A Medic's Tale, page 23
Moral: the adage that would go with the above is ‘you can please some of the people all of the time, and you can please all of the people some of the time but you cannot please all of the people all of the time’. It is a futile task attempting to gain consensus on all the issues that present themselves to you and your co-workers. In trying to do so, an excessive amount of time and effort is wasted. Once again, the knowledge to recognise this fact and to steer people to common ground, where there is at least a fundamental agreement on the major and salient concerns, is often the best policy.
I am sure many readers have their own personal preference and thoughts on the matter. That of course emphasises the point that we are all different and have values and priorities that often conflict with our colleagues. To be able to overcome these obstacles and make progress is itself an art.
All of us will be too aware that society is regrettably becoming more and more litigious. This is consequently reflected in the cost of such cases to the NHS. Do not misconstrue me, there are times when it is right and just that situations where malpractice or harm has resulted. Then it is correct that some form of recompense is seen to be apportioned. It appears, almost inexorably, that it is spreading almost akin to an epidemic, as costs continuously spiral. The average medical practitioner can avow to this as the annual subscriptions to their respective defence bodies continues ever upward year by year. It may result in doctors (and now nurses as they to become involved more in these situations and find themselves being called to court to explain their actions) beginning to practise defensive medicine. This would assuredly be a sad reflection on our way of working. No disrespect to our American cousins, but it would be following in their footsteps. We know that there are practitioners who are guilty of malfeasance and deserve to be punished for their misdemeanours. Many of them seem to be what can only be described as utterly mercenary, simply practising for the monetary rewards. The media has recently deemed, it appears, that the medical profession is an easy target and deserving of the pillorying often reserved for less deserving factions of society. We cannot hide from the horrible cases of notoriety that have emerged in recent years. But we as a profession know, in our heart of hearts, that the majority are still worthy of the public’s respect and confidence. It must be remembered that respect must be earned, it is not simply dished out to all and sundry. The high regard with which doctors are held by their patients is a valuable commodity and must be cherished at all costs.
Recently there was a case of a patient who had presented to one of the MIUs – a minor injury unit – and, having been examined, was discharged. Some nine months on he went to his GP and stated his wrist was sore. He was referred to the local DGH where an X-ray was performed and a fracture of the scaphoid (bone of the wrist) was apparent. It was not healing as normal. This, I can imagine, brings a wry smile to many a face. He was then seen in the fracture clinic where a consultant said, “Oh, they missed your fracture.” It may be a somewhat unfair assumption when considering the time frame. But discussion on that is for another day. I do wish that such pronouncements from certain people would be better considered and remember my Latin teacher’s maxim, ‘silence is golden’. This proclamation really does not assist and being informed in retrospect is all very well. As you can appreciate, the flashing lights started to appear and subsequently a claim was brought by the patient. The usual review and statements from the individuals involved were perused. Independent experts were requested to give their pronouncements on the clinical and physical examination and treatment at the time. Interestingly, the two external experts’ opinions were at odds with each other. The first was a GP and the second a consultant orthopaedic surgeon. The former pronounced that certain procedures and actions should have been carried out. At variance to this was the orthopaedic consultant’s view which, by the way, totally concurred with my deliberations and a fellow hand surgeon on the subject. Despite this, the trust decided to pay out; apparently this is a cheaper option than going to court, it may have been a directive from the NHSLA. An article in the broadsheets has been addressing this topic. The NHS pays £100 million per annum for its apparent failures. An interesting observation in the statistics presented states that the number of successful misdiagnosis claims increased by nearly 80% in the last five years. Doubtless the sum quoted above is now woefully out of date.
Having worked at what is eponymously referred to as ‘the coalface’ for many years (for the uninitiated that is casualty or accident and emergency), one is not in the best position to receive numerous letters of thanks. Since that work is often instantaneous and as sometimes happens the results are utterly devastating for a family when a member die. Usually as a result of either trauma or a medical condition, the obvious pathology resulting in a cardiac arrest. The person has often been well before leaving home or their work and a sudden catastrophic terminal episode occurs despite the efforts of all involved. The family appear hoping and trusting for the best. Then the doctor arrives and must impart the terrible news they do not wish to hear. As the consultant in the department in charge of the trauma team, I considered it my duty and role to personally speak to the relatives. Not an enviable position but despite this the family have often, in my own experience, thanked me for my time and for coming to talk to them. Often, we would retire for a while and return to talk again and provide any assistance or possible comfort regarding their departed. This is a most humbling experience and I cannot contemplate many other professions that are placed in such a sad but dignified position. Having, in my latter years, gone back to running clinics as well as direct clinical contact, I have been most fortunate to receive letters and words of gratitude from patients. This is somewhat surprising as I am involved in minor procedures and consultations compared to many of my fellow workers who have far more detailed and important matters to deal with daily. I am convinced they receive similar and more effusive thanks for their endeavours and this continues to once more demonstrate that the public retain a special place for the medical profession. The corollary is that we continue to respect the individual’s dignity and privacy in terms of their contact and relationship with us.
