In Stitches

No notes

The ambulance pulled up and the paramedic came out. ‘Nick, we need to take him to Resus. His pulse is only 30.’ It seemed a reasonable request so I went off to Resus to see him.

The patient was 80, lived alone and had no close relatives. He had dementia and received care four times a day. The carer had called the ‘out of hours’ GP because his catheter was blocked, he couldn’t pass urine and his stomach was starting to ache. The GP told them to come to A&E as the out-of-hours service was too busy. A much better course of action would have been for them to go and ‘unblock’ the catheter, but that is a moan for another day.

I examined him and, apart from having a blocked catheter, the main problem was his pulse of 30 (normal is about 60). His ECG showed ‘complete heart block’, a condition that makes the heart beat very slowly. His blood pressure was normal, so it wasn’t an immediate life-threatening event, but heart block can be very serious, particularly if it is a new condition.

I asked the patient about it. He didn’t really understand what I was talking about. The carer didn’t know. I phoned the out- of-hours GP, but they can’t access regular GP notes outside working hours. The carer didn’t know anything about his heart condition, and there were no relatives available to ask. I asked our receptionists to get his old notes urgently as I needed to know what was going on. Would he need to go to the cardiac unit urgently or could he go home?

The A&E receptionist said that she couldn’t get hold of the notes. They were in a secretary’s office awaiting ‘typing’ and no-one could get hold of them. I moved on up the food chain and called the hospital ‘Site Manager’, the most senior person present in the hospital in the evening.

‘I need them urgently’, I pleaded.

‘Unfortunately, we can’t,’ I was informed.

‘It is life threatening. Please can we get them?’

‘Computer says no’ (OK, she didn’t actually say that, but it was something to that effect).

I had to practise safe medicine, so I referred him to the medical doctors to be monitored on the cardiac care unit (CCU). I explained that I thought it was a chronic problem, but that I wasn’t prepared to take the risk. They agreed and he went to the CCU.

In the morning, when the cardiologists were debating what to do, the GP was called and the hospital notes obtained. It was soon found that he had had this condition for five years. He had been referred for a pacemaker, but had refused one as the condition had never bothered him. The GP also explained that when the patient had been ‘with it’ he had always said that he never wanted to go for a hospital for a pacemaker. This pretty much swung the treatment plan into discharging him back home.

However, this visit put him at risk of hospital-acquired infection, and took up the last bed on the CCU, which might have prevented someone who would have genuinely benefited from coming to CCU from being there. And why? Because we couldn’t get hold of his old notes outside office hours. It is so frustrating to work in a system like this – what a waste of money. This happens time after time after time – unnecessary admissions occur, expensive tests are repeated and patients are not being cared for properly – all because of poor accessibility of patient records.

The government sees that this is happening and that is why it is currently spending zillions and zillions of pounds on a new computer system. Unfortunately, this system is taking ages to be implemented. Until it is, couldn’t we do something like, say, getting GPs to give every patient/or their carer a summary of their notes to carry around with them? Currently, even if I can get hospital paper notes, I can’t get access to GP records of patients’ latest drugs

Going back to the computer system they are implementing, I say thank you. It is about time too, but why is it taking so long and why the hell is it costing so much? I know it is complicated, but all I want is a system where a patient comes in with an NHS ID card, we swipe it and know what medications they are on, what they are allergic to, any past medical conditions and, perhaps, get a copy of an old ECG. And when they get a new condition or drug change, the doctor can change the ‘care record’ then and there.

We don’t need some fancy thing with ‘choose and book’ and Internet blardy, blah, blah. We just need something that works and we need it now. If Tesco can know exactly what I have bought every week for the last few years and have brought that IT system in at a fraction of the cost of the NHS’s one, can’t we steal their IT manager? Or Sainsbury’s Nectar card computer bod? Without easy access to patient records, we provide worse and more expensive care. Hurry up computer people, please.

Off duty?

Tonight I saw three bad knees and three sore throats, and had a discussion about the pros and cons of being referred for a hip replacement. I was asked about how to stop the symptoms of the menopause and what to do for dry vaginas. I was asked about how to stop babies crying and if I could listen to someone’s heart and feel their pulse as they had been having palpitations … Yes, I was at my mum and dad’s Boxing Day party.

Please, friends, just let me drink and talk about beer and football. It’s my day off. I want to have a laugh and joke and not talk about your ailments.

