Patient priority in A&E

[enigma]

Should an intoxicated patient be given priority in treatment in an A&E dept in hospital ? After having spent an exhausting four and a half hours in the A&E dept yesterday with my eight year old daughter - who as it turns out has a broken wrist following an accident at school yesterday - I was dismayed to see an intoxicated male who was being abusive towards other patients and becoming aggressive with staff , being given priority treatment - well ahead of my daughter who evidently was in a lot of pain , as indeed were many others. We had to wait to initially see the triage nurse , who in turn referred us to the x-ray dept (after a further hours wait) , then we had to wait to speak with a doctor who finally arranged for my daughter's arm to be set in plaster - following another lengthy wait. I fully appreciate that the doctors and nurses work gruelling shifts and toil endlessly , often without thanks for this service and so my argument does not lie with them per se , rather the patient priority. Why should an obnoxious , intoxicated patient , who seeks to antagonise hospital staff and patients be fast tracked to the treatment rooms ? I thought that priority was given - apart from those in dire need of medical assistance - to children and yet my daughter's wait was prolonged whilst this male jumped ahead of her to be treated for facial injuries. Whilst I accknowledge the importance of removing this man from the waiting room for the safety of the staff and patients , surely instead of rewarding his anti-social behaviour , he should have been issued with a stern warning and faced with an ultimatum ie cesssation of the hostile behaviour or treatment would be postponed until he could act in a civillised manner. What is the longest fellow ABers have had to wait in A&E and is this the norm ?

[enigma]

I meant cessation - not cesssation !

[paddy_36]

Sorry to hear about your daughter. I hope she's over the worst of yesterday's events.

Hate to be Devil's Advocate, but can you be absolutely sure that the man in question was intoxicated? If he was, I think it was probably in everyone's best interests that he was removed from the waiting room, as he posed at best, a nuisance, and at worst, a threat to others and himself. Was he definitely taken away to be treated, and not to be calmed down away from other patients? I don't think that a public stern warning and an ultimatum is particularly appropriate if you don't know how someone is going to react whilst under the influence, particularly if he was being aggressive. I agree with your point on patient priority in theory - each case on its medical seriousness - but in this case there were clearly other factors to consider. I do symapthise, though, and not sure I would be quite so reasonable had I been in your position yesterday. I'm not sure if children have priority over adults. Was four and a half hours your total wait from arriving to leaving with your daughter's wrist in plaster? If so, that sounds about the norm given all the different staff/departments involved.

[bondy]

Unfortunately they probably do if theyre in any danger.If its possible anyway.

[MrPahoehoe]

Summat in the hypocratic oath isn't it? I'm not sure, but don't they swear to treat all fairly and equally or summat?? The thing is, your daughter may have been in pain, but its not a serious injury: to have a damaged wrist whilst in a waiting room. Now this bloke may have been acting like an idiot, but if he had facial injuries then delay in treatment could possibly lead to permanent facial scarring.

It may be hard for a parent to accept, with your daughter in pain, but these triage professionals may have assessed this idiot to need more urgent medical attention. Its also possible that they may have decided to treat this person first to get him out of environment for the benefit of all the other professionals/patients.

...continued...

[MrPahoehoe]

..continued....

My A&E record is 7 hours. Some random guy in a club had hit me in the head with a bottle which sort of knocked me out. At the hospital my mates were a bit roudy, i stress not in anyway abusive, but just a bit loud. My wait could have been affected by some of the staff having a bad (Friday) night and think that as my mates were doing their heads in & my injuries were clearly not serious they might make me wait. I have no idea if this sort of thing goes on, but they're only human so I wouldn't be surprised and I can't fault them in the slightest if that happened in my case.

I'm not comparing it to your example, but its probably a valid tactic: a dangerous patient who you have to treat: get him out of the way ASAP for the good of all the other patients. Triage: patient prioritising, is almost certainly not based exclusively on medical reasoning. And anyone in a job where you have to deal with members of the public would tell you that someone who gets up your nose may not be dealt with as fast as other people who aren't as abrasive (this relates to my example: not your own)

Sorry I've just re-read this and its a really long post that says very little, but since i've written it i'm going to post it now ;-)

[joko]

children don't have priority over adults.

The man could have had a head wound, or needed urgent stabilising drugs, or could have had dangerous levels of something in his blood that needed addressing, you just don't know - he wasn't just there because he was drunk!.

I agree about just getting him out of the way as you never know what someone will do next and it is putting the staff and patients at risk.

no offence but a broken wrist is not life threatening.

i waited 8 hours - overnight - once with an ectopic pregnancy - which can be fatal!

