"The bad news please," said the patient.

"Well, I am afraid that we are going to have to amputate your arm."

"And the good news?" enquired the poor patient.

"The bloke in bed two wants to buy your gloves." '

Well, that got him started. The nurses groaned as they had heard it many times before. He was giggling a little at this point, but still thinking about his finger. 'Breathe more of the gas,' I said.

I went through my memory bank of s.h.i.t doctor jokes. Luckily, I know a lot of them.

A patient went to his GP, 'Doctor, I don't know what the matter with me is, but I can't stop singing in a s.e.xy Welsh accent.'

'Ah' said the doctor, 'You have Tom Jones syndrome.'

'Tom Jones syndrome?' said the patient. 'Is that common?'

The doctor responded with a little s.e.xy dance and sang 'It's not unusual...'

The jokes were coming thick and fast. I was starting to win. The room was filling with laughter. I went for the kill. The cla.s.sic man with pain everywhere he touch.e.s.h.e has a broken finger; the old man who has a bit of lettuce in his ear, who the doctor wants to investigate as he thinks it's a sign of something seriousthe tip of the iceberg. Then my favourite: the bloke who goes to the doctor and the doctor says, 'I am afraid to tell you that you have got cancer and Alzheimer's.' 'Oh well,' the patient says. 'It could be worseI could have cancer.'

He was in fits and it was perfect timing; with one more whoosh of the gas and air, the scalpel went in and pus upon pus upon pus came out...it was like a teenager's dream. A bandage and some antibiotics and he was on his way...all of us contented.

Closing your A&E, are they?

I work in an A&E department that the government is thinking about closingit adds to the stress of working. The government thinks that we don't need so many A&Es and district general hospitals. It says this because: 1. Fewer people should attend A&E. 1. Fewer people should attend A&E.2. Most attendances are things GPs/community nurses could cope with.3. Many conditions need home care and not hospital admission.4. With reductions in doctors' hours, we can't have so many hospitals5. Centralised care is better for the sickest 12 percent, so sod the rest of you.

I am going to try and persuade you (just in case you needed it) why closing your local A&Es isn't such a good idea. At the same time I am going to explain why many of the problems A&Es are facing are partly caused by policies carried out by New Labour and the Tories before them.

Attendances at A&E departments are on the riseboth appropriate attendance and the inappropriate stuff we see that is neither an accident nor emergency. The fact is that people do attend...and they need treatment or rea.s.surance or whatever. There are a number of reasons why there are increasing demands on our service. These include: 1. Alcoholas a nation, we are getting p.i.s.sed more and coming to A&E with the problems. 1. Alcoholas a nation, we are getting p.i.s.sed more and coming to A&E with the problems.2. Drugsthe nation is getting higher, and when people fall they present to A&E.3. Increasing violence in societyoften resulting from factors (1) and (2).4. Obesityonly since Jamie Oliver kicked up a fuss has Labour started doing something about it. We see more and more obese patients with the complications that ensue. 5. Privatisation of social caresome care homes are there to make a profit and so might not always have the patient's best interests at heart. If a patient becomes a little tricky to look after, they are sometimes sent to hospital. The same goes for the privatisation of home care. 5. Privatisation of social caresome care homes are there to make a profit and so might not always have the patient's best interests at heart. If a patient becomes a little tricky to look after, they are sometimes sent to hospital. The same goes for the privatisation of home care. 6. Encouraging (or at least not dissuading) the blame culturethe number of patients who come in because their 'no-win, no-fee,' no self-respect lawyer has told them to do so is excessive. 6. Encouraging (or at least not dissuading) the blame culturethe number of patients who come in because their 'no-win, no-fee,' no self-respect lawyer has told them to do so is excessive. 7. Lack of responsibility-takingfor example, I now see kids that have had a fall at school. A few years ago the school first-aider would have dealt with the sc.r.a.ped knee, now they are too afraid that the parents will complain. 7. Lack of responsibility-takingfor example, I now see kids that have had a fall at school. A few years ago the school first-aider would have dealt with the sc.r.a.ped knee, now they are too afraid that the parents will complain. 8. The ageing societyeven I can't blame that on New Labour. 8. The ageing societyeven I can't blame that on New Labour.

