Drunks in high heels, idiocy of 111 operators: what it's REALLY like to be a doctor in A&amp;E By Dr Dan Sefton Dan Sefton, 42, has been an emergency doctor on the NHS frontline for ten years. He has used his experience to write scripts for the TV medical shows Casualty and Holby City. In this candid despatch, he describes what it is really like to work in one of the most high-pressurised jobs in the health service at one of the busiest times of the year - and the truth is more dramatic and revealing than any soap... Dr Dan Sefton has seen it all as an A&E doctor BOXING DAY: All is calm... and then the masses descend Nobody wants to work on Christmas Day - that's a fact. But if you work in A&E, it has its benefits. Because for one day only we see just two categories of patients - accidents and emergencies. Everybody else stays at home. Boxing Day, however, is a different matter. This is when thousands descend on A&Es nationwide - perhaps after a short trip to the sales - as if their life depended on it. Of course, for some it really does. That's what we are here for. But the bald fact is that many don't need to be here. And the more patients we have to see, the less time we have to see them. For the most seriously ill, that is a real concern. My first patient illustrates this conundrum to comic effect. He's a dad with a sore head. No, he didn't drink too much: a toy-laden shelf fell on him. Sensibly, he's rung the NHS's new "non-emergency" 111 line for advice. Ridiculously, the teenage call handler who answered him - or rather, the computer program she works from - advises a trip to A&E. DIY Dad duly obliges - after all, the NHS has said he should go! When I tell him he's fine and there was really no need for him to come in, he gets a little angry with the system. I can't blame him. 111 was meant to reduce the numbers of minor injuries and illnesses turning up at A&E, but if it has, this department hasn't noticed. If anything, we are seeing more. Contemplation over: I'm needed to help with a "resus." A patient is brought in who's suffered an unexpected cardiac arrest. Despite the high stakes, the atmosphere is calm and measured - as it should be. We get a pulse back. The family is elated; the medical staff more guarded. Not everyone makes a full recovery, despite what you see on the telly. No matter how much the public would like a 24-hour service, people have to realise the NHS has limited manpower The resuscitation has taken time and manpower, and now queues have built up in "minors" - those waiting to be seen for minor ailments. It's a three-hour wait. Tempers are fraying; the nurses and receptionists bear the brunt of it. What these patients don't see, thanks to the design of the department, is the ambulances coming in. They don't see the grandpa with suspected intestinal bleeding or the grandma who's just had a stroke. All they see is a queue that doesn't move. It can sometimes be hard to tell if a patient is a genuine emergency or not. One patient frequently attends with chest pain, concerned that it might be a heart attack. He has had heart problems in the past, so it would be unwise to ignore him. But every time we test his blood for tell-tale signs, the results come back normal - so far at least. Of course, we have to be very careful. Some people seem to have no idea of the cost of the "free" treatment they receive in A&E. A couple of "routine" blood tests, an X-ray and the time of a doctor and nurse, and you're instantly talking hundreds of pounds. Perhaps we should show them an invoice so they can see how much it all costs? Not that I'm advocating that patients pay, of course, but I can't help thinking it would help people realise what it actually costs. The hours pass and we finally get on top of the queues. No matter how much the public would like a 24-hour service, people have to realise the NHS has limited manpower. Tired staff make mistakes. Airlines recognise this; medicine needs to. Sadly, too few people realise that our jobs are made ten times harder by having to deal with "noise." Recruitment of A&E doctors is an ongoing problem, and the crisis is worsening. Half the vacancies across the country are going unfilled, stretching staff further and further Of course, many patients come to A&E because they don't know if there's something seriously wrong or not. But I'm afraid some people exaggerate their symptoms, "crying wolf" to legitimise their trip to A&E. All this makes the process of quickly sifting through to find patients who are genuinely, seriously ill, much more tricky. The sheer weight of numbers makes matters difficult too. It might not be obvious but when it's really busy, attendances that could be dealt with elsewhere might put at risk patients who really need us. FRIDAY: A stroke, the drinkers - and a boy who's eaten a cracker toy