Dr. Nick Edwards
In Stitches

The Highs and Lows of Life as an A&E Doctor

Copyright

William Collins

An imprint of HarperCollinsPublishers Ltd.

1 London Bridge Street

London SE1 9GF

www.harpercollins.co.uk

First published in Great Britain in 2007 by Friday Books

Text © Dr Nick Edwards

A catalogue record for this book is available from the British Library

In Stitches is not authorised or endorsed by the NHS and opinions expressed within this book do not reflect those of the NHS. All situations and characters contained within the book are amalgamations of different scenarios at different hospitals and names and timings have been changed to protect anonymity. The author would like it to be known that he is writing under a pseudonym.

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Source ISBN: 9781905548705

Ebook Edition © MAY 2013 ISBN: 9780007332700

Version: 2018-11-15

To Mrs Edwards: everything I do, you make possible and worthwhile. Thank you so much.

Disclaimer: this book is an attempt to take a humorous look at what it is like to work in a British Accident and Emergency Department. Much of it is tongue in cheek, so do not use it as a guide on how to manage illnesses. Call your GP or, if you can’t be bothered to wait for their receptionist to answer the phone, call an ambulance and come on down to your local A&E department for 3 hours and 59 minutes of fun.

Introduction

It was a fairly standard Saturday at work; generally busy and stressful but interrupted by episodes of upset, excitement and amusement. However, being honest, I quite enjoyed myself. I found pleasure in successfully treating someone’s heart failure and liked being able to mend a patient’s dislocated shoulder. I was amused by a drunk and injured tough-looking biker-type who had got into a fight over a game of chess. And I had a quite fascinating conversation with a man in his late 80s (who came in after a car accident), who insisted on telling me about his current sex life difficulties. Overall, if you have got to work, then working in A&E (Accident and Emergency) is one of the most interesting jobs I could think of and I am glad that it is the job I do.

Admittedly, I got mildly frustrated by the sheer number of patients who were revelling in the British culture of getting as pissed as possible, starting a fight and then coming in to A&E. And yes, I got a little weary of seeing a number of patients who had not read the big red (and quite explicit) sign as they walked in, and who had neither an accident nor an emergency and should have seen an out-of-hours GP (if one had been more readily available). However, overall, I saw a lot of patients who genuinely needed our services and whom we could help, which is the bit of my job that I love.

There was one patient that I took an instant liking to. She was in her mid-80s and had such a fast wit and spark to her personality that she felt like a breath of fresh air as I was treating her. She touched my emotional heartstrings because she reminded me of my Great Aunt.

She came in after having collapsed at home with abdominal pain, vomiting and diarrhoea. We were busy and she had had to wait 2 hours to see me. I quickly made the diagnosis of a possible gastro-enteritis (stomach bug), gave her some fluids, took some blood, organised an X-ray and arranged for admission. I wanted to wait for the results, spend more time with her and manage her care accordingly, but in a flash she was whisked away to a care of the elderly ward for me never to see her again. An hour after she arrived on the ward (and before she was seen by the ward doctors), she suddenly deteriorated and her blood pressure fell. This wasn’t noticed as quickly as it might have been had she stayed in A&E as the ward nurses were so rushed off their feet (two trained nurses having to look after 24 demanding patients).

She had been rushed out of A&E to get her to a ward so that she wouldn’t break the government’s 4-hour target (and because the A&E department has not got the resources to continue safely caring for patients for longer than a few hours in addition to seeing all the new ones constantly coming through the doors). I also had to pass responsibility over to the other doctors before her blood tests were back and before a definitive diagnosis was made. I later learned that she had been anaemic, which had put stress on her heart, and that she then ended up on the high-dependency ward, needing a blood transfusion.

For a while it was touch and go as to whether she could be stabilised. I couldn’t help wondering whether, if she had remained in A&E, under our care, all these problems could have been treated sooner and the complications avoided. However, this was not possible as, apparently, I had more pressing priorities. My next job was to go and see a bloke who had called an ambulance to get his ingrown toenail looked at and who had been waiting for 3 hours. He had, incidentally, had this problem for five weeks and wanted it (in his words) ‘sorted out now, as I’m off to Ibiza tomorrow, mate’.

I felt really frustrated. It didn’t need to be like this. Why does the ‘system’ have to impede me from caring for my sick patients and make me worry about figures and targets instead?

When you are surrounded by death and disease, aggressive and drunk patients, and nurses (male and female) trying constantly to flirt with you, it can make working in A&E an interesting and often stressful environment. However, it is the management problems and the effects of the NHS reforms, implemented without thinking about the possibilities of unintended consequences that really drive doctors and nurses mad. More importantly, they distort clinical priorities and can damage patient care. Surely this is not what the government intended? How have we drifted away from the original ideals of the NHS?

