Archive for January, 2009

Going nuclear

“the church’s mission began as the radioactive fallout from an explosion of joy…”

Leslie newbigin
The gospel in a pluralist society

Be good or be gone

I never thought I would be one to get particularly excited about medical politics. But you get older and more frustrated with the system and dare I say it actually more idealistic.

Medical training is one of  many personal bug bears.

I got into medical school on the basis of grades and a UCAS form alone. No one spoke to me and asked me questions as to whether my personality and character and all the rest was in any way amenable to it.

I have said this before about medicine. You do not need to be smart to do this job. You need to be smart enough (echoes of outliers there…), but overall it’s not quantum physics or maths or anything truly requiring smarts.

The vast majority of what i do is talking to people and good old fashioned hard work. Grades are no reflection of this. As grades for entry to medical school continue to rise – in order to find some way of differentiating the thousands of candidates – then more and more we are producing legions of bookish docs with smarts coming out their arse but who couldn’t talk their way out of a paper bag. I’m not suggesting a better system. Just saying the one we have sucks…

I worked out in the first term of medical school that i could pass exams with little work and proceeded to spend five years getting solid below average marks. And no one pulled me up and said you should have done better.

I came out of medical school with just enough knowledge not to kill someone. And no idea how to make them better.

I have spent the past 5 years studying and learning all the things i think i should have learnt in medical school. Medical School was largely a waste of time in my case.

Hopefully that concerns you some what.

Over the past 5 years there have been significant changes in both under graduate and post graduate medical education. Not that they were perfect before but I’m pretty sure they’re a bit shit now.

Most will have heard the MTAS fiasco that made headlines a few years ago. That and the lost tribe of junior docs with few options for further training.

There as been a bit of an obsession in medical education on competencies and juniors being signed off as fit to manage and perform certain skills, procedures and conditions. No mention of them being good at it. Just as long as they’re competent.

Which brings me to this month’s EMJ editorial (yes i read a journal called the emergecny medicine journal. I’m comfortable with that. There’s a journal simply called “gut” for gasrtoenterologists…)  where someone sensible has piped up and said that maybe competencies aren’t all they’re cracked up to be and perhaps someone with all the competencies in the book mightn’t be quite what they’re cracked up to be.

Maybe i just like the cynicsm cause i’m one of the lost tribe in effectively a dead end job who in the grand scheme of things hasn’t so much as a single competency signed off.

Don’t steal our sun

Ireland kicks ass. On a sunny day that is.

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Radio Cure

Most of you will have realised by now that i am a bit of a nerd when it comes to… well everything. I am definitely a nerd when it comes to medicine. I like monitors and ultrasound machines and technology in any aspect.

And so I’ve kind of got into medical podacsting in a way. As if i don’t spend long enough in work or studying or reading uptodate i also subscribe to a number of medical podcasts.

I got into podcasts mainly through lectures and sermons on theology that I could listen to while driving round New Zealand and fed up listening to Pedro the Lion for once.

I then managed to find the wonderful Surgery ICU rounds which keeps me amused endlessly even if it is just the guy’s kids screaming in the background. It also reinforces to me that whatever faults the American health care system has, they do seem to train their doctors bloody well – there aren’t too many plastic surgeons in the UK who know their pharmacology and physiology well enough to run an ICU as well as do what many would call the main part of their job – surgery. Or maybe i’m being harsh on the surgeons in this country.

Between that and my time in the ICU in NZ and the most wonderful Bad Science and How to read a paper I’ve become a bit of an evidence based medicine junkie. This is sad i know but comforting and satisfying none the less.

I recently discovered EMRAP TV which is worth watching even for the non-medics – it seems to be bunch of Emergency Medicine docs in California led by someone who vaguely reminds me of Foy Vance who make bad jokes (well most of them) and talk about complicated medical things while taking the piss out of everything in sight. It’s an odd show.

The American College of Emergency Physicians publish their own podcast with endless comments about how if you kill anyone on their advice then it’s not their fault. Interestingly the manuscripts seem to be read by professinal voice over people with cool voices and dubious pronounciations.

