Sunday, September 16, 2007

In A Bad Light

Another shift down...

I spend a lot of time commuting. This not only costs me a lot in petrol, but gives me too much time to think. I often compose long witty posts on the way home... then give up, and go to bed. Or I rant - lately my beloved bore the brunt of this nonsense, but no more. So for better, or worse, I'm ranting at you this morning.

It's always a bad idea. Especially if you're as histrionic as I am - what seems to have assumed the import of the treaty of Versailles right now, will be as nothing tomorrow. But I've got a bee in my bonnet tonight. Moaning about colleagues is bad juju. There but for the grace a dieu go I, and so on.


Big hospital's protocols are REALLY pissing me off right now. I accept that protocols are valuable, so everyone gets the same, best treatment available. Part of me will never be convinced that they act to cover up poor training, but there you go. What fucks me off the most tho, is that they engender a blinkered attitude. Daring to go off protocol is heresy.

Tonight, when I dared to question the accepted drug dose protocol for one of the analgaesics we use in kids, there was a flat refusal to entertain my questions. It must be said that this is, undoubtedly, in part because of the manner of my questioning.

I'm not very diplomatic.

Even so, I was always taught to ask if I didn't understand something...

In pointing out what appeared to be a misprint, wherein one part of the protocol contradicted another, the answer was: 'we don't care what you say. This is protocol. It must be right'.

This sort of blind faith / refusal to consider alternatives seems the very anathema of good medicine to me. The answer to the question 'Why?' cannot simply be: 'Because'. Can it? Aren't we supposed to think?

I become equally, if not more, frustrated when colleagues decline to discuss there treatment plans.

Again, my method of 'discussion' surely doesn't help.

I recently answered the phone (always a mistake in the ED). On the other end was the father of a young patient, wanting to know where the details of his daughter's echocardiogram were. She had been seen 2 days earlier, and "the doctor" had told them she needed an echo. But no details had reached her GP.

I told him I'd investigate, and fax the necessary paperwork to the GP.

Having dug out the notes, I was plodding through the Department, when on of the specialist cardiac nurses stopped me, having recognised her writing on the clerking. I explained the situation, finishing with my, unkind, opinion that the patient's complaint was likely to be of a non-organic nature.

'Oh, no' my colleague assured me; 'she had a leaky heart valve when she was 5'

I ventured that I didn't think this was likely to be the cause of her chest pain.

'But she was terribly breathless' came the reply.

Somewhat over-zealously, I suggested that if the concern was that this young girl had a 'leaky valve' that so impaired her cardiac function, surely discharging her from hospital, with no treatment, wasn't in her best interest.

'Well, my Reg thought she'd had a PE' (Pulmonary Embolus - blood clot on the lung).

Again, perhaps slightly rabidly, I suggested that if this were the case, surely the best management plan would not be to send her home, untreated.

Why, I trumpeted, if you were so concerned about all these terrible pathologies, did the patient get discharged, with no treatment, and no follow up?

My less than polite manner had it's usual effect... 'Well if you're going to be like that, I'm not going to help. It's your problem.'

Indeed; MY problem. Trying to sort out a patient I had never seen, who had been variously 'diagnosed' as having heart failure secondary to valvular pathology, or a PE, but sent away with no treatment, and the idea that an echocardiogram might be of use, ("non-urgently"), BY THE CARDIOLOGY SERVICE. (Who, in case you haven't been following, were now telling me it was my problem...)

It doesn't make sense to me, to defend your diagnosis, when you didn't take it seriously enough to arrange the necessary admission, investigation and follow up. In fact it seems indefensible.

("Oh, yes, I'm sure he had a leaking aneurysm; so I sent him home...")

Rant over. I'm not quite bilious to have lost all insight, so I hope I have conveyed the petty, small minded nature of my grumbles. When I get on my high horse, I fair see me own arse. I still think I'm right, mind, but I guess I could be a bit cleverer in trying to convince everyone else of this fact...

On the plus side, we treated a fella with multiple rib fracture tonight. Everyone got on, I wasn't rude to anyone, nor did I disagree with the way I as allowed to treat him, and he and his wife were very pleased with the way they were treated


SeaSpray said...

I thought PE's were life threatening?

DrShroom said...

Yeah, me too. This is what annoys me. Either you think there's pathology - in which case, admit, diagnose and treat; or you don't. In which case, don't get in a huff when I suggest I think there's nothing wrong with the patient. **grump**

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