Recruitment of A&E doctors is an ongoing problem, and the crisis is worsening I decide to go to work on my motorbike, or my "donor-bike" as colleagues call it. I like the freedom, but I've got to say some nights I ride home more carefully than others, if I know there aren't many senior doctors on shift. As I arrive, six ambulances are queuing out front. It's going to be a busy one. The peaks and troughs of A&E are one of the major challenges. Matching staffing to attendances is almost impossible - some days you just have to work harder and faster - which increases the likelihood of errors and long waits for minor injuries. As predicted, the department is heaving and the "majors box" is already overflowing. Every cubicle is full and we're having trouble moving patients to other parts of the hospital. It's a high-risk situation - a major trauma now and we'll find it hard to cope. I get to work on shifting the medical patients. My first patient has had a stroke, and cannot speak or move his right arm or leg. His grandson clasps his hand and clearly feels as helpless as I do. I ask the patient to raise his left hand and to his grandson's surprise, he obeys instantly. I address him directly and tell him that I know he can understand me perfectly. One in five patients who turn up to A&E is there because of alcohol, for one reason or another. At Christmas, the number's even higher A two-year-old has swallowed the toy from a Christmas cracker. He's heading for admission until he coughs it up into his mother's lap. Time for a break. It's 2.40pm and the only food left in the canteen is a portion of cold chips, some beans or a baked potato. I gamble on the chips. After a brief stint in majors treating a confused elderly patient, it's back to minors where the inevitable dental pains of Christmas cheer are rolling in. I head into the consultation ready-armed with sympathy, strong painkillers and an explanation that I'm not a dentist and can't actually fill their teeth. 'Returners can be awkward as they are often demanding and 'unhappy Alcohol seems to be a pretty consistent factor in many admissions. At this time of year, the number's even higher. Mr J has collapsed after play-fighting with a friend. He tells me he's "only" had six cans today. I check him over and let him go with advice to try and cut down a bit. Next door is Mr J's ghost of Christmas future - a middle-aged man who has just had two seizures related to alcohol. It's the first time this has happened so his friend is very concerned, desperate for someone to do something. I listen to the tale. He used to be heavily overweight and cut down on food but seems to have compensated by drinking more. These cases are always hugely complex - an iceberg of emotion and pain. I stick to practicalities - advising him not to stop drinking yet, warning him about ongoing liver damage, referring him to our local alcohol service. I'll write to the GP, but ultimately his fate is in his own hands. Saturday: A woman has a microscopic thumb cut. I give her a plaster My shift begins with two patients who are classic examples of what you might call "health and safety" attendances. First up, a colleague who's pricked his finger on a needle. These "needlestick injuries" can be serious - if it has been used on a patient. But this one was still sterile when the colleague jabbed himself. Health hazard: Alcohol, high spirits and high heels lead to many of the problems dealt with in A&E He knows this but his manager has sent him down so I can fill in the obligatory incident form. Next up is a woman who's sustained a microscopic thumb cut at work. Her boss has sent her down "just to get it checked out." She's concerned about how well it will heal. I show her the tip of my own little finger - recently similarly injured in a tragic present-wrapping accident. She appears unconvinced as I hand her the kind of sticking plaster found in any standard first aid kit. Then - heralded by a tirade of abuse and the unmistakable stench of excrement and cider from a cubicle - it's one of our "frequent fliers," a regular patient in other words. My colleague immediately recognises his name. "I've seen him more often this week than my own family," he says. Sensing compassion fatigue, I take the patient card. 