I also saw a lady with a sore throat. I explained that she didn't need to come to A&E. She told me that the GP had told her to come as he was too busy. I phoned the out-of-hours GP receptionist who confirmed that the GP was 'surfing' the net and I informed him that I was sending the patient to him. When I asked the GP why he had told this lady to come to A&E, I was told that he was there for emergencies only. Hang on...Wasn't that my job? What a lazy (but no doubt well paid) colleague.

Then I saw a badly injured motorcyclist (otherwise known as an organ donor). His neck was painful and he needed a CT scan of the neck and head to rule out injury. The head was normal and we got a report for that (it is whizzed across to the radiologist's phone line and down their computer so they don't need to get out of bed to report it). However, to report the CT scan of the neck, the radiologist needed to come into the hospital. Instead of coming in at 1 a.m., he told us to keep the patient's neck immobilised and he would report it in the morning when he was coming in anyway. So this poor fellow had to stay strapped down all night and not move. The nurses had to log-roll him whenever he needed to vomit and I had to make up a pathetic lie of why we couldn't get the CT results straight away. Amazingly, he thought his treatment had been brilliant. It is fantastic how a few half-truths can placate most patients and hide them from the real cause of their delays and difficulties.

All I can say is that the vast majority of my colleagues are not like this. It is only a very select few. The only downside is that I only write when I am angry and so you rarely get to hear about when people have put themselves out and been helpful. But then that's life reallyno-one ever praises the good guys, they just moan about the baddies. Sorry.

MRSA: the good, bad and ugly

The bad and ugly.

A little known fact: one in three of us have MRSA (methicillin-resistant Staphylococcus aureus Staphylococcus aureus). It is a nasty bug that cannot be killed by the common antibiotics. Normally, it lives up your nose, getting on with its own little life and never bothering you. However, if you are vulnerable (i.e. elderly or have open wounds, etc.) it does cause problems.

A well known fact: MRSA can be transferred from patient to patient by poor hygiene and lack of proper hand washing. If you are unlucky enough to get it, then its consequences can be devastating A little known fact: it's not all all doctors' fault. There are things all of us need do, such as hand washing. It is also true that some doctors don't help at all, but there are other causes. doctors' fault. There are things all of us need do, such as hand washing. It is also true that some doctors don't help at all, but there are other causes.

I was at work today and went to clean my hands with alcohol gel between seeing patients. I squeezed at the dispenser and nothing came out. I went to the next one and again nothing came out. It was a real effort to get anything to clean my hands with.

Later on, I went to the toilet. There was no soap, so I went to another toilet. There were no hand towels left either, so now my hands were left to dry in the air (a great way to encourage MRSA). I saw another patient and, as can often happen, I got some vomit on my clothes. I would have to take them home myself and wash somebody else's bodily fluids off in my washing machine. I don't particularly like doing that and, anyway, my machine is not specifically designed to be a sterilising washer. When I wear that top, how can I be sure it won't be harbouring any bugs?

I then saw some important-looking peoplethey had clipboards and ties on. I have stopped wearing a tie because of evidence that they may harbour MRSA bugs, but these men in suits didn't seem bothered. Walking through the department were some workmen. Their muddied boots left dirt all along the corridor outside the department. When the cleaners were called they acted with the speed of a very slow snail that had been smoking weed and had a heavy weight tied to its sh.e.l.l.

A patient with a gynaecological problem then came in. There were no clean cubicles to see her in. As she was in so much pain, there was no time to get a thorough clean of a room done before seeing her. In the corner of the room, I saw spots of dried old blood. I hope she didn't notice them.

Then I overheard a conversation between the bed manager and the ward nurse. A patient had recently died in a bed and the bed manager was trying to rush an A&E patient up to their bed. This was done despite the ward wanting a bit longer to get the area thoroughly cleaned.

Later, A&E became even busier and so we had to fit two patients into a s.p.a.ce designed for only one. This occurs on a weekly basis. The proximity of the patients surely cannot help when it comes to trying to stop hospital-acquired infections.

After work, I went to see a friend who had just given birth earlier that day. She was at another hospital, but there were the same problems. Her mother had complained to the midwives about old blood on the floor. The answer she got was that the cleaning 'manager' had been informed. But 3 hours later, there was still no cleaner. Different hospital, same problems. At the same time, everywhere I lookedat both hospitalsthere were expensive posters on the walls, advising doctors and nurses about washing our hands. From the above examples, surely managers can realise that it's not all our faultthey have to look at more fundamental causes.

