Teaching

I love teaching medical students and medical students usually love coming to A&E as there is much to see and learn. But today I hated it. I had a third-year shadow me for a taster day in A&E. He was the most arrogant, pompous little s.h.i.t I have ever met. He was rude to the patients and just tried to question my management in front of them. He had no ability to empathise with patients and viewed them solely as an illness ent.i.ty and not a patient with an illness. I know he is only a third-year, but I would hate to be his patient if these personality traits are not knocked out of him.

I know when I first started medical school, not everyone was interviewedsome places were offered on the basis of exams alone. It is becoming academically harder and harder to get into medical school. However, you don't have to be a brain surgeon to be a doctor (you do have to be a doctor to be a brain surgeon though). What is needed is common sense and courtesy, not four As at A-level. I don't know what the interview process is like nowadays but I have some worries after trying to teach my student today.

Sorry, there was no real point to this story, I was just expressing my frustration.

Even more hospital inefficiencies

We are ma.s.sively in debt as a hospital and there are plans for a freeze on recruitment. It is not just redundancies in the NHS we have to worry about, but newly qualified nurses and physiotherapists, etc., not getting jobs. Apparently, this is because as a 'Trust' we are short of pennies.

I was feeling in a reflective mood, so on my break I went for a walk around the hospital. Through every corridor loads of the windows were open but below these windows were radiators pumping out hot air paid for by our taxes. I then went to see a friend on a ward. After meal time, plate upon plate of food was thrown away. Not necessarily because it was no good, but because there was no-one there feeding the patients; what a waste of money. I then wandered to the car park, and there were two parking attendants just sitting there, chatting, not really doing muchat our expense.

I walked past theatres and there were surgeons doing b.u.g.g.e.r all, because there were no beds for their patients to go to after surgery, and so their lists were cancelled. I walked back to the wards and saw that tests were being repeated because results had got lost through not being stored electronically.

I then saw patients being unnecessarily admitted to wards because of targets...and other patients who were sicker and costing the NHS more because they didn't get 'gold standard' treatment from the NHS earlier in their hospital stay. Then I went to A&E and saw doctors repeating each other's work.

I then carried on my wanderings. I accidentally went to the management suite. It was late in the evening and no-one was working therebut all the lights were on. Couldn't anyone turn them off? What are all these offices for? We need managers, but this many?

NHS money is being wasted left, right and centre. The NHS needs a bigger pot (especially emergency services), but the pot needs to be used a bit more sensibly. Quite rightly, the government wants to improve efficiency. It is just a shame they are doing it in such a bad way.

A weird rash

Last week I saw something I have never seen before. A child came in with a weird-looking rash that I didn't recognise. I asked my colleaguesthey had no idea either. Then the paediatric doctor had a look, she was clueless. Finally, the senior consultant came to review.

'Do you read the newspapers?' he asked the mother.

'No. Why?' she responded, a bit perplexed.

'Your child has measles. You may have believed the stuff they said about MMR (measles, mumps and rubella). That's why I asked. Did he have the MMR?'

He hadn't. Mum had listened to some ridiculous stories perpetuated by the headline-seeking gutter press. As a result he hadn't been immunised. But he was lucky and OK to go home.

Today, I saw a much sadder case; a little girl who had also got measles. I recognised it now. But she was much sicker. She had to go to the paediatric intensive care ward. Her life was at risk as the virus had caused infection to the brain and she might suffer brain damage as a result. Her mum had also stopped her from having MMR, and was paying privately for single-injection immunisations, but her daughter hadn't had the measles one yet.

Measles is a serious killer (mumps and rubella aren't so good either). The MMR vaccination is not this evil autism-inducing injection that the media sometimes make us think. There is no evidence that it causes autism. However, there is evidence that if your child doesn't have the injection, they are at higher risk of getting these illnesses. Today I saw a child I shouldn't have. Have a proper think before you refuse your health visitor's advice.

Feeling guilty

Have you ever felt that you have contributed inadvertently to someone's demise? I have and I can't stop feeling guilty about it. It happened two days ago, and I have felt really s.h.i.t since. He was a 45-year-olda lovely bloke who came in reluctantly with his wife. Quite poignantly he explained that he didn't want to come in as 'you never get out of hospitals ok'.

He had had some chest discomfort after dinner. He thought it was indigestion. His wife wasn't so sure. She had seen posters advising you to call an ambulance if you had odd chest pains and this pain seemed to be getting worse. She (very sensibly) called 999. He was having a heart attack. The ambulance blue lighted him in, and I met him in the Resus department.

