Above and beyond: a story

The NHS relies on its staff going ‘above and beyond’. Compliment letters from patients and relatives often refer to this quality in nurses or doctors; the extra effort, the small acts of care or kindness that are not required, but which make a big difference. At an organisational level, good and safe care often does require staff to deliver ‘above and beyond’ in terms of time and effort. There is a perpetual tension between what is agreed in terms of hours (more clearly defined in recent years) and what is actually expected, in the name of professionalism, duty of care or sense of vocation.

Trainees can now use exception reports to highlight when they have had to stay late or do extra work. This appears to signify that the NHS recognises that extra work cannot be taken for granted. If a series of reports arise from a particular unit, that unit needs to re-organise itself; this is no bad thing. But trainees are often reluctant to submit these reports, because doing so appears contrary to unspoken expectation to see tasks through to the end and protect colleagues from the overspill.

One response to this is that it’s all about staffing levels. However, medical needs have a habit of filling the available space and rarely respecting agreed boundaries. To deliver good care we will often need to try just a little harder, and dig a little deeper for resources.

The story that follows shows how apparently minor examples of going above and beyond can make a huge difference. It is not intended to suggest that we all go above and beyond all of the time, but to remind us that there are critical points in patients’ journeys that are vulnerable if only the basics are done. It ends at the beginning, the beginning is in the middle, and it starts again at the end…

 

Day 84

“I know this man. I saw this man in the ED, months ago. He looks awful!” said Dr Jack Sommers. It had taken him a minute to place the cachectic, breathless man who had just arrived on the ward.

The patient, David Spencer, had been brought in by a shocked and infrequent visitor to his home, and was far too weak to leave under his own steam. If he could have, he would have.

Jack remembered David because he was there when David first attended the hospital with the tell-tale symptoms of lung cancer. Now David had been admitted a complicating chest infection, low oxygen levels and a chest x-ray suggesting advanced malignancy. The tumour was closing down a large proportion of his left lung. Any passing doctor could have told you –  this patient was here to die. Before approaching David, Jack asked himself – what the hell happened to you? You were supposed to get treated…

 

Day 45

Grigor Slastsky, respiratory consultant, clicked through his emails after two weeks away. There were 193. Most were generic: bed alerts, fire alarm warnings, adverts for the next grand round, requests for bed-side teaching. Many concerned patients to whom he had no connection, as far as he could recall. The odd one triggered a definite memory, and caused him to rush into the results system to check on a blood test result or scan report. The few that required a considered response he marked as ‘unread’ so he could come back later. One of the last to be opened was from nuclear medicine:

                – Your patient David Spencer failed to attend for his PET scan on 4.7.20__. As this was his second non-attendance we have removed him from the waiting list. If you wish to re-instate him please submit a new request. –

Grigor rolled the name around in his mind. No, no memory. He checked to see who had requested the scan – yes, the Clinical Nurse Specialist, on the back of a multi-disciplinary meeting in which the patient’s initial CT scan had been discussed. Yet, curiously, there was no record of the patient ever having attended a clinic.

Grigor glanced at his watch. Time to hit the ward. It was his week to cover the service, a sure way to flush the memory of those marvellous South East Asian monuments and vistas out of his system. David Spencer… no, definitely no memory, and Grigor prided himself on knowing what was happening with his patients. If he belonged to a colleague, they would pick this up. Or the CNS. They should, because PET scans were important, after all – they could make the difference between curative surgery and palliative chemotherapy.

He deleted the email.

 

Day 8

Harleen Dahiya was running late. Her clinic was overbooked – the ‘template’ was 12, but there were 16 on her list. She was 11 down, but well behind, because two of them had required way more than their allotted ten minutes. Follow-up patients should be easy, in theory, because all the facts have been established at the initial ‘new patient’ visit, during a luxurious 20 minutes. At the follow-up visit, it’s just a matter of looking at results, going through them in plain language, and agreeing on a management plan. But Harleen found, paradoxically, that the follow-ups were actually harder. Patients tended to have dwelt over the words, signals and indications given out during the first visit; they reconsidered their symptoms and wished to present them anew. They came with expectations.

