Tuesday, 4 January 2011

Poor Child.

Hospitals need to bring back old fashioned Matrons to kick some ass and knock certain people into line.  And I am not talking about Nurses and Doctors.

What happens when:

Hospitals cut back on staff and beds when demand is increasing?

What happens when wards are full of patients who cannot be discharged for social reasons thus slowing down the flow through A&E?

What happens when drug seekers/ addicts and people with minor illnesses are overwhelming A&E's and demanding urgent attention?

What happens when Nurses and Doctors cannot even triage and assess really sick patients properly because of out of control drunks smashing the place up (a constant thing in A&E) and patients arriving with chronic back pain harassing the staff and making ridiculous demand after ridiculous demand? 

What happens when a family brings great grandma into A&E for abdo pain and by the time they complete all of her tests it is 0200 AM.  The tests show that she is fine and can go home.  Just has wind. There are no beds in the hospital anyway and A&E is backed up with critically ill people waiting to be seen.   But all this family can do is piss and moan about how unfair it is to send their medically stable  and precious grandma home at 2AM and they demand she stays the night in the A&E cubicle.  Then granny makes demand after demand overnight, expecting to be waited on because she is elderly thus stopping the staff from assessing, triaging, and dealing with the potentially critically ill people. 

It is an accident and emergency department for christ sakes!! It is not a place for you to go because you ran out of pain meds for your bad knee or you feel nauseous and your GP is closed. ARGHHHHH. 

It is not a place for your elderly relative to get babysat because she is too precious to have to deal with being discharged and driven home at 2AM and you really don't want to deal with her anyway. 

It is not a place to go for a pregnancy test and then scream the place down because you are not getting seen to first (duh, the damn things are £5.99 at Boots).

 It is not a place for you to go for a morphine fix and stab yourself in the finger and drip the blood in your urine so that we think you have kidney stones.  It is not the place to go because you have been constipated for 2 days.  It is not a place to go because you are mad at your GP for not giving you antibiotics for your viral cold.   It is not a place to throw a temper tantrum because things are not going your way.  It is not the place you should go to demand junk food and snacks from a Nurse that is running around trying to hang blood and implement docs orders for the critically ill.  Especially if you walked yourself into the place.

Oh yes we are SO sorry that the patient with chest pain and shortness of breath was taken in first despite the fact that he came in after you and your sore thumb.  Eye roll.

ER's and A&E's are so overwhelmed with this kind of SHIT that they cannot function.  When the hell are we going to get over this "customer service" crap and start being strict hospitals again where matrons demand that the patients and visitors compose themselves and follow some rules?  If you are not as sick as the others you are not first priority!  Let me tell you what happens when the public abuses the ER's of the United States and the A&E's of the UK.

This happens. 

Important things get missed.  Really sick people wait to long.  The quiet patients who complain the least are usually sicker than the fat twat who walked himself into A&E with a "stomach ache"  demanding a chocolate bar and some Pepsi..
Poor little thing.  It was an extremely rare illness that strikes quickly and is easily missed with all the coughs, colds and flu out there. But I would think that if she had urgent attention she might have been luckier.  Why didn't a sick child like her get immediate attention?  Because of Emergency room abusers.  This dying little girls father had to fight his way past hordes of drunks and ER abusers to get his kid seen. He was right to shout loudly. Had he not done, the staff never would have heard him over the tantrums and moaning of the people who merely have minor illness and the rowdy drunks trashing the place and beating up on staff.

Five hours she waited.  Five hours of the Nurses and doctors dealing with drunks, and people with minor illnesses who think they are entitled to be seen first and then scream the place down.

If you have ever worked in A&E, you'll know what I mean.  If you haven't worked in A&E you will probably not have a clue...


GrumpyRN said...

In UK we have a 4 hour target for 98% of patients to be seen and discharged/admitted so this kind of thing should not happen here. The worst thing (in my opinion) is RCN and Cameron trying to remove the target or make it 95%.
If the target is removed I forsee a day when we will return to 8-10 hour waits for minor problems and things will get delayed.

GrumpyRN said...
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Nurse Anne said...

Grumpy...a child with this problem might get sent home and not seen to at all because of the 4 hour targets.

4 hours would still have been too long for a child this ill to wait.

Anonymous said...