In July 1948, Nye Bevan presided over the creation of the NHS. It is a service that provides free care based on need and not ability to pay; to care for us from the cradle to the grave. It was the envy of the world and the greatest example of social policy this country has ever implemented. It is a wonderful institution that needs protecting and nurturing. Its desire to protect health and not profits means that its efficiency could outstrip that of any other health system in the world. The very thought of working for it filled me with pride.

By 1997, years of underfunding had left the NHS in a perilous state. Massive influxes of money from Blair and Brown poured in, which helped bring in some great improvements in service and much-needed reforms. This is especially true in A&E, where things have improved greatly from the days of patients spending days in corridors on trolleys waiting for a bed. The target brought in was a 4-hour rule stating that 98 percent of people have to be seen and admitted or discharged within 4 hours. Initially, it was a necessary but blunt tool, which effectively brought about urgently needed change. However, its lack of subtlety and implementation without resort to common sense is now impeding care and distorting priorities.

Despite the enormous sums of money that have been spent, for the NHS as a whole the overall benefits have been underwhelming. In the last few years, the government has managed to demoralise a significant number of hospital workers despite these huge increases in resources. To try and get ‘better value for money’ targets have been implemented and reforms made that threaten the structure, efficiency and ethos of the NHS, driving it away from cooperation and caring towards incoherence and profit making. For those of us who believe in the idea of collectivism enshrined in the NHS, it is a worrying time. It is an especially worrying time if you live near a hospital that is under threat of closure or losing its A&E in the name of ‘reforms’.

These worries about what is happening to the NHS (and in particular A&E) combined with the general demands of the job, can sometimes make me feel a bit stressed. Many people cope with this by drinking; however, I usually have to stop after a pint, as I start to feel sick and get a rash. Instead I started ranting to my friends and moaning to my wife: she started to threaten divorce and my friends seemed to invite me out less and less. So, in an attempt to save my sanity and marriage, I turned to writing down my frustrations with the job. A cathartic form of literary therapy.

That is, in part, what this book is about. It is a collection of stories written to try and explain what working in A&E is really like. It is not just about the frustrations – far from it. I have also tried to provide a small indication of the buzz I get from work and the amusement and banter that can be found there, including the dark humour that is used to cope with the stress of the job. I have tried to describe the joy I get from observing the eccentricities of the human condition and the fascinating little ironies life throws upon us. I have, in addition, tried to cover more serious aspects of the problems facing today’s NHS and A&E departments in particular. All the stories are typical of ones retold in staff coffee-rooms up and down the country. They are based on events that have happened to me, or colleagues, working in various hospitals throughout the last six years. However, details have been changed and the stories described are often an amalgam of many similar incidents rather than one specific case. If you think you recognise a clinical situation or problem, it is probably because it is repeated daily in all A&E departments.

This book is certainly not a whistle-blowing exercise, as the situations described are universal problems and not specific to one hospital. I certainly feel that the departments I have worked in are good and the consultants have been supportive. The way they manage to provide top-quality clinical care despite the management concerns occurring in the background, provide me with appropriate role models. Neither is this book a blog as such (although the idea started out as a blog) – there is no real-time order to the various passages. There is no underlying story and neither are the stories arranged into any theme. It is just a random selection of events and experiences as an A&E doctor.

I hope you enjoy reading it – both the amusing and sarcastic bits and the ones where I am being serious. I hope to inform you what really goes on in your local A&E and what the people working there are going through, so that if you happen to need our services, you will understand when things don’t work as smoothly as perhaps they should. The views and ideas in the book are my own and are not endorsed by any political organisation or pressure group. I am not a politician or a manager, but I do work on the ‘coal face’ of the NHS and can see its problems.

I don’t think the NHS is having its best year ever. I think all the recent reforms and targets and private sector involvement are really making things go a bit ‘tits up’. I want to share with you some of my concerns and how they affect my working life, as well as showing you the real highs and lows of life as an A&E doctor. Thank you for reading.

Dr Nick Edwards, July 2007

P.S. For those of you who want a quick summary of what life is like working in A&E, without having to read the book, then here goes. It is a bit like what you see on TV programmes such as ER, but with less sex and more paper work. I, unfortunately, do not look like George Clooney either – more like Charlie out of Casualty. I have also never asked for a ‘chem 20 stat’ and the medical students are not usually as beautiful or as helpful as the ones depicted in ER.

A sign the world has gone mad?

What was happening to my patients today? They seemed to be getting lost when I sent them for X-ray. I’d given the same directions as normal, there had been no secret muggers hiding in the hospital corridors and, as far as I know, no problems with space – time dimensions in our particular corner of the universe.

