O'er The Hills...

Here's Forty Shillings On The Drum
For Those Who'll Volunteer To Come...

And so the Three Line Whip. It has become apparent to me that increasingly, bods at work read this; so I can't pretend to be an heroic world saving, plague-curing stud monkey. I also have to watch who I slag off and / or eulogise. (Or for the crude, makes it harder to pass comment on the finer attributes of my female colleagues)

Anyway - I took the shilling. Years ago, I took it, but not blindly... or so I thought. But the goalposts have regularly changed. Still, took the shilling, can't argue now. The current party line to be towed remains the 4 hour target. Regular readers know what I think of this. To have medical care dictated by time based targets is, in my opinion, at best foolish, and, at worst, dangerous.

But:
All that stands in the way of our glorious hospital achieving the glory of the Third Reich (Foundation status) is the Emergency Department, and the pesky target. So, all must be done to meet the target. We must 'engage' with the target.

So Fall In Lads, Behind The Drum
With Colours Blazing Like The Sun

Our latest pep talk hammered this message home. The Nursing Staff are not finding the middle grade attitude helpful. By which they mean: 'when we tell Shroom about breach times, he tells us he couldn't give a fuck, and that ain't helpful'.

True.

It's not helpful, but I want to know if patients are unwell, or deteriorating, not that I must abandon treatment of sick patients to attend to well (-ish) patients who have been in the Dept a long time.

I guess it ain't their fault, so being rude just antagonises people. And, politically, it won't do me any favours, as my attitude gets referred from Nurses to Bosses to Management. I imagine, I will soon be referred for attitude readjustment, in a gulag somewhere. Or have my eyes pinned open, and be subjected to videos of people managing the breaches appropriately. (Clockwork Orange, anyone?)

If I Should Fall To Rise No More
As Many Comrades Have Before...

Interestingly, I was expecting the whip; it came as no surprise, and I have accepted I must tow the Party Line. Passive-aggressive pseudo-rebellion only goes so far. But my colleagues were upset and put out by it. They seem to have taken it personally; as a slight to their work ethic. Am I too jaded, too cynical to be bothered.

I'm not sure.

We follow the road, to come what may, nonetheless.

If Ever I Enlist For The Army Again...

A post mostly about time; Unfinished.

For starters, Mousie, over at Mouse Thinks has some things worth reading about the current obsession with time that dominates Emergency Medicine in the UK. History would seem to have taught us that when you set a man an unrealistic target, he usually learns how to appear to meet the target, rather than actually meet it. (c.f Communist China, or USSR)Clearly, none of this occurs at Big Teaching Hospital, which is above reproach. I also have a few things to say regarding evidence based practice; none of these apply to my workplace either.

What I most wanted to commit to print, while the mood has me is this:

Purely hypothetically, you understand.

Consider the following:

When a service is judged as much, if not more, by a temporal rating as much as a clinical care rating, might time become pre-eminent? Might time come to dominate the clinical picture? Might this become more so when pressure is applied from above? When this temporal rating comes to have repercussions beyond care? When it might affect the hospital as a whole, and managerial jobs, specifically, might we lose perspective, and come to see time as the pre-eminent factor in patient care?

Maybe.

So, if this temporal rating is measured by timing patients in, and out of the Department, might there be a temptation to 'amend' the reading? If one loses points when patients tarry in your Department beyond a certain time (for example, four hours), might you consider changing figures so that more patients meet that target? Where's the harm? If my patient is in the Dept for 4 hrs and 10 ins, who gets hurt if I back-time him, just a little. Just enough that he appears to have been our guest for 3 hrs 59?

What if this is extrapolated, so you find a patient, still waiting to see a doctor, but ALREADY booked out of the Department? Half an hour ago. Officially, he's not here anymore.

Well... if it's a simple case, done and dusted in a few minutes... where's the harm? Right?

