In Stitches

I want muffins

It was 6 a.m. and the canteen was closed. I was feeling hungry, having been on shift for 10 hours already. I went to help myself to a couple of pieces of toast. Admittedly, yes, technically it is for patient use, but it is one of the small perks of the job that we can get some free toast and tea in the early morning. This morning, on the front of the cupboard door, there was a new sign warning us that taking bread was theft and could end in disciplinary action.

Come on, who writes such ridiculously rude notes? Why, when managers are trying to save money, do they do pathetic things like take away tea and coffee and bread, and not look at really serious issues? I bet they had muffins at the meeting where they decided on this money pinching measure. If they are going to take away our bread, then let us have their muffins.

Bloody trains

For some unknown reason, I am on an eco-drive. I have spent a fortune on energy efficiency lights, become keen on recycling and started to come to work by train. I feel like an eco-warrior (a middle class one who is scared of climbing trees let alone living in one with a bloke called ‘Swampy’, but still in my eyes an ‘eco-warrior’). I feel good about myself. These feelings vanish, however, as I get off the 8.42 train …

When I walked off the platform, there was a group of inspectors standing round a lady who was carrying a ridiculous number of bags. At first I thought she was shouting down a mobile phone. Then I realised that wasn’t the problem.

‘WHY DON’T YOU GET RID OF YOUR KNIVES?’ She screamed in the general direction of the ticket inspectors.

‘I KNOW WHY YOU WANT ME DEAD. BUT I DIDN’T CAUSE THE TRAIN CRASH.’

I approached and was told to stand back as she was apparently dangerous. She was very unwell, but, no, she wasn’t dangerous. I recognised her straight away. She was in her 40s and was a known regular at A&E. She had mild learning difficulties and psychotic paranoia and depression; a diagnosis of schizophrenia had been made in the past. She had a problem with alcohol (i.e. she drank more than her doctor) and her coping mechanism for whenever she got stressed was to self-harm. For years she had been in and out of psychiatric hospitals, and was now receiving ‘care in the community’.

In the past, patients like this may have been institutionalised, but they now are more likely to be cared for at home by community psychiatric nurses. However, these services are often under-funded and patients can slip through the ‘care’ bit of the ‘care in the community’ programmes. Instead, their ‘care’ is often provided by homeless shelters, police stations and A&E departments. This lady was one of these patients. She didn’t cooperate with any of the programmes they had tried to involve her with. She was getting sicker living in the community, but there was little anyone seemed to be able to do for her. As a result she had been to A&E 78 times in the last four years.

I approached the ticket inspector who seemed to be in charge.

‘What’s going on?’ I asked.

‘Stand back. She is dangerous,’ he told me, then started shouting at her: ‘Lie on the floor with your hands on your head’.

‘Bloody hell, she is clearly unwell but she’s not a terrorist suspect,’ I thought. She started screaming in fright and was scratching and biting herself to the point of bleeding. I intervened and called the police. I explained to the 999 control that this lady needed sectioning under 136 powers (i.e. the police could take her to a place of safety). When I explained that I was a doctor and not someone who needed sectioning themselves, they sent round two burly looking officers.

They were absolutely brilliant. They calmed her down and put her in the car while I unfolded my new bike and cycled to work – I really was on an eco-drive.

On arrival I explained why I had been late and that I had brought some work with me. This didn’t go down well. As ‘punishment’, my task was to go and see the patient that I had just arranged to come in with the help of the boys in blue. As I went in to see her, I nodded in appreciation of their work earlier and started to speak to the patient.

‘Hello. My name is Nick. I am one of the doctors here. What happened today?’

I said it in my most reassuring of voices, but it hadn’t seemed to calm her down or helped with her paranoia at all.

‘You aren’t a doctor. You’re a ticket inspector. I DIDN’T CAUSE THE CRASH. NOW GET OUT.’

Later that day, she was readmitted to a psychiatry ward. I saw her two weeks later, after another episode of self harm. It is a situation that we see all too often. In our current world of political correctness and not offering institutionalised care, there seems little we can do. As always, when there is a crisis, A&E is the point of call, but we cannot offer the long-term solutions that they need.

GP receptionists

I was sitting at the desk when this quite rude 45-year-old man marched up and moaned about how long he had waited and demanded to know if we were fulfilling government targets. (The answer, I thought to myself, was that he had not waited long enough as he should have been put to the back of the queue for being so pompous.) However, as he had a tie on and an aristocratic voice, everyone seemed to be getting a bit worried and I was asked to go and see him next. He had been suffering from pain in the wrist for three weeks. He had been doing a lot of typing recently and was suffering from ‘tenosynovitis’ (inflammation of the tendons). The treatment is a splint and painkillers.

