An evening in accident and emergency

The call comes just before 3 pm. “Your mother’s had a fall, her tooth has gone through her cheek, the ambulance is here.”

I’ve tried again and again to get the nurses in the care home to call me before they call an ambulance, but again I’ve failed. I’ve managed to divert two ambulances, but this time I fail. I understand why the nurses call an ambulance, but I don’t understand why the care home can’t manage to get the message through about ringing me first. When I raise the question with the nurses they become defensive, think me uncaring, and probably think “Bloody man. He’s not looking after his mother. He’s leaving us to do it and then getting annoyed when we are doing our best for her.”

The nurses have much more confidence in the benefits of the hospital than I do. Hospitals, I know, are dangerous and miserable places for everybody but particularly for the demented; and the danger is increased in the pandemic. There has to be considerable benefit to outweigh the inbuilt risk

After canceling my outing with a friend, I cycle through the rain to St George’s. There’s a socially-distanced queue outside the entrance to accident and emergency. I learn as I stand in the queue that patients are not allowed anybody to accompany them. Disgruntled relatives are told to get out of the way of ambulances. I wonder if they will let me in to be with Hazel.

When I get to the front of the queue, I tell the security man, who has not very clear English, that I want to see my mother, Hazel Smith. He tells me to write her name on a scrap of paper he has. I have to add her date of birth. He goes inside, reappears after about five minutes, and tells me “She’s not on the system.” (I think “Computer says no.”) But he tells me to wait rather than go. I try ringing my mother’s care home, wondering if she’s been taken somewhere else. There’s no answer.

At this point two ambulance people tell me that they have my mother. The security man is unsure about me being allowed through, but the ambulance people wave me through. I enter, and there’s Hazel on a trolley with a hole in her left cheek that’s surrounded by clotted blood and is less then a centimetre across. She’s her usual self, chatting, and singing tunelessly. She is wheeled through into the urgent (but non-life-threatening) care unit, which is filled with people in blue and green scrubs going to and fro and sitting at computers.

Hazel is moved onto a trolley, and the ambulance people leave. I stand beside trolley and chat to Hazel. She’s keen to go, can’t understand why she is here. “Let’s go upstairs,” she says. I’m wearing a mask, and she’s not sure who I am. We watch the play in front of us, and after about 20-30 minutes Dave (he tells us his name but not what he is) comes an inserts a cannula into a vein in Hazel’s forearm. She’s not keen on having the cannula but eventually agrees. She yelps when he puts in the needle, but generally it goes well.

After another 10-15 minutes a student nurse comes to measure Hazel’s blood pressure. Hazel shouts in pain and protests strongly when the cuff inflates. “Get off of me, you buggers. Get away. I’m going. I hate you. Leave me alone. I want to die.” The nurse doesn’t get a reliable measure. She’s supposed to do a sitting and standing blood pressure—to check for “postural hypotension” (the blood pressure dropping badly when a person stands, a common cause of falls)—but fails. She then has to do an ECG, so glues stickers onto Hazel’s chest. Hazel doesn’t object strongly to this. She keeps reading and reciting the name on the student nurse’s badge, and the nurse (an Algerian, I learn later) tells us proudly that in two weeks she will become a registered nurse. We congratulate her.

Some 20 minutes later a doctor comes. He doesn’t tell us what level he is, but I guess he’s at the bottom. He’s tall and handsome. He starts with asking questions of Hazel but realizes he won’t get far—so asks me. I can answer some of his questions, but I have no clear account of how Hazel came to fall. I say I’ll ring the home. (I do so about five times in the next two hours, but I never get an answer: sometimes the phone rings out, at other times it’s simply cut off.)

The doctor says that normally with a 90-year-old with a fall the patient is admitted for 24 hours for observation and has various tests, including an echo and possibly a CT scan. I say that I’m a doctor, and I think that that’s excessive for Hazel. He asks what kind of doctor I am, and I say that I was the editor of the BMJ. He examines Hazel in what I recognise to be a cursory (and mostly uninformative) way and then looks at her wound, establishing that it goes right through from mouth to cheek. He goes away, saying that he’ll look at her bloods and ECG.

