Bloody Christmas

AT HOPE Hospital in Salford, as in other UK casualty departments, violent and threatening behaviour from patients, already at epidemic levels, is beginning to build to its seasonal height, with the forthcoming round of Christmas parties culminating in the celebrations for the millennium. Over the past year there have been 65,000 violent incidents in the NHS, with nurses the victims in two-thirds of the cases.

A recent survey revealed that half of all nursing staff who were questioned had been assaulted in the previous 12 months. Across the country, A&E departments are bracing themselves for the most violent few weeks in their history.

"Last New Year's Eve," one nurse at Hope told me, "the waiting room looked horrendous, it was like a battle zone. Every year we expect it to be bad. This year, we expect it to be Armageddon."

Saturday, 5pm: A young man called Andrew comes into reception brandishing a 10-inch carving knife, insisting that the staff examine his friend George, who has been bothering him. George, as it turns out, is the name of the knife. It has has been pestering Andrew with psychic messages urging him to stab people at random. He buried the knife in the garden for a few days, and the messages stopped. Once exhumed, however, George returned to his old habits with renewed vigour, this time ordering Andrew to stab himself to death.

The police are called. George is confiscated. Andrew is sent off for psychiatric assessment.

7pm: At its most intense, the ambience in the waiting room resembles Dante's description of the clientele in the Inferno: "The wrathful, the incontinent, those violent against others and against themselves ... makers of discord, with their horrible language, words of pain, and raised voices."

This evening there is a gang of 10 drunken youths, one of whom has been "potted", or struck in the face with a broken pint glass. The wound, which has almost cost him his sight, requires 76 stitches. There is the occasional regular such as Eric, a Yorkshireman with gangrenous feet, who gives no trouble, and tonight is lying unconscious across the seats. On the television set, which is showing Stars In Their Eyes, someone is crooning in feeble imitation of Neil Diamond. Eric suddenly sits bolt upright. "You're f***ing dead, Neil," he shouts at the set. "You've been dead for years, mate."

9.15pm: Kirsten Clinton, a young nurse, painstakingly binds a boy's broken finger. He is seen, treated and discharged within half an hour. This is not fast enough for his father. "You," he shouts, pointing at Kirsten, who is five months pregnant, "are a f***ing tosser".

10pm: The night shift of six nurses and two doctors, who work from nine in the evening until seven in the morning, are on their break. Everybody has a story about patient violence. Alison, a senior nurse, was threatened with a scalpel. Sheenagh had her nose broken when she was headbutted by a 14-year-old boy.

Ann-Marie was on duty here just before Christmas a couple of years ago when a police informer, who claimed to be HIV-positive, arrived in a state of amphetamine psychosis aggravated by just having had his tongue cut out by a drug dealer.

"He needed to be transferred," Ann-Marie says, "but the ambulance crew had to wait for a police escort. All this time his wound was gushing blood." Summoning the police, she recalls, required three phone calls and 20 minutes during which time the patient became ..."

"Menacing?" I suggest. "Menacing would be a very useful word," said Ann-Marie, "Yes. We tried to placate him, but he went totally berserk. He started spitting blood at whoever he could, and hurling chairs at staff." The main treatment area at Hope A&E consists of a corridor with consulting rooms and a resuscitation unit set off from it. Some nurses barricaded themselves in the reception area. "I ran down the corridor," Ann-Marie says, "shouting at patients to get in to their rooms and lock the door. Then I was left exposed, and he lunged at me, spitting blood - I was soaked in his blood. It took nine officers to restrain him."

At first there was talk of accusing the man of grievous bodily harm. "Eventually," Ann-Marie says, "it was decided that, because he had to wait, we could be said to have provoked him, and the case was dropped."

Security has since been tightened. There are cameras and guards with flak jackets in the hospital. They do their best, but are paid a wage which does little to attract those skilled in state-of-the-art deterrence. You don't have to be here long to notice that the nurses don't feel safe at work. They see machete attacks and gunshot wounds from gang fighting, much of it in the neighbouring Ordsall area. Most problems still come from belligerent drunks.