I was a bit fed up that he had come to A&E with a chronic problem, so I asked him if he had looked at the sign outside and which bit of an accident or emergency he had. (OK, I didn’t ask him that; I wanted to, but he had a suit and tie on and a posh voice and I didn’t want a complaint letter. In fact, I just advised him that in future he went to his GP for this type of problem.)

I was a bit shocked when he told me what had happened. He went to his local GP and saw the receptionist, who demanded to know what was the matter with him. He told her and then she advised him to go to A&E as it wasn’t ‘the sort of thing’ GPs do, despite his protests that he didn’t want to go to A&E. (Despite being a doctor, I also get intimidated by GP receptionists demanding to know loudly what is wrong with you so the whole of the waiting room can hear. I once responded, ‘I have got a growth on my dick, genital herpes and want a sex change, how about you?’ and now they seem to let me see my GP without a CIA-type interrogation. This man wasn’t so fortunate. He failed the interrogation and ended up in A&E – without an accident or emergency.) I had no option but to phone the GP. I got through to the receptionist and the conversation went a bit like this.

‘Hi, could I speak to the duty GP please?’

‘I am afraid he is on home visits all day, and then in a meeting so you won’t be able to speak to him till at least next Thursday,’ she responded.

‘Sorry, I forgot to say my name is Dr Edwards. A&E registrar.’

‘Oh … he is next to me. Having a cup of tea. Sorry, I errrr … forgot,’ she responded.

I picked up the phone ready for an argument. I had all my lines prepared. I had real ‘inappropriate attendee’ rage (a bit similar to road rage, but with fewer horns). I thought the best line I had prepared was ‘And what medical school did your receptionist go to?’ I was ready to go. Start off calm and then let the battle commence …

He was brilliant. He had obviously been on a ‘verbal judo/how to calm down irritated twats course’, because he was magnificent.

‘I am very sorry, Dr Edwards – I will look into it and retrain my staff as necessary. If you have any further problems, put them in writing. I would be most happy to meet you and discuss this issue face to face, etc., etc.’ I wanted a bloody argument not an apology. I wanted to be able to moan and rant, but I ended up singing the GP’s diplomatic skills. Maybe the reason he is so good, though, is because he gets so many complaints about his receptionists …

Why I love going to work

A set of seven nights and on night six I at last felt that I had done some genuine good and I remembered why I love going to work. At 1.30 a.m. a lady in her 70s came in peri-arrest (about to die). She had a blood pressure of only 60/30 and was becoming unconscious. We took her into Resus and while the nurses put in a cannula and gave her oxygen and fluids, I examined her and spoke to her husband. It was obvious that she had perforated her bowel and that she was losing fluid into her abdominal cavity.

Within half an hour, we had given her 3 litres of fluid and she was starting to perk up. However, she needed definitive treatment – a laparotomy (a major operation which would remove the damaged part of bowel and clear out the faeces that had leaked into her abdomen). I called the surgeons and anaesthetists and within half an hour she was in theatre. Two hours later, the perforated part of the bowel was removed and she was in the ICU. I phoned up the next day and she is doing so much better. A very good outcome as all of the A&E team worked very well with the surgeons and anaesthetist. Thanks to all of us, everything went perfectly and we saved her life – you would be surprised how rarely we actually get to say that. All in all, it was a very satisfying night.

This is how it feels like the NHS has been run the last few years

Gordon Brown pours money in. The senior nurses on the shop floor sensibly think we need more A&E nurses and so more are appointed. Then interfering politicians are concerned that the new nurses may not be very efficient and they are not getting value for money, so the managers appoint a ‘staff efficiency evaluator’ and a ‘patient pathway flow monitor’.

This ‘staff efficiency evaluator’ and the ‘patient pathway flow monitor’ (separate jobs, mind) also need supervision and secretarial support, so a senior supervisor is appointed and a personal assistant. More money comes in from Gordon and so, to satisfy the finance departments, quarterly figures need to be produced on how efficient the new staff are, and how many ‘direct patient contact’ episodes are occurring. A business manager is appointed to the staff efficiency evaluation team for this purpose. So that the local hospital journal knows about how wonderfully efficient the new nurses are and how patient contact episodes are exceeding expectations (i.e. they have been told to document whenever they say ‘hello’ to someone) a marketing manager is appointed to the staff efficiency team. In truth, their job is to write a small article every two months for the pointless glossy-paged magazine that the hospital wastes its money on.

New concerns about the new nurses are brought up. Are they helping patients make choices to deliver a patient-centred care pathway? A patient-centred care pathway manager is appointed to the staff efficiency team. The election is over and the trust realises it has overspent vast amounts of money and now Gordon is not so friendly.