His ECG confirmed the diagnosis. The treatment for this (in our hospital, out of working hours) is a clot-busting drug. It is a very effective drug in these situations and opens up the artery that has become blocked. I have given it successfully many times in the past but there can be some rare but serious side-effects. One is bleeding in the brain. I took him and his wife through the risks and benefits in his case. I said it was low risk and that I had personally never had a problem.

We started the drug. Very quickly his speech became slurred. I stopped the drug straight away. Then he couldn't move the right side of his body and then he became unconscious. The drug had caused a bleed in his brain and he will suffer severe lifelong side-effects from the drug we injected. Although, medically, I did nothing wrong, and know that it was the right drug for his condition, I still feel guilty that I may have inadvertently contributed to his demise by giving him a drug that should have saved his life, not left him disabled for life. I find that hard to deal with.

Being called at home

I got a call from one of the nurses at home today. She sounded worried.

'I just thought I'd call you before one of the bosses. I think you need to know.' She sounded worried. 'Do you remember the old lady you treated yesterday? The lady with the very fast heart rate?'

I did. I was really pleased about how I had treated her. I had taken her and her son into the resuscitation bay and spent about 1 hour sorting her out properly. I had spent the whole time explaining to her and her son what we were doing and why. They commented on how nice we had been and how she was pleased that nowadays doctors aren't 'stuffy' and take the time to explain to them what we were doing. She also said how much more comfortable she felt that I had introduced myself as Nick as opposed to Dr Edwards.

'Yes I do. What's the matter?' I asked.

'Her son has sent a formal letter to the chief executive and as I was the nurse working with you I have been asked to comment.'

'What the h.e.l.l. I thought...'

'The letter went on about your informal style and relaxed att.i.tude. It talked about letting relatives into Resus and being present the whole time during a difficult and scary time.'

'But I thought they were happy with us,' I responded as I started to panic about such a formal complaint.

'I have got to go now. There is a long wait in minors. Bye. I'll phone back soon.'

She hung up before I could find out who I needed to speak to.

Oh my G.o.d! Why had they complained? What had I done? What was going to happen to me? I felt faint with anxiety. Very soon I was going to need A&E treatment for my own fast heart rate. Five minutes later she phoned back.

'As I was saying, the letter praised the entire department for being so wonderful and the family has given us a case of wine to say thank you! Well done.'

Getting thank you letters really does make work a pleasure. So does practical jokes and being wound up...but only after the event. If she is reading this, then I just want you to know that he who laughs last laughs loudest. Watch out...

Complaint letters

One of the most upsetting things for a doctor or a nurse is getting a complaint letter. We are human and sometimes we fall below the expected standardthen a complaint is justified. However, many complaints are preventable and caused by poor communication. The complaints which are upsetting are the unjustified ones and the ones sent out of a desire to seek compensation. The stresses of complaints are enormous. Your clinical skills are brought into question. Your name can appear in the local press, where everyone a.s.sumes you are guilty. Then there is the concern that it may affect your career as well as the personal feeling that you may have let people down.

Some legal complaints are utter b.o.l.l.o.c.ks, but often the hospital 'pays up' because the cost of the claim is cheaper than going to court against a 'no-win, no-fee' company.

What prompted me to write about complaints is one I received last week and I have been fuming about it ever since. I had seen a really sick and unwell asthmatic mother of three. She was 38. She had been into ICU twice in the past with breathing difficulties. She came in very unwell. I was really pleased with my very swift and good treatment. After the treatment in A&E, she was well enough to go to a normal ward as opposed to ICU. I really felt that we had saved her life.

When she was a bit better, I went and had a longer chat with her. She told me she that still smoked. I couldn't believe it. She had a life-threatening respiratory problem and still smoked. I told her, in no uncertain terms, that she was putting her children at risk of losing their mother. I told her it was easier for her to give up smoking than for her partner to bring up their children alone. The whole time I was being polite and had her interests at heart. It would have been much easier to not give out advice.

I thought I had done the right thing. Apparently, I hadn't. She left hospital a week later and two months later she contacted the hospital. It wasn't to send us a thank you letter. She had called up the patient advocacy team. They had written a complaint on her behalf. I had apparently caused psychological trauma and upset her so much that she had not been able to work since she had left hospital. (As far as I remember, she hadn't worked before coming into hospital.) She was also threatening to claim compensation via 'no-win, no-fee' lawyers (I doubted that they would take her case on, but she was threatening none the less).