I went to X-ray to investigate. I found it quickly because I knew the way. However, I looked for the signs for X-ray and they were gone. The nice, old-fashioned and slightly worn signs had gone; they had been replaced by a sign saying ‘Department of Diagnostic Imaging’. What the hell? I know what it means, but only just, and only because I have been inundated by politically correct ‘shit-speak’ for a number of years. What a pointless waste of money; to satisfy some manager, they replaced a perfectly good sign with one that means bugger all to 90 percent of people. Why don’t they change the toilet sign to ‘Department of Faecal and Urinary Excrement’ or the cafe to ‘Calorific Enhancement Area’? Who makes these decisions? Who is employed to do such pointless stuff? Why? Why?? Why???

I needed a caffeinated beverage in a disposable single-use container – management-speak for shit NHS/Happy Shopper instant coffee. I went to sit in the ‘Relaxation, Rest and Reflection Room’, previously known as the staff room. There, the nurses were moaning that one of their colleagues had called in sick tonight and to save money their shift would not be covered by an agency nurse. In A&E, staff shortages can seriously undermine the safety of patient care.

I am sure this genius plan was decided by some personnel manager who I doubt has ever seen a patient, cannula or trolley, and is therefore obviously an expert at making nursing planning decisions. So we have a hospital that can fund unnecessary new signs, but not replace nurses when they are off sick. So, tonight who is going to go looking for the patients when they get lost en route to the Department of Diagnostic Imaging?

Management madness

If politicians tell you that by instilling the ethos of the private sector we can improve the efficiency of the NHS and improve patient care, then let me tell you that is rubbish. What is needed is good old-fashioned common sense and cooperation. Unfortunately, this is difficult to put on a balance sheet.

Let me give you an example that really upset me. An old man who had Alzheimer’s and was in a nursing home tripped and fell and banged his head. He was on his way to the toilet, but had forgotten that he normally needed a frame and a nurse to help him. He sustained a laceration to his forehead. He needed five stitches, and then to go home. He arrived at 11 p.m.

It was a very quiet night. I was asked to see him straight away as the nurse in charge knew that we could discharge him back very quickly. Fifteen minutes later he was ready for discharge and the ambulance crew that had brought him in were still having a chat and coffee with us all. The charge nurse asked if they would take him back and they didn’t mind at all. They called the coordinator at the control centre (someone who has never worked on an ambulance). He told them that they couldn’t take the patient back to his nursing home, as our hospital (to save money) had changed the terms of contract with the ambulance trust and no non-essential transfers were to be done after 11 p.m. The ambulance man protested and explained that there were three ambulances in the locality, all with their feet up. He said he didn’t mind doing it as it was for the old man’s benefit. Control responded with a statement about breaking contractual obligations, setting a precedent and influencing future contract negotiations.

Further protests ensued. The man was not safe to get a taxi on his own but was still well enough to go back to his nursing home. There was a willing crew who were free at the time and I couldn’t see the problem. I tried to intervene and told control about how the man was confused and distressed about coming into hospital. I explained that staying in hospital until 9 a.m. the next morning would make him worse. However, I was told that the 3 percent funding shift resource allocation caused by the contract change had meant that they could no longer do goodwill gestures such as I had requested.

It was ridiculous. For no good reason beyond disjointed management decisions – made introspectively, without thinking about the consequence for the whole NHS – this man had to stay in an A&E ward for 10 hours. He became very upset and distressed. A&E later became much busier and our nurses didn’t have time to take him to the toilet and so he soiled himself. He screamed all night because he was confused and disorientated in this strange place and the patients in the bed next to him slept very poorly. I was then asked to prescribe sedatives for the patients in the A&E ward, and for him!

I just don’t understand what is happening in management; I don’t think that management understands what is happening on the A&E ‘shop floor’. I found out from one of the senior A&E nurses that the contract decision was changed to save a very small amount of money. Managers would have slapped themselves on their backs for their ‘efficiency’ savings to the transport budget, but not realised that it would not have saved the hospital, or the NHS as a whole, a single penny (the patient still needed to go back in the morning!).

I was annoyed with our managers, but why did the ambulance control man act in the way he did? A few years ago, the crews would have taken these patients back if they were quiet – contract or no contract – for the good for the patient. I suppose nowadays people are instructed to do stuff only if it is for the good of the targets and common sense has flown out of the window.

I got very stressed and angry about this. After a while the junior doctor working with me asked why I was so irate. I explained that, apart from an irate personality disorder and the fact that ranting is my form of therapy, I was genuinely upset. Apart from my lovely family and useless football team, the things I care most about are my patients’ care and the state of the NHS. It upsets me that crappy management decisions done in the name of ‘efficiency’ bugger up both.