A ‘turn-around’ team are appointed at great expense. But they are geniuses and worth every penny of their grand a day. They show the light that no senior nurse or consultant could ever have seen. The answer is lying before our eyes … the nurses are not efficient enough, are not performing enough patient contact episodes and have lost focus on patient-centred care. An efficiency report is needed.

The report is produced – indeed, it is the workers’ fault. The answer is patient-centred streamlined efficiency. This actually means they make the nurses redundant … but, remember, we couldn’t possibly lay off the staff efficiency team as we will need to report to the finance team on how good our ‘staff reorganisation initiatives’ have been. We can’t sack the marketing manager from the staff efficiency team as we need to tell people about staff reorganisation with a positive spin. The remaining nurses still need guidance and so the patient-centred care supervising manager needs their job protected. The business manager not only keeps their job, but needs a pay rise for doing extra work – handing out redundancy notices to the nurses.

And this is how I would like the NHS to be managed

The Prime Minister says here is some money. New A&E nurses are employed. A senior nurse is appointed to monitor their progress and education. Patient care is improved and everybody is happy. No interference occurs from politicians. There are no massive overspends so brakes do not need to be applied (obviously only after an election). So, in summary, we can keep our nurses and let them do the job they were trained to do in the way they see fit. Oh! How I dream.

How does a government that has put so much money into the NHS (and it has), given pay rises and improved many services, still manage at the same time to piss off just about everyone that works in the NHS. It is an amazing skill. What it has done wrong is interfere so very badly in the micro-management of the NHS, arrange ridiculous targets aimed at winning elections and not long-term improvement in patient care, and disengage clinicians from involvement in management. Then there is the problem of pointless involvement of the private sector making profit out of the NHS …

What also pisses me off is when the Tories have their ‘NHYes’ campaign and say that they are the saviours of the NHS. Remember, they very nearly completely buggered it up. Don’t forget the perilous state they left it in 1997.

What it seems to me is that neither party can be trusted to run the NHS. The NHS needs policies designed to look after health now and in the long term. It should not be used as a political football with short-term plans introduced for when general elections are due. We need the politics taken out of the NHS. Make it a semi-autonomous organisation, where management input comes from frontline medical/nursing trained staff and not management accountants (I am not so sure what they actually do). It needs to be run along the lines of the BBC – with guaranteed funding and an independent management board. Whichever party promises that, then they will get my vote.

P.S. Just had to let all the anger out – I just read in the local paper that my hospital was about to make lots of nurses redundant and I got upset.

Ooops

Examining females is always difficult for a male doctor. I always take a nurse with me as a chaperone – it makes it easier for the patient and less stressful for me.

About a year ago, an attractive 21-year-old teaching assistant was rushed into the resuscitation department. She was having breathing problems and her heart was running very fast. I examined her and could hear a heart murmur. This was very unusual for a young patient. I asked her if she could take off her top so I could examine her in more detail.

I put my hand at the apex of the heart – to medical people it is the fifth intercostal space mid auxiliary point. In normal language, it means I put my hand under her left breast. I closed my eyes as I tried to feel for the rushing of blood caused by the murmur – knowing if you can feel the murmur helps to grade its severity. The medical term for a palpable murmur is a ‘thrill’. It feels like a vibration within the chest. It was hard to feel and my hands must have been underneath her breasts for at least 20 seconds. She looked at me nervously, so I tried to reassure her. ‘Don’t worry – I am just feeling for a thrill … ’

Shit! That came out wrong, very wrong! Stuttering, I tried to explain myself – but I don’t think that I managed to dig myself out of the hole very well. I stabilised her medical problem and referred her to the medical doctors for investigation and an echocardiogram. I wrote down the name of my chaperone very carefully. A year later I haven’t heard anything, so I think my faux pas has been excused.

Where have all the dentists gone?

If you needed a plumber urgently, would you call out an electrician because there was a lack of plumbers in the neighbourhood, just in case they could sort you out? No, it is madness. So then why, oh why, do patients with toothache go to A&E. GO TO A BLOODY DENTIST. I know very little about teeth. Very few doctors do. Don’t come to me with teeth problems, go to a dentist.

I got so annoyed with a man this morning – luckily I didn’t show it, as it turned out he was blameless. We were very busy and I felt he was wasting our time. Instead of letting a steam rush come upon me, I tried to have a chat with him (more to calm me down). I asked him why had he come here. The answer surprised me. It wasn’t NHS Direct, it wasn’t even his GP, it was his dentist, or whoever used to be his dentist, who had sent him. You see he had not had a check-up for over two years, so he had been automatically taken off the dentist’s list. The other dentists in the area were not taking new NHS patients and there was no available emergency dentist, so they had advised him of my expertise if he was in need of painkillers, which he was.

He was pissed off. He didn’t want to come to A&E, he wanted his tooth sorted. Luckily, we have an emergency dentist in the area, which our receptionists managed to book him into for the next day.

