This job is hard

As an A&E doctor, you sometimes have to develop a barrier where you don't let emotion get to you. It is important, because only by being rational can you deliver good quality care. But sometimes little things get to you and however hardened you are your emotions can buckle. This morning I buckled.

It was 7 a.m. Only 2 hours before home time. A fry-up and a pint of beer with the 9.30 a.m. regulars at my local Wetherspoon's (the shift workers and enthusiastic drinkers) beckoned. But then the red phone went off: 14-year-old girl, overdose, unconscious.

We called down the anaesthetic team, in case we had to take over the care of her breathing, and also called the paediatricians. She came in and I went into autopilot. You learn a set routine. Check her airway, give oxygen and check her breathing, check her pulse rate and blood pressure and then give fluids. Basically, stabilise the patient and then think. She was soon stabilised and not in any immediate danger. I soon realised that the mum was standing near us. Out of autopilot, I went to comfort her and explain what had happened.

'Nick', the senior sister called out. 'Her blood pressure has fallen.' Some of then drugs she had taken had caused that. Back onto autopilot. No emotions. More venous access obtained and another drip put up.

Soon her condition had turned from serious to stable and I was able to get some history about what had happened from her mum. I asked her if she knew why her daughter had taken the drugs. She cried and handed me a suicide note as she muttered about bullying.

The letter was heartbreaking; it described the feelings of hopelessness that she felt and how she saw no other option to stop the endless cycle of bullying and self loathing. It was the saddest thing I have ever read. She apologised to her parents and asked them to carry on looking after her guinea pig.

I read it and the experience of reading her thoughts made me shudder and think. It put my concerns into perspective. I couldn't stop thinking of her parents. How will they cope if she dies? Then I had a selfish thought. Why do I put myself through this? Am I strong enough to cope with experiences like this? I should be in bed by now, cuddling my own child and telling them how much I love them. It is always hard in situations like this, not to let them affect you personally, but this is often very hard to do. So why do I put myself through this stuff? The answer is simple. Because of all the work we all did, her mum got a chance to tell her she loves her too. I couldn't swap this job for another even if it costs me lots in Kleenex tissues which you can't even claim for against tax.

P.S. She was transferred to the regional centre of paediatric intensive care and made a good recovery.

Another sad case

I saw an 82-year-old gentleman today. His wife had died earlier that month. He was brought in after he was spotted at a local beauty spot with a hose going into his car from his exhaust. The fire brigade broke into the car and the ambulance brought him in.

This was a genuine attempted suicide case. He told me that he had lived for his wife. He had no children and few friends. All he wanted to do was join her in the 'afterlife'. He couldn't cope with the loneliness. He told me that his decision was a logical one, made by a man who had full faculties of mind. He told me that as soon as I had discharged him, he would try and kill himself again. He told me that that was the right thing for him to do, so that he could join her in heaven. He was lonely and missing her.

I sympathised greatly, but still asked the psychiatrist to see him, knowing that they would admit him to a psychiatric hospital. I have no idea if I did the right thing but I was sure that if he left then he would kill himself. I just didn't know if that was the best thing for him. In all honesty, I referred him to the psychiatrist because I had to. I didn't want to feel the guilt if he did kill himself and I didn't want to face a coroner's court case where I admitted discharging someone who had an acute depressive episode.

The importance of banter at work

The department got a complaint letter today. It said that the doctors writing their notes seemed to be chatting too much with the nurses and there was too much 'fun' going on. We then all got told by our bosses to 'cut out the banter'.

Doctors and nurses do need to be careful about how we act in areas where the public can see us. But we need to be careful not to lose the camaraderie that a bit of banter can bring about. It helps keep up morale and can therefore improve patient care. Please just remember that when you see doctors and nurses having a chat (we may even be discussing important clinical information).

One of the best things about working nights is that there is more opportunity for banteror team building as I like to call it. There are no bosses, fewer patients and the ones who are there are usually p.i.s.sed as a fart. In some A&Es doctors and nurses have been known to play 'games' with the patientsalthough this is only done if they are drunk and never if anyone is distressed, ill or sober enough to know what they are doing.

There is the game of seeing how many song t.i.tles from various alb.u.ms you can get into one short consultation. There is the very similar and somewhat more amusing game of trying to get a bizarre but relevant fact into a consultation. These games are only possible because of the fact that all A&E consultations occur behind curtainswhich are not soundproof, and so an independent adjudicator can mark you. Again, just because I am talking about these things doesn't necessarily mean that I approve.

