Today I am continuing a theme that I love: process, and the absence of its value when someone could have been left to use their brain instead. Don’t get me wrong, to paraphrase a quite brilliant fellow MBA colleague, process porn excites me just as much as the next Project Manager. I love the way it can enhance our lives when everything is there at the touch of a button. Then we call it “intelligence by design” or “user friendly” to avoid using the ugly word, “process”. But process is only dehumanising when it fails, raining absurd crushing blows on our heads, sending us internally spinning, and often into a lengthy British queue. I’m getting ahead of myself……………..
Recently, my husband and I spent one of those days juggling one kid off to a cub-scout day trip, one off to badminton club and with the third pair of hands, one kid went to the park to exhaust me. Never did I realise you could push someone on a zip-wire, for hours……..
Suitably exhausted I returned home to find number one girl curled up on the settee clutching her phone, looking particularly more emo than usual. This is the exact moment I learned at what age people start Googling symptoms to self-diagnose an illness. The answer is 11. Suspected appendicitis cannot be treated with painkillers or a hot water bottle for fear of rupture and instant death (I’m paraphrasing WebMD on her phone here). To be honest, if the lower right quadrant of your belly hurts like hell and the left side doesn’t, appendicitis was all I had to go on too, so off we went to the nearest A&E, time of arrival 3:15. Obviously, you can’t park near A&E. If you’re not ill enough to turn up with all sirens blaring in an ambulance you have a 20 minute drop off waiting zone (full) or the maternity car park half a mile away.
So, I’m trying to carry an 11 year old in my arms like a baby from the maternity wing car park. I get as far as the maternity wing (i.e. 10 metres) before I want to collapse, breathless and in agony. Looking not dissimilar to every other patient arriving at the maternity wing, I rush in, looking for a wheelchair. A saint of a porter appears out of nowhere and number one girl is chauffeured round to A&E, in the fetal position. There, she is rushed through as an emergency case for triage. Because a nurse says so, she also agrees to take some paracetamol. She is “overbooked” on the next available appointment at 4pm.
Here’s the first part of my process confusion, how do you get to the point where double booking an appointment is a normal process? Have they cloned the staff to be able to do this effectively? The waiting room was pretty much standing room only with loads of kids with suspected broken limbs, still dressed in football kit. One young girl was skipping with a bloody nose and a scraped knee. I can’t help thinking that perhaps a tube of savlon and some paracetamol was all many of them really needed, not a four hour wait sat next to a paranoid, anxious parent, hoping to be double booked over someone else’s suspected broken wrist.
Surprisingly at exactly 4pm, my girl is called through to see another nurse to go through exactly the same triage process as before, only with the addition of a urine sample request and without the paracetamol again. Also, I suspect because the nurses are fed up of documenting scraped knees on the computer system, our answers are first written on the back of an envelope (I kid you not) before being typed up after we leave that room. It’s a tricky process getting an unsteerable wheelchair alongside a toilet cubicle so that a girl bent double with pain can wee into a small pot inside, but we managed. Don’t ask me to repeat that task.
Second point of confusion, why not just copy the stuff from one form onto the next form? How are our answers going to differ from one hour to the next? Why even have a second form if it has all the same questions on it? One of the questions sounds like, “Is she known to cams?” If you understand this question, then you know it is actually “Is she known to CAMHS, which is the child and adolescent mental health services. If you answer this question, “no” rather than “what is cams?” no-one bats an eyelid or asks how you have come across the mental health services if it wasn’t for one of your kids. I was all ready to say “Oh, it’s our youngest son who’s clearly insane” but no, the box has been ticked, job done. Nurse number 2 seems very skilled and lovely, and “cannot rule out appendicitis” as the urine sample is fine. She’s “going to be assertive” and demand that a doctor sees my daughter. We’re sent round to the paediatric ward half an hour later, and ours not to reason why, but here’s the process on arrival, which in practice is about an hour after we arrive……………A nurse has a look at her, and asks ALL THE SAME QUESTIONS AGAIN, including the urine sample request. This time the urine test has a cardboard bowl to put under the toilet seat with a sterile packaged, plastic container insert inside, which has to be weed into, but only after opening it without compromising its sterility. I go and fetch another wheelchair………… Apparently, although the last nurse wrote up her notes from the back of an envelope onto the system, a) this did not include the results of the urine sample and b) they have big blue folders on the wall of the paediatric wards and you need to click paper in and out of these to look efficient, so to generate more paperwork, we have to start again.