These are the effects of bad management and bad politics. During the Thatcher era hospital cleaning services were privatised and given to the company that offered the lowest price as long as they promised to maintain basic standards. The cleaners working for us in A&E do a fantastic job, considering the pay and the conditions they have to work under. But they are often on temporary contracts. If you are in this situation, you may not care as much as someone on a permanent contract and with a decent wage. When the cleaning managers' priority is their shareholders and not necessarily providing as good a service as possible to the hospital, then no wonder there are occasions when I can't find hand towels and soap.

However, there is a more fundamental problem leading to high hospital-acquired infection rates. When hospitals work at 100 percentcapacity, then there is not enough time to clean properly between patients using the same bed. So when you think about MRSA, don't just blame doctors and nurseswe need a kick up the a.r.s.e but so do the politicians and managers.

The good Lots of patients are not happy when we discharge them. They feel that they need hospital admission even when this is not the case. It is often a hard argument to persuade them otherwise. It is an argument made easier when you remind them about the risks of coming into hospital: hospital-acquired infections.

Errr, I think he has vffxyeez syndrome

This is a true story that has been slightly exaggerated for artistic reasons, but is essentially what happened at work today.

I saw a 28-year-old today. A nice bloke, except for some quite ridiculous 1970s 'love' and 'hate' tattoos on his knuckles. He also had a tattoo on his chest saying 'Danielle 4 ever 2gether never 2part' entwined in a heartI found out subsequently that they split up six months ago.

Anyway, he had appendicitis. So, I called the surgical doctor.

'...yarrr. He hazzz vycchxty.'

'Huh?', I said.

'vcdftys. Yah zloba hytchytd.'

'Um...Could you please come take his appendix out, otherwise he will get septicaemia and die.'

'Yarrrr. zeeee sabch I mean vzyxhcz.'

'...And Danielle might become a bit more sympathetic and then they might get back together.'

'Yar. meesaztre.'

'Uh...why don't you come down to A&E, it must be the phone line'

It wasn't. The phone line was BT and excellent. My communication skills were fine. So were hisif he was in Poland.

So I decided on a game of Pictionary to explain what I thought was wrong. At last we understood each other. I drew a picture of an appendix and a man crying, he smiled and raised his thumbs and 4 hours later the man was being operated on by the boss of our Polish friend. All I can say is thank G.o.d for Pictionaryan international life-saving game. It made me think: how did this obviously competent and friendly doctor, but someone who cannot speak English that well, get to work here? The answer is the European Union and stupid rules.

Now, I love Europefrom French sophistication to German efficiency, Spanish flair to the Italians' generally fantastic b.u.ms. I love the European Unionsecurity in our continent for the last 50 years and international cooperationand I look forward to a single currency instead of having to look at the queen's face every day (if we had to have a British queen on our money I would prefer Elton John or Brian from Big Brother Big Brother).

I am also in agreement with most of the EU treaties, such as the common trade agreements. I also approve of the European working time directive, which has meant that I know what my kid looks like and improved the frequency of when I can see my mates (my mum-in-law still thinks I do a 90-hour week, though, and I am in no rush to tell her about the 56-hour limit). Until recently the only thing I wanted to change about Europe was to bring in a treaty banning female underarm hair.

However, things have changed...new freedom of work laws means that you have the right to work in any European Union country, without a language test. For very junior doctor jobsF1/F2you don't always need an interview, although I understand (hopefully) that is changing. Also, increasing numbers of European doctors wanting to work in England has meant that there are too many doctors for too few jobs. So the government has decided that non-EU doctors who have pa.s.sed English tests, who have lived in England for many years and who may have English as their first language are positively discriminated AGAINST and jobs are given to these EU doctors insteadwho because of EU rules do not have to take English language tests before they work here. They may be the best doctors in the world but if they cannot converse with their patients and colleagues then they are not going to be any good.

Our government's idea of grat.i.tude to the thousands of Asian/Australasian/South African doctors who have kept our NHS running the past 30 years, during severe doctor shortages, is to say 'p.i.s.s off. We are instead going to employ EU doctors who may or may not be able to speak English.' There isn't even a test to see if they know how to play Pictionary, for s.h.i.t's sake!

