Sometimes I find myself in some truly bizarre conversations with patients, but this is often one of the funniest bits of working in A&E. Last night the police bought in two rather large, scary-looking, biker types who had gotten into a fight at the local pub.

'So what happened?' I asked in a slightly disinterested, my department is very busy, could you not have kissed and made up and not kicked the s.h.i.t out of each other? type of way.

'He cheated!' my patient said, getting fired up again and pointing to the man opposite handcuffed by two large coppers.

'Right...but what actually happened?' I repeated.

'I moved my king to D4. He thought I had cheated.'

Slightly bemused, I tried to be not too surprised that not only had he heard of chess but that he was so pa.s.sionate about it he that he had lost two teeth in its honour.

I went on. 'OK. But how did you get your cut? Was it from a punch, a gla.s.s? What happened?'

'Well, he moved his queen illegally. He jumped a p.a.w.n and anyone should know you just can't have that.'

'And...?' I enquired.

'So that's cheating. I retaliated by moving my p.a.w.n across.'

It didn't get any better. Eventually, he admitted that he had gotten so drunk that he couldn't remember what happened but that the fight was definitely over chess. It is stories like this that provide the much-needed, light-hearted relief to stressful days at work.

Training to be a consultant

Many registrars are like me, on a training scheme to become a consultant. It involves two mains bits of education. First, there are training days. These are days of lectures where you are taught how things should be done (the gold standard) as opposed to how things are done in reality. They are also a good chance to meet up with friends and be rea.s.sured that you are not the only one a bit p.i.s.sed off at the moment. However, the vast majority of training is done on the shop floor in an apprentice type of way. The quality of this can vary somewhat, but it sometimes opens your eyes to how the experience of consultants really shows when there are real emergencies. It makes you appreciate them and realise that your skills are in need of improvement.

This weekend I experienced a two-day course of intensive medical education. It was powerfully lectured. They were wide-ranging topics and, best of all, the course was free and included all food and accommodation. Yes, I went home to my mum, who not only knows nothing about medicine but even failed her first-aid at work course. However, she still thinks she knows more than me about health and tries to give me her advice.

I had a nose bleedaccording to her you must pinch near the forehead and then go to A&E. I had years of nosebleeds that didn't stop before I learned to pinch the soft bit of the nose for 5 minutes and wait until it stops instead. Then my cousin came to see me as he had hurt himself playing football. I advised paracetamol and ibuprofen, but no, apparently my mother knows better. Pain killers hide the true injury and you always need an X-ray. The other incident was my dad complaining about his bad back. I advised losing some weight and taking pain killers. But again I was wrong. There is apparently a fantastic herbal remedy, for only 69.99 from gulliblemiddleagedhousewife.com.

Mum, thank you for putting me through medical school but please let me be the household advisor on medical matters and you can stick to your specialist subject: knowing when I do or do not need a coat to go out in.

The last straw

It is not just me who gets annoyed about events at work. A friend of mine who works in another region told me about an event at work. He had been seeing a really sick 24-year-old asthmatic. My friend started giving him nebulisers and various drug infusions. However, he soon realised that the patient would need his breathing taken over by an anaesthetist otherwise he would die. He 'fast bleeped' the anaesthetist and medical team to come down. They arrived shortly after. Between them, they stabilised the patient and while the anaesthetist was transferring the patient to ICU, he was letting the distraught family know what was going on. One week later the patient was discharged. I have no doubt that my friend saved this man's life. He then went back to the main section of A&E, to sort out the wait that had ensued while he had been busy. He did not expect any praise for what had happened, but didn't expect the criticism he got from his seniors and from management about the number of '4-hour breaches' that ensued on his shift. No wonder he is planning on leaving A&E medicine and becoming a GPI think this was the last straw. At least when he is a GP, he might feel valued.

Missed fractures

Part of a consultant's job is to call patients back who have had a fracture, but it was missed by the A&E doctor. Today that task was delegated to me.

The first report I got was from a lady of 65. She had fallen 10 days before, and had had an X-ray that showed a subtle but significant fracture. The junior doctor had missed it and told her that all was well. It was only today that the radiologist had reported it. I phoned her up and explained our mistake and got her to come back and get it plastered.

Far from being angry, she was apologetic about the trouble she she had caused. Some people are just too nice for their own good. She explained that she had not come back as she didn't want to bother anyone. So she sat there, in obvious pain for 10 days, until she got my call. had caused. Some people are just too nice for their own good. She explained that she had not come back as she didn't want to bother anyone. So she sat there, in obvious pain for 10 days, until she got my call.