Only when it gets quiet and the A&E department is left empty can the fun really begin. Most times an empty A&E leads to the staff trying to get a bit of rest or people surfing the net. However, if you are on duty with a 'good bunch' of doctors and nurses, then an empty A&E can lead to some great fun and games. Unfortunately, anything you might have thought about such as 'the key game' or 'spin the bottle' is purely for the imaginary letter pages of Fiesta Fiesta or or Escort Escort: the stock cupboard is usually full of stock and the sluice is probably the least erotic place I can imagine. The A&E games can be much more fun: crutch races, wheelchair races, gloves turned into balloons and then volley ball matches. There are also the practical, slightly macabre, practical jokes to play on the more junior staff. Then there is the routine of drenching with water anyone that has managed to nod off to sleep. These types of things help us cope with the stresses of A&E work at night and also keep us alert in case an emergency comes in.

The best part of nights nowadays is that you can actually have a drink after a night at work. One of the best 'nights' out I have had recently was when all of us had just finished our last night (of a run of seven) and went out 'morning' drinking. After a change of clothes, we went for a fry-up, and then hit the pub at 9 a.m.; eight of us drinking and playing silly pub games till lunchtime. We were then ready for a club and a kebab, but as it was only noon we went home to our beds instead. Sadly, it is not a truly 24-hour city that I reside in.

The wonders of the Internet

Have you ever been to A&E and for some bizarre reason the doctor has said 'I'll just be a minute' then disappears for 20 minutes? That used to be because the doctor was off to ask someone's advice or look something up in a book. While we know many things, often we get stumped.

Now we have the Internet and it has revolutionised things. We can look up symptoms or rare conditions or sometimes just refresh our memories of long-forgotten diseases last heard about in medical school. Often we say 'I'll just be a minute' to go and look up the latest treatment guidelines on the 'net'. One of my favourite (A&E) sites is called Best-Bets, which basically goes through the evidence for what is the best treatment for various conditions. It is a fantastic site and helps enormously; it is one I use very often.

That is until this afternoon, when I 'logged' on to the net with my pa.s.sword and typed in the site details. All I got was a screen saying, 'You have tried to access an inappropriate site. Your manager will be informed. You are reminded that breaches of the computer use code may result in disciplinary dealings.' What an idiot of a computer person; not letting a vital site be used because it has the word 'bets' in it. I am very much looking forward to my disciplinary meeting. Meanwhile, I had to phone up a friend at another hospital to look up what exactly to do on my behalf. Thankfully, my friend is an ophthalmologist and has plenty of free time to help me out when he is at work.

Just a little small moan

Today a son brought his mother into A&E. She had bled from a varicose vein. This was cleaned and bandaged up, but I wanted to a do a blood test on her before we let her go to check that she was OK. I asked him if he could stay for a couple of hours till the blood results were back. He said he couldn't afford to. I enquired why. He showed me the parking prices. I soon realised... the charges are horrendous. It is a tax on being ill or visiting ill relatives. They justify the prices by saying that they are used to pay for NHS services. But isn't that what our taxes are for?

The joys of A&E

Most people, even ones you really don't like, have some redeeming features: someone I met today most people would describe as having not one. They might go on to describe him as the type of person you could only wish to become better strangers with. However, at work I can't jump to those conclusions and am obliged (quite rightly) to treat him in a non-judgmental way and provide appropriate care regardless of the way he treats me or the NHS. Being non-judgmental is sometimes the hardestbut an essentialpart of the job.

The person in question is a man in his 30s and is very well known to the police. Every time he gets arrested, he says his chest hurts and so he gets sent to hospital to stop him having to go to the cells (he has done this over 10 times now, at vast expense to the NHS/police/me and you as taxpayers). This time he got arrested for something vaguely serious. So instead of just saying his chest hurt, he said his chest and stomach hurt. He was initially triaged by an Asian nurse and he responded that he would prefer to be seen by a Caucasian member of staff (he put it in a slightly less polite way).

As the senior doctor, I was asked to see him. None of his symptoms fitted any pathology known to me. Despite his belief that he was going to 'die in the next hour' I felt there were few grounds for concern. When I started to examine him, he started screaming out in pain. All his observations were normal. However, everywhere I touched him was 'f**king agony'; again, not fitting any known pathology. I tried to distract him, and when I did, he became pain free. The best way to do this, I find, is to listen to their abdomen/chest with your stethoscope and press down quite hard. They don't realise that you are trying to elicit pain, so stop acting. I a.s.sured him that he didn't need any blood tests and that he could go back with the police. I don't think he agreed with my provisional management plan.

'I am telling you I need some f**king blood tests to prove I'm going to die,' he said.

Now, I know that these are the days of patient choice, but I declined to take his advice and act upon his choice of management plan. I advised him of this. Unfortunately, in this litigious and complaint-led society many doctors sometimes succ.u.mb to doing unnecessary blood tests due to patient pressure, and just in case there is a problem, as opposed to trusting their clinical skills. I am one of those doctors. However, in this case I was as sure as sure can be that there was nothing wrong.