The other one i follow pretty closely is one from Albany Medical centre. Who appear to have regular Grand Rounds where they have lectures and teaching for their staff, so that they’re continuing to learn and keep up with what’s happening in medicine. What a novel idea…

Though they must live in a different world, imagine taking all the docs off the floor for a few hours a week in A&E. Wouldn’t be a good plan. All the other specialities do it and it turns out all their patients survive without them and have to wait till their finished.  Not so in A&E where the painful toe for seven years has to be seen and sorted in 4 hours – Everything is an emergency it seems… Right. Stop ranting andrew…

They seem to podcast every week, lectures on everything from interpersonal violence to coding and documentation in the ED.

And as ridiculous as it sounds it was the lecture on coding and documentation that really caught my ear (?).

People in America get sick the same way they do in Ireland. The difference is when they get sick here, they turn up at their GP or A&E or wherever and they just say their name and address and get sick and they get literally thousands pounds of care and they go home and get on with their life and think no more about the cost.

In America, you get thousands (and often thousands more) of pounds of care and everything is written down and recorded and you get a nice big bill at the end of the day and someone has to pay for it. The sheer scale of the billing and charging process is simply mind-boggling.

Driving back from Portstewart listening to this guy lecturing the residents on how to fill the charts properly to make sure that they actually get paid for the work they do, and at the same time warning them all against fraudulently claiming care they’ve not actually provided.

I find it hard enough simply looking after the patients I see, never mind thinking about the endless reams of paper work and charging aspects of it. Never have i been so glad to be in the chaotic mess of the NHS. How i love you so…

So next time you see me in the car, you’ll realise I’m rocking out to life-threatining dermatoses…

Sweet soul music

I was never into classical music. It was all dead guys and bow ties and harpsichords. In my ignorance I claimed that classical music, while technically proficient lacked soul. As if somehow skinny guys with guitars had the market sewn up on that one.

Sigh.

I was raised on Simon & Garfunkel, though mainly Simon with a bit of Bright Eyes (no not that one…) thrown in for good measure, long with Abba, Neil Diamond, The Beatles and Buddy Holly. I figure that’s not bad for growing up in the eighties. I give thanks for my parents music taste.

My lasting memory of classical music is off the old Hamlet ads. That and a brief flirtation with some complication album that had some Elgar in it that taught me all new levels of melancholy – I was 16 that was what I lived for at the time it seemed.

I think the main problem I had with classical music is my ignorance. I mean you can’t just look at the titles cause they’re all numbered numerically. You’ve no idea what they’re about really except what number they are and what key they’re in.

And I miss lyrics. I miss lovely little self-deprecating bridges and resolving choruses and shouty backing vocals. I have no point of reference with classical music.

Though I am perhaps learning.

Thanks to the wonders of Spotify (via the office) I can now get any music I want streamed online – I can hook you up with an invite if you’re interested… With my level of ignorance I can simply type Classical music and be presented with reams of the stuff in all it’s “western European dead guy in a wig” glory.

Now there are strict rules for when you play it. The house will be empty, and tidied, and I will have a clear agenda ahead of me, largely involving coffee and books. It is also good to revise to. It is even good for lying down on the sofa and simply plain listening to. Which is something I do far too rarely and too often use music as a literal soundtrack to whatever else I’m doing with my life.

Anyhow the dead guys rock. Someone get me my harpsichord.

You only live once

[Inspired by a lovely little article here]

Something me and CW and Skeeno were chatting about over dinner a few weeks ago. What defines health? What is the state of health that we are aiming to acheive? Is there such a thing as ideal health?

Me and CW are fairly passionate about what we do, more so as time goes on it seems. Medics don’t often talk about this in work situations – at least that seems to be what I find. Most seem pretty focused either on the shift at hand or more depressingly their careers. It is not that often I chat to a doc about the fundamental aspects of what we do everyday. I do this more everyday. Maybe this just reflects how much I’m frustrated with my job. Who knows.

Anyhow. Back to definitions of health. This will naturally have cross over with a slightly larger question – what’s the definition and point of life itself? What are we aiming towards and why do we do any of it? This is a huge topic and I suppose I’d prefer to avoid the wider picture and focus on the health aspect.