P.S. If there are any politicians/managers wanting to see the actual effect of NHS policies (both good and bad) on patient care, please ask your local A&E department if you can spend a night working alongside the doctors and nurses. You will learn more about the problems in that one night, than you ever will from looking at a balance sheet or ‘throughput’ data that A&E departments send their hospital managers.

P.P.S. If you think I will ever talk about how awful things are, please be assured that some things have improved dramatically over the last few years, it is just that I want them to continue improving and not get worse again. Also, when there are no problems, I do not get angry and so do not feel the need to write. So, if you think everything I say is biased, then, yes, you are right. But biased for the right reason: to try and get things changed for the better … and to help with my stress relief.

Treating your own family

It is a well-known fact that you should not be a doctor for your family. This is true. I certainly found out how true last night …

It was the quietest night we had had for a long time. A&E was empty when my wife’s grandpa arrived. He is in his 90s, demented, and spending the last few years of his life in a confused state in a nursing home. The staff at his nursing home had called an ambulance as he was more short of breath than usual.

I got the other doctor to see him and told them all his problems. I explained that on his previous admission, the consultant had declared him ‘Not for Resus’ (i.e. if his heart were to stop, then it would not be appropriate to try to restart it with cardiopulmonary resuscitation – CPR). This was the right thing because his quality of life was so poor. In all honesty, I just hoped for his sake that he would pass away peacefully in his sleep. I had a chat with him and then, when he fell asleep, I left to get a drink. It was very quiet in A&E and he was the only one left in the department.

I was dozing in the coffee room, when the alarm call came through the intercom. ‘Cardiac arrest, Resus’. I ran there past where Grandpa was meant to be. He wasn’t there. For Christ’s sake! Why had they moved him into the Resus room, and why were they doing something futile and cruel? I was livid.

I ran into the Resus room. Everything went into slow motion. There was a nurse jumping up and down on an elderly man’s chest and the doctor ventilating his lungs. I was furious. ‘Let him die in a dignified way and not with broken ribs,’ I thought.

‘STOP. STOP. BLOODY HELL, STOP’, I screamed.

‘It’s not your grandpa, Nick. He has gone for an X-ray. This bloke just collapsed in reception about twenty seconds ago.’

‘CONTINUE, CONTINUE’, I screamed back. ‘BLOODY HELL, CONTINUE.’

Ridiculously embarrassed, I managed to regain my composure and lead a successful cardiac resuscitation. We got back a pulse and called the anaesthetists to take over his breathing. He went to ICU (the intensive care unit) and three weeks later was discharged to lead a normal life. Thank God everyone ignored my advice to stop.

Meanwhile, my wife’s grandpa was sent back to his home the next day and is still in the same sorry way.

Dealing with threatening patients

I get scared sometimes at work. I work in a rather tough town – even the muggers go round in pairs. Consequently, we get some rather tough patients. Give them some alcohol and they become a little hostile. Add the stress of waiting 3 hours and 59 minutes and they become aggressive. The fact that they are often in A&E because they lost a fight sometimes results in them looking for revenge – and A&E staff are often the target.

I am a not a ‘weed’ but I am not sure that I could handle myself if I ever got into a proper fight. With a lack of any training in self-defence, and an A&E security guard that my Nan could ‘have’, you sometimes feel a little vulnerable. I have never been assaulted but I know a number of colleagues who have. The BBC programme Panorama investigated this violence and reported that a NHS worker gets attacked every 7 minutes (for more information see: http://news.bbc.co.uk/1/hi/programmes/panorama/6383781.stm). However, much of the ‘violence’ results from the confusion caused by medical problems. I have been bitten by a lady in her 80s who was short of oxygen. It wasn’t her fault – it was probably mine – I should have been more careful. When she was better she was the most beautifully placid person in the world. These are not the type of ‘violent’ patients that upset me. It is the aggressive, bullying types who know all their rights but have no sense of respect that irk me and make my job scary at times.

Last night I was at the desk, writing my notes, when a drunk and aggressive man came up to me and was forcibly complaining that I was delaying his treatment because I was being anti-Moldovan. (Maybe I need to go on a cultural awareness course, because I didn’t even realise he was Moldovan or, more to the point, where in fact Moldovia is.) All I knew was that he was a man who did not need to be seen before the bloke who need 15 sutures for a bottling injury and who was bleeding profusely.