But what if it's not simple? What if you have to see a patient, already documented as having left the ED, with a diagnosis of "nothing wrong", legally recorded by one of your colleagues? What if they subsequently need treatment, need admission? What happens then, when the times don't match? When you have to explain why your entry in the notes begins almost an hour after that patient was discharged? When your entry is not of "nothing wrong"?

How far can you bend the rules? And if you don't, what of your colleague, who already 'saw' this patient...

This is, of course, hypothetical, and over the next few days, I will explore the hypothetical fallout from such an incident. Hypothetically, you understand.

Coherent edit to follow...

And on a lighter note, I've developed a crush on the Surgical SHO in Holby City...

Burn One Down

Well, after five nights on the trot, you'd think I'd have something clever to write; or something intelligent; or thought provoking. Not really. My last few shifts have passed more or less without incident.

Instead, departmental politics are once again at the fore. I have yet to hear what the Management Consultants who were prowling about have had to say. The breach targets are once again getting maximum billing. The next few months requires an extra big push. One more push, lads, and it'll all be over by Christmas!

(Foundation! Foundation! Foundation! Arbeit Macht Frei!)

The upshot of this appears to be that we are asked to organise referrals for our patients increasingly early. Not, and this must be emphasised, in a way as to compromise patient care however. I am becoming increasingly disillusioned with this. I like treaing patients. It's what I signed up for. But there seems to be an increasing drive to postpone any but the most essential treatment until 'they get to the ward'... aside from the fact that I think we could and should be instigating treatment as soon as it is feasible, the increasing admissions rate is putting yet more stress on inpatient teams who hardly had it easy to start with. So it leaves me with little confidence that the treatment will be started 'when they get to the ward'.

I suspect that actual incidents of patient harm are few and far between, but it feels in general as if we're offering a slightly worse service. But how many times is too many?

My patient with a leaking aneurysm who nearly ended up on a medical ward because somone decided to book them a bed, so they wouldn't breach..?

My patient with low potassium, and attendent ECG changes, referred for admission as not safe to stay on the obs ward, then placed on the obs ward while waiting for an inpatient bed, so they wouldn't breach..?

Maybe I'm just too cynical.

One of my patients over the weekend was a young girl who had taken her second overdose of the past few days. Mostly fairly benign drugs, but enough to make her pathologically sleepy. She deteriorated suddenly, requiring a brief dash to Resus. Her father and sister were in constant attendence, calm and collected. I wondered how many times they'd been through this before. I offer the usual explanation - first we treat the physical, then the psychological. In her case we need to watch her while she wakes up, make sure she doesn't vomit and choke on it, stop her following Jimi Hendrix's example...

As if on cue, she begins to heave; she has enough presenceleft to slide sideways. At first I think she's trying to brain herself on the side rail, but it turns out she's just aiming over the side. She scattergun splatters the floor; her dad has reacted fastest, and has a bowl under her mouth. I'm impressed - he and I started from the same point; standing start and he beat me to it. Maybe he has done this before.

We clean her up as best we can, wiping her mouth, blowing her nose. Then she heaves again; this time her sister lunges forward. For a second, I don't see what she's reaching for. We've got it covered, haven't we? Almost; she brushes a lock of her sister's hair back; it was dangling right in harms way.

The devil, it seems, is in the details.

And Another Thing...

Brevity.

In my previous post but one, I may have suggested that medical students in general were maligning us whinging docs. That is not the case. What I meant was that much of the 'debate' was originating with e.g medical students rather than qualified docs. I did not mean to suggest that most medical students were engaging in the 'debate'.

The Shroom is happy to clarify this, and hopes he had not caused any offence. (This means you, TLM...)

On the matter of the huge piles of cash we're all rolling in: my salary is a matter of public record. You can go to a variety of websites and see the NHS payscale. This is in stark contrast to several of my friends whose salary is so secret that they are contractually forbidden to disclose it. I notice that when we worked for hourly rates, people were only too happy to share their details.

Now, it's vulgar, apparently - although only the people I suspect earn multiples of my salary think so.

