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A&E ARMAGEDDON

By Doctor Anonymous n The writer is an A&e doctor in the South of england.

6.40am: In my scrubs and ready to go... 20 minutes before the start of a ten-hour shift, in time to grab a coffee. But I walk into the Accident and Emergency department to see 27 patients have been waiting through the night, including four children. Several people have been here more than eight hours, and they’re tired, hungry and haggard. Three colleagues see me at the same moment, and they all want my attention. No chance for coffee now.

6.50am: My team gathers around for our daily huddle to see which cases are already being flagged up as high priority. Everyone who arrives is assessed or ‘triaged’, to identify the most urgent. We divide them into three categories: red, amber and green.

7am: One of the children is running a temperature above 40c, an emergency. It looks like scarlet fever, which is highly contagious and a notifiable disease — and she’s been in this waiting zone, surrounded by vulnerable people, for hours. We have to get her into an isolation room.

Scarlet fever season has started early this year, one of the unforeseen knock-on effects from keeping children out of school so long during the pandemic.

7.40am: More people are arriving all the time. Many have been waiting at home, afraid of arriving at night. I’m dealing with one who came in during the small hours, a man in his 40s with chest pains. He swears he hasn’t taken any illegal drugs but I can see in his eyes that he is still wired, probably on cocaine.

Cardiac disease is an increasing problem among comparatively young men, and another one that Covid appears to have made worse — though it’s hard to know if that’s a side-effect of coronavirus or the unhealthy lifestyles that people embraced to get them through lockdown.

9.30am: I’m trying to see people three at a time, jumping from one cubicle to the next. Yet I just can’t make a dent in the workload.

Two police officers bring in a man who was beaten up while sleeping rough. He speaks no English. The police want him seen straight away so they can deliver him to an assessment centre for illegal immigrants. The man can’t, or won’t, say who he is or where he has come from.

‘Just patch him up,’ the older policeman tells me, ‘and we’ll get out of your hair. We can’t hang around here all day.’ But there are people here who need my attention first. The police are stressed, and I’m overstretched.

10.50am: A woman in her 80s shuffles in, supported by a kindly stranger. She looks on the verge of collapse. We have a ‘frailty unit’ where the vulnerable elderly can wait to be seen. I dial their extension and, before I can even introduce myself, a voice at the other end snaps: ‘We’re full!’

‘It doesn’t have to be a bed immediately,’ I say. ‘Just a chair, for now.’

‘I told you, we’re full,’ says my colleague. He sounds like I feel — stressed to the limit of sanity.

This is the cost of an ageing population. It’s one of the most common problems in A&E, and it’s so unfair, so unjust, so completely wrong. Many older patients aren’t surprised when they find there’s nowhere for them even to sit — they tell me this is why they’ve resisted coming into hospital for so long.

As a consequence, many are in advanced stages of illness, exhausted by infections and dehydrated, or with suppurating ulcers that should have been seen much sooner.

I can’t see any obvious injuries on this woman. ‘I’m hungry,’ she keeps saying. It turns out she hasn’t eaten for two days. I prescribe a mug of tea in the canteen and a plate of toast and jam.

But I know she’ll go home to her lonely room and there still won’t be any food in the cupboard. A referral to social services is made — but how long it will take to get things in action is another issue altogether.

11.45am: Ambulances are parked outside with patients waiting to be offloaded into the hospital. We have no space, no trolleys, no wheelchairs, no seats. The paramedics can’t just turf people out in the car park. So they wait... while across the city, people are calling 999 and pleading for an ambulance.

It is not unusual to see elderly patients with broken hips or femurs, sustained in falls at home, who have lain for hours, hanging on grimly till help could arrive.

People now are queuing out of the door and along the pavement outside. There’s a freezing wind blowing in. Worse, it looks like rain is on the way.

In the queue, just inside the door, an elderly man collapses, probably from cardiac arrest. His wife is hysterical. I summon the crash team and perform CPR, or cardio-pulmonary resuscitation, while my team brings curtains to keep the onlookers from crowding around and afford this man a modicum of dignity.