'I need some tests, or I'll die. Then you'll be sorry. Do you want to come to my funeral?' he enquired. I advised him that I try to avoid my patients' funerals (it doesn't fill me or the mourners with great confidence). I again reiterated my management plan, which also involved his apologising to the nurse that he had sworn at and then kindly leaving.

'You can go now, sir,' I advised him, content that my management had been appropriate.

'I need morphine now, you c***,' he explained to me.

I explained that there was a seven-year-old in the department and she did not need her vocabulary expanding. I also advised him why paracetamol would be a preferable a.n.a.lgesic to morphine, considering his objective pain-level and both drugs' side-effect profiles. He then started becoming very aggressive and swearing and putting other patients at risk.

At this point I asked the police to take him away. However, he collapsed and started to fit, arms and legs shaking rigorously, but still flinching when I brushed against his eyelashes. It was really bad acting. I got down to him on the floor and whispered, 'Stop it. I know what you are playing at.'

He continued pretending to fit.

I tried to respond to the humanitarian part of his personality. 'Look mate, there are some really sick people here. I need to go and check on the man in cubicle four with a heart attack and there is a seven-year-old girl in cubicle fifteen who now knows a lot more swear words and has a dislocated finger. I need to fix it for her.' Still no response. I started to get annoyed. Real patients were here and he was wasting my time.

'Please stop, sir. Stop being selfish.' (I may not have used those exact wordsmy memory fails me). He continued and so I decided to go into true bulls.h.i.t mode.

'Sister,' I called out. 'I think he really is fitting. Quick, come. Can you get the largest catheter possible? We haven't got time for local anaesthetic; we need to know his urine function now. Quick, sister, quick!'

All of a sudden he started to wake up and stop fitting. Considering he had been 'fitting' for 5 minutes, he made a very quick recovery.

'I don't know what happened there,' he said, 'and my pain's gone completely. Can I go now please?'

'Yes. I think it was a severe case of AAS, which has resolved. Take care. Goodbye, sir. Always a pleasure, never a ch.o.r.e.' (AASarrest avoidance syndrome) As an aside, I know the police sometimes come in for a lot of flak. But I want to say that all the police I have ever worked with in A&E have been fantastic. How they keep happy and don't show their anger that often when dealing with people like him, I will never know.

Smoking yourself to death

It is not easy giving up smoking. However, it is a lot easier than being told you are going to die of lung cancer.

A gentleman came to A&E after his wife had forced him to. He had had weeks of problems before succ.u.mbing to her pressure.

'So what's up?' I enquired.

The typical hesitant-male-being-encouraged-to-talk-by-his-wife conversation ensued. Eventually I found out what had been bothering himand it wasn't just his wife's nagging.

'I have been losing weight and coughing a lot. But I had to come today because I have coughed up a lot of blood the last two days.' He didn't make direct eye contact, but looked at me as if he was feeling guilty.

I took some more information and asked if I could examine him. The first things that I noticed were his tar-stained hands from years of smoking (he thought that because the cigarettes were low tar, they weren't that dangeroushe believed a myth not denied by the smoking companies). The next thing I noticed was indeed the amount of weight he had lost. His collar was at least two sizes too large and his trousers were falling off him. I examined his chest and while I was doing that, another coughing stint started. I looked at what he was coughing and it was bright red...and there was a lot of itat least an eggcup-full of bright-red blood. The sight of this made me feel sick.

I stopped my examination to get a line into his veins in case he needed an urgent blood transfusion. I then went back to examining him. Listening to the base of his lungs, I heard odd noises, which just didn't seem right. I asked him to say '99', but only because that is what patients expect us to sayall the information I was going to need, I was going to get from a chest X-ray. (Also, I am not as clever as the respiratory doctors who actually listen back when you whisper 99.) I then moved on to his abdomen. I laid him down flat and started feeling his abdomen. I felt his liver. It was hard and craggy. I felt sick. He probably had a metastatic lung cancer (i.e. a cancer that had spread and that he was going to die from). He must have noted my unconscious facial expression.

'What is it, Doc? What is going on?'

s.h.i.t, I need to think of something to say and quickly. 'Erm...well...we need...' Where had my bulls.h.i.t ability gone? Where was it when I needed it? s.h.i.t! Then a great idea came to me. I put my stethoscope on his chest again. 'Can you say ninety-nine, please?' He did as requested and I had some breathing s.p.a.ce. I repeated the request a few more times, pretended to listen, and I collected my thoughts.

'I am not sure what's going on,' I lied. 'I need to do some tests on you. I need to do an X-ray of your chest and some blood tests. When we get those results, I'll have more of an idea.'

