by Rodney Dale

(Notwithstanding political correctness, and for the sake of simplicity and clarity, the patient herein is male; the carer – sorry about that word, but it’s useful – female.)

Having avoided staying overnight in hospital for over 60 years I found myself being an in-patient no fewer than five times in the twelve months beginning 16 May 1995 – two private; three NHS. My first stay was just over a fortnight in the Evelyn Hospital in Cambridge for a resection of the colon – I had cancer, but it’s all right now. A fortnight before Christmas that year I was blue-lighted into A&E at Addenbrooke’s Hospital (NHS) where I stayed in a surgical ward for exactly a week while my septicaemia abated and its cause was sought – nothing to do with my previous condition. Just after the New Year, I was back in Addenbrooke’s for 48 hours for an ERCP (endoscopic retrograde cholangiopancreatography) to investigate my gall bladder. A fortnight later, the septicaemia blew up again and I was back again as an emergency admission – shortage of beds put me first in the Transplant Unit (where everyone else looked rather yellow and battered) for one night, then in ENT (where everyone else had a Hitler moustache – which turned out to be an epistaxis dressing) for three nights, and finally in the correct surgical ward for the last night only. In March, I was back in the Evelyn Hospital for 48 hours for a cholecystectomy – removal of the gall bladder (through the keyhole)..

For some of the time during all these procedures my mind was elsewhere, but for the rest of the time I tried to note the behaviour of members of staff with a view, I hoped, to distilling some observations which might be of interest, though it has been difficult to recapture some of the fugitive thoughts that seemed so important at the time.

One up; one down

Being a patient is a lifeskill and, like so many other lifeskills, is hardly recognised as such – nor (unsurprisingly) is it taught. The patient is (as Stephen Potter would have said) in a one-down position – in the nicest possible way, of course. Paradoxically, the patient is both the most important person in the team (in that without him the whole structure would be pointless) and the least important (in that the structure is in place and weighing down upon him). For the structure to work properly, the patient has to become subservient to it (for example, submitting to having his temperature taken whenever asked), while retaining those facets of his individuality which are also essential to being a good patient (for example, being able to describe his condition, or being pathetically grateful for the ‘care’ he receives).

Who’s who

It should go without saying that the patient should have a good relationship with his carers. An important element of this is that he should recognise who those people are, and it may come as an ego-puncturing revelation to some that the main thing the patient notices about a carer (apart from some distinguishing feature such as unusual size, voice, hairstyle, manner and so on) is the colour of her uniform. To the patient in his stupor, perhaps without his spectacles, name badges mean little; he does not necessarily appreciate that this attendant is the same as, or different from, the previous one – sorry. As time progresses, one certainly becomes interested in who wears which uniform, and how the hierarchy works. However, people seem to be frightened of hierarchies – for example, they work ‘to’ someone rather than ‘under’ her. An example of an interesting hierarchy was displayed on the Day-room notice-board: reading upwards, the levels were: House Officer, Senior House Officer, Senior Registra (sic), Consultant, Ward Sister. Of course, even when one becomes well enough to study any mug-shots on display, the frequent discrepancy between such portraits and their subjects is well known.

Eternal triangle

Certainly a most important attribute of patient and carer is the manner of each towards the other. Thinking in diagrams, I imagine a triangular plane, on which the behaviour of patient and carer must somewhere fall. The three corners of the triangle represent hospital-centred behaviour, carer-centred behaviour, and patient-centred behaviour respectively. One manifestation of extreme hospital-centred behaviour would be strict adherence to inflexible rules and procedures. One manifestation of extreme self-centred behaviour on the part of the carer or the patient would be a complete lack of self-awareness – of the effect one was having on the other. A self-centred patient with a patient-centred carer (or vice versa) might result in somewhat unprofessional behaviour. There are an infinite number of possibe relationships according to the positions patient and carer occupy in the triangle .

As an example of different points on the triangle, let me cite the examples of two night nurses. One stumbled round the ward, talking at normal volume, turning on lights, jogging the bed, snapping the rings of the ring-binder, and leaving the lights on. The other performed (as far as I could judge) exactly the same tasks, moving silently around with a little torch to illuminate what she was doing when it was necessary. You can imagine which of them was the more popular (and the more self-aware).

Names

A name, some say, is one’s most intimate possession. One may be called Sir, Mr Dale, Rodney Dale, Rodney, or the even more familiar Rod or Rodders. In our culture at least we have natural caution – we don’t rush up to strangers in the street and embrace them. We need to find out to what extent we want to know someone before allowing – or exhibiting – intimacy, and one indication of the degree of intimacy is the way in which one person addresses another. If people address you by your first name from the start, what happens if you wish to become familiar?