Back in medical school we had all these nonsense lectures that I never went to that were titled “the man in society” (how did they git away with “man in society” in the early noughties, surely it shoul have been “the person in society” given how PC they were) which were largely about the sociology behind medicine. Despite either hating or missing or dismissing all those lectures as touchy feely nonsense I have to confess that in retrospect they were all true.

The concept of health is undeniably holistic. Which is of course a fashionable word. I tend to describe such concepts as making the remarkably obvious exceptionally complicated.

People are not so easily defined as pathologies. Doctors study and treat pathologies and occasionally we make some impact on those pathologies – though I would stress how occasional that is.

Patients have lives and relationships and desires and hopes and ambitions and fears despite their ejection fraction of 15% or their incipient renal failure.

I spent a good 5 minutes the other day encouraging an 80 year old to keep smoking. What’s it going to do? Kill him?

If you’re 80 and mobile and continent and conscious you’re doing pretty well. You’ll be dead within 10 years. Why stop what you do everyday and enjoy.

Any healthcare decision or intervention is a balance of pros and cons. Of you’re thirty with two young kids and a bad family history of heart attacks then I’d happily spend as much time as needed persuading you to stop smoking – presuming of course that you think seeing your kids grow up and develop as something that is vital to you. As a paternalistic and well educated medical professional I have decided that what you’ll miss and find hard about not smoking is nothing compared to the joy of bouncing your first grandchild on your knee.

Trust me I’m a doctor.

Health is more complicated than cholesterol levels and life expectancy. Our patients need and want us to advocate for their health. Maybe we should ask them what that means occasionally.

I know what I know

Hotels are like a bit of a different world. These little boxes of isolation around the world. Where all manner of indiscretions, infidelities and illegality appear to take place (I’ve seen movies, I’ve seen what happens).

Not that these things ever seem to happen when I go to hotels, no one dies, police never charge down the door looking for drug dealers. Such is life.

Instead I sit around fantasizing about ordering a room service sandwich at 4am and unwrapping all the little miniature bars of soap. Endlessly satisfying.

My personal bug bear is the little sachets of instant coffee. Yes it’s all well and good having a kettle and a few cups but what’s the use if it’s some shitty instant coffee stuff. I despair.

Every hotel you go to you’ll find a nice copy of a Gideon bible in one drawer of the bedside cabinet (something I always remember when travelling so i don’t need to bring me own…) yet in this place you’ll find the Gideon’s in one bedside cabinet and a guide to Buddhism in the other one. It’s a double room so there’s a big double bed with two bedside cabinets. Maybe the husband and wife go to bed convinced Muslims and wake up the next morning a different religion. Neat idea really. If I get a chance I’ll expound a bit on the guide to Buddhism. I’m an ulsterman – I’m nothing if not ignorant.

I’m back in a hotel cause I’m down in Dublin for the (hopefully) third and final part of my membership of the college of emergency medicine (we’re not a royal college yet, we’re too much of a baby speciality in the world of medicine yet) – which if I pass it will give me the privilege of spending 2 or 3 hundred pounds a year to be a member of said college. I’m not sure what else I get for it. Well I suppose I get a few more letters after my name making me the esteemed and confused Nelly And I MB BCh BaO MCEM 5M SwIM bADGe… Da would be proud.

To become a member of the college of emergency medicine (and I know you’re both gagging to…) you have to undergo a series of trials each more fiendish than the next, solving puzzles and surviving death defying trials… OK well maybe not…

It comes in three parts, the first is multiple choice (or multiple guess depending on your level of knowledge). I passed this first time with a comfortable margin of 1%.

Part B is a nice little short note style question format. Thankfully, and surprisingly based on real-life situations that you might encounter everyday in work. This is unlike some exam situations when you’re given the case of the 98 year old pregnant lady with sickle cell trait who is also Jehovah Witness and was born with no kidneys, one lung and two heads, who presents with a ruptured aortic abdominal aneurysm who is too drowsy to consent to surgery and blood transfusion…

Part B was fine. I passed it despite thrombolysing the pregnant lady with the large inferolateral MI. Yes, I hear you cry, of course she should have undergone primary PCI and screw the radiation effects on a third trimester foetus. Next time I see a pregnant lady with an inferolateral MI I’ll do better, honest…

Part C is somewhat like your driving test. I’m sure you remember,  deep in the midst of time the concept of mirror, signal, manoeuvre. Though I suspect it is now text, change the track on the ipod, manoeuvre…

There are lots of things that you read in medical textbooks and read in medical books that you neither see nor do in real life. I haven’t done tactile vocal fremitus on a patient for a long time. largely since the invention of this new and fancy chest x-ray thingy. It’s great. Who knows what they’ll come up with next.

