Normal rubbish: deviant patients in casualty departments

ROGER JEFFERY

casualty

departments

departments have been recognised as one of the most problematic areas of NHS since about 1958. The major criticisms have been that Casualty departments to operate in old, crowded, and ill-equipped surroundings, and that their unwith doctors has meant that the doctors employed as Casualty Officers 5l are either overworked or of poor quality. 'Poor quality' in this context seems to either doctors in their pre-registration year, or doctors from abroad. reasons for the unpopularity of Casualty work amongst doctors have usually couched either in terms of the poor working conditions, or in terms of the absence career structure within Casualty work. Other reasons which are less frequently but seem to underlie these objections, relate more to the nature of the and in particular to the notion that the Casualty department is an interface hospital and community. Prestige amongst doctors is, at least in part, related distance a doctor can get from the undifferentiated mass of patients, so that hospital consultancies are valued because they are at the end of a series of mechanisms. Casualty is one of these screening mechanisms, rather like practitioners in this respect. However, they are unusual in the hospital setting freedom of patients to gain entrance without having seen a GP first; another low area similar in this respect is the VD clinic. Casualty has been unsuited to the of differentiation and specialisation which have characterised the recent of the medical profession, and this helps to explain the low prestige of the , and the low priority it has received in hospital expenditure. material on which this paper is based was gathered at three Casualty departments English city. These departments would appear to be above average in terms of . discussed above: all were fully staffed; only two of the seventeen doctors during the fieldwork period were immigrant; and the working conditions reasonable.

and if they did turn up a great fuss was made of (ii) If they allowed staff to practise their chosen speciality. For some COs. Casualty work had some advantages over other jobs clientele was basically healthy. In order to pass the FRCS examinations doctors need to diagnose and describe unusual conditions and symptoms. but also good cases. merely amongst medical students or in mental hospitals.the rapid early acutely ill patients. Many of the COs saw their Casualty job as the first in were expected to make decisions without the safety net of ready advice from senior staff. [CO to medical students] If there's anything interesting we'll stop. There were three broad criteria by which patients were seen to be and each related to medical considerations.predominantly surgeons. I really do enjoy doing anything where I am a little out of my depth. They sometimes used as if they were an exclusive dichotomy. The who were most prized were those who stretched the resources of the doing the task they saw themselves designed to carry out . because doctors saw themselves as future specialists . Casualty was not a good to discover these sorts of cases. or cardiac arrests. but more generally appe as opposite ends of a continuum. Patients who provided the opportunity to use and model were welcomed. And when the guy finally does arrive you've . or a stove-in chest. or conform to. the characteristics of good patients of this sort were fairly closely defined. Good cases were injuries. or they were RTAs (Road T Accidents). you forget for a moment you are just a small cog incising a very small abscess. These are great fun. It just lets your irU"i:. the model of the surgeon as a man of action who can fairly rapid results. and bad or rubbish. and it was possible to carry out procedures which quick success in terms of returning people to a healthy state. For the doctors. two broad ca were used to evaluate patients: good or interesting. In general. On nights you get some drunken dross in.. They accept. (iii) If they tested the general competence and maturity of the staff. (i) If they allowed the CO to practise skills necessary for passing examinations. But I like doing surgical procedures. roug the r Good patients Good patients were described almost entirely in terms of their medical either in terms of the symptoms or the causes of the injury. Something like a bad road traffic where they ring up and give you a few minutes warning and perhaps give idea of what's happening .""auv run riot really [laughs] you know.364 I Health work Typifications of patients Moral evaluation of patients seems to be a regular feature of medical settings. where I have to think about what I am doing. and you pick up your scalpel like else [laughs].. but there's a of rubbish this morning.