18
Jottings Past, Present, Future
Sometimes matters that have transpired many years ago come back to visit you and can either be quite reassuring or on occasion be a jolting reminder of the weaknesses of the human body. Recently I received an e-mail, with an attachment, showing pictures of a young man obviously in a foreign land. He was holding an animal in his arms and appeared to be in a caged area. Fairly soon I recalled who this was even though I had not seen him in years. The memory of his tragic situation came flooding back. At the time of the incident, he was a young lad at college and it had been his birthday. It apparently was decided by his fellow school mates to celebrate this auspicious occasion by giving him the mandatory bumps. As fate would have it, this happened to be in a room with a wooden floor. Regrettably, on one of his excursions through the air, control was lost of his upper body and he fell to the ground, hitting his head. He was rendered unconscious for a brief period and was transferred to the A & E department. There he was seen by an SHO who considered, noting he appeared to have recovered his faculties, there was no apparent major problem or cause for concern. Thankfully, he wisely admitted him to the wards for observations. This, you need to be aware, was many years ago before the stricter guidelines regarding head injuries that now prevail.
Yours truly was on call and received a phone call later that evening as there was concern regarding this young man. I, as on numerous previous occasions, leapt into my car and raced to the hospital. This was never the easiest as, at that time, I did not possess a blue light for emergencies. Attempting to weave through the traffic quickly but safely was a distinctly hazardous process. On arrival at the ward and with a quick review, it was painfully obvious he had deteriorated. Urgent action was required to enable him to be reassessed and supportive treatment immediately instigated. To facilitate this, transfer to the emergency department was expedited. To make the situation worse, he started to fit. I had, on the way in, called my radiology colleagues as I had deemed a CAT scan would be required. I wanted them to be there and have the scan working and ready to go. They were somewhat reluctant, probably understandable, to do this until I directly saw the patient. My anaesthetic colleagues were bleeped urgently for their support and input to the continued care of this chap. He required intubation. This, as you may understand, takes some time as various drugs and equipment are assembled.
Soon after, a CAT scan revealed a rather large extradural bleed (blood clot pressing on the brain) and he was rapidly transferred to the regional neurological centre where a craniotomy was immediately performed. He made a reasonable recovery from this but there were some sequelae in the form of seizures and a degree of cognitive/behavioural affects. This case is not presented for any gratuitous or salacious reason. It is a salutary reminder of the constant need to be alert and reminds one of the ever-present dangers regarding the apparent simple cases that come into our departments. They should and do prey on your conscience. There is always the harbinger of doubt and fear, what did we do wrong? What could have been performed or assessed better? Is this my fault? These thoughts do not easily disappear, nor indeed should they but act as a timely reminder of the dangerous path that we sometimes tread. It is often mooted by colleagues, ‘There for the grace of God go I’. We are all open to such manifest complications and the unfortunate physical disabilities that the patient may suffer. Theirs can tragically be a lifetime of challenge and impairment in one form or another.
After the events of this, a case was brought against the hospital and one can understandably appreciate the reasons and motives for the family in following such an avenue. People, quite understandably, wish for answers and to determine if anything went wrong or necessitates adjustment to the system. As many of you are aware, when these sad and distressing circumstances enter the legal arena, it can become a protracted and all-consuming situation. In due course, I was directed to attend the Inns of Court in London. There I was ushered into a large basement room with an equally enormous, magnificent craftsman’s oak table. It was dark brown, beautifully polished and measured enough to take six adults either side with consummate ease. It is funny what you remember of such events. Certainly, this encounter is not easily dismissed from my consciousness. A few moments later a group of austere people entered the room. I was seated, on one side, I believe, with some form of legal representation from the hospital and opposite me a trio of my peers, consultants in emergency medicine. They were not personally known to me but one or two of their names, when introduced, did awaken an awareness that they were well respected in their field.
At the top end of this splendid piece of decorative furniture was seated a senior barrister who had a scribe noting every word and possible nuance that subsequently transpired. The whole of the events relating to that specific evening were clinically dissected in a painstaking manner, almost second by second. I do not know if any of those reading this can appreciate the degree of angst and stomach turning that occurs as a procedure, not unlike the inquisition, is unravelled with you as the main protagonist. Even though you are sure of your professionalism, truth and sincerity, in this claustrophobic atmosphere you begin to have doubts and uncertainty crawls into your psyche. The meeting lasted what seemed an inexorable time and my fellow consultants were asked, quizzed and queried about every detail and action that had transpired. The result of the deliberations was that I had acted correctly and just as they would have done under similar circumstances. This was reassuring but did not release me from the knowledge of the poor young man and his ongoing dilemma.