Anyway, depending on how much you think I actually earn, and how many patients I see, the cost per patient works out to be about £20. This is excellent value if you're in a diabetic coma, and I spend six hours of my life resuscitating you. Not such good value if you have a sore throat, and I spend 30 seconds telling you it's viral, drink plenty of fluids, gargle aspirin and munch paracetamol. Granted, but this is averages we're talking about...

Anyway, think on it. £20, all in.

I don't think that's too bad. But then, I wouldn't, would I?

Work In Progress

Yes, I'm buggering around with the layout. Comments welcome.

Yes, I'm still working on the meme set me fucking ages ago, by the Angel of the North.

I'm fairly cross this eve. The blogosphere continues to reverberate with polemic diatribe. There's even more out there than I realised... I'll edit this in due course, to link as apt. But... Dr Rant has drawn my attention to this current outburst. Or maybe it's not current.

In fact I'm sure it's not current; it's eternal.

Forgive me if I oversimplify. I am a simple man.

There appears to be a backlash, directed against 'whinging doctors'. Mostly, as far as I can tell, from medical students, and other non-doctors.

So; currently doctors feel over-worked, and under-valued. There appears to be a campaign in the media to portray us as overpaid, and underworked.

When we complain, the response appears to be that we don't know how good we have it, and should put up, shut up or fuck off.

As far as I can see.

So... I do feel undervalued, and increasingly asked to work to conform to targets rather than what is necessarily best practice.

Do I feel underpaid? Well, I get good money, make no bones about it. Although, I earn less now than I did three years ago. So in real terms I have taken a pay cut in the region of 6 - 8 % over 3 years.

But; if I complain, I'm told I shouldn't because I have it better than many others, or am seen as ungrateful. This is after all a vocation, so I must be altruistic and compassionate, working only for the love of it.

I feel undervalued because I see other professions earning shitloads. My cousin earns as much, if not slightly more than I do, working for a mobile phone company. I'm not sure anyone tells him he is overpaid, or not working hard enough.

GPs and Hospital Consultants have done very well of late, but it is no more than they deserve, as far as I can tell. Their rise has come from the Govt deciding to pay them for work rendered. It's hardly their fault if it turns out they actually work quite hard...

Comparisons to other professions, are, in my opinion lacking in validity. Are we special? Maybe. I consider it an honour, and a provelage to be a Doctor. There is nothing better than treating patients. Nothing. But nothing else offers the highs and lows. We know things you don't, but then loads of people know stuff I don't. However, I think the responsibility we take on is greater. Which is why we get so very roasted when we get it wrong.

Conversely, the public sense of entitlement, with no sense of community responsibility, means when we do it right, no-one notices. Fine. It's not the same as lawyers, or any other professional, as far as I can see. Any individual working in the public sector gets beaten with it. Teachers, Nurses, Policemen (or women)... all fucked, because they provide a community service, and we're supposed to be honoured by it.

Education is as important a concept for society as anything. And we treat our teachers like shite. I can't figure it out.

How else does our profession differ? The public regularly come to my place of work, sometimes drunk, or on drugs; they make a mess, they piss on the floor, they assault me.

And they think it's fine.

We're never really off duty. Have you ever heard the Captain of an aircraft ask if there's a lawyer on board? When the call goes out "is there a doctor in the house?", they sure as hell don't mean someone with a PhD...

Am I special? No, I'm not, but the job I do is.

Am I treated badly, by the Govt, by managers? Yes, I am, but nowhere near as badly as Nurses and teachers, as far as I can see.

Am I worth more, or less, than someone who sells mobile phones?

And will your answer be different when I'm thrombolysing your coronary thrombus, or treating your child's meningitis?

I don't want to be treated differently, but I sure as hell don't appreciate people telling me I can't vent.

My Tears Dry On Their Own

Ranting ahead, and a few housekeeping notes.