(ii) Drunks. In other words.. and is seen as a case of self-injury rather than of attempted suicide. The following were the major categories of rubbish mentioned by the staff. and so on . their hands or their ankles. and several days later looked into Casualty to see if it was all right. as we call it. Normal drunks are abusive and threatening. staff felt able to predict a whole range of features related not only to [the patient's] medical condition but also to his past life. They come in shouting and singing after a fight and they are sick all over the place. and sorting it all out and getting him into the right speciality. and gets you out of bed at 3 in the morning. This is in marked contrast to 'ru bbish'. which sorts of patients made them annoyed. or two days ago. She comes because her boyfriend/husband/parents .Normal rubbish deviant patients in casualty departments I 365 ical settings. They nerally rough idea of what you are going to do. They come in and say 'I did an injury half an hour ago. They who can In an attempt to get a better idea of what patients would be included in the category of rubbish I asked staff what sorts of patients they did not like having to deal with. or they are brought in unconscious. carried on working as usual. It's a thankless task. I'm perfectly all right. because .the normal suicide attempt. ctors. make demands which fall squarely within the boundaries of what the staff define as appropriate to their job. I've just come for a check-up. and they are always unpleasant and awkward. and to his future behaviour. coming through. has been the 'casual' attender. While the category of the good patient is one I have in part constructed from comments about 'patients I like dealing with' or 'the sort of work I like to do'. They come in the small hours of the night. 'rubbish' is a category generated by the staff themselves. ) broad ibish. which is how the staff like to see themselves.d. and why. rather than as an expert emergency service. seeing all the rubbish. Good patients. or half a day ago. and they often have to be kept in until morning because you never know if they have been knocked out in a fight (with the possibility of a head injury) or whether they were just sleeping it off.it's only because it's mostly I wouldn't be making the same fuss in another bloody crumble like women with insect bites. Normal trivia treats Casualty like a perfunctory service. the normal drunk. (i) Trivia. The answers they gave suggested that staff had developed characterisations of 'normal' rubbish . The normal overdose is female. then. on a par with a garage.which they were thinking of when they talked about rubbish. Normal trivia banged their heads. job . The recurring problem of Casualty departments. in the eyes of the doctors. this kind of thing is very satisfying. (iii) Overdoses. having been found in the street. to his likely behaviour inside the Casualty department.' [Trivia] comes up with a pain that he's had for three weeks. These expected features of the patient could thus be used to guide the treatment (both socially and medically) that the staff decided to give the patient. the sm!ClilCr . They come in weekend after weekend with the same injuries.

I don't like having to deal with drunks in particular. or descri as unpleasant or annoying. chose to take an overdose for their own purposes. I find that usually quite aggressive. they will usually sham their symptoms. or by ens that she is discovered fairly rapidly. . Normal overdoses knew what they were . for if one is let in one night then dozens will turn up the next [Tramps are] nuisance visitors. who refuse to These four types covered most of the patients included in rubbish. All normal ru within their own hands the ability to effect a complete cure. who are who have had treatment. New COs and young staff should be warned. '5 aspirins and 5 valiums and I'm ill doctor. you know. then. 'Nutcases' were in this uncertain there were few 'typical' features of psychiatric patients. Patients with these teristics were objected to. Comments which reflected this rule included. but she uses the overdose as moral bl She makes sure she does not succeed by taking a less-than-lethal dose. the sort of By and large they are people who have done it time and time again. seen as the criteria by which staff judged the legitimacy of claims made by entry into the sick role. and in part ideological. Normal tramps can be recognised by the many layers of rotten they wear. leave when you want them to. got themselves into this state entirely through their own follies. and she is likely to be a regular visitor. either for their illness or for getting medical staff can only be held responsible if. who won't go. In the majority of overdoses. Drunks and were responsible for their illnesses like bronchitis which are a direct result life the tramp has chosen to lead. or which seemed to be generated by individual patients. Trivia chose to come to and could be expected to deal with their illnesses themselves. There were some other characterisations mentioned frequently. And I feel that. She only wants attention. was not seriously trying to kill herself. These rules. I've taken an overdose'. Rules broken by rubbish In their elaboration of why certain sorts of patients were rubbish. I don't like aggressive people. and by their smell.366 I Health work have been unkind. The first half of this rule was broken by all normal rubbish. or which to be specific to particular members of staff. or for medical care. they were able to illness. you know. staff organised answers in terms of a number of unwritten rules which they said rubbish had These rules were in part consensual. They are a feature of the cold winter nights and they come to Casualty to try to wheedle a bed in the warm for the night. (a) Patients must not be responsible. Tramps can be trusted. who haven't responded to treatment. 'dirty' and 'obese' patients were also in this limbo. they could not be held responsible to illnesses of normal rubbish. these symbolic overdoses. (iv) Tramps. why the should I have to deal with them on the NHS? So I don't like drunks. but there was no typical career expected for [them). and these were very 'Smelly'. and since there was the Casualty staff could do about it. frequent visitors. in addition.