An upsetting day

I had a real low day at work today. I saw two really upsetting cases that I am sure will stick in my mind for a long time. A 13-year-old girl was brought in by her dad. She was complaining of abdominal pain, had been missing school and waking up in the night crying out because of the pain. The dad had brought in his child during one of these episodes as he was at the end of his tether.

The child had variable symptoms and signs and none pointed to a specific organic pathology. I asked her if she was upset about anything – she denied this and got very annoyed. I asked the dad if I could talk to the girl in private just in case there was something she didn’t want her dad to know; again, she denied any reason for stress. However, the dad came back into the cubicle and with a tear in his eye told me that his wife had died six months previously and that his daughter had not come to terms with it – she had barely shed a tear. It confirmed my belief that all her pains were being expressed via medical symptoms – this is called somatisation. The pain is real and is certainly not the same as malingering or factitious behaviour but is very hard to treat as it requires psychological rather than physical treatment. This poor girl had genuine abdominal pain that no medication could cure.

I am not sure if it was the right thing to do, but I did a battery of tests to prove that nothing was wrong. They all came back normal and I told her so and discharged her, then advised her dad to try and take her to her GP to arrange some grief counselling or something. I hope she is all right in the future – I’ll never know. This is something that makes me a little jealous of GPs – they get to see and shape what happens with their patients. I only get to see them in times of crisis and often never know if I’ve made a difference or not.

The next patient made me even more distressed. She was a lady in her 80s who was brought in by ambulance after becoming increasingly short of breath. She came in with her husband of 58 years. She had been very unwell the last five years since suffering a stroke and then having a series of mini-strokes causing a form of dementia (called multiinfarct dementia).

The husband had refused all previous plans to put her in a nursing home, as he had made a promise to her five years ago that he would look after her himself. She was immobile, incontinent and had severe dementia, but he had still kept to his word. Day after day he lovingly cleaned her, cooked for her and held her hand and talked to her. He was an angel in every sense of the word.

Before the ambulance arrived, we had got a call explaining that they thought she might have suffered a respiratory arrest (i.e. stopped breathing). As soon as she arrived, I could see how unwell she was. My SHO (junior doctor) gave oxygen and fluids and organised a chest X-ray, while I talked to the husband.

It soon became clear what the situation was. Taking over her breathing and sending her to ICU was not an appropriate thing to do. It would be more humane to let her die peacefully. I explained this to the husband. He broke down in tears and just said, ‘Thank you. I can’t cope any more and nor can she.’

I smiled and invited him in to be with her. She spent the last few hours of her life held tightly by her husband, listening to him telling her how much he loved her and recounting all the good times they had in the past.

It was a sad but beautiful sight that I felt privileged to witness. Emergency medicine is not just about the high drama of trying to save someone’s life. Sometimes the most important skill in medicine is knowing when to let nature take its course and not interfere. It was sad to see, but also the right thing to have allowed to happen.

Having to cope with the upset that these type of situations create is something that can never really be taught at medical school.

Right and left problems

I felt like a prat today. This eight-year-old boy came in after falling on an outstretched right arm. It looked like it was probably broken. I gave him my usual preamble with boys to make him feel at ease.

‘So what football team do you support?’ I asked.

‘Man City’, he replied. ‘Joey Barton is brilliant,’ he added. I told him my little joke about our hospital policy being not to treat Man United supporters as a way to save money. He laughed but I am not sure if his dad realised I was trying to be funny.

‘Blimin’ good idea that is. Bunch of pansies the lot of them.’

‘Oh dear’, I thought, and went back to examine the boy, then wrote an X-ray form. I wrote ‘X-ray R wrist please’. I always try and be polite on my forms – it usually helps to oil the cogs of the working day.

He came back with his X-ray and to my surprise there was no fracture. I reassured him and his dad, and sent them on their way, with the advice he was to come back if it continued to hurt.

Seven hours later he was back – this time with his mum – and still in pain. As he was a returning patient, he had to be reviewed by a middle-grade doctor (like myself) or consultant. Luckily (for me and my blushes) it was after 6 p.m. and I was the most senior doctor around. I examined him again, and explained that muscle injuries can be just as painful as broken bones.

His mum then asked, ‘Do you have a policy of only X-raying the wrong hand if they support City, or does it not matter and you X-ray everybody’s wrong hand?’

