The main problem was his head. There are two immediate risks in this type of situation. First, that he might vomit and inhale, and then the vomit would clog his lungs and hamper his breathing. Second, if he had a bleed in his brain, then the pressure in his brain would grow and eventually crush the area of the brain responsible for breathingalso not so good.

Both of these are managed by intubating the patient (i.e. putting him to sleep and taking over his breathing). While the anaesthetists were doing this, the orthopaedic surgeons and I tried to stop some of the bleeding from the broken legs. This generally involves pulling the fractured bones back into alignment. There is no great science to it. Just pull it to the angle that looks right. They can be sorted out properly at a later date; he had more pressing issues.

He was intubated and we phoned the radiology consultant to come in to do a full-body scan and then interpret if for us. Amazingly, there was no argument and the radiologist was in the hospital within 10 minutesgrumpy, as usual, but at least he was here.

The CT scan showed a large bleed in the brain, which meant he was probably going to be badly disabled for lifeeither that or die in the next 48 hours. Which one is worse, I am not sure. Plans were made for transferring him to the local specialist neurosurgical (brain surgery) hospital, so they could operate to drain the blood and relieve the pressure on his brain. In the meantime, the anaesthetists were giving drugs to reduce the pressure in the brain and prevent further damage. It was my job was to talk to the family.

Even though most of my best medical practice is done with my mouth rather than my stethoscope, and even though I have broken bad news countless times, I was dreading this. I hate it, but someone has got to do it, and I feel that I am as good as any of the other doctors on the team at this job. I took one of the nurses in with me as support, both for me and the family.

As I started to talk to them, I felt the slight depersonalisation that I often get. I found myself looking down on myself speaking to them. It doesn't stop me being compa.s.sionate, but it does protect my mental health.

I felt awful. There was I talking them through what had and was going to happen. At the same time I found myself holding the mother's hand as it felt the right thing to dorea.s.suring and comforting. But at the same time, I also felt that it was like an episode of EastEnders EastEndershis mum was blaming herself for having a go at him earlier as he might be late for lunch. He had even told her that he would drive like the wind so that he wouldn't be late. Meanwhile, the dad wanted to know if he had been over the limit from last night's festivities. Apparently, he had been with his cousin, who apparently was a 'good-for-nothing little s.h.i.t', who always made his son drink to excess and who 'was going to pay for this'.

His sister brought some sensibility to the discussion.

'Is he going to...?' she didn't say the word die, but I knew what she was asking.

'I don't know. We are doing everything we can but he has been seriously injured.'

'Don't let him die,' pleaded his mum.

I didn't know what to do so I just frowned. She gave me a hug and begged me to save him.

'We will do our best,' I said. That was the truth, but I wasn't sure if it was going to be good enough.

It was a s.h.i.t start to my Christmas but it stopped me moaning about being at work. I looked at the box of the next few patients who were waitingtwo chest pains, an asthmatic having an attack, an injured finger, a sore throat and tooth ache. Thank G.o.d that these are the normal type of patients we see in A&E. Thankfully, the trauma case is a rarity, otherwise I am not sure that I could handle this job.

It came to home time, and I called my mother-in-law's house to say I was going to be a bit late for Christmas dinner. My wife was a bit miffed, but after I told her what had happened she certainly didn't moan or ask me to speed home.

On the way home, I had a few thoughts. What if he dies? Not just from a 'what a catastrophe for his family' point, but from a professional perspective. If he dies, the family will not blame the medical staff. If he survives, however, we will get the credit and praise. This is very different from most doctorsif a GP misses a diagnosis then they can be vilified. If someone dies in a routine operation, the surgeon will be investigated and their career damaged. But in cases like this we very rarely get blamed as the cause of the injuries are out of everyone's control.

The downside to this is that people very rarely realise that the quality of care affects the outcomethey just blame the initial injury. They believe it was an inevitable outcome from the accident, not one that might have had an alternative ending in a different hospital with different resources and differently trained staff. I am not saying we are responsible for everyone who dies from a trauma. Cases like this involve everyone working their hardest to provide the best possible care. However, we are limited by our resources and the skills and experience of the members of the team, and this can affect the outcome in these types of patients.