Luckily, she didn't put a complaint in. If she had, I think the fault would not have been with the junior doctor but the system for taking so long for a radiologist to report an X-ray. We are soon having X-rays put on computerswhy can't there be a radiologist on to do 'hot reporting' on the X-rays as soon as the X-ray is done? They wouldn't even need to leave their office to do this. At night, couldn't we have one radiologist up for a whole area hot reporting all the X-rays and CT scans done? (Or even sending the scan off to the other side of the world, where the time difference means it can be reported on immediately without having to wake up the radiologist?) This seems to me to be an efficient way of reporting urgent scans: it is safer for the patient and it is good education for all doctors.

Let's bring in reforms to the NHS; but sensible ones, ones that will help and make a difference. I think that this one might be a good idea.

Things have improved...but they need to be better still

For all the moans I have about A&E, some things have got better. Last night I was working and a patient came in with a dislocated shoulder. My junior colleague had never dealt with one before and had only seen them put back twice. I asked them to see the patient with me supervising the procedure. I asked my colleague how much sedation he wanted to give. The answer given was about three times as much as the patient should have received. If she had received that dose of a.n.a.lgesia, she could have had a respiratory complication (i.e. stopped breathing).

The answer given, though, was the dose I gave for a very similar patient about four years ago. Then I had little night supervision and the junior doctors just got on with it. We would be the ones seeing the sickest patients. There was a 'see one, do one, teach one' att.i.tude. There was no senior A&E doctor on the 'shop floor' supervising me when I was doing nights. I don't know if any patients came to harm, but without senior supervision they could have.

Thankfully, because of the extra resources, there is more and more supervision of very junior doctors by middle-grade doctors like me. (We still could do with a bit more supervision from our bosses though.) However, some of my colleagues work in hospitals where it is not the case that there is always a middle-grade A&E doctor present on the shop floor. I think that this just isn't safeif you are acutely unwell an experienced doctor, or a supervised junior one, not someone who is new to the job, should see you immediately. It is barmy that in this country that the sickest patients are frequently seen first by the most junior doctors, especially out of working hours.

If the resources were put into employing more senior doctors on the shop floor 24 hours a day, then patients would receive better care. The NHS would also save money in the long run as there would be fewer unnecessary admissions and good initial treatment is cheaper than expensive long-term care and lawsuits. The argument that there are not enough senior A&E doctors to provide 24-hour care is folly. If the specialty was made more attractive, and training jobs increased, then there would be enough to go round.

Harming yourself

I asked a psychiatrist to come down and see a patient who had taken 10 paracetamol and told me that if they were discharged from hospital they were going to kill themselves. This was her 15th attempted suicide in the last six months. She didn't seem too distressed by what she was saying, but I had to refer her.

The psychiatrist came down to see her. Luckily he knew her very well. Despite what she was saying he discharged her and said to me, 'She has got a personality disorder. By referring her to me you are encouraging her behaviour.' He then muttered quietly, 'Between you and me, she needs more friends and not more prescribed drugsbut I can't prescribe friends. But, hey, that's my job. I just hope I am right and she doesn't kill herself.' I chuckled as he went about writing his notes. It also made me think...

A great deal of the A&E workload is now seeing patients with suicide attempts. It is one of the most common reasons for youngsters (and the not so young) to be admitted to hospital. I don't know what it isthe increased stress of modern living? more and more stresses at school? or the prevalence of drugs?but the numbers of attempted suicides seem to be rising.

Seeing a genuinely depressed patient is upsetting. They deserve your full attention and care as they are just as ill as anyone with a heart attack or broken bone but, as described above, a section of patients do take minor overdoses as a way of getting attention. Instead of being recognised as such they are now labelled as having a personality disorder. It can be very hard to make the distinction between people genuinely in need of help and those with a personality disorder (who also need help but not by being referred as an emergency since that just gives positive feedback to their behaviour). I am just glad that I have got access to psychiatrists who can make that a.s.sessment for me.

There is also a large cohort of patients that comes in repeatedly after having self-harmed by cutting. It is hard to not be infuriated with them, especially when it is very busy, knowing that they caused their own problem. It is also hard to understand how someone could inflict so much pain and damage on themselves. However, they too need our attention and to dismiss them as time wasters is unfair. My eyes were opened to the problem last week, when a frequent cutter came back. As we were very quiet, I had time to chat with her, while suturing her wounds. She told me that she cut as a way of giving herself the control over her life that she had never had and that she had become addicted to it. She had been abused when younger and this was her way of coping. Again, A&E can only solve the acute problem. People like her need more help from other services.