'Have I got cancer, sir?' he asked.

I was honest this time. 'I don't know. I suspect you may, but I can't really say much until I have got some test results back.' He seemed satisfied with that response, and then from nowhere I said, 'I hope not though'. Where that came from, or why, I had no idea. What a stupid thing to say. I meant it though; he was a genuinely nice bloke. He was polite, una.s.suming and obviously doted on his family.

'Me too,' his wife responded.

I sent off a battery of blood tests and sent him for his chest X-ray. I looked at the X-ray when it came back. There was a large ma.s.s in the lower part of his left lung. His blood tests came back. He was anaemic from coughing up blood. I then looked at his liver test. The counts were very deranged. Finally, his calcium level was very highprobably from the cancer spreading to the bones. You didn't need to be that skilled to come to the obvious diagnosis (you rarely do in medicine). My suspicions were right. All the evidence was pointing to lung cancer. However, you do need to be skilled at how you tell someone they have cancer. That is something that comes from your personality and is hard to teach. It is also something I rarely do in A&E as a diagnosis of cancer is rarely this obvious. I went into the cubicle where he was and asked him if he wanted to go somewhere more private. He declined my offer, but knew what my opening gambit meant.

'I've got it, ain't I? I've got cancer. Tell me. I need to know. Tell me.'

'The tests so far show you may have a lesion on your chest. You also have some blood tests which show that the liver may be damaged. Although I can't confirm you have lung cancer, I think that you might have it. We need to do some more tests.'

His wife was silent. He strangely seemed relieved.

'At least I know what is going on. What happens now?' He said it in a matter of fact way. I felt that he already knew his diagnosis and I had only confirmed his suspicions. It was odd.

'I have to refer you to the medical team who will take over your care from now on. They will organise various special tests where they try and get some of the tissue and send it to the pathologists to confirm if it is a cancer and what type. They will also do scans to see if it has spread anywhere else. Until those other tests come back, I can't say any more.'

I also explained that as the A&E doctor I would not be involved in their care anymore and that any future questions would best be discussed with the specialist team.

As I spoke, I soon realised that he was listening but his wife was not taking it in. They both spoke at the same time.

'How long have I got?' he said.

'He won't die, will he?' she said.

I was honest. I told them that I didn't know what was going to happen. She started to cry and he told her off for crying.

'I need to tell the kids...what do I say?'

If I had thought telling him he had lung cancer was hard, him telling his kids would be a lot harder than what I just faced. I left the cubicle and made them a cup of tea.

Ironically, it is at times like this when I wish I smoked and had an excuse to go outside for 10 minutes to collect my thoughts. Luckily, I don't. One coughing fit when I was 14 put me off for ever.

The next patient I saw was a 60-year-old smoker who had just had a stroke...

Patient choice or patient confusion?

In the past if you were ill, you would go to your GP. If you were very ill, you would go to A&E. Now you have many other options: NHS Direct, your pharmacist, out-of-hours GPs, acute care centres, walk-in centres, urgent care centres, walk-in GPs, minor injuries units, major trauma centres, private treatment centres and private diagnostic and treatment centres (which is in essence what a hospital is). All of these are designed to give you, the patient, greater choice.

Did you want all this choice, or would you choose to have a functioning, open, good-quality local district general hospital and a GP that you can see when you need to? I know what I would go for.

Putting yourself at risk

There isn't much risk working in A&E compared with other jobs such as the police, fire brigade or army. However, one of the risks you do have is catching diseases from patients.

At 4 a.m. in came a 32-year-old male. He was a heroin user and had cut his arm on a bottle. He needed suturing. I was doing this when I got a 'nick' through my glove and into my hand. It was n.o.body's faulta pure accident. I went through the procedure of washing my hand very thoroughly. My colleague then asked him if he would consent to an HIV (human immunodeficiency virus) and hepat.i.tis test. He said he was 'clean' and refused another test. I couldn't force him to have one and so I was in the lurch not knowing what his HIV status was and therefore what my risk was. I discussed it at length with the specialists and was told that the risk of catching HIV were minuscule.

However, it is hard to rationalise your own risk. It is much easier telling other people than telling yourself. I refused their advice and went on post-exposure prophylaxis (anti-HIV drugs) just in case. I felt sick every time I had a tablet. I also had to wait six long, s.e.x-free weeks until I found out that I did not have HIV. That was a real low of working in A&E especially the s.e.x-free bit.

I know I have mentioned it before, but shouldn't NHS workers have rights as well? Shouldn't we have the right to do blood tests on high-risk patients when we have sustained an injury helping them? If they don't want the results and don't want anything doing then that is their decision, but to not let health-care workers know the risks they are facing is a bit unfair.

The anger of chess