What the lack of public awareness of this means is that there is a lack of public pressure to improve the care for emergency patients. There are thousands of cancer charities, but very few that promote 'pre-hospital care' and even fewer campaigning for the improved care of trauma victims. This is despite trauma being the leading cause of death in the young adult population. It has been shown that better care and facilities lead to better outcomes. Greater investment in A&E care would ma.s.sively alter the outcomes of many of these patients. Of course, in many cases even the best care in the world could not alter some outcomes, but in many, simply improving research funding and resources could save many lives and decrease morbidity. The decreased morbidity would soon save millions in not having to pay sick benefit and having people back at work and paying taxes. Even government accountants should agree with that spending increase.

Other factors lowering the political interest are the heterogeneity of trauma cases: it is very hard to try and get meaningful trauma survival rates for each hospital as opposed to say, cancer mortality rates. This lack of a target means that the government is not as interested in the quality of care. It wants a target to show off to the voters, so for A&E it has produced a 4-hour waiting target, rather than a quality of care one, which ends up distorting priorities. However, politically it makes sense as there are a lot more voters who have had to wait to get their stubbed toe seen to than have been in a near-fatal accident.

The lack of political interest in trauma outcomes also means there is only a tiny amount of public investment into trauma research. Where there is investment in research, it is often heavily restricted into what can and cannot be researched. Politicians are concerned about not doing trials on people without their express consent (which is very hard to get from an unconscious trauma patient), which means that research into how best to care for these people is very difficult to do in this country. There is currently a worldwide research trial into whether a particular drug that stops bleeding would be of benefit in patients such as the one described. But the UK is one of the lowest contributors to the data because of the complexities of taking part in the trial. We didn't enter the patient into the trial purely because the amount of bureaucracy involved would have made it very difficult. He potentially didn't get a beneficial drug and neither will future patients because of difficulties constructed by research committees in this country.

Added to this are the budgetary constraints being inst.i.tuted across the NHS. Two things that have been cut, and no-one seems to have noticed, will soon affect the care of trauma patients. First, there is a Trauma Audit Research Network which hospitals pay to join. For their money, researchers look at the patient notes, collate data and look at how well they are managing their trauma patients, then recommend how they can improve their care. Some hospitals are saving money by not joining this network and thus are not getting the vital feedback they need.

Second, the study budgets for nurses and doctors are being cut. These study budgets, in the past, have been used to pay for high-quality trauma trainingAdvanced Trauma Life Support (ATLS) courses. Less funding means fewer staff being able to attend the courses, which means less well trained doctors and nurses looking after you, which means you may have a worse outcome. These cuts have not even entered anyone's political debate but then I suppose we shouldn't complain about the NHS not having enough money. The government needs the money for other vital things such as paying for a war in Iraq and renewing the Trident missile system...

As I thought about this, I got more and more annoyedwhy do I mull over things so much after work and why do all my thoughts end up with me becoming angry, ranting and usually getting political? It must really drive my family and friends mad as this is all I think about. So, one of my New Year's resolutions must be to not think about work on my drive home, otherwise I'll send myself mad.

I decided to start my New Year's resolution early. I put on the radio and listened to some inane presenter encouraging me to sing along to 'Rocking around the Christmas Tree' and then 'Mistletoe and Wine'. For the first time ever, I found Cliff Richard relaxing and enjoyable. That is something else I better hide from my friends and family.

The joys of shift work

One of the lows of workings as an A&E doctor is the effect shift work has on your body clock. I notice a number of problems. First, I just can't wake up easily before going to work and second, my bowels go crazy. Things got bad last night before work.

My wife tried the normal tactic of gently kissing me at first, then nudging me and then pulling off the covers, before resorting to pouring cold water over meall with no effect. She has learned that she needs to start getting me up quite early as I take a while to rouse. Her latest tactic has been to start a countdown until I have to leave, with increasing levels of threats of violence if I don't get up. Tonight, however, was worse than usual. The routine shouting soon started.

'Nick it is eight-fifteen. Get up'no response from me 'Nick it is EIGHT-THIRTY. GET UP NOW!!!' Again, no response.

'NICK. GET UP NOW. IT IS EIGHT-FORTY. GET UP NOW!!!' She bellowed up the stairs.