There is also the problem of patients attending with GP-type problems. Yes, they should go to their GP and let me concentrate on treating the sicker patients but it is not always as simple as that. So why do they come to A&E more nowadays?

1. Loss of good-quality out-of-hours GP provision. 1. Loss of good-quality out-of-hours GP provision.2. NHS Direct.i.t costs a lot of money and gives good advice, but at the end of the day cannot physically see patients and so takes a low-risk approach, which often means saying, 'Go to A&E'. 3. Patient choice has been encouragedmany patients now come with primary care problems, as they seem to think they can choose to come to us instead of their GP. 3. Patient choice has been encouragedmany patients now come with primary care problems, as they seem to think they can choose to come to us instead of their GP. 4. The ma.s.sive influx of eastern European workersthere seems to have been no active plans to encourage them to register with GPs and so they come to A&E with their minor ailments. 4. The ma.s.sive influx of eastern European workersthere seems to have been no active plans to encourage them to register with GPs and so they come to A&E with their minor ailments.

With more and more people using A&E as their first point of call for many medical non-urgent problems, is it the right time to talk about closing down A&Es, without having organised the infrastructure of local community-based care? I think not.

Many conditions could be treated at home. However, we have to admit patients because support structures are not available especially if we are trying to organise them out of 'working hours'. Admission to hospital is then the safest option. So, until a proper system of community care is sorted out, it is dangerous and unfair to local populations to close the local hospital. The other factor I think the government has forgotten, is that these patients still need to come to A&E when they are acutely ill to have their diagnosis made and then to be risk-stratified before being sent home for community care. We need a local A&E, staffed 24 hours a day for this to happen.

The government also argues that it needs to shut A&Es and local hospitals to comply with the European Working Time Directive and doctor training requirements. However, there are lots more medical students than there used to bethey will need jobs and will be happy to do shift work when they qualify. Also, all doctors are meant to have generic skills and so can cross cover. Very rarely do you need a senior orthopaedic doctor/ENT/ophthalmologist, etc., in the hospital after midnight...and if you do, then call in the consultant if you are worried. Whatever is done, it should not be used as an excuse to close hospitals, but as another reason to make junior doctors' time more efficient and relevant to training requirements.

Finally, the government's main argument is that centralising care for the most serious of cases is a good idea. I completely agree. Heart attacks and major trauma would do better in large centres where there is expertise and experience. The ambulance could take these patients directly to the most appropriate place. Consultants could work in regional teams rotating around the major centre and so those working at smaller A&E, would not become deskilled. For it to work, we would need to overcome the problem of how we are going to look after these sick patients on their long journey to regional centres, especially when our roads are so clogged up...and, remember, traffic jams are often worse when the roads have had an accident on it. The government hasn't yet got the answers in place. It seems to me that it needs a ma.s.sive increase in funding for the infrastructure of pre-hospital medicine, such as having specialist doctors in ambulances and using more helicopters, before thinking about closing hospitals.

The other thing to remember is that centralising care should only affect the outcome of the sickest 12 percent. So what about the other 99 percentof patients? Centralising their care will not improve their outcome. The government should not use the centralising argument as an excuse to close local A&Es and district general hospitals (DGHs).

If anything, it will harm the health of the nation. Patients will put off travelling miles and miles to get treatment, so will get worse until they are compelled to call an ambulance. It would also be cruel to send elderly people miles and miles for non-life-threatening medical conditions such as pneumonia. The same argument goes for surgical procedures which don't need to be done at specialist centresfor example, mending broken hips. Saying that ambulances should take heart attack victims to regional centres is NOT an argument for closing your local DGH.

What really p.i.s.ses me off is that Blair made a recent speech saying that he is upset that doctors are not on the streets campaigning for his reforms to be brought in more quickly. Mr Blair, I am not on the streets demonstrating because they are ill thought out and community services are not ready to take over the role of DGHs. Your successor needs to go back to the drawing board. Although your reforms may may benefit the sickest of patients, it will not be beneficial to the other 99 percentof patients. benefit the sickest of patients, it will not be beneficial to the other 99 percentof patients.