As an SHO who due to good old fashioned bad rota luck has ended up doing 10 months of A&E straight I'd just like to endorse Nurse Anne's observations and add the fact that if I had to spend any more months working ridiculous shifts at unholy hours being polite to people who really don't need to be there I would seriously have to change jobs.

A classical case over christmas was little old lady, not actually unwell, playing up her family, who demanded a cup of tea from me once I'd finished with her. I politely explained there were another dozen or so patients waiting to be seen, that I'd pass her request on to her nurse but I couldn't promise anything as everyone was very busy. Her daughter became apoplectic - "since when have you been too good to make tea? And I bet you've have a drink". My internal response was since when were A&E doctors in the middle of a busy shift expected to make patients tea, and a bitter reflection that yet again I hadn't drank anything for 10 hrs....

Full respect to the A&E nurses/drs who manage this shit year-in, year-out.

Rant over.

Nurse Anne said...

I also have had patients and relatives telling me how inhuman I am for not making a drink for them.....when I have been 10 or 15 hours without a drink!!

Yeah hats off to ED and A&E staff. Especially in large cities.

GrumpyRN said...

I disagree, a sick child should be picked up regardless of targets. This child had a temperature of 103F or 39.4C, this is sick regardless and the triage nurse should know it. But yes, shit happens.
Targets are being blamed for poor care but A&E departments need to ensure that 4 hours is a hospital target not just an A&E target.

Anonymous, I am hugely impressed with the junior doctors who go through our department. The ones we have had over the past year have been a joy to work with. Annoying really, I like to have at least one I can moan about.
I always try to ensure that staff (nursing and especially junior medical)get a break, you are no use to anyone if you are dehydrated or hungry and the patients will still be there when you get back. Don't let the crap put you off, A&E can be great fun.

GrumpyRN said...
This comment has been removed by the author.
Nurse Anne said...

I don't know if it would have got picked up at my A&E Grumpy. Our department has been left with one RN and 1 HCA staffing 10 cubicles and the resus room. People have died in the cubicles and it has gone undetected because the nurse was with a patient in resus.

I am not kidding.

Nurse Anne said...

and they didn't have a triage nurse....that is the receptionist LOL.

Nurse Anne said...

and no I am not at stafford.

Dino-nurse said...

Target driven culture is what drove me from A&E in the first place. Whilst it works well for a certain group of patients (Fractured neck of femur, chest pain,those who go straight to resus), it is inadequate for those with an unconfirmed diagnosis, as they get shipped to the hellholes that are admissions units. Having patients treat you like shit is also soul destroying. In the US county EDs that I worked in, we had 24 hour armed security to toss out the drunks and those who were only there to cause trouble. Here we have glorified porters who get given a day or conflict resolution training.
Also, having the bed managers ranting about ED about to breach on an hourly basis doesn't really make for a good working environment. How can you discharge patients home when social services provisions are so scant? We often have no beds in the ICU because we have wardable patients who have nowhere to go. The genius that thought up "care in the community" and closing down the remaining community/convalescent hospitals wants shooting.

Sue said...

As an AAU worker, we are hoping that the 4 hour wait does get removed. We can not care for patients because we're being screamed at by bed management to "get the next one in before they breech". We're forced to ward people who need to stay on AAU (where the on-call doctors are based and the nursing ratio is 8:1, much better than 18:1 on the wards), we are forced to take people for overnight observation who could have stayed in A&E to sleep off their alcohol. That means we have to move someone at 4am to let them in.

The 4 hour target isn't working. Nor wa sit working when we had no target, so who knows what the answer is? But using AAU as a conveyor belt is wrong, especially when the bed manager calls the porters to come and take a patient, without telling any staff, and they go to the ward on a bedpan, with no decent handover and the RN doesn't even know they have gone and has to trek all the way to the ward to a) recover the bedpan and b) give a handover and c) hang the medication they were drawing up when the porters arrived.

Sue said...

Anne, it is shocking that your A&E has just ONE RN. And now I know you don't work at our trust! We have our faults (I could name the trust and you'd know it!) but we do have reasonable staffing in A&E, theatres, paeds, and the admissions units. The ward staffing sucks.

BTW, seems like The daily mail is on a crusade to improve midwifery staffing! Why do they slag off general nursing but highlight the issues in maternity!


Nurse Anne said...

We don't always have only one nurse in A&E. But it has happened enough times to be remarked upon.

