Archive for March, 2009

Fairytales and failures

[Before I begin, this is a long rant on the NHS and all that – some of you love it, some don’t. You have been warned]

I always loved morbidity and mortality meetings. The type of meeting that comes under the banner of audit and governance and all that. A good place to go and relive all the horrible mistakes that we all make and how we can learn from them.

There are all kinds of national organisations to point us in the right direction such as the healthcare commision, NCEPOD, and NICE.

They publish lots of documents and papers telling us all how we should be doing things differently and better. In the main these are largely good ideas backed up by fairly decent science. However they seem to fall down badly when it comes to real world implementation.

Such as the NICE guidelines on doing CT scans on head injuries, which were originally put-through a cost benefit analysis which predicted that the implementation of the guidelines (ie imaging far more patients than we currently do) would actually reduce admissions (as we wouldn’t have to admit people for observation as we would know there head was OK after a scan). This – surprise, surprise – turned out not to be the case.

Anyhow, the basic gist of the reports into best management and outcome is fairly straight forward. People should be getting more attention, more quickly and involvement of more senior doctors.

Now I would hardly call any of that groundbreaking. Surely anyone with an ouce of common sense can see that.

The issue as I say comes with the implementation.

[In America this is different. If something needs done, then you pay more for it. If you need more ICU beds in your hospital you pay for them. OK so this is simlistic but there is a rather more flexible pool of resources to draw on.]

The most recent “scandal” (as the daily mail would no doubt put it) was brought to media attention through the mid-Staffordshire hospital and a report by the health care commission. This had some juicy head line grabbing bits about receptionists triaging the patients and managers fiddling the figures so it got a lot of attention.

The hospital concerned is similar in many ways to where I work though it does seem some what more chronically under staffed and underfunded and if I thought the managers in my place were bastards then I clearly have a lot to learn.

Having said that, a lot of what I read (in the 176 page report – I focused mainly on the Emergency department bit) hit pretty close to home. A lot of the “critical incidents” concerning patient care would not be beyond the realms of possibility in any hospital I’ve worked in.

There were clearly a lot of serious issues in the management and running of the trust, but if a similar, wide-ranging inquiry took place at my hospital, there would be a lot of metaphorical skeletons (and hopefully not any real ones… i hope anyhow…) found in the closet.

And there is a very, very simple reason for all of this.

Too many sick people. Not enough resources.

Dare I make it as simple as that?

Virtually all of the recent initiatives to “improve patient care” in the NHS have focused (when you break them down) into improving efficiency of the health service. A lot of this is touted as being about providing better standard care for patients but it is mostly mutton dressed as lamb.

Everyone in authority –  the anonymous, faceless people high up the ladder it seems [My mate Tim who’s training to be a social worker says he sat in meetings with all levels of social workers and management and everyone was bitching about what a horrible system they worked in and how they were all powerless to change it. He sat there thinking – if everyone here thinks the system is screwed then who the flip is actually making this system the way it is] – is interested in squeezing every last drop of work and efficiency out of the resources in place.

There is a horrible misconception (so it seems) that we are making dishwashers or cupboards or something. As if the NHS is one big factory churning out well people.

There is a horrible misconception that a hospital provides the same level of care at 97% (or 100% or 110%) a it will do at 80% capacity.

Although capacity itself is hard to define. Hospitals have a flexible degree of capacity – we don’t tend to turn people away when we’re full, we just squeeze more in wherever we find the space. “There’s always the bunk beds” I say to the patients.

People who are stressed, hungry and in need of a pee (me, everyday in work it seems…) do not do their job as well as those who are calm, relaxed, with a full belly and an empty bladder.

Again, this seems fairly obvious.

If you want to measure quality of patient care there are a few fairly sensible ways to do so.

1) you can ask the patients – though often patients like comfy beds and nice car parks and a nice friendly doctor, who gives them antobiotics for the flu even though they don’t know their arse from their elbow

2) you can ask the staff- if everyone is pissed off, busy and stressed all the time and moaning about all the horrible things that happen to their patients (go on – ask me!) then something is probably wrong

3) check how often patients observations are done – this is probably the most basic aspect of nursing care, it shows how often the nurse actually makes contact with the patient

4) timing of medicine administration – if medicines are consistently late or missed then the nurse is probably too busy to do it

5) health care acquired infections – now this has attracted more attention than anything else in the media and it is a great opportunity for a fat, smoking, non-compliant patient to blame their poor health on the hospital and not the fact that they are fat, smoking and non-compliant.  Due to media attention this is currently top (and I do mean top) priority for many trusts –  mainly because of the media attention – I do not believe it should be top priority. None the less it is a reasonable surrogate marker of quality of care as it you will generally get more MRSA and C.Diff (and whatever other acronyms you might choose) in busier, less well equipped wards.

6) mortality – if more people die something is probably wrong. This first came to prominence with the cardiac surgeons who measured their outcomes at doing bypasses. This is a fairly peedictable procedure in a fairly homogenous population, therefore you should expect fairly standardised outcomes. The higher mortality rate in staffordshire is what prompted their inquiry. Though it must be said that standardising mortality rates across such a generalised population is very difficult and very easily skewed.

7) there also some fairly specific medical ones too – such as prohylaxis for DVT, door to needle/balloon time for heart attacks, time to antibiotics for sepsis – these are all what are referred to as standard of care.

