Archive for September, 2008

You can do better than me

If you talk to me about work (and i advise that you don’t) you will be quickly hit with a mix of enthusiasm, passion and frustration. Most of you have realised this by now and therefore stopped talking to me about it altogether. Ultimately only i find it this interesting. But occasionally some poor naive soul asks about my work and all of a sudden they’re pinned down under a wall of health policy, stories of dying people and how, to be honest, we often don’t really do that great a job of looking after people. By the end of the first pint, most people are moving swiftly toward the corner and onto the weather or the footy results. I don’t blame them, it is perhaps natural that only i am as enthusiastic about it all. This is not to say – as you might presume – that i think what i do is more important than what you do. I just know what i do is pretty important.

But there are a few people who talk about what they do with the same degree of enthusiasm and passion. And i don’t mean what you find most medics talking about – bitching and moaning about things that other people do wrong.

What i’m talking about is more like confession. Owning up to each other that we do not always do well. That in fact we quite frequently do badly and that we’d like to a whole lot better. These are our dirty secrets, fit only to be aired with a cup of coffee in confidence in the staff room.

So why are we so scared of admitting that we are failing our patients? Given that it’s something we do daily.

Part of it can be explained by the natural competitiveness in medicine. Say, for example you have a 12 year old cyclist hit by a car, with head and chest injuries. Waiting for him in the emergency department (apparently that’s what we call it these days, it used to be A&E. An ED seems to be different in that it sees more patients with less staff and gives them a worse deal…) will be at least 4 doctors (more likely 6 or 7) and a few actually useful people like nurses. The doctors will be of varying grades, varying specialities and with varying experience. In most cases (especially after a recent changeover of staff) most of the doctors will not know each other’s backgrounds and levels of experience (which is frequently different from seniority).

The astute observer can observe a bizarre performance. Like the pheasant’s tail in action. There is posturing and great fan fare and internal politics and people finding their place in the milieu of doctors. I know this because i have done this. I have spent evenings in resus rooms, trying to present the most obscure and complicated diagnosis to most impress the on lookers. If someone else mentions an equally obscure diagnosis that i have never heard of, i do everything not to let my ignorance show. I remember an ED consultant in Hawke’s Bay interrupting one of these such sessions of self-aggrandisement with a rather rude though salient comment that “aren’t we all having a nice wank…”

Simply talking the loudest and the most and leading the resuscitation does not ensure your place at the top of the professional pile. Consultants especially are notorious for not listening to what other parts of the team are doing – eg one consultant will say mid-resus “don’t give him more fluid” and within 20 seconds another will say “give him more fluid”. What is a junior to do…

Part of this reign of confusion can be assuaged by having people who know and talk to each other and perhaps, dare i say it, have a degree of respect for each other. This tends to eliminate a lot of the showing off and place finding.

The tangible arrogance that seeps out of doctors is difficult to deal with. From a human level, no one wants to admit they’re wrong, or the potential that they may be. At least certainly not in front of a colleague. On a professional level, self-confidence in decision making is encouraged. Unfortunately, too often this leads to the delusion that you’re somehow special, that unlike everyone else, you don’t get things wrong, you don’t miss things, you never make the wrong decision. This is a very dangerous place for you and your patient to find yourself.

We are perhaps victims of our own (or rather our medical ancestors) success. Penicillin, vaccination, transplants… There is an idea that the medical professional has the answer, however unsure we are about what the question is. While we are becoming largely distrustful of statements that people make – politicians, lawyers, criminals, moisturiser adverts… – there is still great credence given to ‘the doctor’. If the doctor says you’re OK, then you’re OK. The statement the doctor makes is often given more credit than it is actually due.

The problem lies in that people believe that medicine is an exact science. Which popular culture (and no doubt the medical profession itself) has tried to foster. It is however a big stinking lie. Medicine is not an exact science. It is merely educated guesswork. Sometimes the guesswork is more educated than others. People think this uncertainty applies to only the ‘clinical medicine’ of asking the patient questions and examining them, and that therefore scans and tests hold the key to concrete facts. This is also a lie. The scans and tests only contribute to the education of the guess.

Now this is not to devalue medical knowledge altogether, it is perhaps the best we have. However imperfect. But you must know – it is most definitely an imperfect science.

Which means we need to do better. In every single aspect. Something that seems to be getting lost in hitting targets and not eating or peeing over a 12 hour shift. There is not a tangible culture of excellence. Maybe there is, but it seems well hidden below the endless patients and targets and complaints. We are getting by yes. But getting by is hardly good enough.

I think it was done better when i was in New Zealand. That was partly resource driven. There were simply more resources, therefore we could do better. It was also driven from the top-down. The bosses expected a certain standard of care, and a culture of no mistakes. How else do you get better?