I was going to do a post about that daily mail article. Why the hell are they backing up midwives when ward RN's are in a worse conditions with short staffing increased demand etc?

I don't hear them touting the midwives as to posh to care yet the midwives are all degree nurses.

Do you guys know that the fucking CQC has been in repeatedly and all that they fucking care about is if the damn paperwork is filled in?

Nursing Student said...

I would go back to A&E if I felt by in large it had changed but I doubt in the next 2/3 years it will. A&E Nurses and HCA's around the country are burning out. A&E's have turned into hellholes.

Woe betide anyone who comes into A&E, stretcher or otherwise with a strange condition/without diagnosis. You will end up in MAU. Everything else can be dealt with quickly and all benefit from the 4hr target but most do not.

Then you have the problem of patients coming in using A&E as an out of hours GP. Well you'd better have your best pillow in the car because the waiting room chairs are hard and cold and you're due for a long wait for those suspicious and mild flu-like symptoms, sir.

Then you have the problem with patients full stop. I was on a shift one evening and I was informed whilst helping glue up some drunks hairline that there was a toddler in the waiting area who's just come in and I needed to go get her, Emma our registrar went for her first pee break in 8 hours (she was pregnant!) I enter the waiting area and the little girl is grizzly with a big fever so I grab the little girl and the babysitter goes to ring the rents. As I am carrying this little girl into the department a drunken monster bounces infront of me and demands that someone see her drunk son IMMEDIATLY because he has cut above his eyebrow that needs stitching immediatly as he as an "aspiring model"... and by a plastic surgeon. LOL what? The cut was nothing. I said her son will have to wait, for now. She then stands right infront of me between the door and says if I don't take her son in right now I will be the one needing plastic surgery. I asked the woman politely to move as I needed to really get this little girl in and she told me to fuck off. In a moment of frustration I move the woman out of the way myself GENTLY with my free arm and go right through and the woman is left by herself to kick and scream about how I had assaulted her when all I did was move her out of the way. Thankfully the whole incident was caught on CCTV and I litterally moved her to the side to get through but I had all kinds of fucked up managers down my throat the next day about how I shoulden't touch relatives particually if they are aggresive but they could not for one minute see the situation I was in. I had an innocent child in my arms who was esentially my responsibility because her parents were not there, a drunken abusive woman standing infront of me blocking my path and screaming in my face potentially threatening not just me but the child in my arms. I did what I did and I got a written warning about it.

No promises to increse safety, just a lecture saying that nurses and HCA's shouldent "put themselves" in these kinds of situations, nobody saying I perhaps did the right thing, not for myself but the child. Nothing. A few weeks later the written warning arrived, and the morning I did my dad who had been police officer for 30 years told me to quit. He thought it was ridiculous that the NHS teaches us to get out of violence and aggresive behaviour by talking to people or whatever. Some people cannot be dealt with verablly, I shoulden't have a lecture for defending myself and that child. I put my notice in the next day.

If they cut the 4hr targets I will never go back, period. If they don't open up more minor injury units, I will never go back, period. If they don't put more of those drunk wagons out into the cities I will never EVER go back, period. Whilst they might be a drain on the ambulance service they are invaluable to A&E and not enough of them are out there. Finally, if they don't get security staff into A&E units and hospitals, particually at night, not only will I not go back to an A&E unit I will not think twice about defending myself in the future. I shoulden't have to have my life threatened in my place of work. I'd do it again in a heartbeat!

Sue said...

CQC blow. They slammed us for not "spending time sitting to talk to patients", amongst other things.

I've had it with the NHS and want to quit before it sucks any more of my soul. I go home crying after every shift because I know damn well that one day the patient that is neglected will most likely be my mother. It breaks my heart. I will now never do my nurses training, unless by some miracle of good luck I can afford to do it in Australia or the US.

Sue said...

@nursing student- that is crazy! We have security in our hospital. They sit in A&E of a night unless they get a call to somewhere else. We also have a panic button to the police station, they can be there in 2 minutes. Usually there is at least 1 PC there with a drunk, anyway.

I'm beginning to think our f'd up hospital is one of the better ones, and that is scary!

Nurse Anne said...

Nursing Student that is typical.

They blame you for the aggressive behaviour.