'The problem is, it's a dirty job with unsociable hours' As a white male doctor I'm usually treated to exaggerated, over-familiar deference, but other staff aren't so lucky. While in the department the man's mood swings wildly between verbal aggression and tearful self-pity. But he is in genuine pain, so I administer some intravenous morphine before an X-ray. It confirms a dislocated hip and I recruit a colleague to help me put it back. I sedate the patient with some more drugs, which you need to be particularly careful about with people who have been drinking. As long as this patient keeps complaining, I'm happy. Back in "minors," I deal with a young man who has returned to A&E after falling on Christmas Eve. Then he was diagnosed with a sprained ankle after an X-ray and I can see no reason why my colleagues would have got it wrong. Returners can be awkward as they are often demanding and "unhappy." Our policy is for a senior doctor to review such cases - today that means me. I double check the X-ray- no fracture that I can see - and prepare my most diplomatic face. However, he's apologetic to be here again, has clearly got a very nasty sprain and is concerned he can't get back to his bar job tonight. Matching staffing to attendances is almost impossible - some days you just have to work harder and faster - which increases the likelihood of errors and long waits for minor injuries With the help of a diagram I explain why he's still in such pain. It seems to work and he hobbles off with some extra strong painkillers. I expect he'll be at work tonight, no matter how much it hurts. My next patient, back in majors, is a woman who started drinking five years ago when her husband died. She's now going through detox. She's here because her psychiatrist is concerned about persistent abdominal pain. I press her tummy and get a wince. Blood tests show her danger signs have been on the rise for days - but nobody seems to have noticed, so she ends up in A&E on a Saturday night. Organising tests and scans at the weekend can be difficult - it would have been far easier to deal with if her problems had been flagged earlier by her doctors. I get a bad feeling about her and manage to engineer an urgent out-of-hours CT scan. It looks normal so her pain remains a mystery - probably "just" a urinary infection - but I refer her to surgery anyway. One thing I've learned: if you don't know what's going on, don't send people home - bed crisis or no bed crisis. A quiet moment in minors and I talk to a colleague whose background makes him ideal for A&E, but he's training to be a GP. Half the vacancies across the country are going unfilled, stretching staff further and further. The problem is, it's a dirty job with unsociable hours. It's also not as well paid as other medical specialities because there's no scope for private work. It might not be obvious but when it¿s really busy, attendances that could be dealt with elsewhere might put at risk patients who really need us Back in majors the emergency "Bat Phone" goes, and I take details from an ambulance crew about a man who's had a stroke. Their ETA is five minutes. The ambulance arrives and I'm told the man's symptoms started over four hours ago so it's too late to use any "clot-busting" drugs. However his speech is already improving so there's a fair chance he'll do well. I take a history and ask if he has any help at home? He nods - a housekeeper, chauffeur, gardener and a butler. Drinker or duke? . . . we see everyone here. I head home - cold beer and Ashes highlights await. New Year's Eve: Tipsy 'Fooshers' and why I love fracture manipulation New Year's Eve brings the fatal combination of high winds, high spirits and high heels. As the evening drags on, it seems like everybody is FOOSHING - medical jargon for "Fall On Out Stretched Hand." If you're on heels you have an extra six inches to fall and it seems that tonight this makes the crucial difference between dirty knees and a trip to A&E. The usual result is a wrist fracture. Most of these can be easily fixed in the department but each case swallows time and both man and woman-power. Luckily most of the Fooshers are still tipsy so the procedure is good humoured and carried out with minimal analgesia. I must admit I love a bit of fracture manipulation and plastering - it's generally fairly easy to get a decent result and everybody (including the patient) feels the general satisfaction of a job well done. Inevitably, alcohol begins to dominate almost every presentation. And police officers stand by to restrain the worst cases. I don't mind if people get drunk but they have to accept the consequences if that leads to an A&E attendance: someone else might not get treated as quickly as they need to. And if you're going to get drunk and fall over, at least try and be nice and say thank you when we patch you up. The firefight continues into the early hours, then abruptly drops off.As quickly as it all started, it's over. The ambulances stop coming and, as dawn breaks, an uneasy calm settles. It's New Year's Day - traditionally a quiet one - and it's raining hard too. The department exhales. Here's a breather, at least. These are the personal experiences, insights and opinions of Dr Sefton who works in Taunton. Confidentiality has been respected by changing non-medical details to prevent individual patients or their families being identified.