The desire, i think, is there. The desire to do better. The circumstances and structures are perhaps not there.

Efficiency does not imply excellence or quality of care. These are variables that are very difficult to measure and therefore very difficult to win an election with.

I have no easy answer to fix this. i have not the slightest desire to have any role in dealing with health policy and sit in meetings and argue over budgets. I suspect i don’t have the talent for it either. It’s as i tend to say, an important job, i’m just glad it’s not me that has to do it. In fact it would be easier to blame our failings on “the system” something institutional and anonymous and can be blamed on “the suits” in Whitehall.

But that’s probably a tad dishonest. Yes we are failing on an institutional and policy level, but we are also failing on a personal level. An overworked, demoralised, uninspired work force finds it all too easy to blame the system and is averse to admitting any personal failings. That perhaps they don’t advocate as vigorously as they should for their patients. There is a lack of personal responsibility for patients care. The expected level of care seems to be only a medico-legal one, not a moral one.

And this is where, i suppose, the responsibility is mine alone.

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(Ooh) Heaven is a place on earth

So I suppose I better follow up on the last post and the bit about “not going to heaven when you die.” Before the crowd of pitch fork waving believers break down the front door and burn me at the stake for crimes against orthodoxy.

I can only recommend NT Wright and “Surprised by Hope” as a great unpacking of the idea of the Christian hope (where almost all of the following is plagiarised from) and what the Bible actually says about “the resurrection”. There were no mental or theological gymnastics, just a little recognition of a world-view that is assumed without reference to GOD’s word.

The central point of GOD’s redemptive narrative is the death and resurrection of JESUS. I suppose all of us could be happy with that. Some of us will focus a bit more on the death, some a bit more on the resurrection, but we could all agree that neither works without the other.

The central part, to the Christian hope is that CHRIST was raised from the dead. That he was bodily raised in physical form, a physical form that was undoubtedly different from the one he’d so recently been in, but physical all the same. The Bible is quite clear about the resurrected JESUS’s physicality, along with the fact that it not so simply physical as it had been before. And what was so stunning about this is that it is made quite purposely clear that JESUS did not return as a ghost, like Casper the friendly ghost or Nearly Headless Nick. This was something quite different. Indeed a big reason why the beliefs of “the way” in the first century were so unique. Lots of people had a notion of some “spiritual” non-physical continuance of existence. No one had anything like a body physically raised.

JESUS then leaves. Where he goes the Bible is remarkably unclear about – yes to Heaven – but what/where Heaven is is left undefined. Instead we have defined as somewhere “up there” which is why Yuri could (apocryphally) say that once he got up there that there was no GOD cause he couldn’t see him anywhere.

This is where the cultural assumptions come into play. That heaven is a place (somewhere else) with white fluffy clouds and fat babies with harps and bad aim. GOD has a white beard, and a James Earl Jones voice, everyone wears sandals and JESUS never, ever looks like he’s middle-eastern. Heaven is therefore the place where we go when we die, when we will finally be free from these terrible, nasty body things and we’ll float like spirits, free from such boring demands of physicality.

These are ideas that of course have developed within the Christina tradition (centuries of Christian art will give that away) – that does not mean that they are Christian ideas. The idea that we can discard our bodies and float like spirits is good old fashioned platonism (at least a Christian interpretation of it). The idea that the soul is the only important bit of life is not a Christian idea. The soul itself is rarely mentioned in the Bible, yet it is so prevalent in all our talk from salvation to resurrection. This is gnosticism revisited. These ideas are firmly embedded in our belief system but they are not Christian.

Let me emphasise then what is Christian. In CHRIST we have the example. When we die, he promises resurrection. And this will be bodily, physical, in some form not entirely different from what we already have. Though of course there will be some fundamental differences. When we are resurrected we will be resurrected, guess where? Right here. This is the key point. We get new bodies. On a new earth. Rev 21 tells us that CHRIST returns in glory not to snatch us from the evil jaws of the creation but that he returns to rule over the redeemed and renewed creation.

When I think about that I realise I already believe that. This is hardly any new kind of heresy, it’s just that my thinking has been muddied on the whole issue. Because of the underlying cultural (not biblical) assumptions, and all the terrible songs and hymns that we sing that lead us up the garden path in terms of resurrection theology. Let me put it this way. As Christians we believe what non-Christians think that we Christians believe about life after death:

Love of mine some day you will die
But I’ll be close behind
I’ll follow you into the dark

No blinding light or tunnels to gates of white
Just our hands clasped so tight
Waiting for the hint of a spark
If heaven and hell decide
That they both are satisfied
Illuminate the no’s on their vacancy signs

If there’s no one beside you
When your soul embarks
Then I’ll follow you into the dark

Death Cab for Cutie (I sang this song in my cafe gig in NZ cause I like songs that reveal what non-Christians believe about the meaning of life. Though only now I realise how far apart we are in our beliefs)

Most of you will have realised that I’ve left a bit out. That yes we die, and when CHRIST returns and makes everything new and rules on the new earth (not in heaven on the clouds with the fat babies – he’ll be bored with all that by then) that we will be with him in our cool new resurrection bodies, not floating round like disembodied shadows on the cave wall.

