This week I'm delighted to be sharing a first-hand account of what it was like to work in A&E on Christmas Eve. This blog has been written by one of our relatively new joiners; a consultant working with the UK Public Sector Business Model Transformation team covering the Healthcare Industry who joined Deloitte following 6 years of medical training, a degree in Healthcare Management and 2.5 years working as a clinician for the NHS, predominantly in accident and emergency services.
Some ten weeks since starting my new role within the public sector operations team at Deloitte, the desire to retain my medical licence to practice meant that I agreed to cover a night shift in a hospital Accident and Emergency (A&E) department on Christmas Eve. With the NHS constantly in the media, and often for the wrong reasons, I thought I'd use this blog to share my experience of working in a busy A&E department on what is the one night a year most of us, staff, patients and relatives, would prefer to be at home with our families.
From past experience, Christmas Eve in A&E is different to most other evenings. In an attempt to compensate for what people might be missing, cheap Christmas decorations, a constant supply of 'healthy' NHS snacks and Matron's Santa Hat go that extra mile to bring some festive spirit and create a jovial atmosphere in the department. Perhaps this extra exuberance made the dejection even greater when the inevitable Christmas tragedy came through our doors (in this case around 2am).
There was a certain nostalgia to being back in my blue scrubs, with my NHS badge hanging from my neck, next to a slightly dusty stethoscope. I would be lying if I denied being nervous for my first shift in two months, but I was excited to catch up with old colleagues and quell the rumours that my new 'city' life would not see me back on the shop floor anytime soon. There is a unique assault on the senses when entering the A&E department that you can only understand by experiencing it first-hand. Even experience, can't quite prepare you for the hostile bright lights, the flurry of people darting all over the place, the plethora of high-pitched bleeping sounds coming from different machines and of course some of our frequent fliers who may have had one drink too many. Nevertheless, the organised chaos has a familiarity that is almost homely and I immediately felt at ease.
A backlog of patients with almost a two-hour wait meant I started my night shift in paediatrics seeing some toddlers with minor head injuries, a classical presentation of croup, and an ear infection. Nothing out of the ordinary, worried parents, some of whom were directed to A&E by the NHS 111 service when perhaps the clinical need for this was questionable. Of course, that is easy to state once you have seen and examined the child.
There are moments in A&E when you question why patients have attended and feel as though your time is being wasted. The polar opposite is equally true, where you wish someone had come to hospital sooner. At around 11pm, I reviewed a middle-aged lady who was complaining of a headache which started eight days earlier. It's common for an emergency doctor to have an idea of what to expect before seeing the patient, based on the triage notes and basic vital signs (heart rate, blood pressure etc). On this occasion, a generally well woman with normal vital signs has a headache that had lasted eight days, she'd seen her GP a few days earlier who had prescribed some strong painkillers. The headache however had not improved so the patient decided to attend A&E.
On first glance this should have been a simple, 10-mintue, consultation. Examine the patient and send her home with appropriate analgesia and reassurance that there was nothing sinister underlying the presentation. However, being an emergency clinician also means picking up on the subtle red-flags, the history, the symptoms, and the examination that suggests something else has happened. Eight days earlier, her headache was of extremely sudden onset, I noted the woman's speech was slurred, her daughter confirmed this had been the case since the headache began, she also mentioned that her mother's mother had passed away from a brain haemorrhage.
A quickly organised CT head scan was reported promptly by the outsourced out of hours radiology service and confirmed a bleed on the left side of her brain along with a small aneurysm (a ballooned blood vessel that could burst at any moment). As per protocol, I sent the images to the regional neurosurgery centre which took 45 minutes to appear on their screens, the same amount of time it would have taken to print the images and hand-deliver them. I spent an hour on the phone tracking down the on-call neurosurgeons to confirm they would accept the patient for further management. Within 15 minutes she was in an ambulance on her way to the neurosurgery centre, the agreed pathway for acute adult neurosurgical presentations. I couldn't help but think that a more interoperable and compatible IT platform might have helped reduce some of these delays.
I couldn't resist asking the patient's family if they had ever seen the TV advert for 'FAST', where the 'S' for slurred speech should trigger patients to seek medical attention immediately. The family had never heard of FAST. On the shop floor it's sometimes hard to see how the funding spent on public health campaigns is worth it! As is common in A&E, I do not know the outcome of this case, but I am certain her prognosis would have been better had she presented sooner.
After treating a few more patients, and some seven hours since starting my shift, I was starting to flag, in desperate need of a coffee. As I was pouring the milk the familiar 'crash' alarm went off, "cardiac arrest resus bay 3, cardiac arrest resus bay 3". These scenarios are perhaps the only ones where the TV dramatisations of emergency departments are quite accurate. Along with colleagues, I ran into the resus area, grabbing gloves from the wall as a reflex. Autopilot really does engage. Another doctor had secured the airway so I started chest compressions as more A&E staff poured into the hectic bay. Two distraught relatives were taken away to a private room. Within minutes the patient was tubed to enable us to ventilate the lungs, had IV access, bloods taken and defibrillator pads attached. Our consultant (who is on the shop floor 24/7, even on Christmas Eve) stood at the foot of the bed managing the crash, shouting orders, always in an encouraging way.
The patient was from out of town, visiting family for the holidays, and had presented at A&E quite unwell an hour earlier complaining of shortness of breath. In the absence of a national system for accessing medical records and the relatives unable to give much background information, we are forced to rely on the few investigations that already had been performed, including a chest X-ray. Two minutes pass, I checked the pulse, still nothing. The defibrillator records the heart rhythm, not one that would benefit from an electrical shock. We continued compressions, a colleague took over from me as two minutes of full compressions is exhausting. Some more cycles passed, still no pulse. The anaesthetists arrive and take over the airway. Various medications are injected to attempt to get the heart beating again. We start to get a better understanding of his medical history. The X-ray taken just before the cardiac arrest showed a suspicious lump in the top of the left lung. The wife confirmed that her husband had lost a great deal of weight over the previous few months and had been coughing a lot.
Ten minutes passed, still no pulse. Our consultant discussed the prognosis with the family, even if we could restore cardiac function, quality of life is likely to be severely limited, the patient likely has an underlying life-limiting disease. We are dealing with uncertainties. We are fighting a losing battle. Fifteen minutes, another blood test showed a worsening picture. Our consultant suggests we stop, and asked what do we think? The family agree, the team agree. We stop, withdraw from the bed, leave the oxygen flowing and allow nature to take its course. It is not the Christmas morning this family had expected.
While doctors have to be able to disconnect from the emotional aspect, we all feel it in certain cases, and this Christmas morning it was certainly tough to move on to the next patient, give a smile and be in the Christmas spirit.
Very little traffic on the roads, so I'm home by 8 am. Quick glance at my mobile phone, no messages or emails, of course it is Christmas morning.
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