Wednesday, May 07, 2014


I’ve been working COHORT most of the day, looking after all those ambulance patients that the hospital has no space for. It’s a tough, Roman-sounding word, and certainly it wouldn’t take much – a scattering of straw and a few goats – to turn this triage area into the kind of holding pen you might have found under the Coliseum. Maybe instead of this green ambulance uniform I should have a breastplate, leather skirt and scabbard (with a woven pouch for my obs kit). But for all the heat and stress and awfulness, there’s a certain epic buzz to it all. If someone blew on a great brass trumpet and the crowd rose up to take control of the hospital, I’d be happy just to sit down and enjoy the spectacle.
But anyway, the day passes quickly enough.
‘Brutalising’ says a nurse.
Everyone at full stretch, doing what they can, making the best of the appalling conditions. Patients and their relatives protecting whatever space they can make, scavenging chairs. Learning where to find water.

One of my COHORT responsibilities is to keep up a round of obs on my section, along with welfare checks and a general chivvying along.

Gordon has a trolley, at least. He lies on his back, staring up at the ceiling through the smudged lenses of his glasses. A cadaverous man in his early sixties, he looks in poor condition, smudges of faecal material here and there, dirt-caked fingernails, a yellow rind on his teeth and a liberal dusting of scurf over his skin like dried coconut on the crust of a madeleine.
‘Hello, Gordon,’ I say, picking up the cluster of notes from the foot of his trolley. ‘How are you bearing up? Sorry there’s such a delay.’
‘Oh, I’m not worried about that,’ he says, unlacing his fingers and making an empty handed gesture straight up, as if God will still bear witness through these ceiling tiles. ‘But what I am concerned about is a diagnosis. I mean – what can possibly be wrong? I’m intrigued to speak to one of your consultants to see what they have to say on the matter.’
‘Hm. Yes. Well – let’s just have a look at what’s been written down here. I’m afraid I haven’t been told all that much…’
I flick through to the ambulance report form: GP referral for alcohol dependency & acopia. Pt emaciated and in poor condition. Flat worst we’ve ever seen – excrement, flies, extremely unkempt and filthy.
‘Gordon. I just need to run through another set of observations, your blood pressure and so on. Is that okay?’
‘Be my guest.’
He lifts his arm to make room for the cuff, and the foetid smell from his armpits has such a nauseatingly sweet and sickly bloom to it I find myself assuming an even brighter tone to compensate.
‘So how are you feeling, Gordon?’ I ask him. ‘Are you reasonably comfortable like this? Can I get you any water?’
‘No, I’m fine, really, thank you. I’m just keen to know what the medical team are considering. Would you mind if I read my notes?’
‘No, of course not. Let me just finish this and I’ll pass them to you.’
I raise the back of the bed a little and then hand him the bundle of notes. I glance at him as he reads the ambulance report, to see how he’ll react to their description of his flat. But to look at him – head tipped forwards so he can read over the brim of his glasses, tangled eyebrows raised, the palsy of his fingers trembling out through the sheets of paper – you’d think he was some kindly old professor running an indulgent eye over a student’s efforts.
‘Hmm,’ he says, handing me the forms back. ‘Well. Once I’ve had a chat with the consultant maybe it’ll all come clear,’ he says.


tpals said...

The hospital overflows under normal conditions? That can't be good. What happens when there is a major event?

Cassandra said...

Well, I mean he has to know what kind of condition he lives in… he's there, isn't he? I'm with him, though-- I love to read my medical notes.

Spence Kennedy said...

tpals - Quite! We've got major problems with A&E attendance these days. A number of factors & changes feeding it, and no immediate end in sight. That particular day it was unusually busy for some reason - it's normally busy, but not fail-grade!

Cass - You'd think he'd be aware - but he obviously isn't. An astounding disconnect. I think when you live such an isolated life, it must be a problem not to 'slide away' from social norms. Plus his 'denial' or inability to see how things are, is probably a symptom of his alcoholism, I'd guess.

Anonymous said...

I've ended up on cohort duty at my local A&E, it's certainly not confined to London. In fact the ambulance stack seems to be SOP at most of the hospitals in the area.
Not sure I'd ever document a patients home as "worst [I've] ever seen" though. There are degrees of worst... memorably bad had nettles growing inside. The self delusion aspect seems to be a constant though.

Spence Kennedy said...

Thanks Anon. Yep, it's a national problem, all right. Not sure how it's all going to play out. It'll take some bold decisions & significant changes to turn it around.

To be fair to the PRF descript - the crew had written a load of more specific stuff, too. That was just one comment that stuck out for me - prob because when you think of all the awful places you get to see, 'the worst' must be pretty unbelievable (unless the clinician is particularly new...) :/ I like the nettles detail! Very rustic.

Self-delusion def a constant. I suppose you'd never get into such a state if you had even a modicum of personal awareness of your condition.

Cheers for the comment, Anon. Hope you don't have to cohort too often (although some people don't seem to mind it, bizarrely...)

LJH said...

When my partner was unexpectedly taken ill in Norwich a few months back we ended up in the local A&E being looked after in this way - and the staff were fantastically caring and attentive, making the whole experience much easier. Thank you for doing this.

Spence Kennedy said...

No worries, LJH. Sorry you had to face conditions like this at such a stressful time. I hope your partner's made a full recovery.

Blair Ivey said...

Is COHORT Brit-speak for 'acting nurse'? It sounds as if you're being pressed to duty above your pay grade (but below your ability). My brother and I checked out an English clinic while stationed at Lakenheath in the 70's: it made a lasting impression.

Spence Kennedy said...

It's when the patient hasn't been officially given-over to the care of the hospital - a strange, halfway house between ambulance and A&E. The job is sometimes called HALO (Hospital Ambulance Liaison Officer), but it really just means baby-sitting the patients until there's a cubicle to put them in. As an EMT I suppose I am acting above my pay-grade, but there are Paramedics and / or a higher grade there, too, so we're okay as far as that goes. Unfortunately it seems to be a feature of A&E provision these days. Not sure what the solution is (does anyone?)

What happened in Lakenheath? Isn't there a USAF station there? (You don't have to answer...national security &c &c) :/

Anonymous said...

Think Norwich as well are others are to blame for COHORT. The local ambulance trust was getting a beating in the press, when it was mentioned they may wish to count the number of ambulances waiting to hand over at A&E. The local paper did this and it turned out there was 2 more than the number of ambulances on duty. So this of course switch the focas, to back this up the Ambulance trust said they would stick a "field hospital" on the field next to A&E and it all got changed quickly.

Spence Kennedy said...

I think it's a problem throughout the UK. I do remember reading about that whole 'field hospital' thing at Norwich. Quite a PR coup! Have things calmed down there, or are they still struggling to cope with increased numbers?

It's all so political - both on a local and national level. Here, the ambulance trust is constantly playing a tug-o'war with the hospital trust over who's to blame / who's going to carry the fine. In reality, of course, the whole thing quickly escalates and both parties suffer (as well as the public). Don't know what the answer is. Simply asking people to consider using other routes isn't effective, though. The 'other routes' need to be real and readily available!