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DAVE Caesar, clinical director of emergency medicine, Edinburgh Royal Infirmary and St John’s Hospital, Livingston, gives an insight into treating foreigners.

Crazy season is here again.

The hordes of perennial visitors to our spectacular city pose a variety of seasonal challenges to us in the Emergency Department. Not only the “New Town is my second home dahlings” lot, who in the excitement of their latest four-star review (who doesn’t get a four-star review?) forget their regular medications or misplace them in a dank dark cellar at three in the morning, but also the foreign visitors.

“Lost in translation” doesn’t cover some of the difficulties in trying to treat and manage overseas tourists. Not only do you have to grasp their medical problem, but you also have to have some insight into their cultural expectations and preconceptions of their healthcare system and our own beloved NHS, as well as trying to arrange their logistics and travel. It all makes for an interesting month.

An Italian patient came in last week. He was a well gentleman in his 50s, visiting with his wife as part of an organised tour. His triage note said his wife spoke English – true if ordering a coffee, and her English was way better than my Italian – but when it came to translating a medical history, things quickly started to unravel.

Not unlike some of the Fringe shows, we explored a multisensory mosaic of information transfer in an attempt to understand his problem. After 15 minutes or so, I figured out that the patient was in urinary retention – a particularly painful and distressing condition where you are desperate to pass urine, but are unable to, due to a kink at the bladder neck, often caused by an enlarged prostate.

I then embarked on my attempt to explain this to him and his wife, and also to describe what the treatment would be: inserting a catheter (tube) through his penis into his bladder to drain the collecting urine. When I found myself miming this treatment option to these very respectable tourists, I figured another strategy was required.

Cue the interpretation service: a couple of phone calls later, and 30 minutes of to-ing and fro-ing with the phone to the patient, and we at least all understood what the situation was, and how we were going to resolve it.

The gentleman had his condition resolved, had a plan of how to join his tour and get home, and seemed grateful for our intervention. The whole episode had taken twice as long as if he had been a local, and this is often the major difficulty – patients just take longer to deal with.

Shortly after, a German patient was brought in by ambulance from a cruise ship. She came with a letter of barely comprehensible medical German from the cruise ship Doctor, who had diagnosed this elderly lady with heart failure and pulmonary oedema (fluid on her lungs). She had been treated with a slightly unusual (to us) combination of therapy, but seemed to be better than she had been, and after a full assessment, some routine investigations, and some more treatment in the Emergency Department, we agreed that she could go back to her ship.

This, by all accounts, was not what the Ship’s Doctor was anticipating, and the Good Doctor made her way from the ship up to the Emergency Department to discuss our plan. In strides this lady, starched white uniform, somewhere between Hattie Jakes in her “Carry On” prime and Rosa Kleb from 007’s From Russia with Love was matronly but not to be crossed!

After some more pained broken German / English, a consensus was reached, and the whole affair ended with such happy patients that as they left the Emergency Department they were stuffing 20 Euros into our junior doctor’s surgical scrubs like he was in some medical burlesque show. He did his best to refuse, but one glance from the Good Doctor was enough for it to be accepted and later added to the Medic One Charity fund.

Extra 1000 patients in August

EVERY August, the Emergency Department receives approximately 10 per cent more patients than any other month – that’s an extra 1000 patients – and many of these are from outside Lothian. On top of some of the language difficulties, we have to grapple with alternative follow-up arrangements, and making tailored plans for patients to fit in with travel plans and the like. It also makes accessing previous records and understanding current medication, and their interactions with British medications, quite a headache.

In the first week in August, we also are part of the UK-wide junior doctor changeover. This additional dimension adds to the slight slowdown of efficiency, but there are undoubtedly some priceless moments too.