[enigma]

Thank you all for your answers. Paddy_36 , the male in question was most certainly intoxicated because he leaned over me to ask me if I had a cigarette and nearly knocked me out with the stale smell of alcohol as he tottered unsteadily over me. When I told him that I do not smoke , he became more fractious than before and seemed to think that I was a covert smoker who just didn't want to part with her secret stash. I wasn't thinking of perhaps a public warning . more being led to one side or taken away from the main waiting area although I appreciate what you are saying in terms of his unpredicable behaviour and the possible consequences of him remaining untreated in the waiting area. I suppose that in fairness , I am obviously a tad biased because no parent wants to see their child in pain , far less for any prolonged period and perhaps I am just venting my spleen through worry for my daughter although he was so irritating and frightening for my young daughter to watch.

[enigma]

Part 1 : Mr Pahoehoe - The injuries which the man seemed to have sustained looked to me to be no more than bruising due to him becoming embroiled in a scuffle with a couple of other men.(Which he took great delight in telling me and everyone else in the room) Now granted , by my own admission I am not medically qualified to pass judgement on the injuries which he may or may not have sustained , however he did not see the triage nurse at all - instead he was fast tracked to the treatment room to await examination - bypassing the whole process whereby patients must see the nurse before being recommended for further treatment , thus freeing up the doctors' time. In essence it is a wonderful idea , however I feel that it falls by the wayside when people can see the doctor immediately by displaying acts of anti-social behaviour. I acknowledge that my daughter's injury of a broken wrist will undoubtedly not have been the highest case on the doctors' agenda and I am not suggesting that my daughter should have been seen immediately because there were far more pressing cases than my daughter and I am fair minded enough to know that those in most need should be given the highest priority. It just appals me that those of us who appreciate the workload of the stressed out A&E staff and who sit patiently waiting their turn , become sidelined to make room for idiots like the male in question. There was no escape from him either though because he was becoming abusive towards a doctor and nurse who were attempting to treat him so they left him in a cubicle to presumably cool off and put my daughter in the cubicle opposite him ! We had no alternative but to face him all over again until my daughter was moved once more. Even when we finally left the A&E , he was still bouncing about outside muttering loudly.

[enigma]

Part 2 : I don't really have much experience of A&E as the last time I was there I was only a young girl myself so I guess that I have been lucky until now ( .... touching wood as I type this !) That is why I am most grateful for your comments so thank you all once again

[enigma]

Joko - It may not have been life threatening - as I have already stated - but quite clearly my daughter was in distress and a great deal of pain. Let's not forget that my daughter is EIGHT years old and doesn't have the best coping strategies as yet compared to that of an adult , so from her perspective , it IS a big deal. It didn't help matters that my daughter had to listen to this man boasting about his fighting performance through a choice of carefully selected colourful words so as I am sure you can tell from my answer , I do not have a great deal of sympathy for this man because unlike my daughter , he PUT himself in the A&E - my daughter did not and that's the difference. As I stated in my question , I acknowledge that those with a high priority should see the doctor first - I am not disputing this. My gripe is solely with the way that this man was immediately taken to a treatment room - bypassing the nurse and cutting short the whole process which others - many with clearly visible injuries and yes , many with more serious ones than my daughter - were more than happy to wait their turn. My argument is , why should this man be given a higher priority for being obnoxious ? Not that I feel that my daughter should have ben top priority as I have already stated. Whilst you have my full sympathy for the trauma you must have suffered with an ectopic pregnancy , I do not feel that it is fair to suggest that because my daughter's injury was not 'life threatening' or 'fatal' , it is less important than this man's injury !

[enigma]

What I failed to mention of course and perhaps which would have given a greater degree of clarity to the picture , is that my daughter also has a bloodied cut on her head which she gained in her fall , through hitting the pavement. I forgot to mention this as it doesn't seem as important now that I am in full possesion of the facts and know that my daughter has not suffered any form of concussion. However , this was most certainly not known at the time and yet we still had to wait patiently to go through the whole process. So it is not fair to suggest that this man be treated first Joko. We could all have resorted to anti-social behaviour to ensure an easier wait in A&E but most of us managed to maintain a sense of decorum.

[joko]

enigma - I don't recall saying this man should be treated first - do not put words in my mouth!

I merely said, that as you are not a doctor or nurse, you have no idea what was actually wrong with him, so are hardly qualified to judge who has priority.