From time to time, one peruses the various journals that cross my desk and the ever-present British Medical Journal with the hope of enlightenment. Sad to say and largely on my account, I find the latter, as a rule, not very stimulating with regards to the clinical content. But as I browsed through a particular edition of the BMJ and its accompanying tabloid the BMA (British Medical Association) News, read there two articles with similar points of view. The topic being discussed related to the abuse and excessive consumption of alcohol by the public at large and its disproportionate effect on emergency departments and their staff. I would suggest that, alas, many doctors and nurses are directly aware of this all too familiar problem and the occupational hazards it presents. An excessive number of staff have been at the receiving end of verbal and physical abuse from people that attend, having imbibed in excess of the falling-down liquid.
My own experience would bear that out. How often did one have the sheer privilege of an inebriated idiot – sorry, patient – spout forth with words not apparently contained within the normal Oxford thesaurus? They would harangue you and inform you that you were some form of moron and in some instances what they intended to perpetrate upon other unfortunates when they had left the confines of the department. Certainly, one of the cases was a tour de force, a chap so paralytic from attending a wedding reception that he decided to drink his own urine. One hopes to a degree that it was sterile and not infected. Doubtless it would, in time, transit through his kidneys once more and find its way back from whence it had come. I realise that public water is recycled. I was once informed that the domestic supply in London has been passed through the system, if you forgive the crude pun, at least seven times. I doubt if even it could be as offensive as this fellow’s tipple. Each to their own, I suppose. Let me not bore you further with my sad juvenile tales.
Sanguinely, it would be foolish not to emphasise the devastating effect this, if I may refer to it as an epidemic, has on all spheres of society. My colleagues in surgery and medicine know all too well the deleterious physical damage that it produces. Huge resources are spent both on treating the initial insult when they come to the hospital and subsequently the fallout in terms of pathology, requiring some form of intervention. This does not even begin to assess the terrible, tragic social and family disruptions that ensue. We all know there is an increase in domestic violence and drunken brawls with the attendant physical injuries. Added to this the enormous financial resources required from the police initially to intervene and subsequently the input from NHS and other public services. Then the damage often caused to cars and other property compounds the issue. Sadly, there can be a downward spiral with families broken, marriage separation and job loss. In time, the perpetrator slips further down the slippery slope to oblivion. Like litigation, these problems are ever increasing.
One of the articles was reflecting a journalist’s night in an emergency department. He appeared genuinely surprised at the number of drunken people in the hospital presenting themselves or being deposited by friends at the doorstep. In many other instances, they were brought in via ambulance or escorted by the constabulary. The staff carried on as usual and reflected to the reporter that this was not unusual but a regular occurrence. The salient fact that it was not just an aberration at the weekend but a daily happening. Many of the staff are frequently at the receiving end of antisocial behaviour that they take in their stride. Some may consider that I am being a killjoy. May I state I have no objection to someone having a drink and socialising in a reasonable manner, even a bit of fun or horseplay, without offending people is acceptable. But what should not be tolerated is this flood of unacceptable behaviour frequently directed at anyone, let alone professionals who are doing their best to aid and help such people.
I would consider it right and proper that these reprobates be financially penalised for the damage and inconvenience caused. Consider if a member of your family urgently needed a frontline ambulance and none were available because they were acting as a taxi for someone found outside the local nightclub in a drunken paralytic state. This problem needs to be addressed, as it is not just the immediate impact but, as stated, the longer and chronic consequences of such behaviour that ensues. This inevitably produces a social, environmental and financial detriment to the whole of society. Certainly, in an ever-stretched NHS where funding is critical, it becomes an issue requiring deliberation and drastic solutions. Remember it results in a heavy toll on our fabric as a so-called civilised society. There is of course the extra, unwanted strain on the medical workforce that is totally unwarranted.
The second article was written about Dr Samuel Johnson (1709–1784), English poet, critic and lexicographer, who, for information, has a plethora of quotations in The Oxford Dictionary of Quotations. I am obliged to the writer of this noteworthy piece, TD and trust that he is not wronged if I plagiarise, in any way, his excellent notes. Dr Johnson was a gentleman who, despite having been ascribed various ailments, lived to a reasonable age, particularly considering the era in which he lived. He was a religious man and struggled, as many do, to understand how an infinitely wise, powerful, knowing and benevolent God could permit such suffering in the world. In tackling such a question, he wrote:
In making an estimate, therefore, of the miseries that arise from the disorders of the body, we must consider how many diseases proceed from our own laziness, intemperance, or negligence; how many the vices or follies of our ancestors have transmitted to us; and beware of imputing to God, the consequences of luxury, riot, and debauchery. There are, indeed, distempers which no caution can secure us from, and which appear to be more immediately the strokes of heaven; but these are not of the most painful or lingering kind; they are for the most part acute and violent and quickly terminate, either in recovery or death; and it is always to be remembered that nothing but wickedness makes death an evil.