A knock at the door. A nurse put her head round. Harleen apologised to the patient before her and stepped out; it was clearly important.

                “Harls, one of the new patients has rung, he sounds stressed. He’s running late.”

                “Is that the DNA (do not attend)? The 3.10?”

                “Yes. He’s not actually DNA’d yet on the system. Will you see him?”

                “It’s 4.45. I… I can’t really…”

                “No pressure Harls, up to you. Sounds like he missed a train or something… and he’s a two week wait…” (meaning possible cancer).

Harleen considered, but shook her head. “Sorry Diane, I’m going to say no. He’s well over an hour late, I really can’t. We’ll just rebook him.”

Diane nodded and left.

Harleen re-entered her clinic room and glanced at the name on the list before re-engaging with the present patient. David Spencer. She’d never heard of him. But she marked a form to ensure that he was offered another chance. She hoped he would. Maybe next time he would make more of an effort. The symptoms that Harleen had read on the referral letter were, after all, quite worrying.

Harleen left the out-patient department at 6.35PM, an hour after the stated endpoint of the session. She did not notice the tense couple standing outside the sliding door, he smoking, her, curiously similar in facial features, as though related, admonishing him. They were discussing how best to get home after a wasted journey.

 

Day zero

Jack Sommers, respiratory registrar, moved from one crisis to another in the emergency room. Although he had imagined that role would be more supervisory, in fact the construction of the rota meant he had to clerk patients from scratch. Which was fine; he was experienced, and fast.

The next patient was one David Spencer. Jack read the card and felt a wave of annoyance rise within him. The referral was weak; he had been coughing up blood for two weeks. There was worsening breathlessness. But, looking at the man from across the room, he was in no distress whatsoever. He could easily be seen in the two week wait clinic. The fact that it was 1.45PM didn’t help.

Next to Mr Spencer stood a worried looking woman of similar age – late 50’s. She looked as though she was standing next to an explosive object. Jack soon discovered that she was a sister. Why here? To support her brother, ‘…because, doctor, he hates hospitals. I could barely persuade ho come in at all.’ Silently, Jack responded that she needn’t have bothered. This was neither an ‘accident nor an emergency’, as harried and over-worked ED staff were sometimes heard to say.

He took the history. Yes, it was worrying. Cough, big smoking history, degree of weight loss… and on examination, yes, nicotine stained fingers, ominous crackles.

                “Doctor said I needed a scan,” mumbled David.

                “Yes, you do, in fact I think we can overlook the chest x-ray and go straight to a scan. But this can be done tomorrow, maybe the day after.”

                Jack saw how David became tense. The impression of explosiveness that his sister’s anxious, braced position appeared to portend was now doubled.

                “She said I’d have it today.”

                “That’s not really appropriate, given the time now Mr Spencer. I’ll do my best to get it arranged…”

David sat up and swung his legs down from the trolley. “In that case why the hell am I here?”

Except he didn’t say ‘Hell’, he said something stronger. And Jack’s tired mind did not have the spare… tolerance, understanding, empathy… to accommodate this rudeness. He answered,

                “You are very free to go Mr Spencer, this is not a prison.”

His sister seemed to fold on herself; she knew this was going to happen. As he left Jack regretted his impatience and said, “Look, I’ll request a CT scan for you, this week, next week at the latest. You’ll get a letter. And a clinic appointment. Make sure you come!” The sister turned to indicate that she had heard him. David turned into a corridor, never pausing.

 

 

Day 3

Jack had got over his night shift, and he regretted his failure to engage properly with that (highly probably) cancer patient. He could barely remember his name. So he went down to ED and asked the receptionist to show him on a screen a list of all the patients who had been assigned to medical review that night. Spencer, David. It jumped out at him. The image of him and his sister came alive in Jack’s mind. Back in his department he called David’s home number. There was no answer. Then he called the next of kin – the sister, Janet. Evidently married, as she had a different surname.

                “Mrs Marić, it’s Dr Sommers here, I met you and your brother briefly the other night. I wanted to make sure that David would attend the CT scan I arranged for him. It’s tomorrow. Is he coming?”