Sunday, 8pm: The department has its own language. Nurses refer to an RTA (road traffic accident), to an MI (myocardial infarction or heart attack) or to Caz (A&E). Patients who are becoming violent are said to "kick off" or to be "going off"; two phrases which reflect my changing perception of the outside world. Stopping for a drink in the hospital's local pub, I notice how I now look at fellow customers as assault victims in the making, whose hearts are bombs that may explode at any moment, and whose cars are head-on collisions waiting to happen.

Monday 9pm: In the main corridor there is a white and red telephone which rings only in extreme emergency. The phone has been silent since I arrived. Troublesome patients are often "self-presenters", men like Henry Hall, a small West Indian. He has just walked in, cut up rough. He is throwing things, including a Zimmer frame, at staff. The police are called.

"Be careful," Hall warns one of the officers. "I have an MA." "An MA?" says one policeman, "What in?" "MA," says Hall. "Martial Arts. Don't they teach you anything?"

Hall continues: "I am a man of God yet I dwell among the unrighteous."

"I see,' the constable replies. "Do you live in Ordsall sir?"

Thursday 1.15am: "I am coming round there now to cut you up," Owen, a weasel-faced man in his late 20s, announces to the woman who's behind the protective glass shielding the reception desk. "I am coming to f***ing cut you." Owen is with his sister and her husband. He arrived at their flat earlier this evening and threatened them with a knife. "It's a strange thing," says Colin, the security man. "But where we get one of these guys, there's very often two in the end."

1.50am: Enter, as if on cue, Spike, a powerfully built man in his late 20s. The couple with him - his sister and her husband - explain that he has been round to their house wielding a knife. The police have dropped him off here because "he has quietened down now". Spike begins to pace the department, glowering.

A few minutes later comes the first sign that something is terribly wrong. Eric, the ever-present fixture in the waiting room, has disappeared.

We find Spike, who weighs about 14 stone, hunched by the tea-machine, growling and fumbling in his pocket. "Has he got a knife?" Colin shouts. "Are you sure?" With a grotesque posse of eight people - nurses, a doctor and two security guards - at his heels, Spike bursts out into the main hospital, still followed by his retinue.

Spike is out of control, rehearsing kung-fu blows and wearing an expression I have only previously seen on the cover of biographies of Charles Manson. Colin returns with the news that Spike has "gone off" big-time in a lift. Someone calls the police, but 10 minutes later he is still at large, still terrifying, and there is no sign of the Law. The phone goes. "No. I do not require a helicopter," says the nurse. "No. I did not request a dog. Send two men," she says. "Send them now."

When the police eventually arrive, eight people sit on Spike while Colinette, the woman duty doctor, pumps him with a massive shot of Ativan.

4am: The nurses are in broad agreement about the circumstances that have fostered the increase in such incidents. Care in the community, they say, has been a disaster, leading to hugely raised numbers of violently disturbed people on the streets. Long waiting times often infuriate the patient's companions - a problem made worse by the way that, in the Eighties, the belief that naked self-interest was a virtue best advanced by loud, boorish insistence on one's rights - a credo previously restricted to the upper-classes - was adopted by British society at large.

Carol Harmon, a nurse, recalls how, four years ago, she politely asked the sister of a patient to stop spitting on the floor. "She spat in my face," Carol explains, " then she was just hitting me until one of the paramedics came in." Carol had a dislocated jaw and had been beaten and kicked "until I was black and blue". She wore a brace for two years before surgeons could operate.

"If she had done that in Marks & Spencer," she says, "she would have been in serious trouble. But she did it here. She did go to court, but they let her out on probation."

Friday 2am: Another nurse, Joanne, recalls how she was recently injured in a care home by an elderly woman who struck out at her with a wet towel, scratching her retina. "I wanted to go to court," Joanne says, "but I got no support."

She adds: "Traditionally, there has been an attitude that we are the caring profession, and we have to take any crap that people throw at us. But that is changing. I feel very angry. I may lose my sight. The way I feel about this is in line with most people here - and most people here have had enough."

2.10am: "You have to laugh," one nurse, Judith, told me last night, "because if you took all the grief home with you, you would explode." I am standing in the main corridor and one of the nurses is recounting an incident that happened a few years ago. `The phone goes," she says, "and this voice says, `It's Rory. He's seven years old and he's swallowed a whole box of sleeping tablets'. So they sent an ambulance, and when Rory comes in he's an Airedale dog. Well, they give him oxygen and mouth-to-mouth anyway..." At which point, the emergency telephone rings. The atmosphere changes instantly. An efficient knot of people suddenly forms and prepares a bed in the resuscitation room for the patient - a 61-year-old cardiac arrest arriving in one minute. The man has suffered a heart attack while having his fortune told.