It was only when my mobile went off and I saw a text message from my next door neighbour that I realised that I need to get in to a better routine before work. It read 'Nick. Apparently it is 8.40. I think you need get up and go to work!' Oh, the joys of shift work and terraced housing.

The other main problem is what shift work does to your bowels at night. I have nicknamed it SWAC (shift worker's a.n.a.l conditions) as a main term and I suffer from two subtypesnocturnal SACS (sweaty a.r.s.e-crack syndrome) and nocturnal CATED (constipation and then excessive diarrhoea). Luckily, it all goes back to normal once I am on day shifts. I am so looking forward to the coming stretch of six weeks of days before my wife loses her voice and my a.r.s.e becomes an issue again.

Careful with your notes and coffee room chats

In the last couple of months, I have listened to two of the most amusing talks. One by the hospital solicitors and one by the Medical Protection Societya doctor's legal advice service. Both were about how to write in notes and not get sued. Two main bits of advice were given. First, write what you have done. If it is not in the notes, then it hasn't happened. Second, be careful about what is written. Do not use acronymsespecially TLAsthree letter acronymsit leads to confusion. Do not insult people (they can now get hold of your notes) and don't use insulting acronyms (it is the worst of both worlds).

With this on board, and knowing that I was a new breed of doctor who was too scared of being struck off to do any of this (and also someone who believes patients should automatically get a copy of their attendance letter from A&E), all I could do was sit back and enjoy what some others had written in the past...and you thought that all doctors were angelic creatures. (Please note that although I think that the following comments may be potentially amusing, they are insulting and should never be used.) (Please note that although I think that the following comments may be potentially amusing, they are insulting and should never be used.) Diagnosis NFBnormal for Birmingham. FLK syndrome FLK syndromefunny-looking kid FLP with a FLK FLP with a FLKfunny-looking parent with a funny-looking kid (the condition is often hereditary). FLKBOFB FLKBOFBfunny-looking kid, but OK for Birmingham. FLKNLP FLKNLPfunny-looking kid, normal-looking parents (the kid's condition has not been inherited). GOMER GOMERget out of my emergency room. Used for old patient who is ill and you need to admit them to a ward before they become really ill and become your problem. RIP RIPrest in peace. Nothing rude about that, except beneath the notes certifying the death, a doctor had drawn a grave stone with some flowers around it and then written RIP on the gravestone. TFTB TFTBtoo fat to breathe. WNL WNL (as in 'observations were all WNL')within normal limits/we never looked. (as in 'observations were all WNL')within normal limits/we never looked. ECG ECG (heart tracing), (heart tracing), NAD NADno abnormalities detected/ not actually done. COPD COPDchronic obstructive respiratory disorder/chronic old person disorder. PEP PEPpharmacologically enhanced personality (p.i.s.sed or stoned). CRAFT CRAFTcan't remember a f**king thing. NPS NPSnew parent syndrome. Parent anxious. Child well. Oligoneuronal Oligoneuronalnot many brain cells (similarly used is pneumocranialair head, literally air in the head). LPT LPTlow pain threshold. PFO/DFO PFO/DFOp.i.s.sed fell over/drunk fell over. a.s.s a.s.sarrest avoidance syndrome. Similar to PAS (prison avoidance syndrome) and PDSD (pre-detention stress disorder). PTSD PTSDpost truncheon stress disorder. Similar to above but also involves trying to make up symptoms or blame previous injuries on the police. TATT TATTtired all the time. TTT TTT ratioteeth to tattoo ratio. A low ratio implies a difficult upbringing with all the cosmetic effects that has on people. ratioteeth to tattoo ratio. A low ratio implies a difficult upbringing with all the cosmetic effects that has on people. ONF ONFoverall nick factor.

As I said earlier, these terms are rightly consigned to the history books. I always write notes knowing that patients can read them and I don't want to cause upset. However, one place where they are still used is A&E coffee rooms. There are also a lot of slang terms used in these rooms, and since I am trying to show what it is like to work in A&E, understanding some of these terms is quite important.

