This story is set in an A&E department. It’s based on stories reported in various newspapers in January 2017, although it is, of course, fictional. I am not an NHS worker. I am, however, someone with cause to be grateful for the excellent work of doctors, nurses and paramedics 24/7. I apologise in advance for any inaccuracies in the detail of this story.
I was just starting my shift when the paramedics wheeled in my gran; it took me a few seconds to remember that in fact she had died four years earlier. As we transferred the patient to one of our trolleys in Accident and Emergency, she wheezed, “Can I have a fag, love?” and then chuckled hoarsely before wincing.
“You are my gran!” I exclaimed. “You look just like her, and that’s exactly what she would have said!”
We wheeled her into an assessment bay. Doctor Springer, the consultant on our rapid assessment team, glanced at the paramedic’s notes, asked a few questions, quietly told me the tests he wanted doing, initialled my record form and left swiftly.
“He’s a looker, isn’t he?”
I smiled. He certainly was.
“What was your gran’s name, love?”
“Ivy. Sharp scratch now.” The patient jumped.
“Oh, I’m sorry; I didn’t mean to hurt you!”
“No, you didn’t, love. It’s just odd. I’m Ivy, too!”
“I’m afraid I’m going to have to wheel you out of this area into the corridor, Ivy. We’re terribly busy tonight.” On the way, I dropped the blood samples into the pathology lab box on the desk.
“That’s alright, love. You do what you need to. I suppose you couldn’t give me something for the pain in my side?”
I checked my record form. Doctor Springer hadn’t prescribed analgesia; but he hadn’t stated ‘nil by mouth’ either. Would a couple of paracetamol hurt? But there was no record of a pain in the side; Ivy had been admitted with shortness of breath and chest pain. I recorded the pain in her side on the record form.
“I’m afraid we’d better wait until Doctor Springer’s seen your test results. He may want to have another look at you. Sorry, Ivy.”
Just then, Doctor Springer walked quickly past, his face serious, heading towards Resus. He nodded at me to follow him. I gave a little wave to Ivy and chased after the consultant. A middle-aged man had suffered a cardiac arrest. He’d been a ‘walk-in’ patient, and usually they’re less seriously ill; not this time.
We used the defibrillator once. Twice. The third time I held my breath; it was probably his last chance.
The patient heaved up with the current. His heart monitor began to beep. Back from the brink…I passed Doctor Springer the man’s record form and he initialled it.
We’d only been in Resus for five minutes, but there were already two ambulance trolleys waiting for us. We processed the patients quickly. Both of them were basically okay – a bad asthma attack, and an elderly man who’d fallen in the street.
I looked up from the form I was checking.
“Can you chase Majors for bed-space, please? I’d like to move a couple of these trolleys, and when I asked Mark he told me to piss off. You’ve got more clout than I have.” Jonathan was our health care assistant; very useful, but a little lacking in assertiveness.
“I’ve already asked, Jon. That’s probably why Mark was rude. They have two patients due to go to the wards by four o’clock, but that depends on the wards’ patients being discharged.”
“So, fifty-fifty then?”
“Depends on whether they’ve got somewhere to go, Jon. You know that. Go and see if any of the patients would like a cuppa. And remember to check whether they’re ‘nil-by-mouth!'”
Two ambulances arrived together. There’d been a road accident. A rapid assessment team is supposed to eliminate triage. However, when you have simultaneous arrivals, you must have some way of prioritising who the consultant sees first. I grabbed the notes from the ambulance crews, glanced in at the patients. One of them was making a fuss; not surprising with a broken leg. The other was quiet, but had a head injury that could be serious. The head injury goes first.
Doctor Springer examined the patient quickly but thoroughly. “This patient needs a CT scan immediately”. I buzzed for a porter. No response. I stuck my head out of the cubicle; from the corner of my eye, I saw Ivy wave at me but I had to ignore her.
Good! There was a porter.
“Derek! Just in time! This patient must go immediately for a CT scan.”
“I’m supposed to be on reception.”
“I know that. This is urgent. Just do it, please.”
He looked daggers at me, and I can’t say I blamed him. It’s a very physical job, portering, and he was rushed off his feet. Still, the patient’s safety comes above everything else.
“Notes?” he reminded me. I was still clasping them. I slipped them into the wallet on the trolley.
“Ta, Derek.” I smiled at him as nicely as I could.
The patient with a broken leg was soon off to X-ray, and I had a moment or two to catch up. Ivy was waving at me again.
“Hello, Ivy. Did Jon get you a cuppa?”
“It’s this pain in my side, nurse. It’s worse.”
Ivy wasn’t looking too well, but her pulse was steady, and her blood oxygen was okay – adequate, but not great.
“I’ll tell the consultant at your review, when we receive the test results.”
The pace picked up. I literally didn’t have a moment free. Another two trolleys went into the corridor. Ivy had dozed off. Good. That would probably ease her discomfort.
