The NHS is facing one of the worst winters it has ever seen. The Red Cross has described a "humanitarian crisis" in A&E departments as a surge in demand and funding pressures collide, leading to lengthy waiting times, packed wards, and hospitals declaring major incidents.
Dr Mike McLaughlin, a senior A&E doctor, described the reality of life on the front line to BuzzFeed News as he recounted a night shift in an NHS hospital this week...
9:30pm: On the bus to work, the announcement tells me I’m two stops away from the hospital and my chest gets tight. My heart races as my mind jumps to the worst of the possibilities that might lie in front of me.
I know of colleagues who have had panic attacks on the way to work. I thankfully have not. This is my third of three 10-hour night shifts in a row.
9:35pm: I walk in through the waiting room. There are lots of babies crying and coughing. I see a lot of unhappy faces.
9:45pm: I get changed into scrubs and drink two pints of juice and a large Americano coffee. I might not get another drink for the rest of my shift.
10pm: The day staff's faces immediately brighten up when everyone arrives for the night shift. They look battered.
The consultant doctors will be on until midnight, luckily, but then they need to go home – we can’t keep burning them out. Sometimes we have two senior doctors on, but often it's just one of us. Not enough juniors want to stick with emergency medicine training.
The day team do a handover and there are 25 people waiting to be seen in “majors”, which includes anyone with potentially serious medical problems. There’s no cubicle space, so many of them wait on chairs. The bed manager is doing their utmost to open up more beds, but there’s about a three-and-a-half-hour wait to see them. I’m lucky – my hospital finds the beds, many others don’t. For patients whose conditions might not be life-threatening, there’s more than a four-hour wait. The resuscitation bays are full, again.
10:10pm: I check the records of a patient I saw yesterday evening. She has died overnight. I tell the nurse who looked after her and we’re both quiet for a while. We're involved with patients who die all the time, but it’s still upsetting. She was a lovely patient, so pleasant with us. It’s a pleasure to have known her for that brief time.
I see a missed call and then a text from my mum. She feels unwell and wants me to call. It’s odd, because she never asks, so I reply: “Yes, will do in a few minutes.”
10:15pm: I try to go through the “toaster rack”, which is what we call the queue of notes for unseen patients. I order the necessary bloods and X-rays and try to prescribe medications to help where I can.
Amid the chaos I need to try to identify who’s the sickest and try to catch them before they get worse, to try to make the department as safe as I can.
11:40pm: Now I’ve gone through the rack I can start seeing patients. Most of the people in the "majors" department are here for good reasons: chest pains, short of breath, abdominal pains, pains not settled by their usual medications.
You can’t criticise people for coming to an A&E when we tell them to come to A&E with those symptoms.
One patient has a leg infection and needs intravenous antibiotics. She doesn’t need to be in hospital overnight as these antibiotics could be given at home. But the service that does this has just closed, so she has to be admitted to a hospital bed. If only we had 24-hour community services.
I take a sample of knee fluid from a man with a swelling that could be infected and send it to the lab. It may take two hours to get the results as they’re understandably busy.
I ask if he can be admitted to the orthopaedic ward while he waits, to free up the cubicle for another patient, but the specialist declines, saying I haven’t proved he needs to be admitted yet. There’s nothing I can do.
1am: Ambulances are queuing up, and the nursing staff and senior management immediately get on the case to find beds for the patients to get the ambulances back on the street. They are working so hard, but it’s always tight.
Suddenly there’s a cacophony of alarms and shouts for help. I follow staff rushing to a cubicle where someone has collapsed.
There’s no pulse. CPR is started and we rush the patient to the resuscitation room. We get his heart restarted and discover a burst aneurism in his belly. He’s my sickest patient right now.
But I have to ensure the rest of the department doesn’t grind to a halt, so I leave him to the specialist and return to several junior doctors needing advice. Throughout the night I'm constantly ensuring safe decisions are being made.
We're not hitting our four-hour waiting time target by now. I want to tell patients I understand their anger and frustration, that I too have been a patient and a relative in A&E. I want to ask them to direct their anger at those who have created this crisis, but I don’t. You just have to crack on and do what you can.
2:20am: I’m needed in resuscitation to sedate a patient so their joint can be relocated. I’m the only one who is trained in sedation.
The procedure is successful – I actually quite enjoy the clunk of a joint going back into place. It’s the fun bit.