Fact.i.tious behaviour

Some people come to A&E for bizarre reasons. I have seen two recently who have made up symptoms to get morphine or sympathy. The first I saw was a fantastic actress. She said that she had fallen off her bike. She was carrying her arm and wouldn't let me go near it, saying that she gets recurrent dislocations. She just kept on asking me for painkillers.

Dislocated shoulders can be agony, so I gave her some morphine and sent her for an X-ray. I asked her to wait while I arranged for someone to escort her to X-ray; however, as soon as my back was turned she got up and walked out of the hospital, ready for a night high on the morphine. Clever girl! She fooled me and made me feel like a right prat.

The next case was of a woman who pretended that she had HIV (human immunodeficiency virus) and had stopped taking her anti-retrovirals because of the side-effects. At the time I didn't realise she was lying because her story was so convincing. She claimed she was very short of breath and so I referred her to the medical team for treatment of an AIDS (acquired immunodeficiency syndrome)-related pneumonia. They were fooled as well. She was kept in and given expensive drugs for three days, by which time no-one could trace any old notes and her HIV test was negative. It's a weird world working in A&E.

People who work in the A&E department

There are lots of people who work in A&Enot just doctors and nurses. Here is a quick review of the people I spend my days with.

Emergency nurse pract.i.tioners (ENPs) Emergency nurse pract.i.tioners (ENPs)specially trained nurses who can treat minor injuries independently. They have taken a lot of the pressure off A&E doctors and done more for reducing waits in A&E than any other development. They write a lot of notes for each patient and can see fractures on X-rays (which I need a magnifying gla.s.s for) from 10 metres. Pharmacists Pharmacistsgo round improving doctors' spelling with green pens. Often save the a.r.s.es of junior (and senior) doctors. Receptionists Receptionistsrun the whole show. Know how to do everything. Ma.s.sive amounts of common sense. I often think that if we sacked all the doctors and gave the receptionists a stethoscope, the NHS would be a better place. They keep the waiting ma.s.ses in order with flair and frequently an iron rod. Consultants Consultantsthe senior doctors. Have years of experience and when they are on the shop floor, they make the place so much more efficient and patients get excellent treatment. Unfortunately, they are often in their offices answering complaints, or at meetings explaining why patients have 'breached' their 4-hour rule (probably because the consultants were in a meeting explaining why other patients 'breached' as opposed to seeing patients) Registrars/staff grade doctors/SpR doctors Registrars/staff grade doctors/SpR doctorsbelow the consultants, more experienced than the SHOs. We are the ones who, when asked a question, will take off our gla.s.ses and put them in our mouths to look as if we have some intelligence and knowledge when really we are just playing for time. SHOs/F2 SHOs/F2the junior rank of doctors working in A&E. Some are excellent. All are hard workingor forced to work hard by their appalling rotas which often mean that they work mostly unsocial shifts so that the more senior doctors can have a life. However, they only work for 46 months in the A&E department, so medical staffing planners can get away with it without too many complaints. A&E secretar A&E secretaryshe knows everything and everybody, does everything, finds everything and without her the place would fall apart. The most amazing organisational skills I have seen. This is not being s.e.xist, but I don't think a man could ever replace our secretary we can't mult.i.task and she can. Sisters Sistersthe lynchpins of A&E. They make sure that a 'shift' is run properly, coordinate the department along with the senior doctors, run the show, get paid b.u.g.g.e.r all and if they want promotion get pushed into management. Charge nurses Charge nursesmale sisters. I call them brothers. They don't find it amusing except the vegetarian communist one, who keeps on trying to get me to join his commune. Staff nurses Staff nursesthe work horses of the A&E. Usually excellent, but there are a few disgruntled and eccentric ones, especially the breed known as 'agency staff nurses'. Health-care a.s.sistants Health-care a.s.sistantsdo the jobs nurses used to do, except give out drugs. Get paid a criminally small amount for such a vital job. It's a disgrace. Physiotherapists Physiotherapistsspecialists in musculoskeletal problems. Female ones are usually very fit and male ones good at sport. Occupational therapists Occupational therapistsa cross between a social worker and a physiotherapist. Vital in helping elderly patients get out of A&E. Radiographer Radiographerthe person who does your X-rays. Not a doctor, but highly skilled and valuable members of the A&E team. Spend 34 years at university learning about human anatomy, physics and how to read doctors' writing.

Too posh to wash?

I was struggling at work today. The nurses on the 'shop floor' were flat out. I needed observations doing and drugs given, and neither was happening quickly. A patient had been calling out for 15 minutes for a commode before they got one. A patient needed changing from their wet incontinence pad, but it was left on for long enough to make the patient cry. Admittedly, we were busy, but the nursing care the patients were getting was not adequate, although there were nurses around. There were two ENPs, who now treat minor injuries. There was a specialist DVT (deep vein thrombosis) nurse seeing a patient as well. The urology nurse specialist had been asked to chat to a patient about their catheter and the cardiac specialist nurse was looking at an ECG and deciding if a patient needed to go to the coronary care unit.