I have seen Nurse's asked what they have done to deserve it when a drunk came out of nowhere and punched them in the back of the head.

Management says "don't antagonise them".

The thing is that management has never dealt with these people so they don't realise. No excuse though.

You bring up an interesting subject about CCTV. If anyone wants CCTV with audio in the hospital it is Nurses. My colleagues and I want it in every room, at every Nurse's station etc. Maybe if we had that someone might get a clue.

We have overworked porters that double as our security. They resent getting paged because we are being attacked. I could tell you a story about that but you would never believe me.

Nurse Anne said...

I was so looking forward to the CQC coming in and sorting us out.

They only cared about whether or not morse scores were filled in on the paperwork.

I asked my ward sister how can this be? And she replied "they have no medical or nursing experience so they don't have a clue".


Nurse Anne said...

Oh and Sue I have also experienced bed managers transporting patients (who were on bedpans etc) and not safe to go anywhere off the ward without my knowledge or consent. This was done to get patients off of the admissions unit and avoid patients breaching in A&E.

uknurse said...

I work in A&E and if you were to remove all the patients that didn't need to be there (GP conditions, drunks, time-wasters etc) then the standard of care for the really sick people would be amazing (as it should be).

Unfortunately, in my area, people do not know that an Out Of Hours GP service exists (although this too is for urgent cases which cannot wait til surgery next opens).

When they pitch up in A&E at 2am with a 3 week old itchy spot, or on saturday afternoon with a runny nose, they tend to say...'well,y'know, I thought I better come down an get checked out and the docs is shut today so....SO I THOUGHT I'D COME AND SLOW DOWN THE WHOLE PROCESS FOR THE PEOPLE WITH STROKES, HEART ATTACKS AND MENINGITIS!'

When departments are over-loaded and there are 4 sick people at a time waiting for the same 1 cubicle...or when you have a list of worrying Presenting Complaints on your triage screen...and then someone comes in tO you with a blatant NON urgent problem, it makes you want to scream.. DO YOU REALISE HOW MUCH YOU PEOPLE SLOW THINGS DOWN FOR THE REALLY SICK PATIENTS HERE - go home where you belong!!

Nurse Anne said...

Sue I never would have said this before last weekend but I think we are getting worse than stafford. A lot worse.

I am working on a post called bank holiday weekend hell. I never experienced anything so bad before. The place is in free fall.

I hear you UK nurse.

GrumpyRN said...

I want to make it clear before I go any further, I work in a well run, reasonably(ish) staffed A&E department. We have supportive, hard working consultants, management who don't interfere too much and security available for nights. Our procedures and systems mean we meet the 4 hour target over 99% of the time, not just the 98% required. So perhaps I am one of the lucky ones and what everyone else is going through is the norm. Although yet again I would say that I am glad I live in Scotland and health is a devolved issue.
The ignorance and abuse from patients and relatives is standard throughout A&E's regardless of where you work but increasing waiting times can only make it worse.

Anne, 1 RN for 10 plus resus is unsafe and a disaster waiting to happpen, or as you have pointed out, already happened. If people die in cubicles what are the coroners doing? If someone dies suddenly in our department we don't always give a death certificate and will pass it on to the procurator fiscal and let them deal with it. When we do give a death certificate nursing staff are asked if there is anything we have concerns about and we have to be named somewhere on the documentation. OK, yet again, Scotland, different systems but we work to the principal that every death in A&E is classed as a sudden death and may require police involvement.

Dino Nurse, you know who to blame for (no)Care in the Community; Margaret Thatcher when she introduced her white paper in the late 1980's early 1990's. All the money went to social services who have no interest in care of the elderly. They want to spend their money on children and drug addicts.

Sue, this is what I mean when I say that the 4 hour target is a hospital problem. This is part of our procedures and systems and means that the admissions wards are aware of what is happening in A&E and can't just fob us off.

Nursing Student, this is appalling behaviour, students should never be put in situations like this. We tell every member of staff to document, document, document, have a statement written very soon after with names, dates, times etc. What I try to point out is that the person you are dealing with is invariably drunk and you are sober so you have better recall. Our management and police tend to believe us.

GrumpyRN said...
This comment has been removed by the author.
Dino-nurse said...