The clock showed five to six as Neil, our manager, approached.
“Rosie. I’m stuck for cover tomorrow; Katy’s rung in sick.”
“But she’s on at six in the morning, isn’t she? I’m on at ten. If I do both, that’s a double stint on the rapid assessment team.”
“I know. I’m afraid there’s no-one else, and we’ve finished our department’s monthly budget for agency staff.”
“But it’s only the nineteenth!”
Neil nodded. “Even so, there’s no budget left, and that means no agency staff unless we have a black alert.”
“I’m not happy about it. It’s bad for patient safety.”
“If you can’t do it, Rosie, then we work without a Band 5 Nurse. I think that would compromise patient safety even more, don’t you?”
Why do I do this job? The bloody government exploits my goodwill.
“I haven’t said I won’t do it. I don’t let my patients down. But it’s your job to get us an adequate budget.”
“Rosie, we have a bigger slice of the hospital’s spend than most departments; it’s just not as big a budget as we’d all like. At least as a member of a rapid assessment team you’re not facing the possibility of seeing your department close.”
I grabbed a pizza on my way home. I’d been meaning to cook something nice, but that would take too long; I needed an early night ready for the six o’clock start.
It was dark when I rolled out of bed at five o’clock. Although I’d set the alarm, I hadn’t needed it and I’d turned it off when I was sure my concerns about the day had woken me beyond hope of another half hour’s sleep. My partner grunted, but didn’t stir.
When I arrived in the department, it was bedlam. Carolyn, the nurse I was relieving, just said, “It’s been hell”, thrust the notes into my hands and ran. Her mascara was streaked right down her cheeks. It must have been a really bad night.
The notes were a mess. Well, not a mess exactly, but obviously written by someone in a tearing hurry. I blessed the person who had designed the forms so that they were mostly tick boxes or numerical results, with a minimum of free text.
There were more trolleys in the corridor. Ivy was still there, asleep. I checked the stats of all the patients on trolleys; some of them had been there even longer than Ivy. Thank goodness there were no ambulances right now, which gave me time to review the notes. I noted that my record of Ivy’s pain in her side now had a question mark beside it in Doctor Springer’s handwriting. Gosh! He’d done two until six this morning after yesterday’s afternoon shift! That must have been tough.
By ten past six, everything was in full flow once again. It had been a cold night after rain, and people seemed to be slipping and sliding all over the place. We had three fractured wrists, a dislocated thumb and two broken ankles in the first hour, not to mention a postman who’d collapsed with chest pains on his round. At least we were able to send the fracture patients to X-ray so they didn’t add to the numbers on trolleys.
As I passed Ivy on her trolley, she looked up at me. “Nurse,” she begged, “can you please let me have something for the pain?” I stopped and looked at her. She seemed much worse. Her pulse rate was very high, and her blood oxygen low. I looked around for the consultant. Where the hell was he? I grabbed Chloe, the junior nurse. “We need the consultant. Fetch him now, whatever he’s doing!”
Ivy sat up, hand pressed to her left side, wailing, and then slumped back. Her pulse had gone. I glanced to make sure the sensor hadn’t detached, then hit the crash button. “Help me get her into Resus!”
Doctor Springer came up at a run. What on earth was he doing still here?
“Get the defibrillator. It’ll be too slow trying to extricate her trolley from this traffic jam.”
We had the defibrillator there within seconds, but it was no good. We’d lost her. Right there in the corridor. No privacy, no dignity, no peace. Poor Ivy. I couldn’t believe it. What had we missed? What had gone wrong?
Doctor Springer looked haunted. “Aneurysm. Damn. I thought it was a possibility. I was going to go back and check but I never had time. Damn, damn, damn. That’s one we shouldn’t have lost.”
Poor Ivy. I don’t usually cry when I’m on duty, but I wept for her.
Doctor Springer laid his hand on my shoulder, but said nothing. We both knew that she might have survived; we both knew that it wasn’t our fault that she’d died; there simply hadn’t been enough staff. And that didn’t make a blind bit of difference to how we felt
Some facts about the NHS
The King’s Fund reports quarterly on the performance of the NHS. This data is from their latest report:
- The target time for Ambulance Trusts to respond to Red 1 emergency calls is 8′. When this was introduced in June 2012, it was missed 24% of the time. This has now risen to 33% of the time.
- A&E Departments have a target that no-one should wait more than 4 hours from arrival to admission, or transfer, or discharge (as appropriate). During 2009 – 10 this was missed less than 2% of the time. It’s now being missed 10% of the time.
- The target for waiting time after diagnosis is that fewer than 8% of patients should wait longer than 18 weeks before the start of treatment. In 2012, this target was being met comfortably; fewer than 6% of patients waited longer than the target time. The latest report notes that the target has now been missed for ten consecutive months, and exceeds 10%.
You can find the data here.