Instead of this patient's complaint being filed under W for waste of time, my bosses had to do an investigation. My integrity was called into question, along with my patient mannersomething which I am particularly proud of. A grovelling letter was sent back which I fundamentally disagreed with. Money and time were wasted. I am now constantly worried that I will get more letters and more investigations even though all I was trying to do was help her.

I completely agree that doctors should be investigated and complaints looked at if their personal or clinical skills are lacking. But I think the complaining society is spreading too far. If we worry that every bit of advice given may lead to a complaint, then doctors will act in a way to stop themselves getting in trouble and perhaps not always act in the patient's best interest.

If this 'no-win, no-fee' culture continues not only will the NHS be bankrupt from payments but it will also be bankrupt from doctors ordering too many investigations as they will treat people in a 'defensive way' (i.e. not in the patient's best interest but in a way that no one could ever complain about, as they will have carried out every possible testeven unnecessary ones). These worries pervade us as we work. Quite rightly the 'doctor knows best' culture is leaving medicine. But when we live in constant fear of litigation and worry excessively about every decision, then no wonder doctors and nurses are leaving the profession.

Why I am glad I am an A&E doctor

Today I saw a lady who was really unhappy with herself and the world. However, she made me realise why I am suited to being an A&E doctor. She was 59, depressed and had had chronic abdominal, back and head aches. She had come to A&E as she was feeling a bit worse than normal. I went to chat to her and within minutes I too became depressed and had a headache.

There was nothing really wrong with her at all. I did some blood tests to appease her and rea.s.sure myself that I wasn't missing anything. They were all normal. I told her so, and said that I didn't know what was causing her problems. I explained that she didn't need admission to hospital as there was no acute problem. All I could do was give her pain killers and get her to see her GP. I left feeling very miserable and depressedI hadn't really helped her and both of us left feeling a bit dissatisfied.

However, I am so glad that I saw her as she made me realise what is the beautiful part of being an A&E doctor. There are so many 'heart sink' patients that we can't really sort out. They keep coming back to their GP and clinics and it is depressing for the doctor and the patient (who has often got underlying problemsthough not necessarily medical ones). In my line of work, I only have to see these 'heart sink' patients once, whereas their GP has to try and work with them over and over to get to the root of their problems. I admire GPs who can deal with these patients over and over and still remain objective I'm just glad I'm not one of them.

Not enough beds

Today, yet again, there were patients lying in A&E trolleys as there were not enough beds to go to. The hospital 'bed' manager even had to call up the local GPs requesting that they refer as few patients as possible as the hospital couldn't cope. He also came round to me and was basically pleading with me to not refer any patients for admission. What a ridiculous thing for a bed manager to be forced to do. What a wonderful NHS we have at present. I need to treat my patients in the best possible way, not with the pressure of knowing that there is a 'bed crisis' all the time.

It drives me mad when I read that the problem with the NHS is that there are too many hospital beds and that the NHS would improve if we closed beds and got patients cared for in the community. Our wards are swamped with well patients awaiting social services placement and, sadly, also awaiting a hospital-acquired pneumonia. Until adequate community care is in place, we shouldn't be closing any beds. However, at my hospital we have. A ward has been closed to save money. To house the extra patients, the medical a.s.sessment ward has become a traditional ward with one patient staying over four weeks on a supposedly short-stay emergency ward.

This means that, when A&E have stabilised the patients and referred them for hospital treatment, there is an unnecessary extended wait before they go to the ward. It has become a bit reminiscent of the A&Es of 10 years ago, with patients waiting for hours for a hospital bed. The A&E nurses have to act as ward nurses and the new patients that are arriving are given less than perfect care. It is b.o.l.l.o.c.ks that we need fewer beds.

Cutting bed numbers truly b.u.g.g.e.rs up the quality of care that patients receive and has a damaging effect on the efficiency of the hospital. It is sad that the notification of the death of a patient on a ward is received with grat.i.tude by the bed manager as it means that one of the A&E patients could get a bed...and I thought this was meant to be the best year ever for the NHS.

Satisfied doctor and patient

There was nothing particularly unusual today at work. It was just quite a satisfying day. No-one was particularly ill, but those that were all had readily treatable conditions. My treatments resulted in instant improvements, grat.i.tude from the patients and satisfaction for me. They made me feel that I sometimes do useful things as opposed to practising 'defensive medicine', getting stressed by targets and doing audits showing up problems that I know will not change.

The first patient was 26 and had a dislocated shoulder. He had fallen off his skateboard. I gave him some sedation and pulled the shoulder back into place. (Sedation relaxes your muscles and also has the added benefit of making the patient amnesic so they don't remember the pain of the relocation. If you were so inclined, you could take the p.i.s.s out him still skateboarding at 26, without him remembering the conversation.) When the shoulder went back in, the release of pain was enormous.