I think all these jobs are valuable, and A&E would be lost without the input of specialist nurses, especially in the days of reduced doctor's hours. But is it right that we have so many nurse specialists when simple nursing procedures such as washing, doing observations, etc., are being left to a handful of overworked and underpaid junior nurses and nursing auxiliaries who have not got the time to do it properly.

You may think that it is the job of the senior sisters to organise the caring of the patients better. However, so much of their time is spent on managerial matters, planning meetings and worrying about targets, etc., that they have less and less clinical time to spend looking after patients and mentoring the junior nurses.

Often, the basic nursing tasks are performed by the nursing auxiliaries (health-care a.s.sistants). They, I believe, are the least appreciated and most valuable members of the A&E team. They do all the basic nursing tasks except give drugs. They take bloods, insert cannulas, do ECGs and, when time allows, they care for the patients. Last week I went to the leaving do of a health-care a.s.sistant of 10 years' experience. She had got a job at Tesco on the tillsearning more than her present job. But it wasn't just her leaving do: it was a joint one with an excellent senior A&E nurse who, because she wanted promotion and a pay rise, was pushed into a managerial role as a 'patient pathway coordinator' as opposed to nursing.

We need more nurses in nursing care. I am not saying we should cut the specialist nurses. I am just saying that we need more nurses employed to nurse...and they need better pay, both junior and senior, otherwise they will continue to leave the NHS or move into management and we need their skills where it really matterson the shop floor.

How to lose a friend

I am good friends with some of the nurses at work, but I think that I have lost a friend today. She was chaperoning me doing a rectal examination. The patient had diarrhoeaI was checking that she (the patient not the nurse) didn't have something called overflow diarrhoea, where severe constipation only lets liquid faeces pa.s.s the blockage. I examined her and my suspicions were confirmed. As I withdrew my gloved finger, I examined it and saw lots of diarrhoea. As I took the gloves off, the elastic of the gloves acquired a life of their own. It then all happened in slow motion. I saw particles of faeces fly off my glove straight onto my colleague's uniform, leaving a brown splatter pattern right over her left breast. 'Ooops! I am sorry' didn't appear to be sufficient and I found myself cleaning a lot of commodes that night.

Hero to heroin

The ambulance call came through; '21-year-old male. Unconscious, respiration rate 5. Having to be bagged (artificially ventilated) by the paramedics. IVDUintravenous drug user'.

It was the third similar patient this week. I met the ambulance as it arrived and we wheeled him into Resus. Behind came a distraught mother and father. We went through the basic treatment of the unconscious patient. The ambulance man continued to keep him alive by giving him oxygen. I examined him and tried to get a cannula in. It was virtually impossible: all his veins had scarred up from excessive use in injecting drugs. I eventually managed to find one in his neck.

I could now give him the reversal for heroinnaloxone. I was only a relatively naive junior doctor at this stage, with a limited experience of heroin overdoses. I gave him the full dose of reversal medication. It blocks the morphine receptors, and means that the patient quickly wakes up, starts to breathe for himself and comes down off his high....And he did. In about 3 minutes he had woken up, pulled his Guedel airway (piece of equipment used to keep the airway open in an unconscious patient and let them breathe) out of his mouth and started to shout and curse.

'What the f**k did you do that for, you b.a.s.t.a.r.d?'

I tried to explain that his mum had called an ambulance and he had needed the paramedics to keep him alive. I expected him to be grateful. As I said, I was naive to the grat.i.tude of some patients.

'You can f**k off. I am out of here.' He pulled off his ECG monitor and cannula and stormed out, looking for another fix.

Heroin has powerful qualities. It makes the user fixate only on the drug and nothing else matters. They ignore all else in the search for the ultimate 'nirvana' high. No need, therefore, for the social niceties of being pleasant to hospital staff and the paramedics who saved his life. No need to show love to his parents. No need to conform to accepted social standards and so it is no wonder many steal from grannies or take excessive risks as prost.i.tutes to pay for the drug. There is just the need to get that high and so he left looking for a hit again.

The danger of what I did was that the reversal wears off quicker than the heroin, so he may have gone back to his unconscious state. Also, with him in the plucking/cold turkey state he could be a danger to himself and staff. I learned my lesson: give very small doses of the reversal slowly over time, so they are too drowsy to up and leave.