So now that it’s an exam I’m expected to go back to do all the things I learnt (well what I was supposed to learn instead of playing footy, reading CS Lewis and dreaming about pretty girls) in medical school. Though largely, useless it has at least finally given me a decent understanding and performance at a neurological examination. This has been a pleasant surprise.

I expect to fail it despite the time I’ve spent perfecting my instrument suturing technique on my grey fleece in the hotel room. Though I might get lucky.

Anyhow. Studying done. I can run through my planned cranial nerve examination in a neat mnemonic in less than 30 seconds. I am ready to nail this sucker. I say that now.

I tried the pub next door to study in (you doubt me but pubs and indie music are great study aids i find…) , which was empty and horrible and flitted between Joy Division and Enrique Iglesias and both so loud that i couldn’t drown it out with astral weeks, no matter how hard I tried. I abandoned it for the hotel lobby which is at least quiet though doesn’t appear to stock any salt and vinegar crisps.

Buddha and bed methinks.

Little drummer boy

I am not a drummer. Not really anyhow. I was best defined by Skeeno‘s Da – whether i like it or not – as a frustrated country guitarist.

But I’ll have a go. I started drumming in my church cause they’re didn’t seem to be anyone else to do it and i really quite fancied having a go. There was somehwhat of a steep learning curve to that approach.

I used to get nervous drumming – I never got nervous playing guitar or singing (though I should be with the singing) – but with the drumming I was so totally aware of how loud and significant all the mistakes were. With the guiatar you could fluff a note or simply not play the bits you didn’t know. With drumming you have no such options.

People say if you hit one or two wrong notes then you’re crap but if you hit three wrong notes then it’s jazz. I’m prett sure that doesn’t apply to drumming.

I’m getting better and realising that it’s probably the most fun instrument in a band. Well it is for me, if not the most fun for the rest of the band who have to listen.

I’m going to stop pretending that I didn’t break your heart

this story gets headline in the BBC Northern Ireland section as if it’s something new when we’ve been on divert as we call it maybe twice a week for the past month and have done it lots and lots of times in the past.

we’re not allowed to put up a “hospital closed” sign or anything but it means that any patients referred by GPs will get sent to other hospitals.

would be interesting to see what would happen if we did just stick up a closed sign. Very little I imagine. Pulling a randon unsubstantiated figure out of the air, I’d say that 90% of those who come through A&E in a day would be still fine (when I say fine I mean not dead – us emergency medicine doctors have a funny definition of “sick”…) the next day if they didn’t come anywhere near us.

That said, we should still be providing a decent servive for that 90% and we’re not. Believe nothing of what hospitals and politicians say about delivering normal high quality service under extreme pressure – we don’t. Let’s stop pretending we do.

So here we are

I usually have rules about coffee after 7pm. Generally it all goes wrong when I don’t follow them. I end up awake all night with the head buzzing. Oh well, too late now, the coffee’s in the system so I’ll do whatever I usually do when I can’t sleep. Clean or blog. I’m not sure the lads would appreciate the former.

I’ll start with a bit of background.

I live in Portadown. More specifically I live in the middle of the Garvaghy Road area of town. Portadown is famous for very little – though we do seem to do a good line in sectarian violence. Most people know Portadown most famously for Drumcree and the Garvaghy Road came at the centre of that.

It is just far enough in the past (at least the worst bits) for it to become partly history. It doesn’t inflame the same passions it once did. Most are thankful for that.

Whether I like it or not, I am in Northern Irish terms a Protestant. This is how I would be viewed by many definitions. Again I say – whether I agree with that definition or not. As a Protestant I am also expected to subscribe to a number of national past times – being British, Bible bashing, and wanting orangemen to walk down the Garvaghy Road.

