04 December 2010

Grumble and the tramp

Regular readers may have read Dr Grumble's tale about a bag lady he encountered on his way into work earlier this week. She had been sleeping in the ladies' toilets and Dr Grumble suggested that security was called. Grumble knew that security would throw her out onto the streets. Comments following the post suggested that the NHS might be better off if they looked after patients like the bag lady to prevent her getting frostbite or pneumonia. Dr Grumble used to think the same. But you develop a thick skin if you work in a hospital. People you try to help quite often let you down and it is for this reason that hospital staff can sometimes appear a little uncaring.

Many years ago Dr Grumble worked as a medical registrar in a small teaching hospital in London. The main hospital block was on the other side of a small park from the nurses' home where Dr Grumble had his on call room. In those days you worked all night and all day. You snatched sleep when you could day or night. Often Dr Grumble would have to walk on cold nights alongside the park from one building to another. Sometimes it was bitterly cold. Most nights on one of the park benches Grumble would see a tramp curled up fast asleep. He had only one leg.

One night when Grumble was on call it began snowing. Cold weather portends more admissions so Grumble was not pleased. He needed his sleep. Emergency admissions, for some inexplicable reason, always seem to begin to peak at around bedtime but by about two in the morning on that night all those years ago there was a lull and so Dr Grumble trudged through the snow past the park on his way to the on-call room for a few hours sleep. That anyway was what he hoped. As usual the tramp was on his park bench. This time he had a few sheets of cardboard over him to help keep out the cold. The wind was bitter. Even Grumble felt it in his bones as he hurried through the snow from one building to another. He felt utterly exhausted and prayed for at least a little sleep. He consoled himself with the thought that his life of constant day and night work was not quite as bad as the life of that poor tramp on the park bench.

Grumble climbed into bed. The room was not as warm as usual and the sheets felt cold. Dog tired though he was he couldn't sleep. Patients do not know how much their doctors worry about them. But doctors worry a lot about lives that they are responsible for. Grumble had done his best for the day's medical admissions but he was still worried about some of them. He ran them over in his mind wondering what rare diagnoses he might have missed what test he might have forgotten.

Just as Grumble passed into the land of nod he awoke with a start. Was he dreaming that his bleep had gone off? He often did that. He would ring switchboard only to find out that he had not been bleeped at all. Those days were tough. Always on call. Always worrying that the telephone would ring or that a shrill bleep would cruelly terminate the Grumble reverie. But this time it was real. There was a very sick patient in what was then known as casualty. Grumble quickly pulled on some clothes and went out into the dark night. The wind seemed even colder. He tugged his white coat around him tightly to try and keep out the cold. The tramp had gone. The night it seemed was too cold even for him.

Dr Grumble arrived in casualty. There were the usual drug addicts lying around. The staff weren't worried about them. They were regulars. Once their heroin had worn off they would be on their way only to return the following night via casualty's ever open revolving door.

Grumble asked where his patient was. He was in room 3. Room 3 was used for the VIPs. Earlier in the day Dr Grumble had seen a noble lord in just this room but this was not the time of night for lords or ladies. And it was even a bit late for the drunks. There was usually a bit of peace at between 3 and 4 a.m.

The casualty officer had done the usual crap cursory clerking. Even in the days when doctors had more experience the casualty staff never seemed to be thorough. They knew that somebody more senior would have to see their patient anyway so they didn't really try. Doctors who do not really try do not learn. It's like that more often now. Junior doctors know that a consultant will soon see the patient so they don't really try. It's bad. Very bad.

Dr Grumble went into room 3. He shouldn't have been surprised but somehow he was. There on the trolley was the tramp with one leg. They had put him in the VIP's room because of the smell. Nobody had yet cleaned him up. It was Dr Grumble's job to try and work out what was wrong with him despite the stench and the filth and the scabies.

The diagnosis was actually quite straightforward. A chest radiograph had been done. The patient had middle lobe pneumonia. There was loss of the right heart border.

Doctors will have spotted that this cannot possibly be the
tramp's radiograph but it does at least show the silhouette sign.

Dr Grumble's patient was not at all well and there were other quite dangerous problems such as his low body temperature. Younger doctors would be surprised to learn that despite the severity of his illness Grumble treated him with intravenous benzylpenicillin. It used to work well in lobar pneumonia and Dr Grumble's patient got better.

Now in those days doctors, even junior doctors, had some leeway. If you felt a patient needed a bit more time you could keep them in hospital a little longer. If you felt that they needed to stay in while social issues were sorted out you could do that. And that is was Grumble did. He felt sorry for the tramp. He told the consultant, a somewhat dour Scot, that he was going to find him somewhere to live. "You're wasting your time, laddie," said Dr Blunt. But he didn't interfere. And that was how the tramp ended up with his own small flat to live in.