As he left I had a word with his distraught parents. They had been loving parents but he had got in with the wrong crowd. He used to be a footballerapparently quite promising. He was a hero for his school's team, being top scorer for three years, but then the wrong crowd came along. He had started with cannabis and then moved onto ecstasy, cocaine and then heroin. He was in and out of prison and then either on the streets or kipping at various friends' houses. He paid for his fixes with petty crime. He had been on a methadone treatment programme (methadone is a heroin subst.i.tute, but does not give the same high) but it hadn't worked. He had been loving as a child and now they described him as a monster that they didn't recognise. They loved him, but hated who he had become.

At this point in my career, I was new to drug abusers and the thing that I found most strange (which shows that I obviously have deep middle-cla.s.s misconceptions and prejudices) was that they seemed a normal loving middle-cla.s.s parents. His mother was a nursery nurse and his father was a taxi driver. They were not alcoholics and they had not abused him or neglected him. It just shows that drugs can affect anyone, no matter what their upbringing.

They asked what they could do. I didn't have the answer. The police were failing him. The social services were failing and so were the methadone programmeshe still went out and took methadone. He might die soon after another overdose, and they and I felt helpless. That week, three similar patients had come in. The police also said that another had died before an ambulance had been called. Apparently, a new drug dealer was on the street and was selling a stronger version of heroin. It was getting people more and more addicted and killing some of them because of overdoses as a result of its strength. The policeman told me that they needed to catch this dealer quickly or there would be more deaths. His colleague joked that at least the crime rate would go down if he wasn't caught...but it wasn't funny. These addicts are people's sons, daughters, fathers and mothers. They also have potential to be reintegrated into society and to become a.s.sets to the country. We are failing them as much as they are failing themselves and their families.

So could anything be done? Well, possibly. A couple of years after I saw this patient, the government brought in some pilot schemes, some of which are using the experience of the Swiss authorities, who have made heroin free and available to use on prescription in special clinics run by specialists. The patients can go twice a day and get their normal fix, but with a standardised drug so that they don't overdose. It is a clean and safe environment. The users no longer go to the dealers as free heroin is available from the clinics. Crime is down, as they no longer need to mug grannies to pay for their fixes. Dealers have left because of market forces and so fewer kids are starting heroin. The users are medicalised, the glamour of drug-taking is reduced and their lives have been stabilised. They can start to get jobs and when they are ready they can be transferred to methadone and slowly weaned off the drug.

It is a possible solution. But it is controversial because the government is, in effect, saying to people that taking heroin is no longer a crimecome round and have some of our free stuff. However, initial results show that this approach works. I think it is controversial not to consider this scheme. It is just a shame for the user I saw and his family that he does not live in one of the trial areas.

Taking the p.i.s.s

Life can be a bit unfair for patients. If you sit quietly, then you usually don't get pushed to the front of the queue, but if you make a fuss sometimes your care is speeded up. Today I learned that if you p.i.s.s on the floor you'll get seen straight away.

The 'minors' nurse asked if I could see a patient because he wanted him out of the department ASAP. He explained: 'You'll know him. He is a regular. He's completely well and a bit of a pain in the rear (he may have been slightly more fruity in his description). Get rid of him...Oh, and he has just p.i.s.sed all over the floor and is swearing at us.'

The nurse was right. I knew him very well. He was an alcoholic (not a particularly pleasant alcoholic either) who had turned down help dozens of times. He usually came in when a member of the public saw him comatose and called an ambulance.

'h.e.l.lo sir. You seemed to have urinated all over the floor. Is everything OK?' I enquired.

'I couldn't be bothered to walk to the toilet,' he slurred.

'A pleasure to see you, sir. Always a pleasure. Do you want to sit in the chair?' I asked (he was standing and looking a little threatening).

The nurse interjected: 'He has p.i.s.sed on that as well.'

'Well, sir, I suggest we do this consultation somewhere else...why don't you move away from the pool of urine beneath your legs and come with me to the next cubicle? Why are you here?'

'Don't know. I was having a kip and them b.a.s.t.a.r.ds in green brought me in.'

'They are ambulance men, sir. Not in any way do you know their parentage. And please don't swear.' I was losing my patience but also quite enjoying the amus.e.m.e.nt this patient was giving me. I added, 'Are you unwell? Have you banged your head?'

He showed me his arm. He needed to be here because he had a laceration that needed suturing. I explained that to him, went into the theatre to open up all the expensive suturing packs and called for him. But he had leftprobably back to the pub or the nearest park bench to finish the kip that had been so rudely interrupted. Oh well...on to the next patient. I'm sure he'll be back.

Off on holiday