Surprisingly, I think I’ve managed to avoid being in a&e late on a Saturday night, despite all my hospital admissions! It’s a very odd place! I’ve never seen so many policemen, people in handcuffs, passed out people with IV fluids…
Anyway, I’d been having really painful ribs for a couple of weeks which got massively worse on Saturday. I didn’t really know what it was, it turns out I know now that I’ve sprained my ribs/intercostal muscles, and to use the phrase my husband uses for every pain he has, ‘it was the worst pain I’ve ever had’! I couldn’t move at all without being in agony on Saturday, breathing got so bad at one point that I was basically hyperventilating just trying to breathe because my ribs would only expand a fraction. Then I got my ‘I could be in trouble’ feeling I get when my adrenal insufficiency causes me problems at about 1am so I eventually called an ambulance.
The ambulance crew came and said I might have fractured a rib. It’s usually left down to me in these situations as to whether I want my IV hydrocortisone or not. I really wasn’t keen on having my emergency injection because my endo has me on a reducing taper plan and having 100mg would ‘ruin’ that. But then the paramedic rephrased it slightly differently and said ‘what’s worrying you more right now: being ill because of your adrenal insufficiency or ruining your taper plan?’. Being ill was more of a concern, so the tech she was training gave me my HC IM so he could get that competency signed off. I also had some pain relief which didn’t really touch it. Surprisingly all my obs were pretty normal, so that wasn’t much help! In the ambulance, I could hear her explaining to the third crew member about how adrenal insufficiency can be hard to diagnose and hard to treat and she got it all spot on. I was pretty impressed because most HCPs usually only know the medical side in an emergency, not the complexities of managing it day to day and the issues we face.
A&E was busy. Ambulance triage was empty but there were a lot of people waiting in beds in the corridor. I definitely wasn’t having an adrenal crisis, so I was low priority. While I was waiting in the corridor, my lovely nurse appeared with some IV HC. So I said I’d already had some and she went to check with the doctor who said I needed to have it. This is a good thing because a) they knew adrenal insufficiency requires monitoring b) I’m supposed to have IV HC fast on arrival to hospital, but I usually end up fighting for it c) judging by how insistent they were, they’ve finally listened to my complaints through PALs and have a protocol/pathway in place. Hooray! Another 100mg was possibly overkill, but it definitely helped with my pain so maybe I did need that much after all.
The thing about being in a corridor is you hear everything. There’s no privacy at all. Obviously no one gets examined in the corridor, but everyone can hear your conversations, what medications you’re being given, your name and date of birth which you have to confirm before being given the meds, what your obs are… If you need to complain or ask questions, it’s very public. And you’re more likely to have people ‘joining in’ with your discussions. Particularly if they’re drunk. You definitely can’t sleep, and you’re pretty much right in the middle of chaos so it makes the whole experience a lot more stressful. You don’t have a call button so the only way you can ask someone something is if you grab them as they walk past, but quite often you’re told that someone else is assigned to you and get forgotten about. The corridors aren’t wide enough for that level of activity and beds, so your bed gets bashed quite a lot, which is disconcerting anyway but every bump was agony for me. If you’ve got a friend or relative with you, they can’t wait with you because there’s no space, and god only knows what happens if you need the toilet and can’t get off the bed…
One of the things we found a bit frustrating was that there was space for patients in cubicles, but they didn’t have the staff available to deal with it. It was busy, but it wasn’t the busiest I’ve ever seen it. They’d actually closed down most of one section of minors because there weren’t enough nurses and doctors. Most of the nurses were agency nurses rather than ones employed by the hospital.
Eventually I was put in a cubicle and then had to wait a long time for the doctor. The department gets fined for breaches (starting at 4 hours)- you can usually tell when the clock is getting close to a breach because you’re suddenly given a lot of attention quickly, and shoved out the door, if they can get rid of you, or admitted. The longer you’re there, the bigger the fine.
I don’t have an issue waiting if I’m not critical. But I knew I was going to have a problem at 7am when I was due my oral dose of hydrocortisone. I had some with me, but, as I hadn’t seen the doctor yet, I didn’t want to use it if I didn’t have to because if I was getting admitted, I’d potentially need it on the ward. At least in a&e they’re more likely to get stuff quicker.