The winter that year was cold. On countless nights Dr Grumble went back and forth in the night between the hospital and the nurses home. And each night Dr Grumble felt good because the park bench was empty and he knew that the smelly one-legged tramp was now tucked up warm and clean in his own bed. Until one night when Dr Grumble was walking back from casualty he glanced into the park. And there he was. The one-legged tramp was back on the very same bench covered once again with cardboard. "I told you you were wasting your time, laddie," said Dr Blunt.

Dr Grumble sees his former self in his junior colleagues. They fail to understand why Grumble kicks tramps and bag ladies out of hospital. They want to help these people. It is only natural. That's what medicine is about. Sometimes Grumble lets them because he knows that they need to learn the hard way - just as Grumble did all those years ago.


Anonymous said...

...but you did your bit - what the tramp did with that was up to him. You are not reposnsible for his actions - but you are responsible for yours. You still have to do the right thing.

Dr Grumble said...

But what is the right thing? Putting really fat people on a diet might seem the right thing but there is really no point as in the end they all let you down and eventually put on weight.

It's the same with tramps. You can try and help but they will always let you down. It is actually very important to realise that some efforts with your patients will be almost certainly fruitless and in the end will be of no help to them. You can then focus on the things that do make a difference.

the a&e charge nurse said...

There are many situations both clinically and socially where the outcome is unlikely to be favourable (when framed in terms of populations, or discrete groups) but there are almost always exceptions that disprove the rule?

I know of a few "frequent attenders" that were NFA who are now doing well, or at least better - or put another way, not everybody returns to the park bench.

What we do, and when we do it, will always have resource implications, but surely we have to keep fighting for those who are less well off even if Dr Blunt is proved right more times than he is proved wrong?

Anonymous said...

I used to cut myself. It's an ugly thing that few people will sympathise with.

One day, I was admitted to hospital and I saw the same looks on the same people's faces, the disgust of the ambulance crew, the doctor who told me she had more important cases to deal with and left me in the cubicle.

Then along came a nurse who popped his head round the curtain and found that I'd been left to my own devices. He gently took me to another room and carefully explained to a baffled student how very important it was to anaesthetise the wounds properly before stitching them. She clearly couldn't see the point.

Whilst he stitched me up, he gave me advice on the best way to get blood out of clothes.

He treated me with decency and respect and kindness. That was 2259 days ago and I haven't cut since.

Anonymous said...

I think that you did the right thing, and while Dr Blunt was right, at least the Tramp survived that winter. When I was a house officer at a similar hospital we would often admit such tramps, for a bath and a few hot meals. Most were appreciative but some were abusive, some had DT's, most were Some degree trouble to other patients.

Anyone can respond with love to someone who loves them back, it is far more challenging to respond with love to those who will abuse you. That is the essence of medical practice, and also nursing. It is gruelling, and understandably makes staff cynical, but cynicism destroys all it touches.

Great post, I wish I could write to the same standard.

Crippo said...

I'm with the AECN here.

You still have to keep trying, even though they may come back. It's what we do.

An old Jewish story:

A lady sees a tramp on the street, so she stops and gives him £5. He thanks her very much. 'Now then', she says, 'don't go spending that on drink'.

'Lady', he replied, 'you gave me the money, for which many thanks. But what I choose to spend it on is my business'.

Anonymous said...

Are all 'tramps' the same?

Are all 'really fat people' the same?

Sounds like you need some help with sorting out your individual patients from your stereotypes.

Dr Grumble said...

Are all 'tramps' the same?

Are all 'really fat people' the same?

No. But sometimes you do know when you are onto a loser. For example, there is no point in helping somebody stop smoking if their heart is not in it. All you can then do is move them towards coming round to giving up.

As for fat people, even slimmers of the year tend eventually to put on weight again so they are all difficult nuts to crack. They would never have got fat in the first place if they didn't have a major problem.

Some of these tramps, whom in the old days we used to admit for Xmas to give them a wash and brush up and some food, are quite lovable rogues. Sometimes alcohol is their poison, sometimes mental problems and quite often both. Some are delightful until they get drunk when they are obnoxious. A good few have TB and it could be in the public interest to be able to look after them a bit more than is easily possible these days. If you ask them gently many will tell you they have been in prison - sometimes for terrifying crimes.

Dr Aust said...

Weirdly, a comment I have now posted THREE times keeps disappearing.

I must have eaten too much spam.

Dr Grumble said...

Here is Dr Aust's missing post without the links (one was the wrong link I think):

Thanks for adding that, Anon 02.01. It is clear that people in healthcare sometimes wonder "what's the point" (I know Mrs Dr Aust does), especially after a long stretch in the trade. One of the tough things is that it is the ones who genuinely feel compassion for the patients (who in the main are the doctors, nurses etc one would actually want to be treated by) who feel this the most keenly. Dr Phil's post here is worth reading on this.

At the risk of sounding a bit trite, here is a quotation attributed to Gandhi, which I found on Prof David Colquhoun's blog and then appropriated for the sidebar of mine:

"Almost everything you do will be insignificant, but it is important that you do it."