It is now 5:30 and the nurse recommends taking a blood sample so that the results will be available to the doctor when they arrive to help their decision making. “That’s great” I say, “How long does it take to get the blood results then? What time do you expect the doctors to come round?” Here are the clues to the answers I’m expecting: How long = answer in units of minutes/hours; what time = something O’clock. The answers I actually got were, “oh, they come back almost immediately” and “she called me 15 minutes ago, so not long I imagine”. Right, let’s start with “they come back almost immediately” shall we? I distinctly remember weeping into many biochemical tests in a hospital based lab as a PhD student, so I have a little bit of experience with these. It’s really very frustrating to spend two days carefully moving very small, and usually radioactive solutions from one type of tiny tube to another, only to discover that in your sleep deprived state, you wired up the terminals to the last machine in the process the wrong way round and now your samples are swimming in vast quantities of (also now radioactive) solution that you need to carefully clean up and pour down an appropriate sink somewhere. There were no tests that gave you results “almost immediately”. I understand that tests designed for the NHS have to be more robust than the ones I cocked up years ago, but still, the results are not coming back, “almost immediately”. I would bet my hospital parking fee on it. Moving on, how does the past event of “she called me 15 minutes ago” relate in any meaningful way to the arrival time of said doctor? She may live in Timbuktu, she may have 15 wards to walk round and 20 life-saving surgeries to perform before she gets to the blue folder filled paradise that is room 16.
So, sure in the knowledge that it is 5:30pm, but absolutely none the wiser on anything else, we watch anaesthetic cream being put on the back of my daughter’s hand, which will take half an hour to work, after which time, the blood test will be done.
6:35, blood test performed. No doctor around. She’s still nil by mouth and getting hungry. At about 7, dad turns up with the welcome distraction of brothers. As a new face on the scene, dad asks a nurse if there’s any danger of seeing a doctor or a blood test result any time soon. “The blood test results will take an hour” and “the doctors are on their way”. I bite my tongue. Eldest brother asks me why they can’t just X-ray his sister to find out if she has appendicitis. Grateful for the diversion, I discuss the use of X-rays with him and their ability to see bone, but not wiggly appendices, and the value of high resolution, but expensive imaging techniques like MRI and CT scans, versus cheaper, quicker, low resolution techniques like ultrasound.
8pm, we go wild and crazy and ask again if either a blood test result or a doctor are going to turn up any time soon. Miraculously the doctor appears and lets us know that blood test results take two hours to come back. He also asks my girl pretty much, all the same questions we have now answered three times already. However, this time we have brothers present, which livens up the process enormously. When asked if the previous day’s activity was normal, youngest son’s hand shoots up: boy does he know the answer to this one: “we cycled to the river where you can swim and I found a dead fish and a live mussel”. Unfortunately, this information has minimal clinical relevance and the doctor smiles politely. This is seen as a cue for eldest son (aged 10) to ask very bluntly, “Why don’t you just do an ultrasound to look at her appendix?” Gloriously shocked into action, the doctor informs us (in words of one syllable, despite the clear understanding that my son has of the situation, never mind his rather academically qualified parents) that this is exactly what they will do in the morning. Nil by mouth restriction is lifted and supper is offered to my picky eating number one girl. When I say supper, I believe the exact offering was “I think we have a cheese and tomato or egg sandwich in the fridge still?” The look of horror on my girl’s face was enough to send me to the only thing open on a Sunday evening, a vending machine, so that she could eat an entire bag of Haribo Starmix (other types of carpet underlay are available). This can only be good for someone who has essentially had nothing to eat all day on top of severe bowel pain.
9:55pm, a surgical registrar comes to tell us that her blood test results are all normal, which is not strictly true as I pestered the nurses at 9pm and they said that “a couple of things are raised”. They’d like to keep an eye on her overnight before the ultrasound the following morning. My daughter is distraught as it has finally sunk in that she is definitely going to miss her maths test the next day. I drive home to get an overnight bag, incurring a £6 parking charge to leave the car park, even though this is the fee for anything over 5 hours, up to 24 hours. Although I am back within the hour there is no button to inform the machine of this and I start the whole parking ticket process all over again. I return to the ward with teddies and kiss my girl goodnight. Then I go to parents’ room 3 to sleep under the thinnest blanket ever manufactured, whilst ironically bearing a label that says “Imperial quality”; perhaps it was at the time Britain had an empire. I am reminded that your importance to the clinical care of the patient is directly correlated to the temperature of your surroundings. If you are the patient, you are placed in a room heated roughly to body temperature. If you are a mere parent, you are in an unheated room with draughty windows, where the curtains stop 6 inches short of the window ledge.
Any visible source of heating with apparent thermostatic controls is simply there to lull you into a false sense of warm security. I spend the night fully clothed, putting two threadbare towels on top of my imperial quality blanket in an attempt to remain warm blooded. Day 2 continues in the post below.