Musings Of A Medical Dinosaur

A work in progress.
Worth reading, to start with.

The wind is changing; has changed. Jane Doe, writing the jib I've tagged above, typifies what I have come to think of as the 'modern' attitude. Respectable papers in such august journals as the Annals of Emergency Medicine are chronicling the decline of the once mighty General Surgery. In part, this is because specialisation makes being a generalist difficult, but, and perhaps this is the greater part, also because no-one wants to work the hours.

Long hours, once seen as the domain of the macho surgeon, are no, it seems to me, increasingly seen as both unnecessary and unfair. Many young Docs, confronted with the sort of punishing shifts once common in the NHS were taken aback. It was not what they were expecting. I must confess I find this hard to credit; it was hardly a well kept secret, and many medical dramas made it a key feature - see The Houseman's Tale, Cardiac Arrest or even ER for reference. Perhaps I write from a privileged position; Pa Shroom was in the business, so I saw the routine 12 hour days, and 1 in 3 (1 in 2 when someone was on leave) he worked - and this as a consultant.

I knew exactly what sort of hours I would be expected to put in.

But if you weren't sure... surely it wasn't that hard to find out..?

The way I see it, the way I saw it... you worked all the hours God sent when you were young, and I will never be that young again, and it got easier as you got older. I was always at work earlier, and later than either my SHO and Reg; I'm sure they worked harder, were cleverer... but I worked as long, if not longer.

Was I tired? Yes, all the time. Did I make mistakes? I'm sure I did. My shroomy pride has blotted the copy-book of my memory clean, but I know I didn't kill anyone. Did I learn anything?

Almost everything I learned, I did on call; often in the darkest hours of the night, often in desperation. Was this the best way to learn...?

I can't say that it was, that it is. I'm sure it's not, but it worked for me; doing my time pulling scut duty taught me the basics. Some might say that putting iv lines in, mixing and starting iv drugs isn't real doctoring. It certainly ain't glamorous, but it's as much the duty of a doctor as anything else. And what happens when the iv techs aren't there, or can't get it?

They call me, or other grumpy bastards similarly full of themselves.

Continuity? Sure, you can never have absolute continuity, but it seemed to work better. It was the exception, rather than the rule that someone on the firm was away, and we all knew all of our patients.

Is the way I learned better? I don't know, but it did work for me, and I know I'm not alone. Is that reason enough? No. To say 'I did it this way, so you have to too', is blinkered.

But it shouldn't be dismissed out of hand either.

Whirly Whorl

Grumpy Bastard alert.



L'il Shroom's irritability levels have been tripping off the scale of late. Full Tilt Kozmic Boogie, you might say, if ye were that way inclined.


Why?


Dunno, but I am eternally glad that my colleagues at work are prepared to put up with me. I was especially annoyed this evening with a work colleague, who, it seemed to me was showing scant regard for the fact that I was already an hour late leaving; I have at least enough insight to realise that this was unlikely to be an intentional slight, and that I am attributing altogether too much import to myself, and my own self worth, but it stung nonetheless. What hurts the most is the way that we sometimes get taken forgranted; but I am loathe to foster an "Us and Them" relationship. In any close relationship, the partners are bound to rub each other up the wrong way from time to time, and what should mark me out as (mostly) different from the chimps is how one reacts.


Especially when one is a hypersensitive, moody bugger like me.


Anyway, was grumpy, have ranted, proved to have no grasp of modern verse. Feel better now.







An unusual week for ill folks. The young lady with Boerhaave's is still going on ITU. I went to see her. I felt I owed her. At the very least, I felt I owed her husband; I found I could look him in the eye, and, perhaps more to the point, he could look me in the eye. So, now we wait mediastinitis. My prayers are all I can offer her now. We'll know soon enough.




Next: a man with more than his fair share of rib fractures.

Run over; including, if you can believe it, his head. Initially, very uncomfortable (no, really?) Morphia saw to that, and we mostly goggled at him, thinking how lucky he probably was. Then, we spotted part of his chest moving the wrong way. For the non medical, what I mean is that, for every breath he took, most of his chest moved up and out, as per guidelines. But, some of his left chest resolutely declined that option. And moved in; as if it were being sucked in.Which it mostly was. During normal respiration, the diaphragm flattens and pulls down, while the ribs are pulled up and out by the intercostal muscles (between the ribs). This increases the volume of the chest cavity, lowering pressure therein and encouraging air to move in an 'into the lungs' kinda way.



But, if you disconnect a section, by, say, fracturing several ribs in two places, that section moves with the pressure - so, decrease pressure in the chest, chest wall sucks in.



As well as painful, this is bad for the whole process of respiration. In fact, it's number one on my list of 'Unfavourable Chest Wall Injuries'.