and trivia who have been able to delay coming to the department most obviously break this rule. making repeated efforts. It can be seen that each of them required quite fine judgement about. in. the requirement that the activities being followed should be reasonable. there is another aspect to this rule. to give up rather than go on.a warm bed and warm meals.Normal rubbish: deviant patients in casualty departments I 367 tly wants attention se as moral d dose. go. departments. This rule has particular point in a Casualty department. who most obviously offend against this rule are the overdoses and the tramps. (b) Patients should be restricted in their reasonable activities by the illnesses they report with. Or described rons mentioned less ts. The overdoses are seen to want to be ill in order to put moral pressure on someone. and in the end you'd much rather hit the thing over the . and orne to Casualty. for example. or anyone else. hit the thing with your hammer. or which seemed i uncertain position: o were very diffuse. attention. whether a patient was uncooperative by choice or because of some underlying illness. theY've why the hell :s. and the distinctions between those who really tried to commit suicide (for whom there is some and the rest (viewed as immature calls for attention). The patients Punishment Rubbish could be punished by the staff in various ways. Similarly. Drunks fail to cooperate by refusing to stay still while being sutured or examined. they refuse to cooperate in getting 'well' because they cannot be trusted to live their lives in future in such a way that would avoid the same injuries. you get fed up with it. because I've got very ordoses.say you're a plumber and the thing keeps going wrong because you haven't got the right thing to put it right. These are both cases where patients refuse to cooperate. rrnal rubbish had .e there was little sible to treat the rded. the SOrt of ordose'. I don't like overdoses.. It's the same I'm sure in any sphere. The staff normally felt uncertain about the existence of an illness if there was no py that they. and overdoses fight back when a rubber tube is being forced down their throats so that their stomachs can be washed out. Or in this case. rules. [Tramps] Obviously put nothing life. However. that if you're doing something and you're treating it and . The major non-cooperative patients were the drunks and the overdoses. the Protestant Ethic of work is alive and well in Casualty (c) Patients should see illness as an undesirable state. who refuse to ibbish. If a man has led a full productive because he's put a lot into society. can be Ide by patients for for getting better: . the most important being to increase the amount of time that rubbish had to spend in Casualty before completing treatment. or by . -ers of rotten " nights and they hr. you know. as would be the case for patients in epileptic or diabetic fits. then. and it would seem this uncertainty fostered frustration which was vented as hostility towards these ts. and the obvious offenders against this rule are the tramps. little sympathy with them on the whole. or to get attention. s with these characI for [them]. and are always trying to get something :aff organised their bbish had broken. I'm afraid. One example of this was in the comments on overdoses. These four rules seemed to cover the criteria by which normal rubbish was faulted. I think they are a bloody nuisance. In each hospital there were ways of advancing and retarding patients so . (d) Patients should cooperate with the competent agencies in trying to get well. rsually they're know.. able to treat the runks and tramps recr result of the t were doing. rather than being unable to cooperate. could provide to correct the state. he's entitled to good medical out. Tramps want to be ill in order to get the benefits of being a patient . Tramps can d young staff rn up the next night.

or the comments made in discussions with other staff. The other forms of punishment used were verbal hostility or the vigorous restraint of uncooperative patients. However. Punishment was rarely extended to a refusal to see or to treat patients. 1(1). Good patients.' 63 FOr he ELiZ What follows i: practical purpo: paper outlines t menial and bor materials used t the 'strain' this strategies utilise Kitchen maid At the time of writing this article. unlike cases of accidental self-poisoning by children. 90-108 (1979). Drunks and tramps who were uncooperative could be threatened with the police. The staff were very conscious of the adverse publicity raised whenever patients were refused treatment in Casualty departments.368 I Health work that they were not seen strictly in the order in which they arrived. and they were also worried by the medico-legal complications to which Casualty departments are prone. at least in my presence. but defended themselves by saying that it was necessary. Verbal hostility was in general fairly restrained. either by the receptionist or by the ambulanceman. A little later the porter came in and told the CO that the tramp had collapsed and died outside on the pavement. in general being the more serious. could be seen immediately by being taken directly to the treatment area. and this restrained their hostility and the extent of the delay they were prepared to put patients to. Sometimes staff employed a deliberate policy of leaving drunks and tramps in the hope that they would get annoyed at the delay and take their own discharge. University of Edinburgh. who would be held down or sat upon while the patient was forced to swallow the rubber tube used. concerning a tramp who was seen in a Casualty department and discharged. The porter then calmed the worries of the CO by saying 'It's all right. and coated larg prepared any 01 any giblets rernr the elbows in te . Vigorous treatment of patients was most noticeable in the case of overdoses. Patients there were normally left until all serious cases had been dealt with. A cautionary tale was told to emphasise the dangers of not treating rubbish properly. would go first to a general waiting area. and was usually less forthright than the written comments made in the 'medical' notes. Less serious cases. This article is an edited version of one that was originally published in Sociology of Health and Illness. who were called on a couple of occasions to undress a drunk or to stand around while a tramp was treated. I've turned him round so that it looks as though he was on his way to Casualty. f( It was from the meaning of 'foo understanding ( other kitchen st: for around 700 room in the rna canteen which ( During obser food containers their appropriat sackfuls throug chopping and r tedious manner. including the trivia. they showed no sympathy for the victim. Staff recognised that this procedure had an element of punishment in it. sir. Roger Jeffery was a Lecturer in Sociology in the Department of Sociology.

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