Doing a bit of extra curricular reading, I came across a few posts by MonkeyGirl. I apologise for the lack of link at the mo', but my server is flailing... I'll rectify as soon as. The gist runs around a story of a patient dying in an ED after being 'underdiagnosed'. The problems are bilateral - it seems the patient was known to the Department, and had a reputation for being non-compliant, and a drug seeker. (This is how I understand it, and I apologise if I have mis-represented anyone, specifically the Girl Simian). On t'other side, it seems that this ED did not offer a particularly high standard of care to anyone, and has subsequently been down-sized, or closed or something. MG's point centred on the family of the unfortunately dead patient suing for $45m. If I understood, she considers this... taking the piss?

It has provoked some polemic.

This is an old problem, and one unlikely to go away. While a system exists that can be abused - e.g free or subsidised healthcare, for e.g drugs - people will abuse it. People's sense of entitlement seems all too often to find ways to overpower their sense of responsibility, both personal and collective.

I think this is particularly true of the UK. People aren't keen to consider their own 'emergency' in the context of others'. And why should they?

Rationing. That's why.

And people have very different ideas as to what constitutes an emergency for them, as opposed to others.

Yes, I know this is sweeping generalisation. I think that's kindof the point.

As medical professionals, nursing professionals, paramedics, whatever, we seem to have our natural cynicism nurtured and enhanced by our exposure to certain types of people. But if we dare to openly suggest that some people allow themselves to be 'legitimately' classed as ill by the state, allow themselves to slide into a sick role because it might be an easy option, we are pilloried.

Of course there are many folks out there whose lives are ruined by chronic conditions, the effects of which are difficult to see, hard to comprehend, even to so-called experts; but there are equally people out there who make use of the system to live of the state, or feed a drug habit.

We, I mean I, am not suggesting that they are one and the same. But some people allow themselves to become medicalised

And if you have spent years feigning illness, or exaggerating your symptoms to get a quick fix, or a warm bed for the night, or time off work, it makes it a bit harder to take you seriously when you really are ill.

I note that critics of the medical profession have rarely had to deal with manipulative, 'professional' patients; have rarely tried to reason with people who feel that their own unhappiness must be the fault of some internal locus, that absolves them from blame - this ranges from the obese patient who blames all their troubles on some mysterious glandular / hormonal conspiracy, to the man who's bad back prevents him working, but not enjoying leisure time with his mates, to the patient with the unexplainable headaches who chooses your ED over the two nearer his home address, for equally inexplicable reasons.

I don't see the same criticism labelled at banks when they give you a poor credit rating for constantly being overdrawn and defaulting on all your loan payments.

But maybe I'm not looking hard enough.

For every genuine patient, with a seemingly 'dodgy' story and/or collection of symptoms, there's at least one who's motives are not pure. There seem to me to be few other professions that have to spend so much time trying to tell one from t'other.

Cynicism seems almost inevitable; we are human too, are we not. And if we vent from time to time, please don't tell us to get out of medicine, unless you've walked a few miles in our shoes.

Next

I would be sincerely grateful if the press would fuck off, and stop writing ill informed pieces about doctor's pay, posing as factual articles.
The idea that medical salaries have gone up at the expense of patient care is ludicrous. The Government felt that doctors, and specifically Consultants and GPs were not doing enough work and should therefore pay them for the work they did. This, it seemed would equate to large savings. If it seemed fair to pay people for the work they do when you thought that meant a pay cut, how is it now unfair when you discover they actually do more work that you thought, and in fact this has meant a pay rise. This suggests that before now, these doctors were doing that work without due financial recompense. You cannot announce a deal to pay people for what they do, only to try and renege because it transpires these guys and gals work far harder than you realised.

And particularly not when it is MPs doing the carping; a bunch of useless bastards who vote on their own pay increase. (Which is never below inflation, as far as I can see. Oh, and they don't have restrictions on what other jobs they can have... but private medicine is to be discouraged?)

I am a simple Shroom; maybe I've missed the point. But I still remember the glee on one the face of one of my old Bosses, when he submitted his work pattern, as instructed by 'the management' and calculated that he was owed 9 months compensatory rest.

Why should medical professionals not be paid at a level commensurate with e.g lawyers, or dare I say it, bankers?