I felt annoyed with myself for being annoyed with him. It is the system that is at fault and not the patient, but thanks to useless negotiating on behalf of the NHS, the dentistry cover isn’t as good as it could be considering the amount of money put into it. People’s teeth are getting damaged and because people want an instant fix they come to A&E. It is like so much in society. When the normal health services that a society needs to function are not working too well, then people come to A&E, regardless of whether or not they have an accident or emergency.

Should he have called an ambulance?

Some patients really do try your patience. They abuse the system and it is very hard not be judgmental. I had one tonight – I’ll let you decide whether you are happy that your taxes were spent on him.

He was complaining of chest pain, but was well known to us – 14 visits for chest pain in the last year and all on a Saturday or Friday night. Chest pains get seen straight away – and rightly so – so I asked some questions. He said his pain had gone and then he went. I tried to stop him. I tried to explain that he would benefit from an ECG and that I would like to at least examine him before he left.

‘Nah, I have got better things to do,’ he said and walked off.

The ambulance men apologised for bringing him. They had to as he had called them complaining of pains in his chest. It is one of those conditions where it is always better to be safe than sorry and come to A&E. However, this man lives just around the corner from the hospital and whenever he is out and gets pissed he calls for a free taxi and lies about chest pain.

What a selfish and thoughtless act, putting other people’s lives at risk. One day he will have real chest pain and his past action will have put him at risk as the ambulance crew may not believe him or be tied up with other people like him.

I later found out from another ambulance crew that he had done it again. This time they took him to another hospital 35 miles away from this one and 35.1 miles away from his house. He went berserk when he found out that he was nowhere near home. He demanded a lift home after self-discharging. The ambulance men kindly told him where to go.

I understand that it was an expensive taxi ride home, especially on a Saturday night … we haven’t seen him in A&E since. Sometimes you have just got to love your ambulance colleagues. For anyone interested there is a fantastic blog (and book – Blood, Sweat and Tea) by an ambulance man – who describes his joys of working in the NHS (http://randomreality.blogware.com).

A different type of health visitor

I knew I was going to enjoy this consultation from the outset. He was 92, looked 72, and had been flirting with the nurses from the moment the ambulance brought him.

‘Hello sir. How are you?’ I asked.

‘You’ll have to speak up, I am very deaf,’ he responded.

I reassured him that he didn’t need to worry as I was very loud. Now that we knew that this wasn’t going to be a private conversation, despite closing the curtains around the cubicle (which I used to think made the room soundproof), we started the consultation.

I soon found out that he had chest pain. It sounded like angina – a condition he is known to suffer from. Normally it settles with a spray of a drug called GTN. However, he had first got the pain an hour ago and was still in pain. While my colleague did an ECG, I put in an intravenous line and started some medications to ease the discomfort.

‘So what were you doing when the pain came on?’ I asked.

‘It happened when my health visitor was with me. She was the one who called the ambulance.’

I enquired why he had a health visitor and how often she came round to see him.

‘She comes round once every three weeks, just to see how I am and help me … you know.’

I wasn’t too sure what he was talking about, but I thought he must have been describing a new government scheme, whereby community matrons visit patients with chronic conditions at home every couple of weeks to check that they are OK. They then liaise with their GP and try and implement plans to keep them out of hospital. I asked him if that was what he meant by a health visitor.

‘She isn’t organised by the GP. I organised her myself about three years ago. She has been very good to me,’ he responded.

Now I was confused. Naive as well, as it turned out! I continued in my questioning.

‘So does she help round the house then?’

‘No my friend.’ He leaned forward and in a theatrical whisper said, ‘She comes round to help me ejaculate as I can’t really do it myself. It was when she was playing with me that I got the chest pain. It was so bad that she had to stop and call the ambulance.’

‘What a bloke’, I thought, ‘Honest and still enjoying life, and very friendly’. I smiled and in the notes wrote pain started on ‘mild exertion’. It is encounters like this that make my job pleasurable.

How targets can hurt patients and staff

In principle, a target to see and sort out patients within 4 hours is a fantastic aspiration. Unfortunately, it is like a lot of targets and reforms – they comply with the law of unintended consequences by creating an unintentional distortion in clinical priority, which impinges on the quality of care we provide.

I don’t think Labour has deliberately tried to harm patients care at all, or that it has deliberately tried to piss off NHS staff. I think that its heart is roughly in the right place, it’s just that it has implemented some ridiculously stupid NHS reforms without realising the consequences. Do you remember, during the last election, someone complaining to Blair on Question Time that they couldn’t book follow-up GP appointments? He had no idea that his policy of making all GPs guarantee that they would see people within 48 hours would mean that they would stop making follow-up appointments a week or so in advance. It was an unintended consequence. He was clearly shocked and promised to sort it out.