Westminster Hospital

London Newspaper Group — CN/WPN 23-11-1979

BEHIND THOSE WHITE SWING DOORS

CHRISTOPHER LONG spends an evening with Westminster Hospital's hard-pressed but cheerful casualty department...

By Christopher Long

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If ever I have to get knocked down by a passing bus I do hope it happens somewhere near the Westminster Hospital – and preferably in the evening. After spending six happy and fascinating hours in the company of nursing and medical staff at the Westminster's Accident & Emergency Department, I shall be instructing the ambulance men to take me nowhere else.

My evening started at 6.00 when Nursing Officer Miss Milwood took me along to meet A & E's sister-in-charge, Maggie Carr. Sister Carr had kindly agreed to allow me to see what goes on in one of central London's busiest casualty departments. From her bright, cheerful and very welcoming appearance, it was hard to believe that she had already been on duty since midday and that there were still another three and a half hours before she went off duty and was replaced by a night sister.

Already, all six casualty cubicles were full, each with a patient on a trolley, while another four 'walking wounded' were patiently waiting for examination and treatment in smaller cubicles opposite.

Sister Carr's nursing staff of two trained nurses and the doctor on duty and his two assistants were busy coping with the evening's arrivals.

"Let me show you round the place first of all," Sister Carr suggested after she had checked in the latest casualty – an old lady with a cut and bleeding nose who had fallen down some steps at Victoria Station.

"Basically, as you can see, the unit is a long wide corridor with cubicles down each side. At the far end we've got a small theatre where we can do less serious emergency operations; next to that there's a staff rest-room, store cupboards, a room we use for drug addicts, a sterile supplies store, an excellent X-ray theatre, loos and a bathroom.

"Running parallel with the main unit is the resuscitation unit where we deal with cardiac arrests and things like that, while down here, near the entrance, we've got our desks, telephones, records and all that sort of thing"

Dashing off to check on patients, Sister Carr left me alone for a moment to contemplate the fact that this is a place that never closes. Twenty-four hours a day, staff are here. Nobody knows who or what is going to come in next and there is a curious atmosphere of excitement and anticipation, despite the relaxed and competent behaviour of the staff.

Coming back to join me, Sister Carr explained that the major problem on this particular evening was that there were no beds available in Westminster Hospital itself for anyone who needed to be admitted.

"The last male bed has just been allocated to the man in cubicle C. He's suffering from a chest complaint. He's been examined and we've decided that he ought to be admitted.

"So that means that we'll probably have to find beds in other London hospitals for any other patients that need to be admitted – unless we hear that someone's been discharged this evening and a bed becomes available here."

Already, she explained, an elderly gentleman in cubicle A had been waiting since before lunch. He was basically a geriatric case and after ringing round all over the place, a bed had eventually been found for him at St Mary Abbots, but it had been difficult to lay on transport in a hurry.

"Poor old chap! We've given him lunch, tea and supper, and he's still waiting patiently."

The problem, it seems, is not so much what to do with patients when they come into casualty, but what to do with them afterwards.

"If there's an 'exit' blockage – nowhere to send people after we've seen to them – then we're stuck with them here, taking up valuable space and staff time," Sister Carr explained.

It's a bit like Russian roulette, she agreed. When you have a bed available somewhere, you decide who's to get it on the priorities at the time. But if you get a more serious case a quarter of an hour later, you can't chuck the first one out. You have to set about finding a new solution.

Whether this shortage of beds, particularly for geriatric and psychiatric cases, is the result of cuts in health expenditure, Sister Carr is not certain. Indeed, she scarcely has time to concern herself with financial politics.

All through our conversations she was dashing off to check prescriptions, sign forms, examine new patients as they came in, chaperone doctors as they saw female patients, help the nurses with the endless linen changes, make lists of the personal belongings of patients as they were undressed, cope with difficult patients and... and... and...

Next to the elderly man waiting to go to St. Mary Abbots was a young woman in cubicle 8. She had arrived in an ambulance after taking a drug overdose.

Having had her stomach pumped, been examined by the doctors and left to regain consciousness, doctors were anxious to talk to her when she came round. Which she was now doing – with a vengeance.

"You're in casualty at Westminster Hospital," a staff nurse told the over-dosed patient. "You've been taking too many pills, haven't you? No, you can't get up – you'll have to stay here until a doctor's seen you again. What pills were you taking?"

The patient, it seemed, couldn't remember taking an overdose. She was almost a regular at the hospital, however, with three previous admissions to A & E at the Westminster this year alone.