But what happens when we die? Do we not actually go to heaven when we die? This is where the tricky bit comes. The Bible actually has quite a bit to say about the resurrection and where it fits in. But it doesn’t say quite so much about the in-between. Is it some kind of cosmic hibernation? Paul speaks about preferring to depart and be with CHRIST. Which at first glance sounds like “going to heaven when you die” but surely he must mean something different – as it is he himself who goes on to say so much about the resurrection. Indeed CHRIST does the same. Leaving the disciples and telling them he will return. So where does he go in the mean time. He goes to “heaven” which is loosely defined though perhaps most useful as “with GOD” or “in GOD’s presence”. Beyond that the Bible does not have that much to say, at least not in specifics.

Again let me emphasise that when we die, and go wherever JESUS went to when he left the disciples, it is vital to realise that this is not the fulfilment of the Christian hope. The resurrection is the fulfilment. As NT Wright says. It is not simply life after death, but life after, life after death.

There are lots of implications of this. It’s important in that it’s a proper understanding and articulation of what the Bible says, and reveals it’s uniqueness in the hope that we cling to. That the body and the physical world itself is not evil – it is fallen, but not evil. When we die of cancer it is not that mitosis and cellular division and ultimately (well until CERN tells us otherwise) particle physics that is ingerently wrong – more that it is fallen. Our DNA itself seems part of the fall. Indeed it seems that even that will be redeemed.

[As an aside, there was also in the book a “factoid” about the human body that the actual particles (in terms of atoms and so on) are completely exchanged for different ones over a course of around 7 years (undeniably true to some extent –  though impossible to accurately measure). We (quite literally) are what we eat. And to be delicate – dispose of, in terms of skin, sweat etc…). Fascinating. Well if you like that kind of thing.]

It means that we are not to lock ourselves into Christian self-righteous ghettoes and pray that we’ll be raptured (whatever that means…) before this horrible sinful world gets the better of us. It tells us that GOD is in the business of redemption and renewal, and that both we and the creation itself are going to be renewed and redeemed and that it’s our role to inaugarate and announce the Kingdom of GOD by decalring that JESUS is Lord over all of it.

It’s important for lots of reasons, few of which are outlined here, so perhaps it’s just an exhortation to read the book, and more importantly read the Bible, and read it withoout the Plato-goggles on.

Killer cars

Natural selection at work.

If you’re not quick enough to avoid a slow moving volvo on a straight road in broad daylight then you can go the way of the dodo. There was also a brief debate as to which bin it should go in. Reuse, recycle etc…

Flying dream 143

It’s been a while. I have kept myself to terra firma and our fair island of Éire for too long.

It has been over a year since I was on a plane and out of the country, following on from a year when I didn’t go a week without being up in the skies. I called it a moratorium on travelling. The plan is not to leave the country (depending on how you define country) for two years, as some kind of penance for earlier globetrotting.

But there are of course certain exceptions. I have these exam thingy’s to do, in order to further my ‘career’ or whatever. So i’m doing my second part for my membership of the college of emergency medicine. Which sounds very grand but is really a way of people keeping an eye on me that I know enough not to kill too many people.

And so I get to leave the country. If only briefly and if only to london, and if only on ryanair for a tenner.

So I sit in the lounge bar of the royal college of surgeons on a very comfy sofa surrounded by lots of paintings and antiques that all look very pricey. Across the mahogany coffee table sit a bunch of be-suited surgeons talking about NHS politics and workload.

I am unusually happy. It has been a while since I have found myself on my own far from home and people watching. Yes this is NZ all over again.

I have a copy of the guardian, a pint of guiness, the mac with uptodate and the oxford handbook of emergency medicine. This is meant to be studying but I find the discussion about carotid endarterectomies far too interesting not to eavesdrop on.

I find hotel breakfasts kind of odd. The juice from the big machine that swirls it around. Always a tad too much on the sweet side to be pure. Coffee in pots to make it look  proper when it’s only instant. And always the dodgy scrambled egg.