It certainly did nothing for his mood.





But... morphine.





Part of the treatment involves placing a large bore plastic tube between the ribs, so decompress the inevitable pneumothorax, and improve respiration. Not easy at the best of times, it's even harder when the chest is not as... connected as it should be.





So... fentanyl.

When I left, he was remarkably chipper, and gave me a big thumbs up. Well worth it.

Today: forehead versus horse. No contest really, although it did give me ample opportunity to flail, flail and flail again trying to garner assistance in transfer to the Mighty Donut. The injury put into perspective all the times I've palpated a scalp, wondering if I was feeling a step off, fortelling the presence of a depressed fracture. This wasn't subtle. It screamed 'behold! Here I am! The indentation produced by a rapidly moving horses hoof'.

CT showed a fracture through frontal bone and sinus, which, relatively speaking, ain't so bad. She was definitively concussed however, continually identifying her location as such esoteric locations as 'the kitchen', 'Sainsbury's', 'the garden'... anywhere but the hospital really. But she'll be fine, although I can't help but feel it might be a while before she makes any sense.

On a lighter note, I'd like you to consider how you might mime the Horse attack. We theorised that men do it one way, and women another, if at all. Think on it, and let me know, if ye can be bothered.

If I Opened My Heart, There'd Be No Room For Air...

Back On Nights...

Maybe some good news in the personal life of Shroom....

However, what is really cranking my handle at the moment is the ongoing furore about MMR. For those of you disinterested, check here, or thereabouts. I am almost incandescent with rage; however, some of my anger makes me seem decidedly right wing. So what follows is mostly rant, based on some small professional knowledge, but mostly bile.

You have been warned.

Vaccines. Named after the humble cow (vacca) by Pasteur, in honour of Jenner and his work with cowpox. Jenner noticed that milkmaids, while oft afflicted with cowpox, rarely, if ever contracted the far more deadly smallpox. So he experimented, by inoculating healthy subjects with pus from cowpox pustules. The rest, as they say is history. Contemporary records show that people were against such odd behaviour, even then - cartoons depict subjects sprouting small cattle from the inoculations. Fortunately, science held sway.

Does it work? There hasn't been a recorded case of smallpox since the late 70s.

When I was a little Shroom, there weren't so many vaccines about. I had measles, mumps and rubella. It was encouraged, as was chickenpox. If any of you know anyone who has had chickenpox as an adult, you'll know why it's better to have it as a nipper.

Enter MMR. An all in one vaccine to prevent these diseases. Why bother? I had 'em, you probably had 'em... so what?

Because these diseases kill people. Not many, but that ain't much comfort if yours is one of 'em.

And then doubt was cast on the safety of the vaccine. The 'evidence' produced was seized upon by the ever rabid media - in this country at least- and hundreds and thousands of parents voted with their feet. And their children's health.

The problem here is that, as doctors, we have a duty to do what is right for our patients; and if that includes breaking the news that a widely used medication is unsafe, so be it. If I thought the man at the centre of this whole mess was acting in what he genuinely believed was the public good, I'd be less scathing. But I don't think he was.

His research was shonky, and his practices questionable to say the least. And yet the establishment failed in it's duty; the checks and balances, designed to prevent this failed. Medical research is under the cosh a little at the mo', cos it turns out people fudge their research. Well, colour me taken aback. This has always gone on - Mendel almost certainly faked his all too perfect results, and the Thalidomide team hedged theirs in an attempt to prove safety that was to have disastrous consequences.

But now the idea is out there, and there are a number of people who will never be convinced of the wrong-ness of this charlatan's research. Any other evidence will be dismissed as Government cover up; we're back to pictures of cows sprouting from forearms.

But how far can a Government go to enforce the health of a nation? If parents don't want to vaccinate their kids, however ill advised I may think it, can we force them?

Maybe not, but it makes it that much harder to sympathise with the mother who's child is critically ill with pertussis (something I've never seen before either), who explains they decided not to get the kids jabbed after reading the Daily Mail.

By all means make an informed choice, but for Christ's sake, make sure it really is informed.

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)

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

Under Pressure

Some days, I feel like buckling...

More on this in a bit; I'm not really in the mood for navel gazing. I'm in the mood to vent. I often get to work early. It gives me a chance to have a coffee, catch up on e-mails and generally ease myself into the day.
It also makes one a target for people who say things like "As you're here, would you just..."

Of course, the argument runs, if you don't want to be asked questions, hide. (Or don't go in early..?) Either way, I accept this is going to happen, especially in this business. But I reserve the right to say that I'm not on duty. If the fuckers are going to treat me like shit, they can't expect 110% from me. Which I know isn't very caring, but there you go. We're not talking about life and death shit here.