But mostly, I'd like the press to fuck off.

Housekeeping:
I've added a Reciprocity list to the blog. If you've linked me, and I haven't already, I'll link you. I hope this isn't bad blog etiquette; if so I apologise. If you don't wanna be associated with my rantings, let me know.

And, I have decided. You must all now go out and buy Astral Weeks, by Van Morrison.

Now.

Do it.

You won't regret it. (Seriously)

RATty, Mole and Badger

Right.

I'm going to try and pen something sensible, instead of the usual drivel. I'm not sure it'll work.

Big Hospital is trying to achieve Foundation Status. I'm sure this is very important, but can't shake the image of committee rooms full of people stood, arms aloft, fists clenched, chanting 'Foundation! Foundation! Foundation!', in a vaguely 1930s Germany sort of way.

All that stands between them/us and it, is the ED. We need to achieve 98% in the four hour target. To the uninitiated, this means 98% of our patients need to be in and out within four hours. I think it's a facile target. It does not mater what happens to these patients, as long as it takes less than four hours. So, me, a triage room and a large syringe of potassium (or air, for that matter) would actually improve our performance ratings.

Anyway, we're falling short by 0.62%, overall. Most of the damage is done at nights and weekends, when staffing levels fall, and patient numbers do not.

So, the three line whip is out. See more people, faster. But don't let clinical care suffer. After a point, these two things become mutually exclusive. To avoid that, the solution will inevitably be to refer more people for admission. If you're not sure whether you can discharge someone, simply admit them. Why waste time trying to sort out (i.e treat) patients in the ED, when it's far quicker to refer the job to someone else. (Buck, anyone? Anyone? Anyone? Bueller?)

To aid this process, the Senior Docs are engaging in a Rapid Assessment process. (Rapid Assessment and Treatment? or Triage?... I'm not sure. I've missed it being up on PICU, but re-enter the ED today.) Patients are seen and rapidly assessed on arrival, before being palmed on to an SHO, with a provisional diagnosis and plan - i.e. do these bloods, this X-ray and refer them to these guys.

We are becoming triage monkeys.

This will undoubtedly speed flow through the ED. But is it right? I don't think so. We are being asked to work more anti-social hours to achieve this target. To agree to this is surely a mistake. Other specialities do not have two Registrars on overnight. Other speciality consultants do not routinely work on the floor until midnight. (ITU excepted)

By increasing numbers of referrals we will clog the hospital with patients awaiting a 'specialist' opinion. Why not make these bastards change their working practices? Ask the surgeons to have a team dedicated to operating, an another to seeing ED referrals. That would speed up decision making, and flow. Ask the other consultants to work until midnight, seeing patients and making decisions - and, incidentally, for less money.

I can't imagine they'd stand for it.

Why should we?

NFR

More pontificating on the matter of who should or shouldn't be resuscitated, and more importantly who makes the decision.
Frankly, and I'm thinking my opinion will verge on the wrong side of 'PC', it seems like a big ol' storm in a teacup to me. But the public do worry a great deal about it. Fair enough, I guess. There seems to be an over-riding fear that one will go into hospital, and be written off as a no-hoper by a wet behind the ears junior staff member, possibly just so they don't have to get up in the middle of the night and jump up and down on you.

That could never happen, right?

Not any more. God forbid we give our junior staff any responsibility. Or assume that they have any nous at all, after six years of medical training.

And now they want to let nurses make the decision...

Fine. Good. Why shouldn't they? It has been my experience that people who shouldn't be making important clinical decisions generally don't want to.

I guess times are always changing, but one of the bigger differences between the way doctors and nurses function, in this country at least, seems to be the level of inter-professional support. While medics are only too happy to moan about each other, often to each other's faces, or behind their backs, if necessary, we usually back each others decisions to the public. Nurses, on the other hand seem to distrust each other, and rarely seem to stand together; on anything.