The government needs to do what other EU countries do and ignore ill-thought-out laws or at least make sure that non-British doctors must be interviewed so that we know they can at least speak Englisheven if they are going to be doing a loc.u.m job for only a couple of days.

This is not an anti-EU rant, this is a plea for better scrutiny of our doctors. Forget about political correctness and have some common sense. The Polish doctor I was working with was an excellent and incredibly hard-working doctor. I welcome his skills, expertise and knowledge, but just wish he could speak English better before working here.

I spent the whole day fuming...until I had a Polish patient who couldn't speak English. I had to call my new Polish doctor friend back to translate...he used Pictionary with me to explain that he was a trainee surgeon and not a free translation service. So, Pictionary can be used as a life-saving tool and to express your anger. My type of game.

What's wrong with me?

I went to the pub tonight and people were worried. I wasn't myself. I have never been like this before. I was quiet and didn't moan once. I went on about how wonderful work was today. It was the first day I had used our new hospital CT scanner and the pictures it produced were a pleasure to behold. I also went on about how wonderful it is that we have an additional psychiatry liaison nurse working in A&E today. I mentioned that I had got a thank you letter and how supportive my consultants were when I was running into difficulties with a really sick patient earlier in the morning.

Later in the evening I sat next to a member of the ambulance service, who had started his first day as a new emergency care pract.i.tioner. This is a new role invented by the government where ambulance personnel go to patients' houses and try and sort them out there and then as opposed to bringing them to A&E. Apparently, in his first day at work he had prevented five A&E attendances. I told him how I thought that his new post could drastically improve care and what a fantastic use of money it was. For the first time in a long time I was not being sarcastic.

It was weird being this positive about the NHSa very rare experience. It also meant I had a miserable time at the pub as I had nothing to moan about and ranting is my favourite hobby.

Luckily, today was a rare exception. The usual s.h.i.t and problems recurred the next day and I had a happier time at the pub.

When not to get ill

I dread the beginning of Augustespecially the first Wednesday in August. It is when all the newly qualified doctors start. Genius medical planning supervisors have decided to make this the date when all other junior doctors rotate jobs as well another consequence of MMC, which no one seems to have thought through. This is always a nightmare time in hospitals as frequently all the junior doctors are not only new to the hospital but also to the job. The doctors you are working with need a lot of supervision. Some of the doctors you refer to will also be new and although they may be the specialists they might not be able to give much 'specialist' help...it is something to think about when you are planning when to have your next heart attack.

Other times to avoid getting ill are the last Friday of the month. Working in a hospital is a very social affair and once a month there is a big Thursday night outto celebrate pay day. Often the nights are organised with the other emergency services, so called 999 nights, where doctors try their luck with police ladies/men and the firemen get to try it on with nurses. Booze flows and everyone enjoys themselves...unfortunately, they have to come to work the next day.

Out-of-hours GPs

A few years ago the government went into negotiation with GPs about a new contract. Everyone agrees that the government negotiators got well and truly shafted. The GPs managed to negotiate themselves out of night work and Sat.u.r.day work for a relatively small loss of wages (which could easily be made up elsewhere in the new contract). Responsibility for the patient's care was also transferred from the GP to the PCT. As anyone who has ever tried to get a GP out of hours knows, the service is not as good as it used to be. Instead of being able to see a GP who works in the practice you go to, you speak to a central triage service run by a 'cooperative' or private company and a GP triages your call. They either ask you to come to the out-of-hours GP service, often situated near your local hospital, or they go and see you at home, or they tell you to go to A&E. The problem is that the GP has no knowledge of you and does not have access to your GP notes.

The other problem is the way these cooperatives are run. There are only a few (well paid) GPs working at a time and so their time is limited. The chances of them telling you to go to A&E as opposed to doing a home visit are now inappropriately high. These GPs are mostly loc.u.ms and are on an hourly rate, at a rate that is ma.s.sively greater than any senior A&E doctor could ever dream of.