The patient became very aggressive and angry. As he started to walk menacing towards me, I started to apologise profusely (as well as sweat profusely). Experience has taught me that this often stops aggressive people in their tracks as they are frequently expecting a fight back. Worth a try, I thought …

‘I am very sorry sir, but we are very busy tonight. We see people in order of priority and not time order, I am afraid.’

He kept shouting insults and making demands. He was not happy with his wait. Eventually, it was obvious my tactic was not working. I just wanted to ask him to leave in a firm way, but I was too scared of him. Luckily, I could see that there were two policemen in the waiting room, who had ‘smelt’ trouble and had started to walk towards me. I breathed a sigh of relief and suddenly found lots of bravado.

‘I am very sorry’, I said, before adding ‘for having to take your insults. I have been working ridiculously hard all night and don’t deserve your language or behaviour.’

My temper now started to rise. ‘If you dare speak to anyone like this again you will not be treated. Now sit down and be quiet and wait your turn. If you have a problem with this, then leave.’

I pointed to the door and felt like a brave warrior who had just defended his tribe of A&E doctors and nurses, but I knew that I was a warrior of the type that only stands up for himself in the presence of a policeman. In reality, I am still a scared wimp who is polite to rude and threatening patients purely because I am afraid of breaking my General Medical Council code of ethics of treating people in a non-judgmental way … and because I don’t want my head kicked in.

On one occasion when someone would not stop complaining and became verbally threatening, my colleague took them to the door of the resuscitation room to show them what we were doing and why his wait was so long. The complainer commented that it wasn’t his problem and later wrote a complaint letter about the psychological upset he had been subjected to. Unfortunately, my colleague has not felt compelled to be brave enough to do this again and now just ends up apologising behind gritted teeth.

It is very difficult dealing with violence in hospitals. What do you do with an injured patient who needs your care but is threatening? It is easy if they have assaulted someone as you can call the police. But bullying and threatening behaviour is difficult to deal with. Personally, I think it is time that in addition to patients having more and more rights, NHS workers had more rights and protection too – they certainly need it. Unfortunately, we have become too politically correct. The modern NHS thinks of patients as customers and we are encouraged to believe that ‘the customer is always right’ but sometimes that is just not the case.

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.

He was screaming and it ended up being my job to take him off the field and drive him to hospital, bypassing the queues and getting a friend to pull his shoulder back into position. But I didn’t want to be there. I didn’t want to be subbed just because I am a doctor. I wanted to score the winning penalty and then go to the pub afterwards. But alas no. I am still on duty even when I am out playing football.

P.S. My wife has just read this and has reminded me that this book is based on reality not fantasy. I must confess I hadn’t done any fitness training, I was playing shit and we were 3–0 down and playing third from bottom – we are bottom. There was no singing from the crowd, just a bark from a random stray dog. The goal I scored was an own goal, which hit my bum as I fell over after my contact lens fell out. Sorry for the misinformation. The bit about the IKEA furniture and shoulder were true though. What is also true is that we both got back in time to join everyone for drinks. One perk of my job is that my mate bought my drinks for me to say thanks.

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.

Well-intentioned cock-ups like this have happened throughout the NHS. Within A&E, we have the 4-hour target – we have 4 hours from when a patient arrives to either discharge them or admit them; 98 percent of patients need to meet this target. Don’t get me wrong; on the whole, the 4-hour target has banged heads together and brought about some good changes to the way we work and treat patients. Patients no longer wait 12 hours to see a doctor for a broken toe and being admitted to hospital has been streamlined. However, unintended consequences do exist and they can be harmful for patients. Let me explain with a couple of examples.

Last week, we were having a very, very busy day. There were massive delays in X-ray and an old lady who had fallen had had to wait 3 hours and 40 minutes to confirm the diagnosis of a fractured hip. She had been given some morphine while waiting for her X-ray, but was still in pain. The clock was ticking – it was 3 hours and 55 minutes since she had come in and the porters were about to be called to take her to the ward. In 5 minutes I could have given her some more morphine. However, it has side-effects such as slowing down the respiration rate (she also had a chest infection, which had caused her to fall in the first place) and nausea. What is just as effective but without the complications of a second morphine injection, is an injection of local anaesthetic into the area around the nerve going to the hip. It numbs the area within 10 minutes, and around 12 hours of pain relief is provided. However, it takes around 15 minutes to do. I told the nurse in charge that I wanted the patient to have the injection and not go to the ward just yet. I was told that she would fail her 4-hour target. This is known as a ‘breach’. In these days of targets it is so hard to argue back. If a patient breaches, then the consultants have to ‘examine’ why. If too many patients ‘breach’, then the NHS managers come down on the hospital like a ton of bricks and there are potential financial penalties.