I travel on an Irish Passport, politically speaking I’d prefer a united Ireland, I think a lot of people made a lot of mistakes about Drumcree. I think the church in Northern Ireland was either co-opted into the loyalist agenda and in other cases was simply drowned out in the noise.

Portadown has issues in its past. All of Northern Ireland does – in many ways ours maybe aren’t even as big. Reconciliation is a big, tough word. We’re not there yet.

So as a Protestant living in the midst of the Garvaghy Road I realise there’s a bit of history and background that I can’t simply walk away from.

More background.

About 6 years ago I got involved in helping to run a youth club in town for a bunch of kids – from both sides of the spectrum. This was back when it was simple, you were either a Mickey or a Prod. Nowadays we’ve all the overseas guys are making our bigotry all a little bit more complicated.

Stop me if you’ve heard this one before – I grew up in nice sheltered middle-class suburbia in a stable 2 parent family with endless opportunities ahead of me. Some of these kids weren’t so lucky. It was somewhat of an eye opener.

I remember chatting with two other folk in particular thinking that why is it that all the Christians live in certain areas of town, while very few live in others. Thinking that if the church was doing what it should then maybe the church should be moving into certain areas, and indeed maybe I should…

So that’s how I ended up here. 6 years but I made it here eventually. Good thing GOD isn’t in a rush.

Now I’ve never quite understood the concept of calling or vision in the Christian life, maybe I’m a bit better with vocation. Most of the time I am doing what I think most people are doing – making it up as they go along.

But being here, living here is about the one thing I’ve ever felt called (which is a big, complex, hard to explain type of a word and I’m not gonna try that)… to do. That and medicine. I think so anyhow. Glad that’s as clear as mud then…

In particular I’ve always been excited about the idea of a church based on the Garvaghy Road, filled with and for the people of this area.

The evangelicals involvement in this part of town in the past has largely been “ship lots of folk in to do something and then leave at the end of the week.” Which has not been all bad by any means but hardly satisfactory.

More worryingly we have often committed that most heinous of crimes and tried to make good old fashioned Northern Irish Protestants out of them. We have not always covered ourselves in glory in that regard.

We are very bad at grasping other people’s point of view. That maybe not everyone is as keen on the Union with Britain as we are. Maybe not everyone is a big fan of the orange order and maybe everyone isn’t a big fan of some guys coming in and telling them that their mother Church is the anti-CHRIST.

So maybe if we’re talking about church and JESUS and all that we need to see it from their point of view.

People, generally known as missionaries, have been doing this in the church for years, but generally in some foreign country where us Prods can’t see them doing it. We’ve never quite learned to apply the same lessons at home.

And so that’s what we’re kind of about. To put it simply – trying to plant a church here. That term of course carries a lot of baggage and you will no doubt have pre-conceptions of what I mean by that. We are in the process of working all this out.

I think I’m beginning to understand what “working out your salvation with fear and trembling means”. None of us claim authority or all the answers. Anything we proclaim, we proclaim with humility and an acknowledgement that what we are doing we have not always done well in this place.

I get very excited about church. I mean the concept of the church, the big, universal, holy catholic church that they used to talk about back when I was growing up anglican where they had nice things like liturgy.

There are not very many people in Ireland doing this. At least not that I am aware of, though that’s maybe not saying very much. I know Zoomtard does this for a living in many ways in Maynooth and seems to be doing very well.

The North is one of the most churched places on earth though we’ve not always been renowned for being innovative in how we do church.  Hopefully we’re learning.

At the minute we’re still only beginning. There’s a group of us living here, with the same vision, the same heart for the place and the people. We meet on Sunday mornings in this house to chat and pray and eat bacon. Kind of simple but it’s a start.

Baby it’s cold outside

One of the advantages of working lots of evening shifts is the random free mornings when people with proper jobs have to go to work and I get to lie around worrying about going to work. Occasionally I manage to do something useful with the mornings, especially when big brother is off work too.

Cold weather, ice, snow and rain are no obstacle to a bit of kayaking. I’ve found myself even wanting it to rain a bit more so we can get a bit more flow on the upper bann. I never thought I’d think such a thought.

But even a quick paddle from town is nice when you get it.