So if your gran has a chest infection outside 96, the out-of-hours GP may now advise her to go straight to A&Ethere are not enough of them working to enable them to go and see everyone who needs a home visit. Previously, they would go and visit to determine whether such patients needed hospital admission. If they could cope with oral antibiotics, then they prescribed them and organised their regular GP to review them in a couple of days' time. If the patients needed hospital admission, they organised a bed and referred it directly to the medical team and directly to a hospital bed.

I had a similar experience two days ago. A 94-year-old bed-bound patient came in by ambulance from a nursing home. The carers had called the GP as she was a bit more chesty than usual. The out-of-hours GP stated that he was too busy to come and see her and that if the carers were concerned then they should call an ambulance. So an ambulance was called and I saw her. She was quite well, but the nurses were right, she had a chest infection and needed oral antibiotics. I prescribed them and gave her a week's course, but she couldn't get home as it was now after 11 p.m. and, as discussed before, we don't have a contract with the ambulance service for non-urgent transfers after hours. She had to stay the night and was distressed...and she was exposed to other patients' germs and other patients on the ward were exposed to hers. This was all because a GP would not go and see her. I don't blame the individual GP as he was probably too busy but do blame the system that has been brought into place which makes this commonplace.

The government has written a paperDirection of Travel for Urgent Care; a Discussion Doc.u.mentcontaining all these suggestions on how to prevent hospital admissions and A&E attendances. They talk about 'patient centred plans' which are to be used after hours: for example, health workers visiting people in their home to give them appropriate treatment and arranging extra help at home. What a fantastic idea! But hang on a sec...these were services that used to be provided out of hours by GPs. The government is the one who took away the out-of-hours responsibility from GPs and is now bemoaning the fact that the level of care has gone down and hospital admissions up. Politicians talk a good game but are not so good on the actions bit. I don't think at present I would trust the government to run a bath, let alone the NHS.

It is incredibly important to run out-of-hours care properly and efficiently. We need a rethink. True accidents and emergencies should come to A&Eno argument there. Elderly people who need to be seen at home should be seen by GPs (if medically unwell) and minor injuries and the like should be seen by the new breed of paramedicsemergency care pract.i.tioners, who can do things such as suture wounds, etc. The GPs' databases of notes should be freely available to these health professionals out of hours.

Anyone else should come to A&E and be seen by a triage nurse. She can determine if they are sick enough to warrant the specialist skills of an A&E doctor. If, however, someone has a minor injury, then they could be seen by an emergency care pract.i.tioner (with supervision and advice from senior A&E doctors) or, if they have a primary care problem, then they could be seen by a GP based in or near to the A&E department. Everybody would work together and there would be a parity of pay for out-of-hours work between the hospital staff and GPs.

The government would like to think that this is what its policies have tried to create via creating new 'urgent care centres', but the reality is we are a very long way from this particular Utopia.

Sick outside 95, Monday to Friday?

Working hours are only about a quarter of the hours in the week. I have a secret that I want NHS managers to knowpeople get ill outside these times. This, however, doesn't mean they don't deserve the same standard of care.

From lack of access to GPs, to A&E doctors often being more junior at night and not being able to get investigations done, people don't always get optimum care if they are ill outside the hours of 95.

I have had several cases recently that have really upset me. For example, a 26-year-old student nurse came in at 9 p.m. on a Thursday. He had come off his mountain bike and had immediately fitted for 1 minute as a result of the head injury he sustained. This is an indication for an urgent scan. There are even guidelines produced by the National Inst.i.tute of Clinical Excellence (NICE) saying that a scan is indicated. However, there is a shortage of radiologists at my hospital and they have a very harsh on-call regime. Therefore, there can be occasional resistance to moderately urgent scan requests such as this one.

I saw the patient and tried to organise a scan. The request was deemed 'non-urgent' by my seniors and the radiologist and was turned down. He had to wait until morning. If he had come in between 9 a.m. and 5 p.m., then he would have had the scan without any arguments. Luckily, it was normal, which prompted everyone to say, 'See, we told you so' and 'You didn't have to worry'. But it might not have been normal and he could have been sitting there with bleeding in his brain all night. I also had to explain to the patient why he wasn't going to have a scan immediately when I believed he needed one.

