funny, but please don't laugh on my behalf'.

Seriously though, there is nothing better than having a bit of banter with your patients at work. It makes my day so much more enjoyable. So although I have heard those jokes before, on second thoughts keep them coming.

Ooops again

Blaming tiredness was no excuse. Blaming lack of experience was also not an excuse. I genuinely mucked up but luckily the patient didn't complain. He was a 90-year-old war herohe had won a VC in WW2. He had tripped and got a cut to his forearm which needed st.i.tching.

It was at the beginning of my working life and I was still keen to suture. Now I find it very time-consuming and usually delegate it to the nurses, but at that point in my training I found it really satisfying. I cleaned the area thoroughly. I then sterilised the wound with some Betadine (antiseptic wash) then opened my sutures and slowly and methodically put in 10 st.i.tches. The wound closed easily and I was proud of the cosmetic appearance.

'There we go, sir,' I said. 'Not a bad job if I may say so myself.'

He looked at it in a satisfied way. 'Should I go to my practice nurse to get the st.i.tches removed?' he asked.

'Yes, in seven days. Take care now...'

He picked up his stuff and then took five steps away and came back to me. 'Is it normal to not use local anaesthetic nowadays?' he asked.

I thought he was joking and then I realised that I had completely forgot to use it. WHAT THE h.e.l.l! I had forgotten to put in local anaesthetic, and he had been too polite to tell me. Oh my G.o.d! I'll get the sack. The pain he must have felt! I went white and then nearly cried.

'I am so, so sorry...' I started to confide in him.'I have been so stressed recently. It's my first A&E job and I just seem to find it all so stressful. I don't know what I was thinking. I am so sorry.'

My eyes started to well up and my bottom lip quivered.

'Don't worry. It didn't hurt that much. It was nothing when you have been fired at on the Normandy beaches. You're a good doctordon't get stressed by one mistake.'

He was so nice.

'I only asked because I wanted to know if it had become normal practice.'

He left and I went to cry for a minute or two. I don't know why this encounter had made me cryperhaps it was just the stress of the last four months coming out.

Two weeks letter he sent a letter to the hospital. He thanked me personally for a 'pleasant and pain-free visit to the A&E department'. Thank G.o.d for patients like him.

More inefficiencies of hospital care

Despite what you see on TV, most cases coming to A&E are what are termed 'medical' cases, such as chest infections, chest pain and little old ladies with a 'collapse?cause'.

Last night I had a large number of medical cases come to A&E. Some I sent home, but quite a few needed admission into hospital for in-patient care. These patients are called 'medical referrals'. Although they are seen and stabilised by the A&E doctors, they need to be referred to the medical doctors for admission and continuing care. The medical team of doctors is generally the busiest specialty in the hospital and in a medium-sized hospital will often admit over 30 patients in a 24-hour period.

As it routinely takes over an hour to properly sort out a new sick patient and write up their notes, not to mention catch up on the routine day-to-day jobs, you can see why they are so busy. Once I have referred a patient to them, it can often take several hours before the patient is reviewed by a member of the medical team and a final plan of action made. This means that the more I can do in A&E to diagnose, treat and manage the patient, the better and faster it is for everyone concerned. However with the 4-hour target and the lack of staff compared with patients, this is often very difficult to do.

Last night the A&E SHO and I were working flat out all night. So were the medical team of doctors. Because we were so busy, sick patients were waiting about 2 hours to see us (the A&E team) and then about another 3 hours to see the medical team (if they needed to). Despite everyone's best efforts, I don't think that as a hospital we provided that good a service that night.

Many of the patients I saw had quite simple problems that, although needing admission, were very easy to treat and construct a management plan for. However, once they had seen me and been referred to the medical team, the hospital policy is that they are then 'reclerked' by the medical team. Re-clerking means that all the same questions that I had already asked are repeated and a full examination is performed again. The results of this re-clerking are then written down on hospital paper as opposed to the separate A&E notes where I had written the exact same things several hours earlier. For the busy medics, this is a complete waste of time. Especially so as one of the medical doctors reviewing the patients that I had referred used to work with me as one of my juniors and has a lot less medical experience than I do.

Now, I do agree that it is good for patients to be reviewed by the team they are coming in under, and it is vital that important questions are clarified and important parts of the examination rechecked. But why do they need to do a time-consuming rewriting of their notes? Sometimes it is necessary if the A&E team have been so busy that the patient might not have been properly sorted out before referral, but often this is not the case. Because of pointless hospital rules, the notes are simply copied out by the medical specialists from the A&E doctors' notes. Haven't we heard of a photocopier and then writing: 'In addition:... ? '

As well as being inefficient, the system is demoralising. The medical doctors have not trained as doctors simply to repeat someone else's work and the A&E doctors get annoyed as they think, 'What is the point of me writing all those notes if they are just going to get re-written?'. What is needed is a single 'tier' of care. Who that initial doctor is, is not that important. The only thing that is important is that the doctor treating the patient has had sufficient skills and supervision. The skills to treat 'medically' ill patients are something both A&E and medical doctors should have. There should then be a system in place for handing over the care of the patient to the inpatient team, who then appropriately review them closely.