But aren’t we in the job to provide the best possible care for the patient and not there to worry about targets? No wonder so many nurses and doctors are leaving A&E. They are doing so because they are not allowed to do their job properly – caring and managing patients.

After a 10-minute delay, we all agreed that it was in the patient’s interests to give her this injection and the figures were fiddled. (I deliberately do not get involved in this fiddling, because I think we should be producing honest figures so that something gets done rather than just massaging the ego of the Secretary of State for Health.) The department pretended she had left A&E 20 minutes earlier than she had. The figures said that she stayed 3 hours and 59 minutes. It is ridiculous that so much time and energy is spent trying desperately to meet targets, but when we fall short, someone has the job of adjusting the time. I don’t blame the A&E department for adjusting the figures. There is such pressure on us to comply with the target that adjustment is seen as acceptable. It means the hospital won’t get penalised financially or by a reduction of its ‘star performance score’ status. By fiddling the figures, it also means that we can concentrate on looking after our patients.

If there hadn’t been this target culture, then there wouldn’t have been this unnecessary stress and pressure on everyone. Perhaps if targets were used to identify where more resources were needed, rather than to punish failure, patient care might be improved. This time the potential breach was caused by a delay in X-ray (which often occurs). The solution might be to hire an extra radiographer. If this was done – if cash was invested to sort out this problem – then this delay might not occur again. But no, we fiddled the figures so we didn’t lose money and hence no one could highlight the problem. And the government could say everything is lovely-jubbly.

Another example was a 16-year-old girl who came in last Thursday. She had been drinking in the joyous surrounding of the local park. (Oh, the joys of the Anglo-Saxon drinking culture.) The ambulance was called because she was unconscious in the street. She needed fluids and a period of observation. At 3 hours and 30 minutes, my colleague reviewed her and determined that although she was now conscious, she was not well enough to go home yet. She needed another few hours to ensure that she didn’t still choke on her own vomit, etc. Before the days of targets, she would have stayed in A&E until she was well enough to go home. However, now we could only keep her for 4 hours, although she needed more time. My colleague was then told to refer her to the paediatricians to go and sober up on the kids’ ward. This was not appropriate. The paediatricians were busy enough and didn’t need to see a patient that my friend knew didn’t need their specialist skills, but then there is this bloody 4-hour target. Except in a very few clinical exceptions, we are not allowed to care for someone for longer than this time period. My colleague refused to succumb to the pressure of the nurse managers and did not refer her to the paediatricians and ended up getting a lot of grief for it.

She reviewed the girl 2 hours later. She was fit enough to go home with parental supervision. However, she was discharged about 45 minutes earlier than would have been ideal. The next day the doctor was expecting an interrogation into why she had let someone ‘breach’ but the figure had been fiddled and the patient was apparently discharged at 3 hours and 59 minutes. Again, I can understand why the figure was fiddled, but if we hadn’t fiddled the figures we might have seen the problem and a solution – a properly staffed paediatric A&E observation bed, where patients can be admitted while staying under the A&E team.

Figure fiddling happens everywhere. A recent survey by the British Medical Association and the British Association of Accident and Emergency Medicine showed that 31 percent of A&E doctors admitted to working in a department where ‘data manipulation was used as an additional measure to meet emergency access targets’. In other words, they admitted to working in an A&E where the figures were fiddled (for those of you who want to read more on this please go to http://www.bma.org.uk/ap.nsf/Content/Emergencymedsurvey07).

This is further backed by research from the City University business school that looked at the records of 170 000 A&E attendees and applied ‘queuing theory’. The conclusions were reported by lead researcher Professor Les Mayhew, who said:

‘The current A&E target is simply not achievable without the employment of dubious management tactics. The government needs to revisit its targets and stop forcing hospitals into a position where they look for ways to creatively report back, rather than actually reducing waiting times for real people.’ (further information is available from http://news.bbc.co.uk/go/em/fr/-/1/hi/health/6332949.stm).

When the Department of Health spokesman responds by saying back to the BBC, ‘It’s absolute nonsense to suggest that the A&E waiting time standard is not being met,’ who do you believe?

It is not just the raw data that is manipulated. There are other ways in which 5 hours to you and me means 4 hours to the Department of Health. Examples I have heard from various colleagues throughout the country include:

1. Corridors are re-designated admission wards by the simple application of a curtain rail. As soon as you are admitted to the ‘admission ward’ the clock stops.

2. Patients are discharged on the computer before they have left the A&E (i.e. before they have got their discharge drugs or similar).

3. As soon as a bed on a ward is allocated to the patient, the patient is transferred to that bed on the computer, regardless of whether they have to wait an hour for the porters to take them to it.

4. Patients can be admitted by computer to an A&E ward (and not breach) but physically not move because there are a lot more beds on the computer than there are in real life.