"Of course, she may well have been admitted to other hospitals in the past, too," Sister Carr explained.

"We normally expect to get several OD's (overdose victims) in an evening. Typically they're young women in their teens or early twenties who are just trying to attract attention after boy-friend problems, although we get quite a lot of men and women in their forties, fifties and sixties as well."

"The older ones are usually more serious and make a better job of it – which can be tricky. The important thing is to find out what they've taken as soon as possible and the ambulancemen are very good at looking for signs of what the pills might be when they pick the patients up."

While she was talking a senior registrar cardiologist arrived to examine the OD patient and, having advised the doctors on duty, recommended that she should be transferred to All Saints Hospital, south of the river, which is the psychiatric out-post serving the Westminster Hospital.

Transport was arranged and the patient took up a lot of nursing time as staff tried to persuade her to stay put and wait for an ambulance.

Meanwhile, news had come through that a patient had been discharged from a bed in the hospital, which meant there was at least one bed free for a casualty needing admission. Sister Carr was clearly relieved.

Shortly before I arrived, a man had been brought in by ambulance after he had fallen from a ladder and suffered multiple injuries. He had been thoroughly checked over by the doctors and was already receiving treatment for his fractured wrist in the A & E theatre when I arrived.

A radiologist had been called to take X-rays of his neck, arms and wrist after he complained that he had lost all sensation in his left arm. Further X-rays were now being taken and it was clear that he would immediately have to be allocated that one free bed.

"Of course, it's quiet tonight. I expected that when I heard you were coming! I hoped we might be able to offer you a really busy night, but it never is when you've got someone here watching!

"I think a lot of the appeal, though, is the people you meet and the people you're working with. And I love working out priorities and solving problems – which is what most of it's all about."

Sister Carr has been a nurse for 10 years. She's been a sister at the Westminster for nearly five years and has a particular interest in multiple injuries. So much so that she spent a short period at the Royal Victoria Hospital in Northern Ireland, which is famed for its expertise in treating multiple-injury cases caused in the 'troubles'.

Taking me round the unit. she showed me the small, cell-like security room where up to four drug addicts at a time can be 'dealt with'.

"There's not a lot we can do with them. We search them, do whatever we have to, lock them in for the night, and they usually just walk out of here in the morning. They're very pathetic, but the numbers are increasing still, I think, even though last winter killed off a lot of them."

Round her waist, the Sister in charge caries a bunch of keys. She is the only person with access to dangerous drugs and is responsible for them. With the nightly batch of addicts due any time that night, it was understandable why the keys are firmly attached to her person.

"Back to square one," Sister Carr pointed out ruefully. "Once again no more beds!"

The injured man was left to await transfer in cubicle D.

Next door in cubicle C was the man with the chest complaint, while in cubicle E, on the other side, was a young woman who had come in with a urinary tract infection.

Normally, in a busy day (what was this if it was not a busy day?), A & E would not have time or space to deal with a problem like this, but it had been decided to examine her and treat her if possible.

"Frankly it's not an emergency really," a doctor told me. "She could just as easily have gone to her GP."

But would she have found a GP prepared to see her, one wondered? She was a foreigner and casualty departments are increasingly becoming the only port in a storm for overseas visitors and local residents who either can't find a doctor or who are often automatically sent to casualty departments if they do find a GP in the first place.

A similar case was a girl in the next cubicle along, cubicle F, who had come in with a painful abscess on her upper arm. It too could not come strictly under the category of 'emergency', but although it could have been dealt with as a small operation in out-patients, Sister Carr and her doctors had decided to treat the girl.

The abscess was drained; she was left to recover; and like the girl with the urinary infection next door, she later left with antibiotics, comforting advice from the nurses and with a problem solved.

But even these apparently minor cases involve endless work. A strict routine must be followed in each case. New bedlinen and trays laid out on the beds, by the staff-nurses or young pupil-nurses; the new patient checked-in, notes and personal details recorded on cards, belongings checked; examinations made by Sister Carr, the doctor, and, if necessary, by a specialist called down to give his opinion.

Then come all the preparations for treatment, providing sterile instruments, dressings, drugs, etc...

All this and more, for nearly every one of the 50 or 60 cases that can come in for treatment on an average night – the 100 or more who might be seen in a full day.