Also, why didn't you tell us about it before the last election?

So, sign that pet.i.tion and write to your MP. Pray that our new Prime Minister changes Blair's plans. Go on the streets and campaign to keep your local hospital A&E department. But just understand why it may be good for the ambulance to take you a bit further afield when you are having a heart attack.

Nasty walls

Many people think that there are a lot of nasty people in my town and that is why there are so many people who turn up with hand injuries from punching. I believe not. In my town, we have some really nasty walls. These walls p.i.s.s people off, antagonise the good young men, s.h.a.g their birds and probably their mums, and generally create trouble. That's why these walls get punched and that's why these walls need to be stopped.

I hereby pledge to campaign for the Home Secretary to introduce a wall ASBO. Lock up these evil collections of bricks which so upset these fine examples of upstanding members of the community. Make their parent ceilings pay for the damage they do to the 5th metacarpal (little finger knuckle) bone of these young upstanding members of the community. WALLS MUST BE STOPPED! WE MUST BAN WALLS FROM CITY CENTRES. This is especially so on a Friday and Sat.u.r.day night when walls become especially antagonistic.

If this ban came into force, then we could virtually eradicate the broken hand problem and its victims would have no reason to come to see me at 4 a.m. It has been getting worseyesterday I saw evidence of a wall that had teeth. This shows how nasty the walls have become.

On a serious note, if you have given someone a good punching, don't say you punched a wall. The truth is obvious and we like to know all the details...and it makes my job more interesting. If you do say that you have punched a wall, beware. You may face a sarcastic response from the doctor treating you. For example: Dr says Dr says: 'Did the wall have teeth?' Dr thinks Dr thinks: 'Tell me the truth so I know whether you need antibiotics or not.' Dr says Dr says: 'This will hurt a little.' Dr thinks Dr thinks: 'St.i.tching up your cut with only h.o.m.oeopathic levels of local anesthetic will hopefully teach you a lesson.' Dr says Dr says: 'You'll still have to wait for another 3 hours until I see your hand.' Dr thinks Dr thinks: 'Please self-discharge.' Dr says Dr says: 'When I get angry I say oh fiddle-dee-sticks and count to 10. Have you ever thought of that as a way of controlling your anger?' Dr thinks Dr thinks: 'There are two very hard coppers with us, and you are nicked and I can joke as much as I want.'

This is just a brief synopsis of a ridiculously common injury. Let's get this wall ASBO campaign up and running. Please write to Dr Nick Edwards c/o The Friday Project.

P.S. On a serious note, even if you have got into a fight and then lied, you will still get properly treated in a non-judgmental way. The doctor just might smirk a bit behind your back. Also, if you have genuinely punched a wall then I apologise.

Tired again

It was 5 a.m. on night six of seven consecutive 12-hour shifts and I was exhausted. The last patient came in with heart failure. I examined and treated her, but her condition was nothing to get an adrenaline rush for. I think that I treated her well, but on reflection I am not sure. Did I give the right dose of morphine and frusemide? Did she really need that GTN infusion? Would I have treated her the same way if I had not been exhausted? If not, would it have been my fault?

Well, in this case I think I did do the right thingshe improved and was well enough to leave the resuscitation room and go to the ward within one and a half hours. However, I feel that there are loads of other patients that I have treated at this time of night when I may not have treated this well because I have been so tired.

Anyway, 8 a.m. came and I left for my drive home, luckily only 20 minutes away. I don't know how, but despite two strong coffees before leaving, I was driving on the main road home and then suddenly I wasn't. As the road was curling left I was sleeping. I had crossed the hard shoulder and hit the gra.s.s hill on the other side. Luckily, no-one else was involved. However, the car was destroyed, the air bags were brilliant and the police very sympathetic. An embarra.s.sing trip back by ambulance to work, for my neck to be checked out, ensued. I was furious with myself. But again, was it all my fault or were the people who designed my rota (medical staffing) partly to blame?