Another patient came in on the Sat.u.r.day of a bank holiday weekend. She was eight weeks pregnant and had had a v.a.g.i.n.al bleed possibly a miscarriage. She was desperate for a child and had already had three miscarriages. She was distraught. I examined her and her abdomen was soft and pulse was normalshe did not have any worrying signs prompting an urgent scan. However, she needed one for her psychological well-being. The next 'Early Pregnancy Clinic' appointment was in three days' time. The gynaecologists at the hospital said they wouldn't do one because they were too busy and that it wasn't an appropriate 'out-of-hours' request. I felt awful for her, but there was nothing I could do but send her home with my heartfelt apologies and 'unrea.s.suring' rea.s.surance.

Another patient came with an attempted suicide. He was very distressed and he needed to see a psychiatrist. However, the psychiatrist was doing a 24-hour shift and was on 'protected sleep' except for dire emergencies. He could wait to see the psychiatrist on our observation ward, but this only added to his distress.

There are numerous other examples of the problems of out-of-hours care. The NHS should be planned so that you can expect the same level of care whatever time of day you are ill. People should do only a maximum of 12-hour shifts so that there is no such thing as 'protected sleep', and so we can get specialist doctors down to A&E at all hours of the night even if the patient's condition is not life threatening.

Whatever the problems are, surely A&E needs to be able to get specialist help 24 hours a day? The resources need to be made available so that this happens. Specialist help is available for life-threatening conditions 24 hours a day, 7 days a week. But perhaps it also needs to be available 24 hours a day for less important, but still potentially treatment-altering reasons, if only to speed up patient care and reduce the number of unnecessary admissions (and hence also save money). We live in a 24/7 societysurely it is time the NHS joined the twenty-first century.

A sick man

His pulse was getting weaker and weaker. s.h.i.t, I had given him too much of the sedative drug. s.h.i.t! s.h.i.t! s.h.i.t! I got an ECG. His rhythm had changed into an irregular one. I started another drug. It didn't work. He was starting to become unconscious. I tried to call out to the nurses to get the consultant in to help me, but nothing came out. I had to take over this patient's breathing. I tried to intubate him, but I just kept on getting the tube in the gullet and not the windpipe. His oxygen levels were falling. My pulse was racing. I called for an anaesthetist and finally someone came running to help. But he was dressed as Pudsey Bear. I begged my wife to help. Hang on...What the h.e.l.l was my wife doing at work, holding my hand? Why was the anaesthetist dressed as Pudsey Bear? What the h.e.l.l was going on? I breathed a sigh of relief. I was dreaming again. There was no sick man and I could get back to sleep, knowing that I hadn't been party to anyone's demise in the last few hours.

But there was one sick man. Me. Why can't I sleep well at night? Why do I ruminate about problems? Why do I worry so much about how I treat patients? And, what is worse, spending all my time worrying and driving my wife mad, or not worrying at all?

Why I love A&E

The wonder of A&E is that you never know what is going to happen and who or what is going to walk through the doors. It is not like being a specialist doctor, where you will only see packaged patients who fit a certain criterion. That would drive me crazy. I love the unknown.

It was 4 a.m. when the ambulance brought us an 86-year-old man from a nursing home. He was unconscious. As he arrived, I directed the ambulance into the Resus area. I grabbed my junior colleague and went through the set pattern of treating people when they are sick and you haven't got a clue what is going on. It's the ABCDE approach. Basically, you treat the things that could kill them first and then move on.

A is for airway A is for airway Check the airway. This gentleman couldn't keep his airway open because he was unconscious. He was at risk of dying from a lack of oxygen. To solve this problem, I inserted a naso-pharyngeal airwaya small tube that goes through the nose to the back of the throat. It means that even if the patient is unconscious, they cannot block their windpipe with their tongue. It can appear a bit barbaric to do, and it's not particularly nice for relatives to seebut it is simple and life saving. Check the airway. This gentleman couldn't keep his airway open because he was unconscious. He was at risk of dying from a lack of oxygen. To solve this problem, I inserted a naso-pharyngeal airwaya small tube that goes through the nose to the back of the throat. It means that even if the patient is unconscious, they cannot block their windpipe with their tongue. It can appear a bit barbaric to do, and it's not particularly nice for relatives to seebut it is simple and life saving. B is for breathing B is for breathing Check the breathing. He wasn't breathing well enough and so I gave him oxygenagain ridiculously easy and cheap and a life saver. You then move on to C. Check the breathing. He wasn't breathing well enough and so I gave him oxygenagain ridiculously easy and cheap and a life saver. You then move on to C. C is for circulation C is for circulation His blood pressure was low, so we inserted a cannula and gave him intravenous fluids. This brought up his blood pressure, thereby improving his circulation. We then moved on. His blood pressure was low, so we inserted a cannula and gave him intravenous fluids. This brought up his blood pressure, thereby improving his circulation. We then moved on. D is for disability D is for disability Find out how unconscious he is and then look for a cause. He was very unconscious and it soon became obvious on examination that he had had a major stroke. Find out how unconscious he is and then look for a cause. He was very unconscious and it soon became obvious on examination that he had had a major stroke. E is for exposure E is for exposure Examine the rest of himis anything else going on, for example hidden injuries, etc. Examine the rest of himis anything else going on, for example hidden injuries, etc.