5. The time it takes from the ambulance bringing a patient in to being logged onto the computer can take up to 30 minutes longer if there are no nurses to meet the ambulance. The clock starts ticking when we are ready and when the receptionist has had her cup of tea, NOT when you arrive.

6. If a patient has been referred by a GP, they don’t come to A&E anymore, but to an admission ward. As they are technically admitted, there is no target for how quickly they get seen and so they can often languish for hours before seeing a doctor.

7. Patients for whom A&E doctors have asked for a review by a specialist can get admitted to a ward regardless of whether the specialist has seen them or not and regardless of whether they actually need to come in or not. Once admitted to a ward they can stay there for ages without being seen by the specialist as they are no longer in A&E and so cannot breach.

8. Originally, there were specific days when the 4-hour rules were being assessed. On that day, the hospitals would cancel elective operations so that there were spare beds and employed loads of extra locum doctors and nurses to make it look as if the hospital was more efficient than it really was.

So, as you can see, hospitals feel compelled to massage their figures. The target was brought in for the right reason and initially did a very good job. But we need clinicians to make the priorities, not politicians. If the government is going to insist on targets, then let’s make some sensible ones such as all urgently triaged patients to be seen within 5 minutes of arrival. Or how about patients being able to expect a bed 30 minutes after they have been fully treated in A&E, etc? These targets may not be as glamorous to tell voters about, but they might actually improve care without distorting priorities.

The reason I moan so much about this is that what was once a tool to improve A&E is now damaging patient care and doctors’ and nurses’ sanities. I just hope a politician or two reads these words and does something about it other than claim that what we are saying is just ‘nonsense’.

At work on New Year’s Eve

I am writing this on New Years Day. Last night I was at work and it was absolute hell. The A&E looked like a war zone – police restraining aggressive drunks, teenagers vomiting and crying and overworked staff acting as bouncers. I can only assume that the managers thought that someone might fiddle figures for the night and so didn’t bother to employ any extra staff despite knowing how busy it was going to be. I was knackered by the end of the shift and was pissed off with some of the patients’ attitudes, but in all honesty, I quite enjoyed myself.

But I can hardly blame the new drinking laws. I started my shift at 9 p.m. and the drunks were already there. The first was quite a nice lad of about 17. He had fallen asleep in the street and someone had called an ambulance because he had wet himself and was vomiting.

‘So what happened?’ I asked.

‘You tell me,’ he retorted.

‘No. I asked first. What happened?’ I countered.

‘Don’t know mate. Been larging it,’ he said in his irritatingly pretend street speak accent – posh but with a touch of Estuary English.

‘It says on the notes from the nurse that you have been drinking. That can’t be true as you are under 18 and so surely can’t have been drinking. What actually happened?’ I mocked.

‘Nah mate, I gone massive. I am quality,’ he retorted in Mockney.

Luckily, I listen to Radio One, so I sort of understood what he had said.

‘So how have you gone massive mate?’ I enquired.

‘Vodka mate. Bottle of vodka – down in 1 hour. Larging it. So what I am doing here?’

I explained that an ambulance had been called for him as he was so drunk.

‘That is quality. Coming to hospital ’cos so drunk. Quality.’

I asked some questions to check that he was OK and had suffered no ill-effects from his night’s drinking. I asked him if he thought a bottle of vodka was really that sensible for a 17-year-old’s liver.

‘I can do it because I am so f**king hard. I am hard as nails me.’

‘Right … so hard you end up vomiting all night and pissing yourself so that your mummy had to collect you at 10 p.m.? Yep, hard, aren’t you? Well done mate.’

I called in his mother, and as soon as he was able to walk without falling over, he went home. Except that that wasn’t all he had to say for himself. While waiting for his mum, every couple of minutes he would call out to one of the nurses.

’Oi! Beautiful! I am quality – do you want to come home with me?’

He was harmless but irritating after a while.

The next case was a 14-year-old girl. The ambulance called ahead to say they were blue lighting her in as she was completely unconscious. The nurse and junior doctor tried to wake her up and couldn’t. I got a call on the intercom.

I walked in and initially failed as well. If she was truly unconscious then we might have to intubate her (i.e. put her to sleep and take over her breathing) so that she wouldn’t choke to death on her own vomit, which I was currently sucking out of her mouth (with a suction tube). Then I tried a ‘registrar’s trapezius squeeze’. (Basically, you squeeze as hard as possible on the bit of muscle between the neck and shoulder, then carry on squeezing until they wake up.) She did wake up – very quickly. I checked that she hadn’t hit her head or taken any drugs, asked the senior nurse to put in an intravenous cannula, watch for more vomiting, and give her some fluids.