I was flabbergasted. I protested. Surely her son was making things up. I went and got the X-ray form to prove that I had written R on it. I had written R, but the radiographer had read L as, to be fair my R looked like a L. I looked at the X-ray – yes there was an obvious ‘Left’ written on it. What a dick I had been. I apologised to the mum profusely. A new X-ray form was written with ‘Right’ written instead of R and it duly came back with a small undisplaced fracture needing a plaster of Paris cast. Luckily, no harm was done.

I apologised, held my hand up and admitted my error. I told the mother that I was never going to write R and L again, but spend the extra second finishing off the word. She seemed to accept my apologies. She also wanted to clarify that her nephew would be able to come to hospital if he ever got ill. He is a Man United supporter. ‘Oh dear’, I thought, as I went on to explain myself for a second time.

A note to all readers. The Man United comment was meant as a sarcastic joke. All NHS hospitals will see supporters of any football club. Don’t worry … well, unless you support Chelsea – then you are on your own.

What a waste of talent

I am writing this passage with an almighty hangover. What a night. We had a lot of celebrating/commiserating to do. Three of my close colleagues are quitting work as A&E doctors. One is retraining to be a GP, another is moving to Australia and my third colleague is retraining to be a management consultant – she doesn’t want to give up medicine, but she has kids at school and a mortgage to pay and is worried that she is going to be unemployed in August, because of the uncertainty of the new recruiting system. All are fed up with the lifestyle and the way they are treated.

However, it is not just A&E where hospital doctors are feeling fed up and angry. Hospital doctors, both junior and senior, throughout the country are becoming more and more disillusioned and are leaving in droves. These decisions have been entirely justifiable for the individuals concerned, but for the country as a whole it has been an enormous waste of talent and money. This is happening at a time when more and more money is being pumped into the NHS. How can this be? There are a number of reasons, but ultimately it is because hospital doctors are feeling undervalued and are being blamed for the NHS’s ills; they are fed up with poor working conditions, ungrateful management and feeling unable to direct the reforms occurring in the NHS. Tragically, there has been a new way of recruiting junior doctors, which is impeding some of our best-qualified and most experienced junior doctors from getting jobs and thus forcing them to leave the NHS. The problems for hospital doctors are exacerbated when they see that even when they do qualify there are apparently going to be too many consultants and not enough jobs to go round. Will they finish all their post-graduate training to end up working only as subconsultants?

Junior doctors are feeling especially angry. It is true that there is no longer the ridiculous culture of 48-hour shifts. However, there are still unpleasant lifestyles associated with working as a doctor. Once qualified, there are the chores of having to rotate round various hospitals every six months, the stress of post-graduate exams and the worries of having to apply very frequently for new jobs. They say one of the most stressful events in life is moving and/or starting new jobs (along with getting married and having children). Junior doctors do this every six months – not the kids and marriage bits. The government has tried to rectify this by implementing changes to doctors’ training but has only managed to demoralise a whole cohort of doctors in training (see next rant).

Hospital juniors are also getting annoyed because of the way they feel they are being treated compared with their GP colleagues. The GP trainees have much more training built into their rota, they get more supervision and are not just thrown into the deep end when they start jobs, as is sometimes the case with hospital jobs. Then there is the question of pay. I do not begrudge GPs their money – that much (the average GP does not earn as much as the press says), but when I am doing an A&E shift and a GP is doing a locum out-of-hours shift round the corner he is often getting more than treble my pay. When you know that, you feel undervalued and underappreciated. However, by comparison, I have absolutely nothing to complain about compared with the nurses, receptionists, cleaners, etc.

Consultants are also becoming more fed up and some are reducing their commitment to the NHS as a result. There are numerous reasons for this but they include disillusionment about the NHS reforms, loss of continuity of junior staff and having to work to artificial targets as opposed to clinical need.

The NHS is its staff. We need a hospital staff with high morale instead of this disillusionment we are all experiencing. It is not about money – it is about having job security, feeling valued and having our time and skills used appropriately … The only good news is that with more people leaving I am getting to go to more and more after-work drinking sessions. My wife can’t really ban me if they are for long-standing colleagues’ leaving dos …

MMC – mangling medical careers

A few weeks ago doctors organised a march against what the government is doing to junior doctors’ training. I have never seen so many placid, conservative, non-volatile people on a demonstration before. They were campaigning against a programme called MMC – Modernising Medical Careers (otherwise known by some as demoralizing/mangling/mismanaging medical careers). It certainly has benefits in terms of organising doctors’ training from when they finish their ‘foundation jobs’ (the first jobs they get after qualifying). In A&E it has the added benefit of ensuring that every junior A&E doctor works for a time in anaesthetics and intensive care – jobs that are often hard to come by but that can teach you vital skills.