Hazel continues to be restless, singing tunelessly much of the time, sometimes chatting with me, and sometimes getting angry, telling me that she hates me, wants to go, and wants to die. The student nurse brings black coffee, biscuits, and water. Hazel yelps when she drinks the water but drinks it and the coffee and eats the biscuits.

The doctor comes back with a slightly older doctor, a fattish, blonde woman, with a cheerful and forceful manner. They seemed to have dropped the idea of the 24-hour admission, but the debate now is between options of do nothing, put in stitches, or refer Hazel to maxillofacial surgeons. The younger doctor says the maxillofacial surgeons are doing an operation and won’t be able to see her for a while. I’m keen to get Hazel out, and so are they. We opt for stitches.

There’s then a long gap before the younger doctor comes to insert the stitches with support from the student nurse. He needs to wash the wound first and has a large bag of saline. After a half-hearted attempt at sterilisation, he tries to get at the saline but doesn’t know how. Nor does the student nurse, but they both (him supposedly sterile, her not) handle the bag. Eventually they manage to get at the saline and start trying to wash Hazel’s wound. She objects strongly, pushes away the tray to catch the saline, and tell us that she hates us and wants to die. Next the doctor tries to inject local anaesthetic, but Hazel screams and pulls away. I try to calm her, but with no success. After a few tries the doctor gives up. We discuss sedating Hazel but agree that’s a bad idea.  So the doctor sticks on some steristrips. Hazel doesn’t protest strongly, and he has some success. (During all this I tell him that I had to do similar things 40 years ago in casualty in New Zealand. I’m trying to say “I know what it’s like not being very competent,” but I’m not sure that I get that message across.)

The doctor goes away. Somehow time stops in accident and emergency. How long have we been here? I’m unsure. Hazel wants to go, I want to go, probably the staff want us to go. But who will let us go, and how will we get out?

Hazel sings tunelessly and loudly. As Lin later says, she probably doesn’t know she’s doing it. While I sit there, I have a vision of my smart, controlled, highly-organised mother in her 50s looking at the 90-year-old version of herself and being appalled. Luckily, the women in her 50s is no more.

The younger doctor comes back with the older doctor. The older doctor looks at the wound and wonders about “gluing it” with “special glue that is basically superglue for flesh.” She consults a much older nurse-practitioner who has just started a shift. They agree that glue plus steristrips would be best.

There’s then another long pause. The younger doctor comes and says he’s leaving, his shift has ended. Eventually the older doctor comes with the glue. This goes well, although at one point she’s worried that she has glued Hazel’s lips together at one side but luckily hasn’t. She manages to put on two steristrips. (The ones the younger doctor had put on were already coming off.)

We can now go. A staff nurse comes with antibiotics for Hazel. She’ll help us get Hazel out. Luckily, Lin has rung and offered to come in the car—otherwise, we’d have to wait hours for an ambulance or try going in a taxi. With difficulty Lin has managed to park about 150 yards away, on a main road. After having wanted to go for hours, Hazel now says that she isn’t going. She’s going to stay here. The staff nurse and I manage to persuade her to leave. We get her off the trolley, and one each side manage to get to the exit of the department. As we go outside Lin appears.

With Lin and I on either side of Hazel we begin to walk towards the car. It’s now dark and cold, and Hazel doesn’t have adequate clothing. The car is on the other side of a busy road. I can’t see how we can get Hazel across, so when we come to some benches Hazel and I sit down while Lin goes to get the car. Because of the hospital’s one-way system she can’t bring the car to where we are sitting, but she can get drive it to the near-side of the road. She comes back and we walk Hazel to the car and get her in without much difficulty.

We drive to the care home, and I go to get somebody to open up. I know that it’s going to take many minutes, and it does. I go back to the car, and we move Hazel into the home, into her wing, and into a chair in the lounge. I give the antibiotics to the chief nurse, and Lin brings a cup of coffee and a sandwich. We leave.

As we drive home, I reflect both how wrong everything feels and begin to think of a system that would be better—with much less discomfort for everybody and much cheaper. I have a vague vision of such a system.