So, there seem to be two ways a person might approach the early Shroom at work, while he is quite clearly attending to personal business, and not at work.

--- Firstly, you might bid the Shroom good morning and ask if he wouldn't mind reviewing a patient, as the SHO is tied up, and it'll save delays, etc.

Unless I'm in a really bad mood, I'll do it.

--- Secondly, you might march up to the Shroom. Do not say hello, do not introduce yourself. Instead, start moaning about the grief management is handing out about The Situation. Demand to know what Shroom is going to do about it. Look aghast when he explains he's just walked in, and doesn't know anything about The Situation. For extra sympathy, walk off while he's talking to you.

Whatever mood I was in before you started, it's now bad.

Of course this sort of thing could never happen in the NHS. Managers there value their Doctors, and more importantly, their patients as humans, not numbers, or targets. And God forbid that such a situation arose because the Management couldn't get the Department staffed adequately overnight.

In case you were wondering, the situation here might have been, for example, that waiting times had reached three hours. They hadn't, of course, so I'm sure that wasn't it.

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.

"I came through time for you, Sarah..."

The Terminator, of course. But what a brilliant line, eh?

Right, I've got a fair amount to get off my chest, so this may be in several parts. First off, I'm come over all viral - hot, cold, shivery, cough, sore throat, stiff neck... that's right. I've got man flu. So I'm a bit grumpier than usual.

Next - the allegedly drunken bishop. Last week, it was reported that the Bishop of Southwark had been mugged while coming home from a party at the Irish Embassy. Shortly afterwards, a man came forward claiming that, in fact, the Bish had been stone drunk. This fella alleged that he had found the Bishop rooting around in his van. Being unaware who it was that was rooting, he extracted the chap from the van, during which the bishop bumped his head. An Ambulance was subsequently called, but the Bish, allegedly, ran off.

Over the next few days, when our witness discovered who the interloper had been (from news reports, and personal effects left in the van), the first ting he did was to call The Sun newspaper.

Class.

Initially, I thought this whole thing was pretty funny. I'm not so convinced now. This is a tawdry tale to be flashed over the front pages of the popular press; granted, we should probably expect more from our clergy, but binge drinking seems almost de rigeur these days... so should we really be surprised that it permeates all levels of society.

But I think what has really left me with a sour taste in my mouth, is that the alleged witness to the affair thought first of calling the press to make a quick buck from someone else's misfortune. I'm sure he could just as easily have quietly returned the stuff. What price dignity..?

Next - a recurrent rant, reverberating around many medical fora, and heard throughout the British blogosphere... how fucked up is the Health Service? I share the feelings of far more eloquent colleagues, Drs Crippen and Rant (among others).

The Health Service is being run into the ground. There isn't enough money - free health care is bloody expensive. What money there is is being spent on managers and chasing targets.

Once again, the Government insist on fucking around with training. The opportunity to spend time trying the feel of various specialities, before committing yourself, would appear to be long gone. So, too, the idea that medicine would be a job for life. I remember talking this over with Pa Shroom when I was 17 or so. He was keen to dissuade me from doing medicine for the sake of it. Hard work, he said, but rewarding. Pa Shroom thinks there's nothing better than treating patients. A job for life, he said. (Unless of course, you're shit)
A job for life.

Now there are people finishing medical school with no house jobs to go to.

Now there are basic trainees who can't find a higher training job to complete their education.

Now there are higher trainees who face the prospect of no job waiting when they finish. (Shroom counts himself among this number)

As far as I can see, ever since Nye Bevan agreed to choke the throats of doctors with gold, there has been a steady attempt to reduce their power and influence. Technically, we are no longer professionals, as we no longer exclusively govern ourselves. (Although this may not be such a bad thing...)

Although, generally speaking, the public still hold Doctors trustworthy, the Government seems to be in competition with their predecessors in showing us as little respect as possible.

What few perks there were to this job, are fading fast. Even now, my training budget, which is not a perk, but, I thought, a contractual obligation on the part of the Deanery, has been pulled from under me.

So; I am now expected to fund my own training, in the hope of being qualified for a non-existent job. It is surely no wonder that the medical profession does so well in the depression / substance abuse league tables.

And what are we doing about it? As far as I can see, fuck all. I will freely admit that I am a simple man; so maybe it just seems like we're doing fuck all. But the body politic of the junior doctor, should be among the most powerful in the country.

If we stopped signing death certificates, the country would grind to a halt inside three days. Then that bitch Patsy Fuckwit would have to listen to our concerns...

I am worried that we idle our time away, while all around us, Rome burns.

Autologous Autosplenectomy

I really hate it when there's a departmental fuck up waiting for you when you get to work.