Also, rather than convincing me that what happened was unfair, I think, from your account, that the staff did exactly the right thing!

They have a duty to ensure the safety for everyone in the building and, according to you, he became agitated simply because you didn't have a cigarette! They were already aware he was a violent man, as he was bragging about being so earlier. They need to not only treat the already injured people, but to prevent any more people becoming injured. How do you expect them to do their job if they have to watch this mans behaviour and suffer his verbal abuse?

This man needed to be removed asap as he was becoming a threat - had he been healthy enough they would have called security to remove him from the premises - but he obviously needed some form of treatment - perhaps even just a few dressings - and they figured the quickest way to get him to leave was to treat him and then chuck him out

this makes perfect sense to me! I fail to see your problem. Sure its annoying and you were anxious about your daughter, but would you really have wanted to sit there with him while he waited his turn - for 4 hours? I doubt it! Imagine the kind of mood he'd have been in after 4 hours! It doesn't bare thinking about!

.

[joko]

continued...

Yes, its unfair, yes, he should have waited his turn like everyone else - but under the circumstance the safety of other people was their prority, not a broken wrist. He certainly wasn't being given 'special treatment', you say that like he was being rewarded! Their 'priority' was to remove danger, which is what they did.

What if he had attacked someone? Or something? Or you - or your daughter? You'd have been wishing they had seen him and got rid of him sooner!

As for the other comment - you asked people for their longest waiting time in triage - and I answered - i did not make a comparison to your daughters wrist. All I said was 8 hours with a potentially fatal condition! Again, don't tell me what i said.

8 hours and you think 4 hours with a broken wrist is a long time? - i'd say you were very lucky! It is always a long wait regardless of your injury - people are treated equally, its not children first - don't know where you got that idea from!

you need to calm down and stop getting irrate at people and imagining slights were there are none.

just be glad it wasn't more serious

[Supernick]

I had the misfortune to break my foot playing football on bonfire night. Never break anything on bonfire night because you'll join a queue stretching round the block, and feel a compulsion to let the latest howling child vs sparkler incident in front of you. I must have been 6 of the most painful hours of my life there.

The last time I was in casualty with torn ligaments, (football again) I was there 4 hours and all the drinks machines were broken. When I asked if I could get a glass of water, I was told that there wasn't anywhere I could get one, and that I would just have to wait until I left. Fabulous.

[enigma]

Part 1 : Joko - The situation was most definitely a 'you had to be there' type. The man in question WAS there because he was drunk - whatever way you dress it up. He informed the patients in the waiting room that had been the instigator of the scuffle and seemed proud of the fact that the other men had come off worst. To reiterate the point in my last post , he - unlike my daughter - PUT himself in the A&E as a direct result of his behaviour. You seem to be trivialising the issue of my daughter's wrist and although it may not be the most serious of injuries which the A&E will have undoubtedly seen that night ( as I have already stated ) it is hardly on a par with a stubbed toe. My daughter was in distress and clearly in pain and had to listen to this man's foul language. If you had bothered to fully read my answer before your last post , you would have noted that the removal of this man from the waiting room did NOT keep my daughter away from him and in actual fact had quite the opposite effect - he was in the opposite cubicle to her for a prolonged period !

[enigma]

Part 2 :
' I agree with just getting him out of the way ..... no offence but a broken wrist is not life threatening !' When did I say it was ? I was not attempting to put words into your mouth , rather , I was paraphrasing. My interpretation of your answer was that the man should indeed have ben treated before my daughter because as you have stated on a couple of occasions now , a broken wrist is not life threatening or fatal. The fact that you have mentioned my daughter's wrist in this way so often suggests that it is more a bone of contention with you.

I am truly amazed by your supercillious attitude and can not believe that you have the temerity to tell me that I need 'to calm down and stop getting irate at people and imagining slights where there are none' Firstly , I did not input any anger to my posts , it was frustration and weariness which was coming to the fore. I was not attcking you for your answer however , I picked up on your liberal use of exclamation marks in asserting your answer with your first post whereby you felt the need to emphasize your point about the man not being there because he was drunk and furthermore , seeking to advise me - again emphasized by an exclamation mark - that an ectopic pregnancy is potentially fatal. I am acutely aware of this fact and did not need to have it spelled out to me with an exclamation mark for emphasis. I suppose that this is the problem with non verbal communication - it can be difficult to pick up on tone in conversation , giving the illusion of anger or undertones of animosity

[enigma]