I would have liked to teach my juniors, but there’s no time – we just need to get the job done safely. Two years ago I could have stopped and educated, but now we need to crack on – there are patients waiting.
2:50am: I see an elderly lady who’s fallen, but is to fine be discharged. We can’t send her home though, because she has nobody to check on her, so she is admitted into hospital. If only we had 24-hour non-emergency community services.
3:15am: An angry relative wants to know when her son will be seen. He has a lot of pain in his belly and feels sick. I apologise for the wait and give a prescription for pain relief and anti-sickness medications for a nurse to administer. The relative tuts and walks off.
I walk past a nurse who’s red in the eyes from crying. She tells me she feels like she can’t be as good a nurse as she wants to be because there are too many patients to see. We're friends and she confides in me that she's found another job, she's leaving A&E. She's been resilient for so long, but now feels broken. One of the good ones has had enough.
3:20am: A man who is intoxicated on illegal drugs is being violent and I’m joined by security. He’s got fresh bruising over his head and keeps falling asleep.
He wakes up and demands that we let him leave, but we are concerned about his safety. He threatens to “fuck me up” and “wait for me at the end of my shift”.
It’s scary but I don’t let it show. The police won’t take him into custody because I can’t medically clear him and eventually he falls asleep again without needing to be restrained. Hours later he wakes up and asked for a cup of tea and sandwich. I am able to medically clear him for discharge and then he’s arrested.
Physical and verbal aggression is a common occurrence in every A&E. I hate it most when someone spits at you. You never feel clean after that.
3:30am: A colleague brings me a coffee – it’s my first drink since starting. I also inhale a few biscuits left on the nurse’s station. That’s my fuel for tonight: black coffee and whatever sugar-coated biscuits are lying about.
3:40am: I’m asked to go back to resuscitation, where a very elderly lady is dying. There’s nothing more that can be done – we feel death is imminent. It’s always difficult to explain to a family that we think their loved one is dying and there’s nothing more we can do.
It’s a conversation that any senior A&E doctor will have repeatedly in their career. It demands time and consideration. I wait with the family and hold the elderly lady’s hand. She’s got thin black hair and black glasses, like my grandmother. That hits home a bit. But I’m aware there’s a department out there that needs my attention. I need to get back and I feel terrible.
4am: I look at the “toaster rack” and there are still so many patients to be seen. We’re not getting on top of this. It's soul-destroying.
Ambulances keep arriving. We’ve been told other busy hospitals have started diverting emergencies here, and we receive more patients.
5am: I’m asked to intervene in a dispute. One of my juniors has said a patient can go home but the daughter of the patient doesn’t agree and is unhappy.
Her mum has complex needs and she feels like she’s getting nowhere with her GP, the local council, who are responsible for social care, or her specialist doctors. But at 5am in the morning we can’t help her with that. We are here for emergencies.
I understand people will vent at us on the front line. I knew this before I came into the job, but it still grinds you down. It also takes time when I could be seeing other patients.
The daughter makes an off-the-cuff remark about me not understanding what it's like to have a sick family member and I remember that I didn’t call my mum back.
I feel pretty bloody rubbish.
6:30am: I see a patient who says he can’t breathe so we prioritise him. It turns out he has had a blocked nose for a year. He shows me all the medications his GP has tried but wants a second opinion.
I explain that this is an unnecessary A&E attendance and he looks shocked – he says he's going to complain and take me to court for negligence. He’s quickly discharged.
7am: Day staff start to arrive and the “toaster rack” is thinning. There are only three patients still in the queue from last night. The end is in sight.
I thank juniors for how hard they’ve worked, and the nursing staff who have put up with a lot more abuse than I did. They never complained, they just kept going.
I don’t envy the decision-makers. When there are no more beds available, it’s not just about the beds. You can’t go through a period of “efficiency savings” and then open more wards to deal with more demand. That requires more funds. The demand for community services is at a peak – we need more of it.
NHS leaders are trying to get more nurses and doctors into A&E, but fewer people want to work right at the front line. Can you blame them? The most depressing part is that there seems to be no plan to improve the dire situation from our political leaders.
7:30am: It’s time for me to go home. As I leave the building my chest tightens again. Is that violent guy from earlier waiting for me as he promised?
Laura Silver is a reporter for BuzzFeed News and is based in London.
Contact Laura Silver at firstname.lastname@example.org.
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