There are two ways of bringing about changes that I believe are needed to improve care and improve efficiency. The first route is what some smaller hospitals are starting to do when they are 'down grading' their A&E department. Instead of having A&E doctors see patients, a triage nurse sees them and then asks the appropriate specialist doctor to see them straight off. In principle, this is fine. It gets rid of the inefficiencies of 'double clerking'. It is also a model that can be used in areas of the country where there is not a large cohort of experience emergency doctors. However, I think that this is a poor solution. The A&E doctors have a specific interest, training and skills in emergency medicine. If you come in with an acute problem then we are the right people to see you initially and give you immediate careespecially if the cause of why you are unwell is not easily identifiable by the triage nurse (e.g. being unconscious could have a surgical cause, medical cause or be the result of trauma). Also, properly trained A&E doctors are particularly good at preventing patients who do not need admission from being admitted unnecessarily. They are also very good at treating the sickest of patients who do need admission.

For all those reasons, I think that A&E doctors are the ones who should see the patients initially. But we need sufficient resources so that we can spend time with our sick patients and we need to not be constrained by targets of getting them out of A&E ASAP. Once referred to the medical team they should be reviewed by medical doctors with a specific interest in acute problemscalled acute physicians. In the UK we have started to increase the number of acute physicians, which is fantastic for patient care as they have the specialist skills in caring for very sick patients in the first 48 hours of their admission and, if appropriate, organizing speedy discharge.

There is a system in Australia where patients stay under the A&E team for a lot longer and it works very well. However, they have a greater number of A&E doctors than we do in the UK and so have the manpower to properly sort out their patients before pa.s.sing them on to the specialist doctors. We are not going to suddenly triple the number of A&E doctors overnight so we need to think about how things can be improved currently.

What we need to do is improve the integration of the A&E teams and medical teams. For example, an A&E doctor could a.s.sess the patient and, if necessary, admit them to the acute ward with a management plan and drug chart written up. This would happen without the need for a medical doctor to repeat the whole process. They would then be handed over to the medical team on call who could review the patient without repeating all the notes. The medics would therefore have a lot more time available and could come down to A&E and see patients directly (i.e. instead of their being seen by A&E doctors first) as well as the other admissions such as those that are referred directly from GPs. This would also mean that A&E doctors would have more time to sort out their patients properly and do a 'good clerking' which doesn't need redoing by the medical doctors.

To bring in this mind-set of changes of managing acute medical patients would require doctors of different specialties (A&E, Acute Medics and 'General Medics') to work together and trust each other. People then need to realise that what is important is how well the patient is being treated and not which particular specialty the doctor seeing them works for.

I hope that these changes get brought in and that I can just get on with my joblooking after sick patients who have not had to endure long waits to see me. I don't want to have to move to Australia to get job satisfaction. I want things to change over here.

P.S. Mum, if you are reading this, don't worry, I wouldn't really move to AustraliaI'll stay here and just rant after work instead.

Sad request for a MAP

The computer showed that the next patient was 'requesting MAP'. The medical student shadowing me believed me when I told him that as we were becoming a 'foundation hospital', one of our hospital's money-making mechanisms was giving out directions to lost people. I explained that we were in partners.h.i.+p with the AA and charged only 1.50 per direction. I was baffled when he muttered that he thought it was a good idea and could he come and watch how to give out appropriate advice. I shook my head, distressed that sarcasm had been taken off the medical school curriculum and replaced with b.u.m licking. I went in the cubicle and started to ask the patient about her request for the morning-after pillMAP.

She came with her husband and three-year-old child. She told me that the condom had split and therefore she needed the morning-after pill. They were holding hands and looked like a perfect couple. As I was going through how to take the pill, she burst into tears.

'But I want another baby. And I want to give my little one a brother or sister,' she said tearfully.

I asked why she had come for a morning-after pill then. I was being stupid and naive and she quite rightly told me so.

'It's all right for you. What with your good salary and three-bed semi. But we are struggling to pay the mortgage on our two-bedroom flat. My hubby is a Postie and we rely on my wage to pay the bills. I can't afford to go on maternity. We can't afford another baby. I want one, but can't have one. Give me the pill and don't ask questions please.'

I gave her the MAP and all the advice it entails. I couldn't really respond to her distress. I have the benefits of a good job and decent pay-packet (a terraced house though not semidetached). For me, poverty and how people cope or don't with it, is something I see at work, but which doesn't ever enter my private life. I am so lucky and this encounter made me realise that.

P.S. I don't want this book to be burdened with patient advice, but please realise that the morning-after pill is a truly s.h.i.+t name. It is best used asap, but is still effective for up to three days. End of lecture.