While waiting for my X-ray I started to thinkwe are told by managers all about patient safety and how to stop causing harm to our patients. It feels (even in this no-blame culture) that doctors and nurses are taking all the blame, but the managers who design our rotas are escaping scot-free. Do airlines let their pilots work seven consecutive nights? No, it is dangerous. Are train drivers protected? Yes. Lorry drivers have maximum times they can drive for. Why? To protect you, the public. The police, ambulance and firemanas far as I knowhave had research done into night working and know that it is dangerous to do so many consecutive nights. They only do a maximum of three or four at a time. Again, safer for them and safer for the public. But doctors...sod themlet them do seven consecutive nights and let's just hope they don't kill anyone at work or on a drive home. Anyway, if they do kill someone, we can blame the doctorwe can say it is because they haven't taken part in a patient safety course, or been keen enough on continuing professional development. We can refer them to the GMC, smash their confidence and wash our hands and just say, 'Oh well, it shows that the problems in the NHS are all caused by useless doctors.'

But seriously, it is not right.i.t is dangerous and it does affect you. I wouldn't want to be seen by a colleague who had just done six straight nights. In the days when I first qualified, specialist junior doctors (i.e. not ones who worked in A&Ebut to whom A&E referred to for admission and advice) often did 24-hour and 48-hour shifts. That was wrong but at least you got a bed and then were not on call for a few days after that. You never had to do seven consecutive nights.

The government rightly changed it, but delayed the implementation of the full working time directive and made (sorry...allowed) doctors to opt out of it. This allowed managers to devise the most dangerous working patternswho cares if it damaged doctors and patients? What makes matters worse is that junior doctors often rotate around hospitals on training schemes. We often live 12 hours away, and often not near public transport. There also used to be rooms where specialist junior doctors could sleep when it wasn't busy (this was even more important for them since, unlike A&E doctors who can go home after their 12-hour shift, they often had to stay longer on the ward round telling the consultant about the patients admitted overnight). Admittedly the beds were used only occasionallybut a half-hour nap really can refresh. Now they have generally been taken away and in most cases turned into vital managers' officersthe room once referred to as 'Medical SHO On-Call Room' is now often called 'Patient Liaison Facilitator Deputy Manager's Sub-office' and the surgical SHO on-call room you can find under 'Patient Pathway Discharge Facilitator Deputy Coordinator's Deputy a.s.sistant Manager's Officer'.

Is this just my view? No. In October 2006 the Royal College of Physicians published a study 'Designing Safer Rotas for Junior Doctors in the 48-hour Week' Its main conclusion was, 'Most junior doctors work night shifts, many of them are doing seven consecutive nights, each lasting 13 hours. That has been shown to be potentially the most dangerous type of rota that could be devised, in terms of risks to both patients and staff.' For futher information, please go to http://www.rcplondon.ac.uk/pubs/brochure.aspx?e=180.

Now that we know that the politicians have the evidence we shouldn't allow them to let hospitals arrange such dangerous rotas. The Labour government has brought about good changes to our working life styles but it needs to do more and do it faster for the patients' sake. Change rotas now. It won't necessarily cost anything, it will just mean that medical staffing managers will have to think about things a little bit harder.

Oh, and one more thing on nights and sleeping: the seventh night of my week was very quietluckily. The nurses knew I had had a c.r.a.p day and not slept that well and so I slept for an hour or two when it was very quiet. I slept in the side room where we often put patients when they are going to die, to give relatives some privacy. It was a little spookybut needs must, especially when you are working a dangerous rota.

Changing emotions

It had been a very pleasant day at work. We were well staffed and everyone was in a good mood as someone had bought some Nescafe Gold in to replace the Happy Shopper coffee. How easily pleased we all are.

I picked up the next card: 28-year-old male. He hadn't been triaged yet so the only information I had was from the receptionist, who wrote 'not feeling right'. (I also knew his religionfor some reason they always find out the patient's religion. Maybe it is just in case we need some extra special help and it helps us to know who to call?) I started chatting to him. He was a delightful man. He was there with his pregnant wife of seven months who had forced him to come. He started to tell me his symptoms. They were all a bit non-specific. He had felt tired and a bit sick for the last few days. I was about to advise him that he should have seen his GP instead when he added that he had tried to play the piano and it just didn't seem right. His hands didn't seem to touch the keys properly (he was a good jazz pianist apparently).