12.05pm: I’ve managed to restore a heartbeat but the patient is very ill. He is lifted onto a trolley and rushed away. There was nothing more I could do, and I know I’m unlikely to be told whether he lived.

There’s a nasty atmosphere. People are muttering that it’s the doctors’ fault, that I should have seen him sooner, that his wife was telling everyone the man’s chest pains were getting worse. Someone shouts, ‘F–– ing useless! If he dies, you’re the one to blame!’ I pretend I haven’t heard.

12.35pm: A couple come running in with a child limp in the father’s arms. The little girl is conscious, with her eyes open, but too ill to make a sound. She can’t be more than three years old.

The parents are flapping and they don’t speak English. I call for a translator, as the mother tries to tell me in sign language how long her daughter has been sick.

My first thought is that this might be pneumonia as her oxygen levels are low, but I also know that there has been an outbreak of diphtheria, so we have to think about appropriate measures for infection control while looking after the family appropriately.

Diphtheria was eradicated in this country, but this year it’s back. Parents are terrified, and no wonder — it can kill.

There has been an outbreak of polio, too. A drop in vaccination uptake during the pandemic may have contributed to this. This makes it more difficult to reassure parents with poorly children, especially when they’ve been up all night Googling the symptoms.

Every childhood ailment can look fatal to an anxious mother.

2.10pm: A retired man with a lump under his arm tells me he’s been waiting to be seen since 7pm yesterday. He’s concerned that it might be cancer and is weak-kneed with relief when I tell him he merely has a cyst.

I suggest, perhaps a little brusquely, that he should have gone to see a GP. He explains that he did — he waited weeks for an online appointment but he couldn’t get his video-link to work properly.

Like half the people in the waiting area, he has also phoned the non-emergency 111 service, only to wait for a return call that didn’t happen for five hours — and then was told to see his GP.

He came to A&E because he was desperate. He thought he might be dying. He wasn’t, but I cannot criticise him.

3.25pm: A man bleeding from a head injury is shouting and swearing. Staff have asked him twice to pipe down but he’s frightening people. A father with a little boy tells him to mind his language, and it feels as though a fight might break out. Security have been called but we’re on our own at the moment.

The head wound looks superficial and I have more urgent cases, but this man has to be dealt with. He stinks of alcohol. He denies he’s been drinking, demands to be treated, says he is leaving, then says he has a blinding headache.

It might just be drunkenness — but he should have a CT scan to be sure. He refuses, and I’d love to send him away, if I could only be sure he was safe to leave. Instead, I waste time negotiating with him,

until he agrees to go for the scan. A security guard escorts him.

4pm: No, I haven’t had lunch. In fact, I don’t think I’ve taken a single lunch break in two years. I’d kill for a coffee but it’s better if I don’t. I’ll only end up needing a bathroom break and I can’t afford the time.

Medicine is my life. I came through the ranks in the days when junior doctors were routinely expected to work 100 hours a week. I did it and I never questioned it — but I could not have imagined the pace I’m working at now.

4.40pm: Oh, this is bad, and it’s something I just was not expecting. A quietly spoken woman says her five-year-old spilt her father’s mug of tea all over herself — but when I lift up the T-shirt, the burn is oblong with sharp corners and straight edges. It is also serious. The child needs immediate attention at the burns unit, which is off-site.

I tell the mother that this is not a splash burn. It has been caused by a hot, hard object and was apparently inflicted deliberately. Suddenly, the woman doesn’t speak English. A translator is called, as are social services.

The woman is pleading now. She has no idea what happened, she says, and she just wants to go home. But this is a safeguarding issue. We can’t send the child away to be abused again.

5.10pm: My shift is over... officially. Where did the hours go?

It’s been a blur. But there are still more than 40 people to be seen and several of them have been here longer than I have today. On top of that, one of my junior doctors has been throwing up and signed off.

