Meet the real casualties

A car-crash victim is fighting for his life; a breast-cancer patient is waiting for pain relief; an anxious young man is getting abusive. And I've got to decide who to treat first, says Dr Catherine Blake

I am in A&E. It's the early hours of Saturday morning and I'm waiting on the phone, having paged the lab technician for the third time to try to get an urgent blood result for my patient, Jane. The department is windowless and strip-lighted, and the Government's four-hour wait target is in force. It could be any time of day in any A&E in the country.

I am in A&E. It's the early hours of Saturday morning and I'm waiting on the phone, having paged the lab technician for the third time to try to get an urgent blood result for my patient, Jane. The department is windowless and strip-lighted, and the Government's four-hour wait target is in force. It could be any time of day in any A&E in the country.

Jane has come to A&E feeling dreadful, with a very sore throat. She keeps apologising; she wouldn't have bothered us except that she has been prescribed a new tablet for her psoriasis and was warned that a sore throat could signal severe infection, because of the side effects of the medicine. So the blood test is crucial: either her white cell count will be normal, meaning that she just has flu and can go home, or it will be very low, indicating that her immune system has been suppressed and she will have to be admitted urgently.

Jane arrived in A&E three hours and 17 minutes ago, and the A&E super sister is on my back - am I going to refer her to the speciality team or send her home? She is going to breach the four-hour target. It depends on the blood result, I say.

That is clearly not good enough; the sister fetches the doctor senior to me, who insists that I refer the patient regardless - he will be held responsible for the list of patients who breach the target in the morning. So Jane, who waited three hours to see me, will have to wait hours more to see the specialist junior doctor before she knows whether she can go home. She looks pale and tired, but accepts this idiocy without complaint.

I have four other patients under my care. Mrs Moore, who is in severe pain and has metastatic breast cancer, still hasn't received the pain relief I prescribed for her an hour ago. I try to find the nurse responsible, but they are too busy to spare the two nurses required to get morphine out of the cupboard. I apologise to Mrs Moore, and my temper begins to feel frayed. I try to send Mr Burnstock, an alcoholic and a regular attender, home, but discover he still hasn't had his intravenous fluid because he has pulled his drip out. I gather together my equipment - two needles, alcohol wipes, saline flush, tourniquet and adhesive tape - and go back to put another cannula in his vein. "Fuck off," he says, clearly forgetting that he had called an ambulance to bring him here. "Why don't you people just leave me alone?" When I get the drip in, he yanks his arm away, showering me with blood.

I see another patient and sit down to write up my notes: 76-year-old man, retired civil servant, presents with three-day history of cough productive of green sputum, one-day history of rigors... Tess, an excellent A&E nurse, leans across the desk: "Can you just look at this ECG? He is in the waiting room." I want to know if the patient has chest pain. He does. "What is it like?" "He says it is central heavy pain."

I say he needs to be seen by a doctor, then, but this tracing of his heart, which means nothing in isolation as to whether he is having a heart attack, is relatively normal and there are six to be seen before him. No queue jumping; they have all to be seen in time order. So I have to sign the ECG to say it's all right, and therefore carry the can for whoever came up with this senseless protocol - when he collapses, nobody will sue the policy-makers.

I go back to trying to remember the history of my patient with pneumonia when a young man gets off his trolley and walks over to me: "When am I going to be seen?" he demands. As soon as possible, I assure him. "This is serious!" he shouts: "People are dying in here." My temper fails me for the first time in six months: "Yes, they are, but you are not."

And, before I can try to make up for my meanness, the trauma bleep goes off again, white noise muffling around the department, then: "TRAUMA CALL, TRAUMA CALL. TRAUMA TEAM TO A&E RESUS, ETA 3 MINUTES... TRAUMA CALL..."

Two young men are wheeled in on stretchers, and the ambulancewoman reads from her sheet: "Crashed into a lamp-post at about 60mph, passenger not wearing seatbelt ejected from the vehicle, conscious but combative at scene, obvious fracture right leg. Pulse 120, BP 100/60. Driver bull's-eyed windscreen, unresponsive on scene, other observations stable. Front of car destroyed."

We get to work. The driver has a severe head injury and has to be intubated and ventilated straight away; he's in danger of blocking his airway. The young man who was thrown out of the car is losing a critical amount of blood, and it can't all be coming from his broken leg. He's still talking and saying his stomach hurts. I manage to get two IV lines in and squeeze two litres of fluid into his veins, but his blood pressure's still falling. My registrar thinks he may have a ruptured spleen; the surgical registrar comes to take him to theatre for an emergency operation to stop the bleeding.