This concerned me. This shouldn't happen to 28-year-olds. I examined him and he had a neurological sign that concerned me he couldn't tap his hands together properly. It worried me, first because it implied that he might actually have a brain tumour, and second because I had to write down such a long word in the notes that I would invariably spell wronglydysdiadokinesis. (Many doctors love medical jargon and long words because they think they are clever when they say them. I don't, partly because patients don't know what you are talking about, but mainly because I am s.h.i.t at spelling.) I left him for a moment to plead with the radiologists for a scan. After being told that I was probably wasting their time/ making up symptoms/exposing my patients to unnecessary radiation, they eventually agreed to the scan after I promised to sacrifice my first born child in their honour.

I explained to the patient that although the signs were probably caused by 'something minor' we had to rule out 'something more serious' going on inside his brain. He seemed satisfied by my explanations and went for his scan.

While he was in the scanner, all my colleagues were taking the p.i.s.s out of me for organising another 'unnecessary' test and just looking for something dramatic to excite my day. I explained to them all why I believed he might have a brain tumour and went into detail about the anatomy of the damaged bit of brain. They explained to me that I needed to get out more and realise that most people's symptoms are caused by stress.

Just as I was saying 'I bet you he has got a tumour' and my colleagues were saying 'I bet you he hasn't', the radiologists called. 'You'd better come down and have a look at the scans.'

'Oh f**k', I thought, as I looked at the scan. But I am a professional and so collected my thoughts before contributing to the academic discussion about the scan results. 'Oh f**k', I said.

He had an obvious tumour. Not only that, but he had swelling of the brain and he would need immediate transfer to a specialist centre. This was the worst possible scenario that I could have imagined, but, strangely, from a purely academic point of view, I was pleased.

I was pleased that I had been proved right. Pleased that I had worked out his diagnosis from a weird set of signs and symptoms. But de facto de facto I was therefore pleased that this man had a brain tumour with a possible death sentence. This is surely not right. I went to speak to my colleagues/doubters. A 'told you so look' went across my face as I told them what the scan had shown. However, as the glow of academic satisfaction dimmed, the reality struck. He had a brain tumour and would need an urgent operation tonight. He was seriously sick and might not see his child grow up...and I had to go and tell him. I was therefore pleased that this man had a brain tumour with a possible death sentence. This is surely not right. I went to speak to my colleagues/doubters. A 'told you so look' went across my face as I told them what the scan had shown. However, as the glow of academic satisfaction dimmed, the reality struck. He had a brain tumour and would need an urgent operation tonight. He was seriously sick and might not see his child grow up...and I had to go and tell him.

It didn't go well. I told them what the scan had shown. He was stoical. His partner was hysterical. It was awful.

I left the conversation feeling sick. It had been a day of weird emotions: pleasure from an academic viewpoint and heartbreak from a personal one. It can be a very interesting job this one...but also very upsetting.

Career stresses

There is a lot of uncertainty about working in A&E at the moment. In the past, to become a registrar, you had the stress of pa.s.sing exams and having to move around the country for different jobs, but at least you knew that once you had finished your training, you could settle down as a consultant and help run an A&E department.

However, for the registrars of today's A&E, it is very different. More exams and constant revalidation, are things all specialist doctors should expect, but it is the uncertainty of what our role will actually be that is worrying.

Emergency nurse pract.i.tioners see a lot of the minor cases that doctors used to see. This was supposed to give us time to see the sickest patients. However, the government's 4-hour target is taking away our role in their ongoing emergency care (which is often beyond 4 hours) and it is being taken over by a new creed of doctorsacute medics.

Then there is the question of whether there will be jobs in the future for us once we have finished our training and are consultants. Hospitals are cash-strapped at the moment and there seems to be a reluctance to take on new consultants. Even the government has said that it antic.i.p.ates that there will be too many consultants in a few years' time. Also, how many A&E consultants will we need in the future, if the government has closed all the smaller units?

So, if you see your A&E doctor looking stressed, it may be because of career worries on top of the other expected ones.

b.l.o.o.d.y Jobsworth

Your job is hard enough and then you get t.w.a.ts making your job harder. They read protocols and policies, and then think they have power. I have had quite a few examples during my time as an A&E doctor. Here are a couplethe first one happened a couple of years ago.