Can't Decide Unit Can't Decide Unitother name for Clinical Decision Unit. The bit of A&E where we put all the patients in who have been there for more than 4 hours so they don't break the 4-hour target. Meet, treat and street nurses Meet, treat and street nursestriage nurses who can now put on a sticky plaster and then say goodbye. Code blue Code bluea really non-urgent ambulance that should never have been called. Smurf positive Smurf positiveblue colour of patient owing to hypoxia/ lack of oxygen. Simpson positive Simpson positivea patient with jaundice. Homer Simpson positive Homer Simpson positivea gay patient with jaundice. Rooney fracture Rooney fracturefracture of the fourth metatarsal. Beckham fracture Beckham fracturefracture of the fifth metatarsal. An Owen knee An Owen kneeknee pointing in the wrong direction (as per Michael Owen in the 2006 World Cup). Ear ring sign Ear ring signthe larger the hooped earring, the more likely she is to have pelvic inflammatory disease as opposed to appendicitis. Similar to the toe ring and ankle bracelet sign. Granny dumped Granny dumpedhappens on Christmas Eve, when family want to go on holiday. Speaks for itself. Gomergram GomergramGOMER who you do a battery of tests on if you have no idea what is going on (ECG, chest X-ray, blood tests and in America a CT scan). Buff Buffmake the patient easier to refer to another team (i.e. moderate chest pain, gets exaggerated to excruciating chest pain). Turf Turfsend to another team so it is not our problem. Fluttering eye syndrome Fluttering eye syndromea patient who fakes unconsciousness, but we know they are making it up as they flutter their eyelids when you stroke them. O sign O signold person dying with their mouth open. Q sign Q signold person dying with their mouth open and tongue out. Dotted Q sign Dotted Q signold person dying with their mouth open and tongue out and fly on the tongue. Chav ChavEnglish equivalent of trailer trash. Not really sure what it stands for. A policeman friend of mine claims that it means 'Council Housing and Violent'. Chavet Chavetfemale chav. Chavlett Chavlettyoung chav. Ash cash Ash cashmoney for signing cremation forms. Personally, I think that the amount of money people pay for us to sign a form, so that they can cremate their relatives, is disgusting. However, I am hypocritical and happily spend the money. In quite a sick way lots of junior doctors buy rounds and then toast the person whose family has just paid for the drinks. Ash machine Ash machinea doctor's cash machine. A part 2 slimer A part 2 slimera doctor who makes friends with the morticians, purely so they can get to fill in parts of the cremation forms and make lots of money. Bash cash Bash cashmoney the police give us for describing the beating that we treated in A&E.

To an outsider, these may seem sick and cruel words, but they are used away from patients and are part of the black humour that keeps A&E staff sane. So, be wary of going into a staff room in any hospital and, please note, my describing these terms does not mean that in any way do I approve of them.

An embarra.s.sed husband

Working in A&E you always get to see a few patients with rectal foreign bodiesthings placed where they shouldn't be. It's an occupational hazard of a.n.a.l play, but it's not my cup of tea. However, it really doesn't bother me at all if that's how you like to get your kicks. I don't get embarra.s.sed by it (much) and I often feel genuinely sorry for the patients. They are very embarra.s.sed and doctors and nurses can only make it worse by asking too many questions or taking a moralistic view.

There a few cases that spring to mind. However, there is only one that is truly memorable, but mostly for the reaction of a fellow doctor to the patient. The gentleman in question came in with a 'personal problem', and he had asked to be seen somewhere private. I asked what had happened. He started to lieit was obvious.

'I was lying on the couch and fell asleep. I had taken my trousers off because I spilt wine on them. Then my phone went. I went to pick it up off the sofa and I slipped and it sort of...'

'Is there a phone up your r.e.c.t.u.m sir?' I asked. He nodded nervously. 'Don't worry. It doesn't bother me. I am only here to help you.' I didn't ask what make, or if it was on vibrate mode. I X-rayed his abdomen and there it wasfrom the look of it probably a Nokia 6250i or something similar. I just hoped that it wouldn't ring. There was no way that it would come out without a general anaesthetic and the skills of a good surgeon. Some foreign bodies even need a cut to be made in the abdomen so that they can be pushed out from the inside so to speak. I explained all this to him.

'But you must get it out now; my wife can't know...she doesn't know about that side of me and I don't want to lose my kids.' He started to panic.