Poor you Supernick , that's awful. As I have mentioned before , I have been extremely lucky up until now so had very little knowledge of how the A&E dept actually operated so I appreciate what you are saying. I realise that my daughter's situation could have been a lot worse and I am obviously thankful for the fact that she did not sustain any serious head injuries in her fall. People like you and indeed all of the others who have had a hefty wait in A&E have my full sympathy - a drunken man who put himself there by his own actions does not , I am sorry. I honestly had no idea - as naive as that may sound - that the wait was just so long. In my daughter's case though , the waiting room wasn't exactly bursting at the seams as it was 4pm on a Tuesday afternoon - not the weekend where I would have expected it to have been heaving , of course I accept that obviously accidents can and do occur at any given time. At least I know what to expect now - I just hope that I don't have to repeat the experience any time in the near future !

[jake-the-peg]

I think there are two issues here that are getting confused.

Firstly the man's drunkeness secondly his behaviour.

A&E decissions have to be made on somebody's clinical need not the manner in which they received their injury.

You can't ask medical staff to put patient A over patient B because B's injury was because he was drunk or over C because he was careless with a lawn mower - otherwise the A&E department would become a court with moral judgements being handed out!

So the real point is not that he was drunk but his behaviour.

Abusive patients are a hot topic in the NHS you might find this interesting

http://www.dh.gov.uk/PublicationsAndStatistics/LettersAndCirculars/HealthServiceCirculars/HealthServiceCircularsArticle/fs/en?CONTENT_ID=4003624&chk=Khg%2Bym

it's the guidelines around witholding treatment from abusive patients.

Reading between the lines I'd guess that in this case there was no actual violence and the staff thought that confrontation and "a stern warning" or whatever might precipitate it.

Given that a fist-fight in A&E could increase their workload getting him in and out sounds like a good idea.

Lets face it, if they'd tried to kick him out and you or your daughter had been hurt in the struggle that would probably have been worse.

Hope your daughter's feeling better - they mend quickly - my son broke his arm at 10 and was right as rain very quickly

[enigma]

Thank you for your link Jake-the-peg , it was very useful. I understand what you are saying about the need to remove him from the A&E dept and in hindsight , I completely agree with you that he should have been removed to maintain a level of safety for patients and staff. I just found his removal to be ineffective however , when he was placed in the hub of the treatment rooms , where my daughter and I had to sit opposite him once more. It was quite terrifying for my daughter to witness his violent outbursts , so unfortunately there was no escape from him. She's not used to witnessing such diplays of violence and I guess being her mother , I was trying to protect her from all of that but such is life I guess and I realise that I can't wrap her in cotton wool forever. It's just infuriating to see someone who deliberately engineered a fight - and thus subsequently sustained injuries as a result - demanding to be seen immediately. This by my reckoning is not an accident but the consequences of his violent actions. It was just the way he was being disrespectful to the staff and alarming other patients which annoyed me because it could have all been avoided if he had not engaged in a fight with the other men. I'm just not used to dealings in the A&E and it was certainly an eye opener. At least my daughter is over the worst now and thank you to those of you who asked after her. She has bounced back quite well and is enjoying being fussed over - especially at school where her classmates want to sign her cast.

[joko]

enigma - your self righteous attitude is laughable.
Just because it was his own fault he was there doesn't mean he doesn't get treated! The hospital staff are not there to punish and judge they are there to treat people who have been injured plain and simple. And no, he wasn't there just because he was drunk! He was there because he had injured himself whilst being drunk - try to see the difference!
I personally agree with you, from an anger point of view, this scumbag should have been made to wait for hours and suffer and be in pain and then arrested and thrown in the cells, and he would have clearly deserved it - but that is unprofessional and the staff are taught not to make those kind of judgements.
You seem to post over and over again yet every time you ignore the fact that he was treated first to get rid of him, not because they thought he deserved better treatment than your daughter - why is that so hard for you to understand?
You little punctuation nonsense just shows what kind of person you are - pathetic. I hardly think that about 6-7 punctuation marks in 2000 words is liberal and the fact that you are offended (!) at my use of them when mentioning a fatal illness, unbelievably assuming that I was implying you don't know how serious fatal is, shows that you are oversensitive, neurotic, argumentative, unrealistic and you need to get a grip. You clearly don't understand what others are trying to say so maybe more punctuation in needed!
Besides, that mark was to emphasise the stupidity of keeping someone with a potentially life threatening condition waiting for 8 hours - backing up your question about how ridiculously long the waiting times are! - or didn't you understand that from my previous explanation - or in your blind rage didn't you even read it?