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Despite the Volvo not starting (yet again – looks like I’m buying a new battery tomorrow, either that or always parking the car on a steep hill..) we were eating brekkie at 8.30 and on the water by 9.30.

I had not feeling in my hands for the first 10 minutes or so. Must buy those fruity looking fingerless goves Simy has…

There were a lot of swans who seemed to have abandoned the town in fear of Eastern Europeans poaching them for Christimas lunch. That may only be a vicious racist rumour that’s going about but there have been reports… I have to say I could eat a swan given the opportunity… Err yes…

Maybe the Eastern Europeans don’t know that the queen owns them all (actually, i think she’s official protector or something, whatever that means).

I dislike swans. There was an incident in NZ with a swan that has left it’s scars. More mental than physical i must say. In fact they’re all mental really but it’s a genuine phobia honestly…

There were also two boys with a gun shooting things. Though thankfully it was birds and not protestants. Good that times have changed eh…

I let you down

I’m one of the slightly grumpy bitter ones who never enjoys new year – perhaps because I tend to have a difficult time actually enjoying myself at the inevitable social occasions that go with it, or maybe it’s the compulsive happiness that i object to. Or the reinforcement of the social ideal that is implied – get trolleyed and pull a random bird to go home with – do anything but don’t be alone…

Anyhow.

Since starting work I’ve now got a wonderful excuse to avoid such revelry. I’ve managed to work 3 out of the past 4.

3 years ago – with dying nursing home patient in resus in A&E in craigavon, wondering where all the nurses had buggered off to and not looking at my watch

2 years ago – sticking tubes and lines in the lady in NZ who was too pissed to walk home and drove – into a tree

1 year ago – outside a cottage in Donegal with cigars and Bushmills, trying our best to ignore countdowns and the fact that the rest of the guys in the cottage had locked us out…

Last night – examining some woman’s manky infected toe. Poor dear.

I was not looking forward to last night’s shift – these days I’ve progressed to on-call from home overnight instead of being in on shifts but New Years Eve is normally chaos so we put extra staff on on purpose. Though i the end it was lovely and we were twiddling out thumbs at 3am wondering if maybe the credit crunch meant that people couldn’t afford to go out, get hammered and punch a window through.

I spent most of the night thinking through my latest medical mistake.

We all make mistakes, most of you reading this will know this. And mostly that’s not killing people, it’s more missing things that you could treat, and usually only missing them for a few hours till someone else notices them.

Medicine is not exactly an exact science and the luxury of time and observation usually gives you the diagnosis. unfortunately thanks to the wisdom of our government we don’t always have that in the emergency department.

None of this is excuse, none of this gets me off the fact that I missed something, but all of it put together makes all of us medics go “yeah, I’ve done that, I feel your pain…”

Yes it was busy, yes I looked at the x-rays for where i presumed the pathology would be and not looking at it as if it was a fresh slate – one of those situations where seeing the x-rays only and not the patient is actually a benefit cause it forces you to be thorough and not just look at the part of the x-ray where the swelling and bruising is… And yes it was a difficult patient who had absolutely no regard or responsibility for his own health. Yes he was hammered and that always makes everything more difficult. And yes alarm bells in my own head did go – that cautionary panic in your gut about a patient (which I have found bizarrely to be almost never wrong – i wonder how we could evidence base and audit that one…) – but still I did not listen. Still I got it wrong.

I’ll not mention what I got wrong -if you’re keen to know I can send you some interesting scans that even the non-medics could spot from across the room. The problem is not the scans, the problem was the decision to order them.

Now let it be clear that it made absolutely no difference to the patient. My gaff was picked up on the x-ray review within 2 hours of him leaving the department. We brought him back the next day and got him sorted having come to no harm whatsoever.

But still. You can’t help but take a little bit of a look at yourself. You can’t help but beat yourself up about it.

Mistakes are an inevitability of the job – this is probably my biggest in 5 years –  thankfully of no consequence, though that’s hardly the point. The point is that it happened, and it happened due to a mixture of busyness, pressure, timing, a difficult patient and most of all breaking almost all of my own rules.

Lesson learned? I hope so. Though I got away with it – and maybe one day I won’t and some poor patient will face the consequences.  Anyone have a better idea of how we do all this?


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January 2009
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