However, its implementation is what is really pissing off a vast number of doctors, damaging morale and, in the future, may damage patient care. Again, the intention was sensible enough – streamline doctors’ training and try and make job opportunities fairer – but the implementation is farcical. Instead of bringing it in gradually, there has been a most ridiculous attempt to transfer a cohort of doctors from the old scheme to the new one at the same time as implementing the new training scheme for the very junior doctors. As a result 30 000 doctors are applying for 22 000 jobs.

It is the way that they are being forced to apply which is outrageous. The ‘system’ consists of a computer-based questionnaire that assesses your ability to write politically correct crap in 150 words. Doctors with experience, exams, research and wisdom are losing out to others who have been on a course on how to fill out the application form.

The lucky ones who are offered interviews are faced by senior doctors who have not seen their CVs and who have had to mark 600 applicants’ forms in a weekend – but only one question on the form – and so they cannot possibly get an idea of the candidates. The lucky ones get jobs, but often in different parts of the country from where they live and where their kids go to school. They only get told about their jobs at short notice, then have to scramble to find somewhere new to live and somewhere to send their kids to school.

I know of so many doctors whose current contract is finishing in August and then do not know what they will do. Individually, it is upsetting; these doctors, who have debts from medical school and haven’t hit high earnings yet, are left with the threat of no job and no future in the NHS. Collectively, it is a disaster; it costs £250 000 to train a doctor – we are losing thousands of doctors and that is millions and millions of pounds that we as the tax payers have wasted.

Tragically, no-one seems bothered. There is a campaign group (http://www.remedyuk.net) and a few Internet blogs that have taken a big interest such as http://www.nhsblogdoc. blogspot.com, http://www.drrant.net, http://www.thelostdo ctor.blogspot.com and http://www.drgrumble.blogspot.com. However, the national media has not seemed that concerned about the plight of the country’s junior doctors and the fact that many of them are leaving the NHS at our expense.

How did this happen? I think it is government arrogance. They thought they knew best. They ignored the advice of the British Medical Association, which was to ‘slow down, take stock and do this sensibly’. They rushed it through and now, despite a last-minute review, we are faced with this disastrous outcome. They then had the audacity to blame the senior doctors (via the Royal Colleges) who were the very ones urging caution against this whole system.

I know the politicians have said that doctors need to live in the real world and not expect a job for life and should expect competition for popular jobs. That is completely fair and in the past it was totally wrong that some doctors were helped by an ‘old boys’ network’. However it is the utter lack of care that the system shows for its employees that is upsetting. No other group of workers would accept such a shambolic arrangement: where thousands of junior doctors have had their contracts expire in August and then have to apply for new jobs where they can’t show their CVs, don’t know where they will work or what their pay or conditions will be. Then if they are lucky and get a new job, they will only have a couple of weeks notice to uproot themselves and their families before they start their new jobs – remember, this is not just happening to people just out of medical school, but to doctors in their mid thirties who have up to eight years experience and who have roots and families which they need to consider as well. The only people smiling at this mess are the employment lawyers who could be in for a windfall. Oh, and the Australian health service, which is getting loads of very good, well-trained doctors at the British tax payers’ expense. No wonder the application system called MTAS (Medical Training Application System) has been nicknamed Migrating To Australia Soon.

P.S. Since this was written a review group have looked at how to try and improve everything. They are hatching a last-minute plan to try and save the government’s blushes, and thousands of junior doctors’ livelihoods. I wish them luck – they’ll need it.

Still off duty?

When I am not at work, I love Saturdays. In the mornings I play for a local football team and in the afternoons I go with my dad to watch my apparently professional football team play in a depressive mid-season battle. However, this is only when the wife allows and so is becoming a rarer treat. Saturdays are now usually DIY-based – or screaming at some random IKEA instructions-based – as I fondly think of it.

But this Saturday I was allowed to play. We were playing top of the league and for those of us excited by regional lower division non-league football, boy, this was a big game. It started well. My fitness training had worked and I had played a blinder. One – nil down at half time had only spurred us on and with 15 minutes to go I had just scored a screamer from 40 yards to bring us level. The crowd was singing and I was feeling fantastic. Five minutes later, the ball came back to me. A one – two followed and we beat the offside trap. My mate sprinted forward. Rushing towards goal he was tripped. A penalty was awarded, but he was in agony. I ran forward and realised that his shoulder was obviously dislocated.