I explained that there was no alternative. Leaving it there was a definite no-no as it might perforate the bowel and cause septicaemia and death.

He continued to panic. He explained to me that his wife was a medical secretary at a local GP practice and would have access to any notes sent to his GP about the episode. I a.s.sured him that no notes would be made available to his wife and that we wouldn't tell her anything. However, that didn't satisfy him.

'I can't have the operation or my marriage is over. I am leaving,' he whispered. I tried to stop him leave and then offered him a solution.

'You could lie. We can't lie for you, but you could say you have an a.n.a.l fissure that has started to bleed and they need to do an examination under anaesthetic.'

He seemed a little calmer now. I phoned the surgical team on call and explained to them what had happened and his embarra.s.sing predicament. I explained to them the explanation I had given him to offer to his wife, so that they would know what he was going to say so they didn't put their foot in it. The response I got shocked me.

'You can lie if you want, but it's his sin and his problem. I am not taking part in your deceit.'

I didn't see the patient after that. I hope the surgeon was a little bit more understanding of his predicament face to face, otherwise, if it ever happened again, then the patient would be too embarra.s.sed to come back to A&E and could end up with the complications of foreign bodies where they shouldn't besepticaemia and death. It is not our job to moralise but we often do and sometimes you can't help it. However, part of the job is hiding your own views from the patients.

The human effect of reconfiguration and lack of beds

Just in case you thought that the NHS emergency care reconfiguration was a utopia of improved health, I want to remind you of the reality.

A 19-year-old patient had been involved in a ma.s.sive car accident. He needed his breathing taken over for him and for that he needed to go to ICU. The only problem was that there were no ICU beds available. This was not a new problem but had been exacerbated by an increase in serious cases coming to our hospital as the other local A&E had, in all but name, been closed. However, the genius planners had not considered the fact that the only hospital in the region with a fully functioning A&E would now have a busier ICU. Consequently, there had been not enough increase in funding and not enough new beds were funded for all the extra patients.

The problem of a lack of ICU beds existed before the reconfiguration, but now in my hospital it is a lot worse. In this case the patient, instead of going to ICU, stayed in A&E till they could 'create' a bed. This involved waiting for a ward patient to die, a high-dependency patient going into their bed, a patient from ICU going to the high-dependency unit (HDU) ward and then quickly cleaning the spare ICU bed.

This meant that an anaesthetist had to stay with the patient for 6 hours until they were on ICU. This in turn meant that the appendicitis case that I referred 4 hours ago, and the patient who needed a 'ERPC'removal of an embryo after a miscarriage who both were due for an operation that night, were delayed. Those patients were unduly put at psychological, if not a serious medical, risk. Not knowing this, they did not make a fuss.

Another patient who suffered was a gentleman needing his oesophagus removed for cancer. His surgery was booked for the next day. However, it is a very large operation and he would need an ICU bed post-op. As there now were none, the operation was postponed. All these patients were told it was an exceptionally busy night, no-one could have predicted it, etc., etc. They were not told that the root cause was poor managerial planning.

So, the inpatients had their length of stay increased and their cost to the NHS rose. The cancer patient had another few days' wait for the operation and the surgeon and his team sat frustrated that they couldn't operate.

Reconfigurations without proper planning have made our hospital ICU run at close to 100 percentbed occupancy. What managers must realise is that this leads to decreased efficiency and care. It is not just ICUs running at close to 100 percentoccupancy, but the whole hospital. Surely the managers have got to realise that the point about emergency care is that it is unpredictable and you need to have spare capacity to cope with minor surges in need. Even the Department of Health in 2002 said that the optimum bed occupancy rate is 82 percent. However, week-in, week-out we go above this and patients do suffer. That's why you need clinical advisors when a hospital needs a 'hit squad' to come and improve things, not some city kids in suits, who are called management consultants, charge a grand a day and know b.u.g.g.e.r-all about patient care.

While I am on the case about managers, it is important to realise that there are a ma.s.sive number of excellent ones working in the NHS. But they have to implement politicians' plans and with limited resources and skewed targets. I need to remember that when I get frustrated with them.