So I always felt, even as a junior Shroom, that when I made decisions by myself, they would be supported by the rest of the Firm, provided I had a robust justification for them. Nursing staff seem to have a morbid fear of overstepping their boundaries. This seems to be crystallised in the current climate of rigid adherence to protocol.

This is not a criticism, but suggests to me that many nurses would rather not make a resus decision, unless there were strict guidelines about how to do so. Not because they aren't capable of making a well informed reasoned decision, but because if it became controversial, their colleagues would hang them out to dry.

From day one on the floor, I was making life or death decisions for the patients in my care, especially decisions about resus status, and frequently late at night, on my own, without consulting anyone. Should I have been? I suspect most people would now say not. But that was the way things were; and I like to think I made appropriate decisions - most of the time. Where it turned out my Boss differed, in the cold light of day, his reasoning was calmly explained, and the decision reversed. And I learned a bit more about how these decisions were to be made in the future.

So... who should make these decisions? Anyone who's prepared to, I say. Stand up, and be counted. Someone's got to...

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.

However...

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.

Example:
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

I Wish That For Just One Time, You Could Stand Inside My Shoes, The You'd Know What A Drag It Is To See You...

Again, long time no jib...

Sorry. If any of my dwindling readership are still trying, I'm sorry.

I've been a little distracted of late. Shroom's fallow period has ended.

I have a new object of my affection. And it is mutual! I'm not a stalker. My current squeeze, my babyluv may feature here more later, but not for now. I don't want to jinx it, and I'm not sure I have the right to publish her the way I do myself; yet...

Anyway; I have a few local interest 'pieces' to blog about, but they will follow. They're mostly me grumping about what's happening at work. What follows, since we were talking of stalkers (sort of) is the tale of Shroom's only stalker - to date.

I know I've alluded to this recently, but don't think I've covered the details.

The whole sordid affair took place years ago, when I was a Plastics junior in a London hospital. At the time, I had rotated on to the Burns Unit, which meant I spent my days there, but shared the on call rota with the other SHOs covering Plastics and Burns. One Wednesday night, I took handover, and did my rounds, as usual. On the ward was a patient who had been waiting for surgery for a few days. I'm not sure why he'd been waiting but it was a bone of some contention to him, and he already had a reputation as a 'troublemaker' among the nursing staff.

The duty Reg and I stopped by to examine him, and see if we could get the op done overnight.

As I recall, the history was that this chap had been in a house that had been firebombed, and in trying to escape the inferno, he had gone out of a window, sustaining glass laceration to the dorsum (back) of one hand. On exam, it was obvious that his injury was substantial. There was significant skin loss, tendon and nerve damage. The op would require complex reconstruction and full thickness grafting - well beyond the capabilities of the Duty Reg and I, and as no consultant had expressed an interest in staying on to do it, we had no choice but to tell him he would have to wait another day.

He was not pleased; as we continued on our rounds, I was summoned urgently back to the ward. The fella was screaming and shouting at the nurses. When I went to find out why, he turned his attention to me. His primary complaint was that too much time had elapsed before the replacement of his dressing. He claimed that his hand had been left undressed for half an hour, and he was furious at the thought of it becoming infected.

When I pointed out that we had only left him five minutes before, he changed tack; the most vitriolic stream of abuse followed, the gist of which was that nurse were "bitches in skirts" who should be at his beck and call. He expected them to fetch and carry for him, and, I kid you not, "peel me grapes".

As this, almost laughable, rant continued, Sister attempted to re4place his dressing - made more difficult by the fact that he was gesticulating wildly. It must have been uncomfortable, because he flinched, mid-diatribe, and i saw his (good) fist curl up, and he went to swing at Sister. I did the only thing I could think of, which was to step in the way, and place my hand over his fist.

I suspect, in my mind, I was Clint Eastwood - as the Man with No Name.

This is part the first... I'm mid edit - apologies

Handbags And Gladrags

A tough day, followed by a quiet - ish (so far) night.

I've been in absentia for a while; sorry. For my occasional reader - no, I have not thrown you over. How could you think such a thing?! I've just been lazy preoccupied. But I'm afraid I'm still not letting anonymous posts in.