His clairvoyant, far from having predicted this turn of events, apparently fled, leaving the motionless client drifting between life and death on a sea of tarot cards. A team of six injects him with Adrenalin, performs heart massage and checks the monitors. After five minutes or so I notice that Sheenagh has stepped back from the group and is staring up at the ceiling. "I always do this," she says, "because I've read about out-of-body experiences and I hope that if they're looking down on the room I might be able to will them back." The team stands back to view the heart monitor. "It didn't work," says Sheenagh.

11.50pm: Brian Flavin, a young registrar working at Hope, is one of the few doctors who has chosen A&E as a career. "It's always varied," he told me, "and always challenging." On one occasion, at another hospital, Brian's chall -enge took the form of an HIV-positive patient wielding a blood-filled syringe. "At which point I punched him in the face."

Sunday 3am: A paramedic wheels in Derek, a man in his early 20s, who is accompanied by his girlfriend. His nose is a gruesome mess, his jaw is broken and he is bleeding heavily from wounds to his head.

The police arrive. At one point, an officer addresses a question to his girlfriend. "What would she know about this?" asks Derek. "She's from Wilmslow." He adds: "That is a posh area. I'm from Salford, and in Salford people get stamped on every day." He defiantly insists he has no idea of his attacker's identity. "I do not wish to make a complaint and I will not support the police in their inquiries," recites the policeman who, being local, knows this line by heart. "Sign here."

4am: Gary, Derek's best friend, turns up with his right hand bleeding and broken as a result of "dealing with a burglar" in his flat. "Why worry about him?" he asks Derek. "He's fucking dead. I'll have him fucking shot. He may be laughing now, but next week he'll be six inches in the local paper."

5am: Pat Walsh, a paramedic, has just brought in a drunk. `The centre of Manchester tonight,' he says, `was like Beirut. I have done this job for 21 years and it has never been as bad as it is now.' In the past few nights, he has been spat at, and two people he's helped tried to assault" him.

"What will happen here," Walsh adds, "is what usually happens, the police send him to casualty, he sleeps for a few hours, he wakes up, and abuses the staff - at which point the police are summoned again. It's a vicious circle, and it's a circle that should never have started."

Some attacks on A&E staff are the result of mental illness, but a high percentage on casualty nurses are criminal assaults committed by people whose only medical complaint is that they are very angry or very drunk. Since neither condition is a legitimate defence in law, A&E staff see no reason why the situation should alter when the crime is committed on hospital property.

Most nurses I spoke to feel that the range of recent measures announced by the Government in its Zero Tolerance Zone campaign - they include statistical targets for reducing the number of attacks in hospital trusts, and a formal plea by the Lord Chancellor for stricter penalties from magistrates - are pathetically inadequate. They believe that violent aggression against hospital staff should become a specific offence, equal in gravity to assault on a police officer.

"It seems strange," one nurse said, "that when somebody punches an air steward, they know that, however intoxicated they are, they will get a prison sentence, yet most people who attack us expect to walk away free."

The turbulent state of the UK's A&E departments has pen-etrated the public consciousness to the point that nobody attending casualty at night does so without apprehension. The knowledge that, for many of us, the trip to casualty will be the last substantial journey we make, adds a new and uniquely British anxiety to death.

The Government - surprisingly for a regime which has been at its most agile when reacting to groundswells of popular opinion - seems unwilling, on this occasion, to draft new legislation. As the millennium party looms, A&E nurses are left to contemplate their predicament with anger, bewilderment and resignation.

As it is, Salford perseveres through the good grace of its nursing staff, most of whom are paid less than a junior temp in an office, and whose job demands that they be - to use a devalued adjective - heroic.

At one point in the staff room at Hope, when a nurse had just described a beating she had taken, I asked her whether she had considered retiring to a safer, more profitable, occupation. "I think about that," she said, "every day." Then Eva, the quietly spoken woman who has the unenviable job of manning the reception desk, interrupted. "You can't - you mustn't - give up," she told the nurse. "Because if we give up, they win. And if they win," she added. "That will be terrible."

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