The situation is akin to swearing. I have a theory that, when your speech is liberally peppered with swear words, there’s nothing left in your vocabulary for that sort of emphasis, leading you to emphasise your point with that of a knife.

In the Evelyn Hospital, I was always Sir, or Mr Dale. When the ambulance called for me for my first Addenbrookes’ stint, a paramedic asked me what I would like to be called; I replied ‘Mr Dale’ (difficult to utter, as I was brought up in the belief that one should not self-style oneself ‘Mr’ unless one happened to be a consultant). That preference penetrated A&E, and the private room in which I spent the next two days, but seemed to evaporate when I was moved into the main ward. The pinnacle of the name game was a raucous ward maid working her way along the line of beds: ‘Wake up, Albert; Wake up, Bill; Wake up, Peter; . . .’ She reached me: Wake up, Rodney’. I refused to budge; she tried again. Twice. Finally, I growled: ‘How about calling me Mr Dale?’ She tried it; I ‘woke up’.

I couldn’t help wondering what Albert, William and Peter thought about her mode of address. They were older than I (and some would assert that name preference is an ‘age thing’). If it is, so be it; why shouldn’t I be called what I wish? Why should both my mother-in-law and my mother, advanced in years and ending their days in hospital (at different times) have had to endure extra suffering by being addressed by their first names against their wishes? The sign over the bed (Name, Consultant, Primary Nurse, Diet) should show what the patient prefers to be called; all too often, the name in the box doesn’t reflect the patient’s wishes.

If I seem to have gone on at inordinate length about something some may think trivial; perhaps that means it’s not so trivial after all.

Distinguishing the patient

Not all people with grey(ing) hair lying in bed are deaf and senile. It would be a service if the carer were not only to establish the patient’s characteristics (which may be done by completing one of those at-times-oh-so-patronising forms) but also to remember the more important ones – such as the facts that he is not deaf, and retains a reasonable quantity of marbles. This might avoid one having to suffer (shouted) phrases such as: ‘Have you had your bowels open today?’ or ‘Will you pop this under your tongue for me?’ ‘Pop’, by the way, is a favourite carers’ word, and applies to everything from sub-lingual thermometer placement to flowers in a vase, via such things as nightwear and trays of food – all ‘popped’ in one way or another.

Listening

Carers ahould listen to what the patient says. A form in my folder said: ‘Assess and locate pain’, with the word ‘ongoing’ written by it – this in spite of the fact that I had said clearly, many times, that I HAD NO PAIN (and continued to be pain free). I had a double difficulty – convincing people that I had no pain, AND getting them to remember that fact. I was regularly asked about my (non-existent) pain, and whether I would like a pain killer. Perhaps ‘a pain’ = ‘something to latch on to and treat’; the confusion of the patient (a person) with the ‘set of problems’ with which he presents.

I had a similar difficulty with a Senior Registrar; while my septacaemial condition was still being investigated, he was keen to find some change of diet which might have caused it. Unguardedly, I mentioned the moules marinière I had enjoyed some weeks previously, and thereafter that once-enjoyable meal was held up as a prize piece of detective work whenever he had an audience of admiring apprentices. He became known as Mr Mussel.

Reading the (correct) notes also helps – the consultant who asked me (as an out-patient): ‘When did you have your heart by-pass?’ brought his resultant red face upon himself.

Spot the difference

‘So’, you may ask, ‘what differences did you perceive between the public and private sectors?’

The most important thing (in my opinion) that the private sector gives you is privacy, followed by unrestricted visiting, plenty of space, your own telephone and television, excellent food (for your visitors as well, if you and they wish) and a wine list. You have your own room, so your cards &c can be displayed opposite you, rather than behind you, and your flowers can be similarly positioned for admiration. The desk staff attend to you (or at least acknowledge your presence) as soon as you appear; the NHS tends to confer total invisibility on the patient approaching the desk. In the private sector, the consultants seem to be more accessible and less hurried. But I found their helpful attention the same in either sector.

Most important in the present context is that the spectrum of carer behaviour in the private sector is little different from that in the NHS – there are good ones and bad ones, as I have described, and many appear to work in both sectors anyway.

The Patient’s Charter

What of the Patient’s Charter? In my view, if you do your best, you can do no more, and the added burden of trying to meet Guidelines merely diverts time and effort from the core business. Perhaps it is all summed up in a somewhat confusing notice displayed on a ward noticeboard:

We aim for your stay in hospital to be as comfortable as possible.

This is the tool we use to assess whether your pain is well controlled.

This assessment occurs regularly.

(D7/painass)

I wonder whether that ‘painass’ is entirely serendipitous.