I can't really explain why I've gone off the boil of late. I suspect mostly because I ran out of things to say. This will become increasingly apparent as you read on...

I've been a little busy, too. Two of my very good friends got married at the end of February. A grand time was had by all, and sometimes it seems the only time we can manage a get together these days is Weddings or funerals. Which is a shame, really.

Work is beginning to get me down, again. Ironically, I can consider myself lucky, because at least I don't have to contend with the MMC/MTAS shit. But, my sloth, as always, is catching up with me, as the amount of extra-curricular work I should have produced grows ever further from the actual amount. I fucking hate research. I'm not interested in it, and I'm no good at it. Why can't it be left to those who are? I do enjoy teaching, and seem to be passably good at that. Why can't I trade?

Whatever; a period of hard work beckons. I need to focus.

I am pleased to see the medical profession develop some backbone over MTAS. As readers of my previous posts will know, I am fed up to the back teeth of the disregard, the disrespect that successive Governments have shown the medical profession. I have to curb my enthusiasm most of the time, for fear of sounding like the arrogant fucker I so nearly am.

But enough is enough. Unfortunately, my fear is now that the profession will descend into chaos, as no-one gets a job, or knows what the fuck is happening. I predict an orgy of finger pointing, as people struggle to distance themselves from this god-awful disaster.

The Royal Colleges have started; this comes as no surprise, as they are supposed to be the guardians of post-grad training, and collect ample cash from trainees. It's too little too late, as far as I can see. It is risible and contemptuous of them to now try and blame the government. The Royal Colleges were not in the dark about the monumental shafting being planned; but they sat back doing nothing.

How have we become so impotent in controlling our own destiny?

And yet we soldier on.

At work, a very young child was brought to us in extremis. I wasn't present, but such a terrible event leaves a miasma of grief behind it. The whole department is tensed, looking for ways to void the grief. But it will not be drawn tonight. We have been to busy, rushing from crisis to crisis, and the day staff, who bore the brunt of the psychological onslaught are at home now. I hope none of them are alone.

At the same time, a patient with some non specific limb pain took it upon themselves to start throwing shit at the nursing staff. This patient was not demented, not delirious. She was in full possession of her faculties. It was a deliberate, spiteful act. And it goes unpunished. This sort of thing really brings my contempt for this whole system to the fore. I cannot think of another profession where this would be acceptable.

I might try going to my bank tomorrow, and if I have to queue for more than a minute, start throwing faeces at the teller.

Lastly, I was struck tonight by another vignette you only see in hospitals. Parents with sick children bring in their favourite toys, to try and smooth the experience. Fair enough, but it looks a little incongruous to meet a flustered parent, red faced and anxious, furiously gripping a massive plastic elephant in one hand, and some unidentifiable soft toy in the other.

Maybe it's just me.

I couldn't have said it better myself (2)

Read this... I dare you

Gimme Shelter

And the beat goes on...

I see that it's becoming almost de rigeur for a story to be published daily documenting to horrific slide into oblivion that the once mighty NHS is undertaking.

Was it ever really as mighty as we think? My recollection is always of a service over subscribed and abused; that the Tories can now paint themselves as the party of the Health service, after years of Thatcherite neglect, beggars belief.
Maybe we were once great, but we sure as hell aren't any more.

---How can anyone think such a massive organisation can be managed centrally?

---How can anyone still not realise that free health care costs a shitload?

---Why aren't we doing more to stop the Government ripping the guts out of our system?

Morale is in danger of bottoming out, and this administration seems intent on providing health care that is cheap. Which sounds good, until you stop to think that that is apparently their only criterion for success.

And cheap does not equal good.

It fills me with rage that there seems to be a pervading thought that the job that Doctors do can be broken up and provided piecemeal by various non clinical specialists. What's worse is that all we seem to do is complain (natch) about it.To top it all, I now understand that a significant number of us will be "surplus" by the time I'm looking for consultant posts.
This is ridiculous. How is it cost efficient if the Govt spends money on training me for ten or twelve years, and then I fuck off to another country because either there's no job, or it turns out I don't, in fact, like being treated like an halfwit?