It was a quiet night and I was the only doctor in a small A&E where everyone knew everyone else. At about 3 a.m. the k.n.o.b of a security officer came over on his rounds. He was the type of security officer who instilled no confidence in either his fighting abilities or his conflict resolution skills. He was fat, greying and very sweaty and all he looked good for was making the tea for the post-fight a.n.a.lysis.

'Evening, Edwards,' he said in his quite irritating Birmingham accent. He walked off to check a door or something and then came back. 'Have you got your ID badge on you?'

'No.'

'Well, have you seen the new trust memo section 4, paragraph 6.2 section 3, line 7 on improving patient safety. It says if you have not got your ID badge, then you can't see patients and so I can ask you to leave.'

'Oh well...bureaucracy etc.' I responded.

'No, seriously, I could ask you to leave and I'll escort you off the premises if I want to,' he said.

'Look, just let me get on with my job and stop being pedantic,' I responded.

He retorted, 'I am just doing my job. I am not padantic.'

'Pedantic. Not padantic,' I responded, in what I thought was a witty way, but he didn't get. 'I would be delighted if you escorted me off the premises. But who is going to see the patients?'

'Not my problem...section 4, paragraph 6.2, etc., etc.' He went on and on.

Now, I wouldn't have minded this conversation if he was joking, but he wasn't. He was deadly serious. I fought back in this game of verbal judo.

'Actually, please escort me off the premises, and you can explain why all the patients had to wait until the morning to see a doctor.'

He backed down, but then a week later I got a letter advising me about my section 4, paragraph 6 from the personnel manager and copied to my bosses. What a waste of NHS money and time.

But this wasn't as bad as the Jobsworth a colleague of mine got told off by. You may not have noticed, but recently the NHS has gone 'smoke free'. A great ideano smoking in the building or grounds but a blanket ban lacks common sense. It is a fact of life that in A&E stressful things happen, and some people smoke for a bit of urgent stress relief.

A colleague of mine had been telling a dad about his 20-year-old son who had had a serious motorbike accident and had to go to ICU. The dad asked him if they could talk outside as he needed a cigarette. They went outside and carried on the discussion and my colleague explained in detail what was going to happen when his son was on ICU.

As they were talking, a health and safety manager, or something like that, walked past. 'You are not allowed to smoke in the trust grounds,' he said, while pointing to a ridiculously expensive, large banner draped across the outside wall of the hospital. My friend said he was trying to tell his patient's dad about his son's critical illness and asked him to leave them alone.

'Well, you can tell him without him smoking. We are a smoke-free site,' he said in a completely dispa.s.sionate way.

Ten minutes later the safety officer came back to tell off my colleague for encouraging members of the public to break health and safety regulations and advise him that if he did it again, it was a disciplinary offence. What a c.o.c.k. People need to think about the problems people face when they come to A&E and think outside their own small box.

While I would never encourage smoking, in very stressful situations nicotine withdrawal can make the stress a hundred times worse. Don't make life harder for staff and patients/relatives. Rules need to be bent where appropriate.

Lack of staff

One way A&Es have adapted to the 4-hour rule is to bring in A&E-run observation units/clinical decision units (CDUs) for patients who are waiting for test results before they can go home or who only need a very short admission. They are not intended for people who are going to need admission regardless of the blood results. However, some hospitals don't have these wards, or perhaps only have a few beds, so patients are still needlessly admitted to the main hospital for a few hours.

Yesterday I found out how frustrating it must be to work in an A&E without these wards and with the government 4-hour targets. I was working on a day when our 'CDU' ward was closed because of staff shortages. I had a gentleman who had walked in from the street 10 minutes after taking 16 paracetamol tablets. The medical management for this is to measure the levels of the drug after 4 hours to see the level of paracetamol in the blood and then, depending on the level, to treat the patient with a drug to protect the liver. Absorption varies from person to person, so not everyone will need this treatment. It was unlikely that this man would need the treatment, but he would need to see a psychiatrist for his suicidal intention.