For a moment there's a welcome lull in activity. The little old lady who fell down the stairs at Victoria Station has been sent home with reassurances that nothing too serious has happened to her. The four 'walking wounded' (mostly cuts, bites, bruises, and sprains) have been and gone, while the OD in cubicle B is, to everyone's relief, having a quiet spell.

Having reassured a young West Indian girl with a gynaecological problem that she won't have to wait too much longer for transport, Sister Carr is able to turn her mind to other matters. Like supper, for example.

Her decorative staff nurse, Lavinia, takes an order for shepherd's pie which she'll bring back on a paper plate. One plate for Sister and one for me – to be eaten whenever there's a five-minute break.

Time off doesn't figure large in A & E departments, she says. Already one doctor has stayed on for an extra hour and a half in order to deal with a patient and help out a colleague. Having started work at 9.00 in the morning, he didn't get away till 8.00 that evening.

Why do nurses like her go in for a job like this?

"Oh, being in the front line! The excitement of it sometimes! I like the responsibility and the stimulation you get. Also, I like working under stress. It is interesting and exciting not knowing what's coming next."

With more patients drifting in throughout the evening (including a Dutchman who collapsed in a restaurant with a suspected heart complaint, a nun who had damaged her foot and a pregnant woman with 'gynae' problems), in the back of everyone's mind was "Will we get a cardiac arrest tonight?".

In the large resuscitation unit next door, everything is in a permanent state of readiness for such an emergency. With often only four minutes warning, cases can sometimes arrive as often as two or three times a day.

Everything is switched on and ready. Large scissors are ready, too, in case clothing needs to be cut off the patient in a hurry.

Everything that might possibly be needed is close at hand, and everybody knows, or should know, exactly what they have to do when the siren goes off to announce the ultimate emergency.

There is even a kit of equipment that allows a flying team to rush to the patient outside the hospital if necessary. A slightly sinister room, it's nevertheless impressive to see the constant state of preparation.

Many patients are not successfully resuscitated, of course. The ones who are justify it all.

By this time, looking at my watch, it was amazing to see that only an hour and a half had gone by. There was still another two hours before the doctors and nurses clocked-off and were replaced by the night team at 9.30 who would be on duty until 8.00 the following morning.

Transport was eventually arranged for the old man who had been waiting so long. The OD discharged herself from the hospital against the advice of doctors and nurses alike.

The nun and the Dutchman went home, feeling better, and they were the only two out of all the evening's patients who thought to say thank you – "They reckon they've paid their stamps so why should they thank us," Sister Carr observed.

More patients were arriving all the time. The barmaid who was struck in the face by another woman was not seriously hurt, it was decided, while doctors were rather more concerned about the 41-year-lady who was pregnant and having internal problems. She was seen by a specialist and told to rest for a while.

Now the first of the night team were arriving and there was a good deal of banter and medico-wit as the flow of patients eased up temporarily.

Sister Carr was fixing up a game of squash with a friend. A young Welsh doctor arrived to take over for the night, telling me that he is soon going off to the Antarctic as medical officer of a survey team there.

Another very attractive and competent-looking Sister, Julia Rickards, arrives to take over from Sister Carr and is filled in on the current situation.

A policeman rings up to find out about a lady who was hit by falling scaffolding earlier in the day, while doctors and nurses tell each other unrepeatable stories about the antics of unusual and eccentric patients.

Soon, the early evening shift has left and the night starts with the new team. Casualties continue to arrive with the strange combination of the ritual preparation and work for the nurses, and the infinite variety of patients, problems, personalities and peculiarities.

Westminster Hospital's Accident and Emergency Department is an impressive place. No doubt it has its faults and its quota of dissatisfied customers. But in six hours there I found it hard to spot them.

Perhaps there were a few patients who seemed to be waiting for inordinately long periods before they were transported elsewhere. Perhaps, too, the place seemed understaffed at times so that nurses didn't always have the time they might have liked to spend with patients, reassuring them or comforting them.

But I came away feeling that it will be a massive tragedy if poor pay, cuts and rationalisations are ever allowed to damage any further the excellent, friendly and very competent service that Westminster's A & E Department is offering.

How sad that only two people, out of all those who came and went while I was there, bothered to say thank you to the people who'd looked after them.

A young man found dead in a lavatory, surrounded by syringes, will not be able to say thank-you. Shortly after I left, Sister Rickards and her team spent 20 minutes trying to resuscitate him, without success.

Thousands of local people and others, though, have a lot to thank these hard-working, dedicated and very cheerful teams for.

NOW... Where's that bus?

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