Giving fluids to someone who is drunk is a little controversial. We spend tax-payers’ money helping them to sober up and not get as bad a hangover which may positively reinforce their A&E-seeking behaviour after drinking. This can’t be good, but I am still a believer in giving them lots of fluids when people are drunk because it helps to get rid of them more quickly. It helps them sober up, and also they soon wake up needing to go to the toilet. Sometimes it backfires and they end up losing full control of their now full bladder – but the risk is worth taking as it is so effective in aiding appropriate discharges.

I explained to the girl’s mum what was happening and why we were giving her daughter fluids. We put the girl on her side and left her where we could watch her closely. We also gave her little sister, who had to enjoy her New Year’s Eve watching her big sister vomit, a chair and a blanket to cuddle into.

After 3 hours and 59 minutes the girl was sober enough to go home with her mum, who was furious with her daughter. As I came to see her, her mum was in the middle of telling her off.

‘This is the second time you have done this now. You have ruined your New Year and everyone’s else’s, you selfish girl,’ I heard her say. I introduced myself to the young girl and checked she was OK. I then said she was free to go but before that I wanted give her some useful patient education.

‘You could have died you know – you are only 14. Don’t be so dangerous in future.’

She looked at the floor.

‘Do you want me to tell her off?’ I asked her mum.

‘Please do,’ she said.

‘I have seen loads of people ruin their lives by binge drinking. You have been so stupid. We had to suck out the vomit from your mouth. Do you realise that? Do you? You could have had the vomit go into your lungs and then you wouldn’t have been able to breathe properly. You could have died, and in that state anybody could have done anything to you and you wouldn’t have known. Don’t be so stupid again and drink with some self respect.’

Her mother seemed suitably pleased with me. But I hadn’t yet finished.

‘You have also stopped me seeing really sick people who needed my help. The elderly lady in cubicle 5 had to wait an extra 30 minutes for me to give her pain killers for her broken leg because of your selfish stupidity.’

Her mum seemed very pleased with my chastising abilities, but then said, through gritted teeth, ‘You wait till you get home and then you’ll get a proper telling off.’ I felt sorry for the girl: I obviously had not been stern enough!

There are probably some trust guidelines saying that my attitude to this patient was probably not appropriate – I didn’t treat her in a holistic way and I didn’t communicate in a way appropriate to understanding her cultural needs (i.e. she was an Anglo-Saxon who culturally needed to binge drink). A lot of doctors, who are worried about having to be politically correct, may not have acted in that way for fear of being complained about. But I think that we should be complained about if we don’t try and educate patients on harm prevention. We need them to know the danger of their behaviour and it has been shown that short blasts from A&E doctors can make a difference. It is also quite enjoyable for us, but that is not the point. If I really wanted to go into a job so I could tell off teenagers, I would have gone into teaching. But then all my teacher friends say that if they really wanted to go into a job where they could tell off teenagers, then they would have been A&E doctors. Anyway my fears that I had gone a bit over the top subsided when in the morning, her mum brought round a thank you letter and a box of chocolates. I have never been thanked so kindly for being so forthright to someone’s offspring before.

The effects of drinking continued. Luckily, as it got later in the evening, the patients generally got a little older. Unfortunately, they also got a little more abusive as their waits to see me increased. There was a lot of drinking going on – mostly on empty stomachs but largely on empty heads as well – a particularly dangerous combination. The only difference from New Year’s Eve in the days before liberal drinking laws is that now cases of alcohol intoxication continue from 8 p.m. to 6 a.m.

The thing to remember is that these patients do need proper medical care – in fact they often need even better attention than sober patients as it is easy to miss injuries when someone is drunk. More seriously, it is easy to misdiagnose an unconscious patient as someone being drunk, when in fact they have had a serious head injury. I left work absolutely exhausted, but with a thought. If only we could videotape these patients and then show them what fools they made of themselves …

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 pocket – the 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 horny 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 outside – ACCIDENT 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.

3. Man with chronic hip pain – no worse – had 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 quickly – even if they have done it in a very expensive and divisive way.)

4. 28-year-old man – pain 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 analgesia. 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 lethargy – Man ’flu, I diagnosed, and so I agreed to look after our non-sleeping child all night. I was nervous and the anticipation of being awakened stopped me falling asleep. I resorted to desperate measures – I started reading the 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 teething – something 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 bastard 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 crew – paediatric 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 drugs – you 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 helping – nothing was. We were keeping his blood pumping with the compressions and the anaesthetist was breathing for him – but he was dead and had been for a long time. We all knew it but nobody wanted to give up. Nobody 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 dose – no-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.

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