Hospitals versus Patients

By SUSAN CATLING HAVE you ever been run over by a bus, or had acute appendicitis after 6 p.m.? If you have, and have lived to tell the tale I expect you share my feeling that Enoch Powell might well employ himself in doing something for those unhappy persons who happen to be taken to hospital as emergency cases

I was one; and I received the routine treat- ment for emergency cases. At 6.15 p.m., what had been a severe stomach ache suddenly turned into pain remarkably like that experienced in the final stage of childbirth—only I wasn't pregnant. At 6.45 my GP arrived, examined me, and said he believed my appendix had ruptured. He rang for an ambulance, and then rang the hospital nearest my home to ask for my immediate adniis- s'on, informing the hospital of his diagnosis.

At 7.15 the ambulance drivers appeared and with considerable skill transferred me into some kind of stretcher which they got down the steep, winding stairs between my bedroom and my font door (I observed that if pain is bad enough, one literally cannot move, even a hind). I was driven to the hospital, brought in, and laid on a bed-table in the admissions room.

From then on, I am vague about the time; 1 was not always conscious. But I was aware of voices on the other side of the partition discussing the patients who had apparently been brought in ahead of me. I wondered when my turn would come. I hoped it would be soon.

When it came, I was questioned and externally examined by the sister. She said I seemed to have acute appendicitis, and went away.

In time, the houseman arrived. He questioned me and examined me. He said I seemed to have acute appendicitis, and went away.

In time, the registrar arrived. He questioned me and examined me. He said \ it was his view that I did not have appendicitis, acute or other- wise. He thought it would be a good thing if I was X-rayed. He added that it would take a little while to get the X-ray department functioning, as everyone there had gone home. He went away.

After what seemed to be a particularly long period of time, I remember the efforts of some- one to hold me vertical while an X-ray was taken. I was then carried into a ward and undressed by the nurses. I asked what time it was. It was 1.30 a.m.; I had been in the hospital for six hours.

Some time after that the registrar reappeared and said that when the theatre was free he intended operating to see just what was the matter with me. I was asked to write my name on a piece of paper saying the surgeon had my permission to do what he thought necessary. As he had mentioned that he thought the difficulty might be with my ovaries, I refused to sign the paper until he assured me that if that particular suspicion proved correct, he would not do any- thing drastic without first discussing the matter with me or a member of my family. I signed the paper.

When I last asked the time, the answer was two o'clock. After that I was preoccupied with swallowing a tube into my stomach. Some time after that, I was anaesthetised. Later on Saturday 1 came out of the anms- thesia. Besides the tube in my stomach, there was another one which fed into my wrist. I learned that my appendix had been removed Peritonitis was far advanced

My experience suggests that something must be done so that patients brought in emergency into British hospitals are seen by a specialist and treated without delay. While appendicitis can often bear delay, many other things can't. Quick and correct diagnosis is obviously essential To have specialists on duty in the emergency ward can be achieved without appreciable added costs to the taxpayer. It can be done by scrapping the casualty departments in eight out of (en hos- pitals and organising efficiently the casualty services in the remaining two to provide a twenty-four-hour service.

At the moment, it is the rare hospital which has a consultant in charge of its casualty depart- ment. In most, there is no one in charge This means there is no one to report to a higher ad- ministrative authority on ways to improve the service. It also means that the junior doctors are working without adequate supervision If the young housemen are worried about an emergency case, they can telephone the home of a senior consultant. But they are reluctant to do so: they do not want to lose face. This can result in a patient's being very much more ill than is neces- sary; it can sometimes result in his dying quite unnecessarily.

There will be a certain emotional resistance to any changes. Most hospitals in Britain are be tween thirty and a hundred years old. Each one is part of a community. People in that corn munity are accustomed to goihg to the casualty department of their hospital when a finger has been cut, or a pin swallowed. And if you closed all those departments, the people in those areas would suffer. But there is no need to scrap them completely; they can be left for minor emergen cies, instead of trying to be prepared--,-or rather, half-prepared—for major casualties.

As the regulations now stand, the ambulance must take you to the nearest hospital—even though that hospital's casualty department i tucked away in what used to be store cupboards, its equipment out-of-date, its X-ray departmen t closed, and the junior doctor on general ward duty not immediately available.

Less vital, but not altogether inconsequential, is the indifference of hospitals to the emotional condition of ward patients (I say hospitals, be cause most of the nurses within them do a fin job). Why, for example, can't all hospitals pro vide a tiny, post-operative room for patients coming out of anaesthesia? It would require no equipment; it would need only enough floor space to park the trolley the patient is on. Because the fact is, many patients scream while coming out of anaesthesia. Is it really necessary to bring that patient directly back to a ward and put her in a bed amen people desperately sick and frightened already?

And if it should be a child who requires a tube in her stomach after surgery, must she be brought back and put into a bed next to another frightened child while the houseman tries, some- times taking more than an hour, to get the tube into her? The wretched little girl will be no worse off in a post-operative cubicle, and the other sick patients would be considerably better off if they didn't have to listen for an hour to the little creature pleading, then screaming, and finally hopelessly whimpering.

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Because I had been an 'after 6' emergency, the consultant surgeon had not performed the initial operation. He wasn't around. As it was a Friday night, he wasn't around until three days later. On seeing me, he asked the registrar how long the 'drip' tube had been feeding into my wrist and was told about sixty hours. He directed that the tube be taken out immediately. He added that he only liked the 'drip' kept going in his patients for twelve hours at a time. When it was removed, the nurse pointed out that one reason it had become increasingly painful was because a clot had formed in my hand.

Was it, I wondered, at all odd that the registrar had not already been informed of the consultant's views? The registrar used linen thread for my in- side stitches, and when I was sent home a fort- night later, the wound came open again with ab- scesses. During the next five weeks, the district nurses probed my stomach daily and extracted linen stitches. But they didn't get them all out. I had to go back to the hospital's casualty depart- ment one morning to ask the consultant surgeon what he could do about locating the rest of the stitches which remained some- where inside me.

The surgeon said I must keep my hands by my sides and lie absolutely still if he was to do his job properly. He gave me no pain-killer of any kind, local or otherwise. He recommenced the cutting. I protested. This time I had had enough.

The surgeon wasn't pleased. He explained to me that I must choose between three things: doing nothing and having the abscessing continue for another year, letting him probe the wound and find the remaining stitches and get them out, go back into hospital the next day and be given an anaesthetic while he opened me up again.

I took the third choice. Also, I decided to have him do it in a private nursing home; possibly because while I was lying on my side on the casualty table, my eye was caught by the appear- ance of the floor. It seemed to move. Then I saw it was not the floor, but small, partly white, partly translucent bugs with lots of little legs that were walking about on the floor beneath my operating table. Anyway. I decided to ask the same surgeon to perform the operation in a private nursing home.

He did. And he did a good job. And I dare say he might have done a good job on the table in the casualty department. But what struck me as interesting was that if a private patient should be given a heavy anesthetic, doesn't this suggest that the operation was sufficiently painful for the same patient, when public, to be given some kind of relief?