You can only take meds which have been charted by a doctor, and the doctor can only chart it if they’ve reviewed you or your file. This is what usually happens when I’ve been given IV and I want oral hydrocortisone:
– I push the buzzer and ask the HCA for my oral dose. She can’t just go to the doc, she has to go to the nurse, who can then go to the doc
– the doc looks at my chart and thinks ‘she had some at 3.30am, she doesn’t need anymore until 9.30am because she’ll be covered by it til then
– This gets filtered via the HCA back to me. I send them back again and say it doesn’t work like that, can I speak to the doc or at least the nurse
– HCA comes back and says no. I wait a bit and then start the whole process again.
– eventually, someone will get significantly fed up of me asking the same question that they’ll come and talk to me, usually with the attitude of telling me how wrong I am. Or they’ll start to ignore me, in which case I go stand next to the nurses station until someone has to listen to me.
– then I’ll get told it’s not that time sensitive and it doesn’t matter if I take it a bit late. Again, it doesn’t work like that.
At this point, I usually run through my rationale calmly:
– HC is time sensitive. It doesn’t matter how much you tell me it’s not, it is time sensitive, and I can die from wrong dosing. If a doc hasn’t reviewed me, it’s even more important that my doses are on time, because you don’t actually have a definitive idea of what’s going on yet.
– an IV might ‘cover’ me, but it’s supposed to be in addition to my normal baseline in emergent situations, not instead of. I still need my baseline.
– if I have an oral dose later because of the IV, that’ll push my other doses back. So my 7am dose at 9.30 would mean my 11.30 dose would have to move etc. That messes up my circadian rhythm, which will mean a longer recovery time. But giving me my dose on time won’t do me any harm at all.
– there won’t be any oral hydrocortisone in the department so regardless of how much I want it on time, it’ll be late anyway because someone will have to hunt some down. Which is why I usually leave an hour to start this process off.
– The other problem I knew I was going to have is that handover from night to day shift would be happening around the time I needed my meds, which meant I really didn’t stand a chance in getting them on time if I didn’t get it sorted before.
My nurse was on break when I started this whole drama, but when she came back, I told her all of the above, which she understood completely. The problem is, people assume you just want bumped up the queue because you’re impatient, whereas actually, I just wanted the doc to chart my meds so the nurse could give them to me. I didn’t mind waiting longer, I just didn’t want to die before he got down his list! And, on a Saturday night, everyone has short tempers and low tolerance for people moaning, which isn’t fair to people like me who are genuine.
The doc (apparently) got fed up of listening to my nurse and the matron pestering him about me and my hc, so marched down to give me a lecture about why I don’t need any oral Hc. He got a polite lecture back. And because everything I ‘predicted’ had happened, right down to not having any hc in the department, the nurses were very firmly on my side by this point. The doc had been querying kidney stones up until this point but then told me I had an infection instead, which means double steroids and even more need to have it at the right time. After trying to write up prednislone (big no) instead and trying to tell me again that it didn’t matter what time I had it, I ignored the doctor and me and the nurse negotiated 25mg IV HC which would be an almost equivalent of my oral dose.
I never used to be so persistent with asking for my meds at the right time because I didn’t want to bother people. But you actually have to be like that because otherwise your care can really suffer. It’s like a game of Chinese whispers, and I have no guarantee that the person who answers my buzzer actually goes and asks the person who can deal with my request. And, when it’s busy and understaffed, things get missed or forgotten about.
I was all set to go with my antibiotics when the doc comes back and tells me my lactate is high and I need a bolus of fluids before I can leave. He’d already given me my blood results and had said they were all fine, so something must have been niggling him. The nurse hangs the fluids and I have about half the bag when the doc reappears and says that the consultant says I’m fine and don’t need them so can go home.
Again, this is all based on numbers on my chart. Numbers are good indicators, but for me they don’t necessarily work. I’ve had blood work that says I should probably be in a coma or close to it and have felt pretty alright in the past, or vice versa. I didn’t argue the point because I actually felt ok. However, this is where short staffing has its pitfalls- numbers on a chart shouldn’t replace actually looking at the patient. You get a lot more from sticking your head around the door and seeing how sprightly someone looks than just going off numbers.
It was a bit annoying that a lot of the people in a&e that night had ‘self inflicted’, alcohol related illness or injuries. The NHS is free, but because it’s free, there’s absolutely no reason for people to actually think about the consequences of their actions and take responsibility. We happened to leave at the same time as a couple of drunk students and their friends who accompanied them, and they seemed to have found the whole experience almost like a rite of passage and part of being a student.
So my weekend was a bit more eventful than I’d planned. And a&e on a Saturday night isn’t fun. At least it wasn’t a full moon too!