And I forgot to bring a paper which brings the perennial problem of what to do with your eyes. If you have  a paper then it gives you something to do with your eyes,in the same way a cigarette gives you something to do with your hands in a pub or a cup of tea at a funeral. Breakfast was therefore shorter than it otherwise would have been.

The exam itself was odd. In that it was some kind of return to GCSE again. The long rows of tables, the pencils, erasers and slightly bored invigilators making bad jokes. And of course the obligotory mistakes in the paper that where it says answer question 4 it actually means we should answer question 5… Of course… we should have know that…

This in a room surrounded by huge 10 ft portraits of 19th century surgeons looking down on you saying ‘i hadn’t a clue about penicillin or the genome or electron microsocpy in my day and I was still better than you. Don’t screw this up…’ I won’t. I promise.

Exams are odd in that they mostly don’t test what you know. They mostly test how well you can answer the question which is something quite different.

I make the classic mistake and finish too early and then go over the questions again, and make changes because I think about the questions too much. These changes are almost invariably detrimental.

Most humorous of all is that three guys (all in their thirties) have to wait behind at the end having committed  the cardinal sin of not putting their pencils down when the bell rang. It’s like being 13 all over again.

The trip home is largely uneventful except for the always magic moment when the plane finally breaks through the clouds and you’re into blazing sunshine like that bit in the intro of quantum leap. Why do we humans waste our time on the ground when we could have mastered the air instead of developing opposable thumbs.

And so i’m back dear ireland I missed you so.

Conventioneers

Tonight I want to be anglican again. Not that i was ever properly anglican anyhow. And not that the anglican church i went to was ever particularly anglican either. Which i suppose was one of the nice things about being anglican – that they weren’t always that easily pigeonholed.

And now that i’m presbyterian – well sort of. The people I love happen to be part of a presbyterian church. I am more presbyterian by accident than choice. Anyhow, now that i am whatever i am (which is of course different from being “i am who i am), whatever that may be (goodness this has started badly) I realise more and more how the presbyterians seemed to get stuck with all the crappy old buildings (though i confess I quite like church house). I suppose it’s their own fault, in over-reacting to catholicism by being petrified of anything even remotely pretty in the church in case some one mistakes it for some kind of a idol and before we know it we’re selling indulgences to evil, rich English kings…

At least the anglicans have retained some of the sense of mysticsm and importance of aesthetics and location and architecture. Though I suppose us presbies think that they’re what my dad used to call “the thin green white and gold line between protestantism and catholicism” (my dad was anglican, again more by accident of birth than choice. His dad was probably more of a socialist).

I blame this on all the heretical, hairy lefty books i’ve been reading (tom wright and brian mclaren both have beards) which have no doubt left me with something of a reawakened appreciation of lots of the other traditions of the faith. This along with the fact that it turns out we don’t go to heaven when we die (a statement which requires some qualification which I’ll not go into right now, but it’s OK I’m not a heretic… honestly… ) which came as a bit of a surprise but is actually remarkably clear when you read the bible without the old plato/gnostic goggles on.

So anyway.

Tonight was the first night of the Portadown Christian Convention

[we do odd things, a convention to most people is a business or work thing. (On the one occasion i met zoomtard he said that he wasnt going to a New Horizon meeting cause if his dad found out he went to hear a christian preacher in a big blue tent that would be a step too far). When you think about it, we do a lot of odd things, like all meeting together in a big building on a sunday evening, singing a few random songs, listening to a guy talk about an old book and a “dead guy” and then doing this remarkably strange thing where we all close our eyes and “think stuff” – this whole religion thing really is most bizzare when you look at it from the perspective of those outside the church. That implies nothing about it’s value or truth, simply that it’s unusual.]

Anyhow it’s laudable, most of all for the fact that it’s one of the rare opportunities that the Church of GOD in this town manges to (mostly) get together without bickering and moaning quite so much as usual. There’s always so many people (most of the churches cancel their evening services) that they normally hold it in the big church of ireland in the centre of town.

And i suppose this is what makes me want to be Anglican. They got all the nice buildngs in protestantism. Huge arched ceiling, stained glass, a sense of awe and presence associated with, i suppose, the presence of GOD…

Makes me feel a part of this place, this community (perhaps my favorite word of the moment, along with resurrection), this group of people who love and struggle to follow JESUS. Reminds me I’m a part of the Kingdom and I have a role to build it, to help see GOD’s justice and mercy goodness begin to rule here in part, as it one day will in totality.

The island – come and see

It has been a while since the last trip in the canoe. For various reasons. I regret not taking them out during the floods when you could have canoed over all the fields. But it’s Ireland and i’m sure it’ll rain again.

Incidentally the pink life jacket wasn’t ours it was a “friends”.

This desert life

http://www.pbfcomics.com/


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