                “I’m not his keeper doctor, but I’ll do my best. Will they be… understanding, you know, he’s got a temper, always has.”

                “As much as they can Mrs Marić. I’ll warn them that David as problems with hospitals. I’m sure they’ll be kind.”

Jack walked to radiology and did all he could to prepare them for this ‘special’ patient. He suggested they allocate for time. He also asked the CNS to meet the patient when he arrived at the hospital, to grease the wheels. Jack had no idea whether all this would work or not. But he had done his best.

 

Day 15

Harleen Dahiya was running late. Her clinic was overbooked – the ‘template’ was 12, but there were 16 on her list.

A knock at the door. A nurse put her head round. Harleen apologised to the patient before her and stepped out; it was clearly important.

                “Harls, one of the new patients has rung, he sounds stressed. He’s running late.”

                “Is that the DNA (do not attend)? The 3.10?”

                “Yes. Said he missed a bus.”

                “Five buses more like. What’s the referral anyway?”

The nurse proffered it, prepared for the question. Coughing blood, weight loss, smoker. Urgent referral. CT scan already done… Harleen could not work out how or why; the GPs didn’t usually arrange them. But somebody had.

                “Leave it with me.”

Harleen finished with the present patient, dictated the letter, and typed in the details of the late ‘new’ patient into the result system. The CT report was published. Large tumour, some enlarged nodes. No other deposits. Harleen could tell that this cancer was potentially resectable. A cure was possible – theoretically. Yes, many fell at one of the hurdles, a PET scan showed a deposit, or the patient’s lungs were to destroyed by cigarettes to sustain major surgery… but there was a chance.

She left the room and told the nurse to accept David Spencer onto the clinic list.

 

Day 23

Grigor Slastsky, respiratory consultant, clicked through his emails after two weeks away. There were 193. One of the last to be opened was from nuclear medicine:

                – Your patient David Spencer failed to attend for his PET scan on 4.7.20__. As this was his second non-attendance we have removed him from the waiting list. If you wish to re-instate him please submit a new request. –

Grigor rolled the name around in his mind. No; no memory. He checked to see who had requested the scan – yes, the Clinical Nurse Specialist, on the back of a multi-disciplinary meeting in which the patient’s initial CT scan had been discussed. Yet, curiously, there was no record of the patient ever having attended a clinic.

No. He did remember something. Both the specialist trainees, Jack and Harleen, had mentioned something just before his holiday. A patient with issues. Anger issues, hospital-phobia, something. But potentially curable. Grigor was now a few minutes late for the ward round. It was a mistake to get into emails at this time. But because his name was on the system as ‘named consultant’ for this unreliable patient, nuclear medicine had dumped this problem in his in-tray.

In a rush, with rapid keystrokes, he re-ordered the PET scan and wrote to both of his trainees (CC. the CNS) – ‘please get hold of this man and make sure he attends!’

 

Day 51

“I know this man.”

Jack Sommers was on call again. A familiar name popped up on the list of patients to be seen. Spencer, David. Jack remembered him well. He presumed the presentation was due to some sort of complication of the tumour – infection, bleeding, maybe just breathless. Jack took the card for himself – he knew the story so well it would save somebody else having to go through it all for the first time. ED staff had already performed an x-ray. Jack reviewed it – the entire right lung space was full of fluid.

David looked rough; on oxygen, breathing hard, still thin. Jack introduced himself, and then noticed the sister. She looked worried as usual.

                “What’s happening Doctor?” she asked.

                “It’s the tumour, they make the lungs leak fluid sometimes. We’ll get it drained, it will make him feel better quickly.” But privately he was worried. In his experience, albeit still limited, this suggested things had advanced, that surgery was less likely to be offered.

                “But they said the tumour was all gone!”

                “What?”

                Jack moved to David’s back and saw the tell-tale scars of recent surgery. David had already undergone a resection! Jack smiled, relieved, happy that the patient he had made an extra effort for had progressed through the system, passed the hurdles, been selected and operated upon.

                “Don’t worry too much,” he now said. “Fluid can build up after lung resections. We’ll deal with it. Don’t worry. You’ve done the hard part already.”

 

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