Today, a patient fell through the cracks in the system. She presented short of breath and was seen promptly by one of the SHOs (junior docs). When he went home, some of her investigations were still outstanding, so he handed her care over to one of his day shift colleagues. Sadly, he did not document to whom he handed over; it appears that his colleague promptly forgot about the patient.

She sat in the ED obs ward for 8 hours, with little or no intervention. Both shifts of doctors and nurses failed to notice this patient... she was then admitted to the main hospital, to the medical service; but sadly without any prior discussion with the medics. This provoked much wailing and gnashing of teeth.

When I came on shift, everyone knew about this problem, but no-one had done anything. I realise it had been busy, but it isn't going to get any quieter. So, 12 hours after we began to neglect this patient, I had to try and clear up the mess. I hasten to add that she has come to no harm; but this certainly appears to be more luck than judgement. Some days, I'm really proud of my profession.

Going Nursical

Brilliant. The title bears no real relation to the post, but a fellow Blogonaut - the Bohemian Road Nurse - left it, and I thought it too good a phrase to lie hidden. I hope she won't mind.

So, I have returned. I've spent the last few days on a fairly intensive ATLS course. This is the Advanced Trauma Life Support course, care of the American College of Surgeons. It teaches one safe way of caring for the trauma victim. The courses are pretty good fun, but fairly hard work. Since part of my job involves looking after trauma victims (or at least the British definition - we don't have much "proper" trauma per se) I expected, and was expected to do well. Which generally increases the potential to fuck up. In front of the boss.

Well, you'll all be pleased to hear I managed to avoid all / most banana skins. I am now all shiny in the ATLS fashion. It is interesting to see that not much has changed since I first did the course six years ago. I tend to find these courses are arbitrary, as they are trying to teach a UNIVERSAL method, which is 'proven' to be safe. Trauma care is especially difficult to get evidence for - it's very hard to ethically justify depriving multiply injured patients of care to see how it affects outcome. Getting consent can be a real bitch, too! A good case in point is the use of steroids in head injuries. This was considered a gospel treatment, in the UK at least, for years. Only relatively recently has it become apparent that not only did this not improve outcome, it actually does harm. Primum non nocere? Ooops.

Consequently, as far as I can see, most of the developments in trauma care originate with the military - WWI, WWII, Vietnam, Falklands, Afghanistan and now Iraq. Wherever there's a war, there are large numbers of traumatised patients... of course, they're mostly young, fit men and women. Or pigs. It always seems to be pigs that the military surgeons practice on...

So extrapolating data to the real world, which is slowly filling with fat, older people, may not work. Even so, I was disappointed not to see any comment on issues such as permissive hypotension / hypothermia. I seem to remember these being contentious issues six years ago, and I guess the picture's no clearer.

Thanks again B.R.N

Delusions of Grandeur

Education day today. Gives me far too much time to think. Today's thorn in my side, is my ongoing God complex - I'm definitely nowhere near as important or clever as I think I am; but what is really yanking my chain is the intermittant storied that the media run with along this line. Why is it the medical profession is always accused of playing God in a negative way? It's always when we don't offer treatment, or when someone dies that the accusations fly... Doctors tried to play God by disconnecting my baby from life support, etc...

Whatever your personal views are about Doctors with God complexes, surely it has to work both ways? If I can play God by not treating someone, what am I doing by treating someone. Didn't God create meningitis? Is a ruptured aorta too not God given? As far as I can see, you can't have it both ways; playing God as meaning making life-or-death decisions..?
So why do the papers never scream 'Doctors played God by saving my critically ill baby'? Not good news? Or do I just need to up my lithium dose?

Answers on a postcard, please

Things that made me smile

No. 1 in an occasional series
--- Many years ago, when Shroom was just a little fungus, he was asked to come review a patient. He had learned that when some nurses asked you to come, you came a'running; so he came apace. "I'm worried about this guy. He's blue"
Blue should also be on the list of colours you're not.

Rounding the corner I was confronted with the patient. Sure enough, he was blue. But he looked well with it. He was not 'so cold I'm blue' blue, or 'so breathless I'm blue' blue. Just blue.

This puzzled me. It was a dreadful night, and the guy was sleeping rough, but he looked so well. To hide my confusion, my eyes scanned the cubicle, finally lighting upon the sad bundle of stuff the patient had abandoned on the floor. It was sopping wet, sitting in a little puddle. A little blue puddle. Picking it up revealed it to be a thick, wet, blue blanket.
"Are you sleeping under this?" Nod, shiver...
Gently, I rubbed his skin; the towel came away blue, the skin beneath gloriously pink. 'Cured, Sister' winks the Shroom; 'needs a new blanket...'


Guilty Pleasures, no. 1
--- I'm secretly delighted every time a Paramedic or Policeman calls me "Doc"

I seem to have a little hope in my heart this morning; I hope this doesn't signal the onset of mania