My apologies for the lack of blogs recently. There are loads of reasons, but the most significant reason, I think, is that winter has hit my hospital, and therefore me, hard.
We're stuck between a rock and a hard place in emergency medicine. If we say it's hard and difficult and busy and unsafe all of the time, people think we're just a broken record. If we say it's "about normal" we get accused of normalising poor care. The resulting internal conflict within yourself, and within the body of staff is difficult.
Everyone thinks it won't happen to them. They all say "if I attended ED1, there would be space for me". But they're wrong. The young, the old. The sick, the well. The needy or the undeserving. There's not space for most of them to be seen. The day to day decisions about rationing healthcare (yes, it does happen), whilst trying to maintain morale amongst the staff, all in a hostile and noisy environment, take a toll on people.
Maybe it was just as tough in your day. Just because it was tough for you, doesn't mean we shouldn't aim for it to get better. I doubt it was as tough in your day. Yes, there's been corridor care for a while. But healthcare has changed; NICE2 was invented in 1999 and guideline quantity has multiplied ferociously since then; NIV3 outside the ITU4 took off in 2000; and PALS5, who advise and support patients who wish to complain, was created in 2002. The result is healthcare is ever complicated, we're living longer, and patients (and staff) expect more than we can give, and complain if they don't get it.
But what's this got to do with hypnosis? Well, maybe hypnosis could be the answer to corridor care? What do you think? Let’s have a tour around my emergency department and see if hypnosis could help a few specific patients.
Let’s start in the rapid assessment area, where all patients who arrive by ambulance are assessed. Unfortunately, this area of nine beds has been converted into a ward for patients to stay waiting for treatment. We've got Mrs Dyspnoea, with her COPD6 exacerbation. Hypnosis could have helped her to stop smoking, and then maybe her COPD wouldn't be as bad. Mr Ethanol is addicted to alcohol, fell whilst drunk, and now has a fractured tibia and fibula. Hypnosis can help with substance misuse - so maybe Mr Ethanol wouldn't have broken his limb. But now he's here, maybe the hypnosis can help with bone healing, and reduce his length of stay.
The major’s treatment area. These are more patients who should have been assessed, but are waiting for the treatment to work. Mr Framingham has attended with chest pain and some ischaemic ECG changes. His markers of cardiac ischaemia are high, but not high enough to need transfer to a tertiary hospital. Could hypnosis help? Well, it can help address the modifiable risk factors, but there's also some evidence it can help improve prognosis. Miss Sticky has attended with a flare of sickle cell disease. Hypnosis can certainly help with the pain, and probably also help with the frequency of flares (trial result pending - see https://clinicaltrials.gov/ct2/show/NCT00393250 ). Mrs Pea has attended with severe abdominal pain, and we're suspecting a ruptured ovarian cyst. The pains all started after she was raped ten years ago. She then got married, and is having trouble conceiving. Maybe this is somatisation, maybe it's not. Hypnosis could help with the PTSD, and it could help with conception.
The ambulatory treatment area. Mr Jones attends because he's got neck pain. He's had it for a while, but it’s worse now he's looking after his mother who's a bit of a pain in the neck. Will hypnosis help, or just good communication? Ms. Begum has attended with leg weakness. She's had it for a while, and has had lots of imaging. The working diagnosis is a functional stroke. Hypnosis can help with that. Mr Urate has a flare of rheumatoid and can't walk. Hypnosis can help with that. Miss Upset has taken an overdose. Hypnosis can help with that. Mr Angsty has tonsillitis and can't swallow saliva - I'm not sure if hypnosis can help with that, but dexamethasone can! Mrs Ginny is withdrawing from alcohol, with a CIWA of 30. Hypnosis can't help now - but it might have stopped her from getting to this state! Mrs Stressed has a high blood pressure - hypnosis! Mr Histamine has a really, really itchy rash - hypnosis!
Resus. Mrs Nonny has possible sepsis, with a heart rate of 130. Hypnosis might help improve her immune response, making it more likely she'll survive with a reduced length of stay. Mr Caffeine has a heart rate of 148 - is it atrial fibrillation or is it stress response? Hypnosis! Mrs Blue is struggling to tolerate the NIV mask - maybe hypnosis will help. Mr Shaky is waiting for an intensive care bed, with his poorly controlled epilepsy. Maybe hypnosis would have reduced seizure frequency and improved compliance. Gravida's just on her way in - nine months’ notice of imminent childbirth wasn't enough, and the labour ward's too far away, so the ambulance has diverted to ED. Luckily, hypnosis can certainly help with that.
Paediatrics. Master Bristol has constipation causing severe abdominal pain. Let’s try hypnosis! Miss Jumpy has a laceration needing suturing, but is very needle phobic. We could try sedation - but our resus area is already full. Maybe hypnosis! Master Hot has a burn. It's sore. Hypnosis can help - both with healing and the initial pain. Miss Active has started self-harming. Hypnosis? Mr Bunk has got a head injury. His parent is worried about concussion. Hypnosis?
The corridors, the waiting room. Who knows what hypnotic delights wait there? I'm sure the hypnotic suggestion given to patients as soon as they arrive will have a huge impact on their wellbeing. Hypnosis could certainly improve people's health and reduce the attendances to the emergency department. One in the emergency department, hypnosis could help improve outcomes, reduce pain and improve wellbeing. Once admitted to hospital, that initial hypnosis may even reduce length of stay, drastically improving flow.
And of course, the staff are the backbone of the NHS. Would hypnosis help them? Of course. I've utilised some informal trance techniques with excellent results, and will continue to use them.
So, will hypnosis save the NHS? It seems to me, like it's the best option we've got at the moment. Oh, and did we mention, it won't need £34 million to implement.
Dr C Davies
1: ED: Emergency Department
2: NICE: National Institute for Health and Care Excellence
3: NIV: Non-invasive ventilation
4: ITU: Intensive Care Unit
5: PALS: Patient’s Advice and Liaison Service
6: COPD: Chronic Obstructive Airways Disease
I am aware that things are definitely worse in ED since I was working at the West Middlesex back in the 70s. In my view it all went crazy after the change in out of hours. Prior to OOH being outsourced, all medical admissions were first assessed by a GP working in a co-operative and most sent straight to the appropriate department. It was regarded as a failure and just lazy to send people to A+E to be sorted out. However, getting the whole A+E staff skilled up in hypnosis and comfort talk sounds brilliant, both for the patients and staff. Maybe approaching the managers and offering them this as a partial solution to the crisis? Run a pilot?