At this point his respiration became more and more erratic. I thought that it was because of the swelling from the stroke pressing on the brain. I thought he might 'arrest' (i.e. his heart and breathing stop). I then had to make a very quick decision as to whether trying to restart his heart would be a good idea.

There are three main questions that must be asked at times like this: first, what was his quality of life like before?; second, what are his chances of surviving the cardiac arrest and then the subsequent treatment?; and third, what are his wishes, either expressed by him or by his relatives?

There are two common misconceptions here. First, the decision whether to restart a heart is ultimately the doctors' and not the relatives'. I know some doctors make patients' relatives feel that they are making the decisionwell, they are not. It leads to relatives feeling guilty and that is not fair. Consult them and take their opinions into account. But do not let them decide.

Second, 'not for Resus' does not mean not for treatment. You can have full, active treatment to try and prevent a cardiac arrest, but not resuscitationbasically if the treatment has not stopped you having a terminal event (i.e. a cardiac arrest) then nothing we do as doctors will change that. To proceed with a resuscitation attempt under these conditions is fruitless and cruel. The same applies (and a lot of doctors don't get this oneand it is also only my opinion and not necessarily medical gospel) if your underlying condition means that any treatment in intensive care would ultimately be futile. You can survive a prolonged resuscitation only if you go to intensive care afterwards. If that is not appropriate, then what is the point in trying to stop you dying now, only to die 2 hours later but with multiple rib fractures?

I spoke to the nursing home. The patient had a poor quality of life, didn't get out of his wheelchair and had multiple medical problems. If he did arrest, his medical problems might hinder any resuscitation attempt and his quality of life was such that we might be making things worse rather than better. Therefore, he was a patient whom I indicated not for Resus (or intensive care) but for active treatmentwe gave him fluids and oxygen. I called his son in.

By then I thought he was going to die. I explained to the son what had happened and what we were doing. Although we couldn't save his life, I think we made the inevitable death easier for his son to bear. We then handed over care of the patient to the medical doctors who would provide ongoing care. He died the next day with his family around him.

Patients' wrong priorities

Part of the fun of working in A&E is that you get to work with challenging patients who are accompanied by the police. A lot of doctors hate working with this subsection of the community, but I find it...interesting.

Last night I saw a patient who had strong personality traits that other people might find offensive, but which I, as a doctor, couldn't possibly comment on. He had nicked a car, then been chased by the police. He crashed at about 90 m.p.h. and was thrown about 20 metres along the ground. He tried to run away, but with one leg at a completely unnatural angle to the rest of his body; he only managed to get as far as a waiting ambulance.

The ambulance service called us up to let us know what was coming in. A trauma call was put out. When he arrived he was in a bad state. His leg was mangled, but it was important to not just focus on the obvious injury and ensure that the rest of him was not in trouble, especially his lungs, heart and abdomen. We went through the usual treatment of my colleagues a.s.sessing him while I explained to him what was happening and getting relevant information.

'How old are you, what medical problems have you got, any allergies, do you take any medications?' I asked.

His answers were not that helpful. 'Get the f**k off me and get those f**king stupid things off my neck.'

I tried to explain that those things were neck blocks, which were protecting his neck in case he had damaged his cervical vertebrae and possibly his spinal cord. I again explained what we were going to do to himgive him fluids and pain relief, take blood tests, examine him and organise some scans if necessary. He seemed a little bit quieter for 10 seconds, but then he started again.