The next patient had fluid on the lungs and was really short of breath. A couple of drugs and some oxygen and within 1 hour she was a different patient. I felt quite happy.

Then a child came in with a 'pulled elbow'. It is a condition where the elbow slips from its ligaments, often when they have been 'yanked' up. They just don't use the arm. Some gentle manipulation and within 15 minutes they are back to normal.

Later in the evening we had a diabetic patient brought in unconscious by her panicking friend. A simple sugar test told us that she needed an injection of a drug to reverse the insulin she had taken without eating. Within minutes the patient was back to normal and the friend was impressed by our quick actions and calm att.i.tude (as were the patient's parents)and told us so.

Just before I was about to leave for home, I was asked to see a man in excruciating abdominal pain. A quick a.s.sessment and I realised that his bladder was blocked. I inserted a catheter and his pain vanished within minutes.

I drove home and thought that work is quite good fun; I am lucky I do what I do. I didn't moan once in the pub that night.

Mad bureaucracy

There are some rules in the NHS that I just don't understand. Today, I had a patient who needed blood tests. I asked one of the nurses, who wasn't busy, to take them for me and she was very happy to do so.

She was an experienced nurse, and had just got promotion to become a sister. She normally takes blood without any problems, having had the appropriate training by her last hospital trust. However, since she had moved hospitals, she apparently is not allowed to do it until she has been on a course and had 10 patients signed off. This is ridiculous. Junior doctors, who have only seen blood being taken a couple of times, are let loose to do their best as soon as they qualify. But here was an experienced nurse not being allowed to do a job she was perfectly capable of, because of bureaucracy. Let nurses' skills transfer between hospitals and let's have less form-filling and more caring.

NHS Direct...to A&E

Two patients I saw today had been told by NHS Direct to call an ambulance and come straight away. The first was a sore throat and the second a case of long-standing arthritis. They were fine and didn't need to be in A&E. I was initially annoyed, but after speaking to a friend who works at NHS Direct, my annoyance left and was replaced by pity for their difficult working environment.

I can see why the government has promoted NHS Direct. It is a great shiny thing to show off to the voters. And it is good in some respectsit is good for non-urgent advice (for example, it gave my friend fantastic advice on their non-sleeping newborn). However, for emergencies it is not so good. First of all they take a long time to get through to and second, they can't see the patient or get a general feel for how they are. Third, the treatments and advice are very protocol-driven and the staff that man the phones have got to be safe.

Hence, when there is something confusing going on, their frequent conclusion is to advise people to go to A&E...and we see some spectacularly inappropriate attendances. The sore throat clearly went down an 'airway obstruction' protocol (why else was an ambulance called?) and the hip pain must have gone down a 'fractured leg' pathway. It is not the nurse advisors' fault, they are just doing their job. People often cannot describe their symptoms clearly and when someone can't see the patient, they have to err on the side of caution. Anyway, we never hear about the ones that they prevent from coming in. Last but not least, I am sure that people lie and say NHS Direct told them to come, to lay the blame on someone other than themselves once they realise that maybe A&E is not quite where they should be.

While I think NHS Direct has its uses, I can't help but think that there may be a more efficient and safer way to help potential patients. How about more triage nurses in A&E who can give out advice? Because the patient is right in front of them they can evaluate the problem safely. Or how about taking a step back in time and paying for an out-of-hours GP service where these patients in distress would actually get a home visit at night as opposed to a protocol telling them to call an ambulance?

In the meantime, it looks as if NHS Direct is here to stay and will continue to be nicknamed NHS direct to A&E.

Why I hate laziness

I hate lazy people. Whether they work in and around A&E and delay treatment, or whether their actions force someone to come unnecessarily to A&E. All in all, laziness is not good for patient care. Last night I had three cases that really upset me.

A psychiatric patient was sent in from the local unit by ambulance. It was 3 a.m. and the nurses had called the psychiatric doctor to go and see the patient but he couldn't be bothered. The patient was short of breath so the psychiatric doctor, instead of getting off his lazy a.r.s.e to a.s.sess the situation, just told him to call an ambulance. When the patient arrived, there was a very distraught family. The patient had severe dementia, and had recently developed a chest infection. Doc.u.mented in the notes was a plan not to transfer the patient to hospital if she deteriorated, but let her slip away peacefully. But as no one could be bothered to properly a.s.sess the patient she was sent to the dumping ground known as A&E.