7. Patients for whom A&E doctors have asked for a review by a specialist can get admitted to a ward regardless of whether the specialist has seen them or not and regardless of whether they actually need to come in or not. Once admitted to a ward they can stay there for ages without being seen by the specialist as they are no longer in A&E and so cannot breach.
8. Originally, there were specific days when the 4-hour rules were being assessed. On that day, the hospitals would cancel elective operations so that there were spare beds and employed loads of extra locum doctors and nurses to make it look as if the hospital was more efficient than it really was.
So, as you can see, hospitals feel compelled to massage their figures. The target was brought in for the right reason and initially did a very good job. But we need clinicians to make the priorities, not politicians. If the government is going to insist on targets, then let’s make some sensible ones such as all urgently triaged patients to be seen within 5 minutes of arrival. Or how about patients being able to expect a bed 30 minutes after they have been fully treated in A&E, etc? These targets may not be as glamorous to tell voters about, but they might actually improve care without distorting priorities.
The reason I moan so much about this is that what was once a tool to improve A&E is now damaging patient care and doctors’ and nurses’ sanities. I just hope a politician or two reads these words and does something about it other than claim that what we are saying is just ‘nonsense’.
I am writing this on New Years Day. Last night I was at work and it was absolute hell. The A&E looked like a war zone – police restraining aggressive drunks, teenagers vomiting and crying and overworked staff acting as bouncers. I can only assume that the managers thought that someone might fiddle figures for the night and so didn’t bother to employ any extra staff despite knowing how busy it was going to be. I was knackered by the end of the shift and was pissed off with some of the patients’ attitudes, but in all honesty, I quite enjoyed myself.
But I can hardly blame the new drinking laws. I started my shift at 9 p.m. and the drunks were already there. The first was quite a nice lad of about 17. He had fallen asleep in the street and someone had called an ambulance because he had wet himself and was vomiting.
‘So what happened?’ I asked.
‘You tell me,’ he retorted.
‘No. I asked first. What happened?’ I countered.
‘Don’t know mate. Been larging it,’ he said in his irritatingly pretend street speak accent – posh but with a touch of Estuary English.
‘It says on the notes from the nurse that you have been drinking. That can’t be true as you are under 18 and so surely can’t have been drinking. What actually happened?’ I mocked.
‘Nah mate, I gone massive. I am quality,’ he retorted in Mockney.
Luckily, I listen to Radio One, so I sort of understood what he had said.
‘So how have you gone massive mate?’ I enquired.
‘Vodka mate. Bottle of vodka – down in 1 hour. Larging it. So what I am doing here?’
I explained that an ambulance had been called for him as he was so drunk.
‘That is quality. Coming to hospital ’cos so drunk. Quality.’
I asked some questions to check that he was OK and had suffered no ill-effects from his night’s drinking. I asked him if he thought a bottle of vodka was really that sensible for a 17-year-old’s liver.
‘I can do it because I am so f**king hard. I am hard as nails me.’
‘Right … so hard you end up vomiting all night and pissing yourself so that your mummy had to collect you at 10 p.m.? Yep, hard, aren’t you? Well done mate.’
I called in his mother, and as soon as he was able to walk without falling over, he went home. Except that that wasn’t all he had to say for himself. While waiting for his mum, every couple of minutes he would call out to one of the nurses.
’Oi! Beautiful! I am quality – do you want to come home with me?’
He was harmless but irritating after a while.
The next case was a 14-year-old girl. The ambulance called ahead to say they were blue lighting her in as she was completely unconscious. The nurse and junior doctor tried to wake her up and couldn’t. I got a call on the intercom.
I walked in and initially failed as well. If she was truly unconscious then we might have to intubate her (i.e. put her to sleep and take over her breathing) so that she wouldn’t choke to death on her own vomit, which I was currently sucking out of her mouth (with a suction tube). Then I tried a ‘registrar’s trapezius squeeze’. (Basically, you squeeze as hard as possible on the bit of muscle between the neck and shoulder, then carry on squeezing until they wake up.) She did wake up – very quickly. I checked that she hadn’t hit her head or taken any drugs, asked the senior nurse to put in an intravenous cannula, watch for more vomiting, and give her some fluids.
Giving fluids to someone who is drunk is a little controversial. We spend tax-payers’ money helping them to sober up and not get as bad a hangover which may positively reinforce their A&E-seeking behaviour after drinking. This can’t be good, but I am still a believer in giving them lots of fluids when people are drunk because it helps to get rid of them more quickly. It helps them sober up, and also they soon wake up needing to go to the toilet. Sometimes it backfires and they end up losing full control of their now full bladder – but the risk is worth taking as it is so effective in aiding appropriate discharges.
I explained to the girl’s mum what was happening and why we were giving her daughter fluids. We put the girl on her side and left her where we could watch her closely. We also gave her little sister, who had to enjoy her New Year’s Eve watching her big sister vomit, a chair and a blanket to cuddle into.
After 3 hours and 59 minutes the girl was sober enough to go home with her mum, who was furious with her daughter. As I came to see her, her mum was in the middle of telling her off.
‘This is the second time you have done this now. You have ruined your New Year and everyone’s else’s, you selfish girl,’ I heard her say. I introduced myself to the young girl and checked she was OK. I then said she was free to go but before that I wanted give her some useful patient education.
‘You could have died you know – you are only 14. Don’t be so dangerous in future.’
She looked at the floor.
‘Do you want me to tell her off?’ I asked her mum.
‘Please do,’ she said.
‘I have seen loads of people ruin their lives by binge drinking. You have been so stupid. We had to suck out the vomit from your mouth. Do you realise that? Do you? You could have had the vomit go into your lungs and then you wouldn’t have been able to breathe properly. You could have died, and in that state anybody could have done anything to you and you wouldn’t have known. Don’t be so stupid again and drink with some self respect.’
Her mother seemed suitably pleased with me. But I hadn’t yet finished.
‘You have also stopped me seeing really sick people who needed my help. The elderly lady in cubicle 5 had to wait an extra 30 minutes for me to give her pain killers for her broken leg because of your selfish stupidity.’
Her mum seemed very pleased with my chastising abilities, but then said, through gritted teeth, ‘You wait till you get home and then you’ll get a