Unexpected laughter

Today, I had a tragedy turn into a comedic episode. I had to certify a patient's death and the family ended up in fits of giggles. It was a very odd experience and just shows that people cope with grief in different ways. The patient, who eventually died, came in from the ambulance in 'cardiac arrest'. She had no heartbeat and the ambulance personnel were doing chest compressions.

During the cardiac arrest, I was supervising one of the junior doctors on how to 'run' a cardiac arrestshe was doing very well. However, cardiac arrests are not like you see them on TV. Only rarely are they successfulthis is partly because we have all forgotten the importance of actually compressing the chest properly when the heart stops, as opposed to giving fancy drugsfor which there is little evidence that they make any difference. Patients also rarely wake up and say thank you and walk out. They go to ICU and three days later they may or may not wake up with some brain damage. After 15 minutes we realised that this case was 'futile'. We couldn't save her. My junior colleague quite rightly asked if we all agreed to stop her chest compressions. Everyone nodded.

She was placed into the 'quiet room' ready to transfer to the 7th floor (we have only six floors and it is a euphemism for the mortuary). The family was by her sideher daughter and three grandchildren. Before she could be moved to the chapel of rest, she had to be formally certified. This was the first 'cardiac arrest' my junior colleague had been in charge of. I therefore offered to certify on her behalf while she composed herself.

I had already met the family and explained what had happened to their mother, and so had no problems speaking to them again. I explained what I needed to do, and asked if they wished to stay. They did. I then asked if they had any questions. They did. The youngest of the grandchildren spoke.

'Did you used to live in Stanford Drive?'

'Why?' I asked.

'A few years ago?' he asked.

I nodded and again asked why.

'See, I told you all,' he said to his family. Looking back at me, he continued, 'Did you used to have a dodgy "kung fu fighting" dressing gown?' he asked.

'Yes, when I was a student. As soon as I went out with my wife, she chucked out all my clothes and I became well dressed. Why?' I really wasn't expecting this type of questioning and was becoming a bit perturbed. I think my facial expression was showing that now.

'And did you used to have your milk delivered?' he continued.

In a rather shocked way, not expecting my retail preferences to being the main points discussed in this meeting, I nodded. He seemed to take glee from this and said to his family once again.'Told you so!'

He turned to me.

'I used to be your milkman mate...Tony. Do you remember?'

I smiled and everyone burst into laughter. Had he more to say?

'Word of advice mate. Wear boxers with that dressing gown. It was a bit too see-through if you know what I mean.'

He burst out in tears of laughter and I couldn't stop myself smiling and nervously joined in with the laughing. All the time his grandma lay dead between us. It was a very surreal experience and his mother could obviously tell my unease.

'Don't worry, love. She liked a good joke and tease. It's a tribute to her that we can still laugh about things.'

As I walked out of the room still laughing my junior colleague walked past.

'Why are you laughing?' she asked.

'I've just certified the death of our last patient and I haven't been so amused for days.'

I needed to do some explaining before I was thought of as the most insensitive doctor ever to have existed...

Repeat attenders

Some patients I love treatingothers I don't. I have just finished a set of seven nights and seen the same bloke five times. Each time he has come in drunk, with nothing wrong. Each night he makes up a symptom. He is homeless and there is nothing wrong with him except that when it is raining he wants a bed for the night. He can't get a hostel because he won't stop drinking. It is a very difficult situation and very hard to discharge people into the cold outside. We can't give in to his demands because otherwise it would set a precedent and we wouldn't have the beds to look after people who genuinely needed them for medical reasons. His problems need to be sorted out by society.

On the fourth night it was very cold and raining and he refused to leave. He started getting loud and swearing and began upsetting the children in the department. We had to get security to escort him off the premises. As soon as he left he called an ambulance from the nearest phone box and complained of suicidal tendencies and came back. Eventually, we had to call the police. I explained to him that I couldn't let him stay for the night. He asked the police if they could take him for the night. They shook their heads and tried to escort him off the premises again.

'You can only get a bed if you get nicked mate,' they informed him, much to our cost. He then kicked the window of our A&E and smashed it. They nicked him and he got what he wanted. What a sad reflection on society.

While I don't blame him for wanting somewhere warm for the night, it was very frustrating for all concerned.