Yes Grumpy, the loathesome Mrs T is responsible for the downward spiral that social services and the NHS are now in. She started to dismantle the NHS when she decided to bring in non clinical managers.
A few years ago one of our ED consultants decided to man triage herself. She basically turned away 50% of the timewasters with a preprinted letter that told them to go to see their GP. Those that argued with her were told that they would have to wait 4 hours to be added onto the database as in her medical opinion they were not emergencies so had no reason to visit an EMERGENCY department (so in effect would not be admitted) and after that, another 3-4 hours to be seen by a doctor. Abusive drunk patients were escorted to an empty room to sober up. Those that spent the night were given mops in the morning to clean up their own mess and two burly HCAs to make sure that they did. Brilliant. For a few days we were able to hit the targets without endangering people and the admissions units were not full up with drunks. Unfortunately she was hauled up by the ankles by the non clinical board members and told to stop being a naughty girl, as triage was not the job of a consultant. Quite why we now have a generation of halfwits that think a small cut requires medical attention-ie a nurse will put a plaster on it, at a cost of around £50 (assuming time to be seen by triage nurse (usually band 7) cost of bandaid and the follow-up letter we are obliged to send to the GP. If the muppets just went to Boots they could by a pack of plasters for around £3. Meanwhile old ladies (like the one I saw today) will only phone for an ambulance when they are at deaths door. As for drunks- well bring back the drunk tanks. The swedes have the right idea- you get put in a room and fined around £200 for the privilege. If you need medical attention they do have docs around but you are not clogging up ED being abusive. Alternatively we need to grow a pair and point out the all alcohol needs to be put back into off-licences (so NOT in the local corner shop or supermarkets), increase the cost, maybe raise the legal age to 21 and get rid of 24 hour drinking. The UK and Eire have always had a problem with drink, going back hundreds of years. Why should we be making it easier to get hold of?

Dino-nurse said...
This comment has been removed by the author.
Dino-nurse said...
This comment has been removed by the author.
Nurse Anne said...

Our coronor has made his views known. CQC has been in. Nothing changes. Not from my vantage point on a ward anyway.

Nursing Student said...

GrumpyRN, I was a HCA then. This was just before I went into nursing. Unfortunatly, it is appaling behaviour but I got the brunt of it. We did document it (we being emma the registar as she was behind the blocked door for the last 20 seconds of the ordeal) but documenting meant nothing the next day.

Anne you're right management have no clue because the majority of them if they are modern morons bypassed A&E and went straight into management. The upper management are enablers for these drunk lunatics. I had all kinds of things told me to the next day "what did you say to the patient" and "she doesn't seem drunk on camera". It's like, side with your staff once in a while you fucking arseholes? When the written warning came my dad told me there and then to quit and submit my UCAS for Nursing as it was late december and never go back to A&E once I graduated unless things had changed. I didn't. I won't either, unless things do change.

When my dad was in the police force for 30 long years he did whatever he had to do to protect other people and HIMSELF, and that would include reasonable force or the use of his baton. I'm not saying Nurses should use batons but we should be able to protect ourselves without fearing we might get sued for it. It's the same kind of service, police are there to protect people and nurses are there to help. If in potentially hostile environments such as A&E there is a threat to Nurses and Patients then there should be different rules. Nurses should protect themselves.

Believe it or not though, I miss A&E, I just don't miss the bullshit that comes with it. I don't miss having to tell my family and boyfriend that I'm on nights for the next fornight and it's a busy time so there will be plenty of drunks, so I'm going to be more irritable than usual when I wake up at 5pm for a shift. I don't miss telling my best friend I coulden't be bridesmaid for her wedding or god mother to her first born because the A&E manager woulden't give me the odd sunday off despite the fact I asked up to 3/4 months in advance for each. I don't miss telling drunks to wait and getting abuse for it and spit in my face. I won't miss ambulance staff huffing down my neck. I won't miss having bowls of vomit thrown at me and throwing my back out (like one evening) dodging a bowl. I wont miss real sick people people being ignored because people with non-emergent cases or cases that can wait 3 hours in the waiting room screaming on top of their lungs that they need to be seen now. But alas, I will miss it. I am built for A&E. I am wired for emergency care. I'm even considering aeromed evac in the RAF when I graduate because I'm the kind of student/nurse/person thats built that way. I deal better in stressful circumstances.

My A&E covered some of the roughest valley's in south wales and 2 towns that amount to about 80,000 people. It was hell on earth sometimes.