You'll notice that in the above two-hour period, I was only able to collect one new patient from the waiting room, and even that one hasn't had his blood tests or his chest X-ray, or any treatment yet. It is six in the morning and I haven't stopped, have had no coffee, nothing to eat and no time to go to the toilet since my shift started 10 hours ago. There are two doctors on the overnight shift, and my colleague John looks as bad as I feel.

Government targets mean that it must take no longer than four hours from your arrival as a patient at reception to leaving the A&E department, either to a ward or to go home. During this period, you are assessed by a nurse; a doctor takes your whole medical history, examines you and formulates a likely diagnosis; blood tests are sent and the results awaited (this can take at least two hours); X-rays are requested; and, if you need to be admitted, you are referred to a speciality team for further assessment and treatment before transfer to a ward.

For better or for worse, the target is generally being met - my seniors and the nurses are now much less likely to ask what is wrong with my patients than how quickly I am going to offload them. The pressure is constant.

The question everyone is now asking is: how can it possibly take more than four hours to see a patient and to find out what is wrong with them?

It is awful to be unwell and in pain, and it is enraging to be kept waiting, even when you feel physically well. Anybody who has sat there with a twisted ankle they can't walk on, or with an elderly relative they're worried about, knows that. The reasons that it takes so long are three-fold. First, the service is stretched to breaking point, both with genuine accidents and emergencies and by people with long-standing, less serious problems who ought really to have gone to their GP. Such as: "I fell over and hurt my hand three weeks ago and I want an X-ray," or: "I went to my GP about my piles, but it's going to take six weeks to see a specialist," or: "I have had this rash for a year, but it's not going away."

Even worse, there's a steady stream of ambulances carrying elderly demented people from private "care" homes. Nobody ever comes with them, and the ambulance sheet will say something like "constipated for two days" or "confused", and we have no way of knowing what the person is like in normal life. It takes days of research to establish that the patient never does know where they are or what their name is, and that there's nothing new wrong with them.

So A&E is where everybody comes when they are worried or don't know what else to do, which is a slightly broader remit than the title "accident and emergency" implies.

Secondly, as a doctor I spend most of my time doing things that do not require any medical expertise: phoning the lab repeatedly, photocopying notes for patients, collecting and analysing urine samples, wheeling patients to the X-ray department.

This problem is growing steadily as the Government pushes through with the gradual privatisation, casualisation and outsourcing of key support services. It's no longer the lab's responsibility that the blood samples didn't arrive in the chute, because the chute is the responsibility of a separate company. The printer is broken, but there is no one on site to fix it, although you can leave a message on the company's answerphone and someone might get back to you during office hours. There used to be four porters at night, but now there's only one.

And on it goes. It is the doctors and nurses - the only people who have actual responsibility for the patient - who have to compensate for this growing shortfall.

Third, because we have a duty of care, and because of the fear of legal action, everybody who attends A&E, no matter how trivial their complaint, has to have a thorough medical assessment, and that takes time - time that could have been spent seeing people who actually are unwell.

But there is a more worrying question, which is perhaps only obvious to people who work in A&E: does meeting the target reflect good patient care? It is certainly a good political target. With a general election looming, the Government has provided a clearly measurable outcome, which most voters can identify with, and which seems sensible.

But the constituency we, as doctors, are most concerned with is markedly different. The most unwell and most needy people tend to belong to groups less likely to vote: the elderly and infirm, the demented, the mentally ill, the homeless, alcoholics and drug addicts, people who don't speak English, young men who get shot and stabbed - in effect, the disenfranchised. It is those who are most sick and most in need of care and attention who are short-changed by this target, although it is a good deal for the "worried well".

Ill people who need to be admitted are moved to "cheat wards" around the corner from A&E, where they are technically no longer in the department and are therefore no longer a threat to performance data. In practice, this often means that people who are critically unwell and have not been given a definitive diagnosis nor started on treatment are moved, by management, away from a safe, monitored environment into a random bed or chair, where they can wait many hours without further medical intervention. Priorities in A&E, in my opinion, are moving dangerously away from treating patients and towards management "paper" targets, sometimes with fatal consequences.

Performance targets like this one are too narrow, and demonstrate a poor understanding of the nature of the challenge health professionals face. If we are serious about providing proper medical care, free to all in need, we need to invest in primary care and public education about what actually constitutes an emergency. We also need to halt the privatisation of NHS services - nothing is going to ruin an underfunded service faster than people taking money out of it as profit - and instead invest properly in clinical and dedicated support staff.

Failing all that, a friend suggested, we could install an enormous glass panel between the waiting area and the resuscitation room so that people with less serious ailments could see the steady stream of people being treated for heart attacks and life-threatening asthma, and people who have been pulped by a passing lorry or stabbed in the chest. It wouldn't solve the wait, but it would provide the public with a new perspective on it.

Catherine Blake is the pseudonym of a junior doctor working in A&E in an inner-city hospital

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