There are rumours of a potential norovirus outbreak which can have huge ramifications, even causing a hospital to close. ‘Can you just stay an extra half-hour?’ says a colleague. ‘Please?’

5.15pm: Yet another patient tests positive for Covid. For a notifiable disease that’s supposedly on the wane, there’s a lot of it about. There are also many vulnerable people breathing the same air, including cancer patients on immuno-suppressant drugs. They are supposed to be seen quickly, thanks to their ‘fast-track cancer passport’. But in A&E, ‘fast-track’ is non-existent.

5.50pm: Another child with a nasty injury, another mother who needs a translator. This little boy crushed his hand four days ago, apparently in the hinge of a door at the immigration hotel. What can I do? If I send them back there, he could hurt himself again — but I already know there will be no other accommodation available.

The child has no broken bones and the mother swears she won’t let it happen again. I make a safeguarding referral, explaining the process through the translation line and, reluctantly, discharge them.

6.20pm: A pregnant woman is brought in by her partner. He answers every question for her, even the most personal ones. She says nothing. At first, I think she’s in pain, then I realise she’s in fear.

‘I want to speak to your wife alone,’ I tell the man, and he kicks off — she doesn’t speak English, he yells. One of my colleagues leads the woman away and directs her to the maternity unit while the man fumes and threatens in my face.

Though it’s only a few minutes, it feels like a very long time before security arrive and steer him outside. Now I’m not even sure the man was her partner.

Most of the information he gave us — names, addresses, etc — doesn’t ring true. I try to phone my colleague in maternity to suggest asking the woman whether she has been trafficked. The line is busy.

7.30pm: The same colleague who asked me to stay on is now suggesting firmly that I need to go home. ‘You need to eat,’ she says. And she’s right. The room is spinning, as it often does at the end of a shift.

8.50pm: I can’t switch off. One of my jobs is to draw up the rotas, and that means looking at the flowcharts, identifying the busiest parts of the day to make sure we’re fully staffed — or, when that’s not possible (like today) to redeploy the staff we have and cover the gaps.

These aren’t just numbers on the charts. They’re patients, people I tried to help today. But did I do the right thing for all of them? What about the old woman who was hungry — I should have checked her over for other symptoms. And I’d like to take another look at the X-rays on that boy’s crushed hand.

We know our hospitals are on life support. But nothing captures the crisis more vividly than this minute by minute account from a frontline doctor of just another day in a major casualty unit

12.05am: I’ve been asleep for less than an hour, when the phone goes. The A&E ward is overwhelmed. ‘We wouldn’t ask,’ explains the night doctor, ‘only no one else is answering, and of course you can take time off later, if you could only come in for another couple of hours. Now? Please?’

12.30am: I count 17 people who were waiting here when I left five hours ago, and ten more people — including a teenager who arrives, arms wrapped in kitchen paper and dripping with blood, at the same time as me. Her father found her in the kitchen, stabbing her skin with a broken ruler. She’s 15.

At first, she doesn’t want to talk. Then she tells me she can’t bear to go to sleep, because she has nightmares about her family dying. Cutting herself is a distraction. She says she wishes she was dead.

I ask if she thinks she would ever try to take her own life and she bursts into tears. It all spills out: she has swallowed every tablet she could find. She has poisoned herself. It should have been the first question I asked: ‘Have you taken anything?’ But then, she wasn’t communicative at first. I had to win her trust. Could I have done anything differently, done better? Yes, perhaps, if I hadn’t been so tired.

4am: I’m back in bed. I can’t sleep for thinking about that teenage girl hooked up to monitors. In the morning I’ll try to find out what happened to her, if she was OK. That will be the first thing I ask, when I arrive in three hours for the next shift.

Only, I know, I won’t have time to ask. As soon as I walk through the door, it will start all over again.

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2022-12-03T08:00:00.0000000Z

2022-12-03T08:00:00.0000000Z

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