When I went back a few months ago with a friend who had smacked her head on her steering wheel when she did an emergency break, we waited for 3 hours and the A&E looked worse than ever. She had a serious concussion it turns out when she was seen almost 3 hours later. She had to stay in because she had a 2 year old alone at home and coulden't go home to him alone so I watched him whilst she recovered.

I want to work in GrumpyRN's A&E!

Anonymous said...

This is all so true and makes me furious. As a person with an incurable serious illness I have the misfortune to have to experience my local A&E several times a year. I have never been there without being shocked by the awful behaviour of other patients and their relatives who usually appear to not be in need of any serious medical attention. It is very clear how the medical staff feel about these people, but I can fully understand why the scary, potentially violent, loud, mobile, and apparently well man gets his request for refreshments met, whilst I quietly sob lying in bed waiting for my morphine.

It isn't just A&E of course. In my experience there is always someone on every ward who doesn't seem too ill and is driving the nurses mad with stupid requests.

I suspect the bed-blocking discharge rules about elderly people are partially to blame for this. Whenever I have been an inpatient there is always an older woman they are desperate to discharge and trying to make arrangements for. As these patients are no longer seriously ill they are more likely to have non-medical demands, where as the critically ill patients are unlikely to be noisely making requests - they have other concerns!

Nursing Student said...

Yes the nosiest, most abrupt and verbal patients are usually the ones who can wait. Not as an excercise or a lesson learned, but I'm not going to believe for a second that someone has a pain rating of 10/10 for a twsited ankle when they are simultaneously talking to me - absoloutly fine - and bellowing at someone down the phone to Sky+ Eastenders. They can wait, and they do wait, whilst I worked there they waited anyway. That's just how it goes. Kicking and screaming louder and making more of a disturbance usually wont resolve it or get them in quicker unless one of the doctors has had enough and takes them in by themselves. On top of that we had a BRUTE of a night receptionist who unfortunatly left due to sickness and she would not take any shit and and the same time had the kindness and love for anyone and everyone, even the pissheads. When she was around the wait in reception was bareable because she basically told all the naughty kids in there to shut the fuck up, or they could get out. More polite ofcourse, and lovingly. She reminded me of my mother. But she meant it. She used to work in a primary school I did one of my placements in (during sixth form) for kids with Behavioural Issues and my god her skills there worked in A&E. She could calm a box of mexican beans if she needed to. When she left it was like a free for all in there, a few of the regular pissheads that ventured there knew it, too. Carnage.

We will just filter out the swines in the waiting room causing a riot and check to see that none of the quieter and ill-looking patients who are triaged and having to wait haven't either left or accidently died, or worse, started causing a riot with the others.

But the quieter and iller patients I always felt bad for. On a weekend it was the worst and ofcourse due to GP closure we always had a surge of not just pissheads but people with long-term illness in. Trying to focus on 3 really poorly patients who need attention is hard when the other HCA needs a hand controlling the drunks in the other 7 cubicles. I would leave in tears sometimes.

Anne said...
This comment has been removed by the author.
Anne said...

honestly don't know how A&E staff cope at times, I've had 3 trips unfortunately to A&E in the last couple of months (for emergencies I.e. unable to breathe) and
each time there were police present and patients who were kicking off in reception and in the cubicles.

The staff were very good despite all this going on around us, I work for the NHS but would never work in A&E, I'm just not that brave!

Anonymous said...

MMN this is the first time I have read your blog and I must say I am hooked...

I'm currently an A+E CT1 (I.e. I'm a doctor who wants to spend his life in A+E :S) and I couldn't agree more with the comments posted here.

I've worked in 2 very different casualty departments (one in middle of big city, one in rural DGH) but both seem to have the same problems....under immense pressure, lack of nursing staff and at least 1 or 2 (Usually SHOs) doctors down. The sheer number of people I have seen who could quite literally have seen their GP is staggering. 3 months of abdo pain-check! The painful ankle you fell on a week ago but are ok to walk on-check! The cut finger you called an ambulance for at 3am-Check!!

I love this job-mostly for the commararderie between myself and the nursing staff and other doctors (i genuinely love working with them all) and the occasional interesting case however emergency medicine is being destroyed by those who no longer have a concept of what an A+E department is all about.....oh yeah lets not forget the drunks and druggies!!

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