I truly fear that the NHS has become so rotten to its very core, that there is no way back for it... at least not in a form that Pa Shroom would recognise.

--Rant interrupted--

As a follow up to my ranting about training, I've been thinking about trying to clarify my position. The divide seems to be between those who want a life, and those for whom work is life. Work to live vs Live to work .
I'm increasingly in the latter category. I'm not saying this makes me big or clever. In fact, I can't help but suspect the exact opposite. But it is true. Every major decision I've made since I was about 18 focused on my career.

Why can't these two tribes co-exist? There surely is a macho culture associated with how long you work, but if you don't buy into it, that's fine. There's always someone, somewhere trying to prove his balls are bigger than yours.

I don't think working long hours has made me a better doctor than you; but it has made me a good doctor, and I firmly believe the experience I gained working long sleepless shifts has given me confidence and knowledge I would otherwise lack.
Sadly most of it is surgical, and so not very applicable in the ED under the bootheel of the bitch Hewitt.

But I know it's not the only way. And I'm sure plenty of excellent Docs out there have enjoyed shorter hours and fuller lives.

Is there a way..? maybe not.

If you don't already own it, I commend Let It Bleed, by the Rolling Stones. Your life will be immeasurably poorer without it, in ways you can't even imagine.

Five Live Yardbirds

Back again.
I have it my mind that there's plenty to tell, but that it keeps slipping my mind. In my version of reality, I regularly imagine my occasional readers struck by how informative my posts are, or gasping at my rapier-like wit. Please don't disabuse me of this fragile charade.

While I was on holiday, I was at a friend's house having Christmas drinks. This year seems to have marked a watershed of sorts amongst my friends, as we now 'do lunch' or have people over 'for drinks', and it's all very civilised. I'm guessing we're trying to convince ourselves, and anyone watching that we're grown up now. Personally, I'm not fooled. Anyway, towards the end of festivities the doorbell rung, and was answered by the host's brother-in-law. A young woman came in, waving hello to one and all. She made it about half way to the kitchen before she came back to do a double take. She was in the wrong house. Brilliant. Apparently it was only that the walls were the wrong colour that tipped her off. She was undaunted by not knowing any of the guests. Very social I guess.

See, I was right. It's all slipped my mind.

I've seen a few posts about junior doctors hours recently; this is enough for me to throw my tuppeny's worth into the ring.

This eternal problem is forever rearing it's ugly head. Old school doctors worked long hours as juniors, got very good experience and an unrivalled breadth of knowledge. The current generations work less hours, and resent hearing endless "in my day" stories, from grumpy bastards like me. In this country the European Working Time Directive has had the final say in the matter, although in many cases people still work over their hours; they just don't get paid.

Personally, I think we should work longer hours as juniors. Someone's got to work the hours, and trying to employ more doctors to share the load is bankrupting the NHS, according to her holiness Patsy Fuckwit. Less hours as a junior means more hours as a senior, and less experienced seniors. I'm sure the policy is short sighted. There is also, it seems to me, an effect on continuity of care. Pa Shroom marvels at how the surgical service has changed since he first started at Shroomville General. Then there were 3 consultants, 3 registrars and 3 house surgeons. Now, the hospital has been down-sized, so there are less beds, but somewhere between 30 and 40 on the surgical staff.

I have had to field questions from house surgeons such as "how do I give an injection?" (Although I hope this level of lack of knowledge is rare)

It seems to me that a person needs a certain number of hours experience to be a good consultant. So less hours per year equals more years training. Although the government's idea id to shorten training. The choice may be between someone who is well rested, but doesn't know what to do, and someone who is tired, but does know. Yes it's unpalatable, and the idea that people should train in a certain way because their predecessors did is unacceptable.

But long hours seems to have produced good doctors. I'm not sure shorter hours and less training will.

I couldn't have said it better myself

Read this. Please.