What is perhaps not a good measure of quality of care is the wonderful 4-hour target for emergency departments. The problem is that there are two ways to fulfill that target:

1) you can appropriately staff and resource a department to assess, manage and treat patients as they arrive in the department

2) if that is not possible, you can just shortcut everything or fiddle the numbers. This is, unsurprisingly, much easier to do

Guess which one of the above happens.

It is not unreasonable to think that maybe people who work in hospitals are just like everyone else – ie lazy buggers who wouldn’t work in a fit. There are of course plenty of lazy people in the NHS, just like everyone else. Though even lazy people give a shit when they have to deal with sick people face to face. That old human element makes it hard to be a callous and lazy bastard.

I would also point out that doctors have some of the lowest sick day rates around. Turns out we actually enjoy our jobs. Given half the chance anyhow.

[as an addendum check out this blog on the BMJ website by the clinical lead in the emergency departement of the Stafford Hospital. A mix of humility, dedication and perseverance – good stuff]

Nice places to walk the dog – No. 1

[Part of an occasional series]

Brackagh Moss is a bog. Yes a bog. Us Irish like bogs. We were all born in one or something.

Anyhow. It feels like proper Ireland, the one before we chopped down all the trees and killed all the pagans.

Apart from the used condom at the entrance (dogs will find everything) it’s lovely. Though a tad damp underfoot. But you all knew that because it’s a bog…

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How could I just kill a man

Just watched In Bruges.

Such a film.

I love them sitting on the bench rationalising their assassination and comparing it with the morality of helping little old ladies with their shopping.

The doubting, thoughtful, repentant assassin is a dying breed.

For some reason I don’t think it would work if they weren’t Irish. What does that say about us?

Love is a series of scars

“we try to make ‘love’ an individual emotion that does not ask someone else to suffer because of our love”

Resident aliens
Stanley hauerwas & william willimon

To protect the family name

I take part in a bible study on a Sunday morning in the house at the crazy early time of 0930. We’ve been running through the book of Acts and after 3 months we’ve made it to chapter 2. This could take a while.

Anyhow we’re at the bit helpfully entitled the fellowship of believers in the NIV. Which has this wonderfully radical bit about the believers holding the finances in common – which we have somehow managed to either spiritualise or edit out somewhere along the line.

But it also has this use of the word koinonia, translated as “fellowship” or by some as “the common life”.

I’ve been brought up in the culture where fellowship is either a cup of tea and a bun after church or merely as Christian banter – whatever that may be. So forgive me if i have a somewhat dim view of the word. Though I think we can redeem it a bit.

Anyhow we were chatting through today what we thought was meant by the common life of the believers in the early church (so early they hadn’t even worked out the name Christian or the word Church).

We figured this was a lot of things, including the financial aspect but perhaps the analogy of the family was the best. [Another clue that all the basic things than human beings do (marriage, family, kids etc…) point towards something bigger than themselves.]

When something in a family situation goes spectacularly wrong – divorce, alcoholism, unwanted teen pregnancy, unemployment, financial crisis – then it is the whole family’s problem, even if it is only the mum that has the drink problem or the son that got some girl pregnant. Families (in general) do not walk away from each other. They do not hold each other at a distance and view an individuals problems as just that – the individuals problem. Your problems become our problems. This is simply the way families work. Blood is thicker than water and all that.

And so when it comes to the church then is this the model we should be striving for?

[as a brief aside I am not so naive to think all families are like this – I just see this at work in mine and lots of others]

The skin of my yellow country teeth

On a slightly more positve note. And that wouldn’t be too difficult.

Come on the Ireland!

Though cutting it a little bit fine with all the silly dropping the ball and needless penalties near the end. Good flipping rugby game.

When it feels like you are losing

Distinct lack of blogging over past week. Mainly cause I’ve been too depressed to even get out of bed. It has not been a good week. So it goes.

Nearly 6 months have gone by since Da went. And i haven’t the slightest clue what to make of it all. Too many memories. So it goes.

Life is not easy. This is probably elementary to most of you. It is likely as plain as the life before you.  I’m only beginning to get used to the idea.

Anyhow. Wrote a song. If you’re gonna feel miserable you may as well get something out of it.

Middle class heroes

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Getting a bunch of mid-twenties professionals together in the same place at the same time for 3 days in a row is impressive enough. Getting near 30 of us together for a weekend to Scotland is even more so.

Originally planned as a stag do, it became more of an anti-stag-do for reasons I’ll not go into but it did provide us all with a fixed date and tickets for a major international sporting event. We booked all this in August. Perhaps that’s the only way to get us all together by planning six months in advance.

The only other real time we get together seems to be either weddings, when we’re all dressed quite nicely and behave rather dignified and polite and also when we stay in wee Phil’s house in Donegal and we live on our jammies and insult each other at close quarters. You need the variety really.

img_0092Due to quite remarkable forethought and planning (praise and glory to dear Jose, G and the conspicuously absent Office) 24 of us ended up on the same flight and picked up at the airport by the mighty Raymond (there was of course a Sparky inspired version of Raymondo sung to the tune of Abba’s Fernando…) in his fun bus. Staying in what i can only consider a rather posh hotel in the very centre of Glasgow overlooking George Square. It must be posh, Fred Elliot from Corrie was staying there.

I don’t mean to be harsh on Glasgow as a city, only being there a very brief period of time but to be honest George Square seemed to be the most pretty bit of it. But i stand to be corrected.

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The focal point of the weekend was a decidedly poor Ireland beating Scotland at Murrayfield. Despite the cold and long beer queues it was a quality day out. My ticket was in a different stand from the others but fortuitously put me beside a good mate, a kid who work shadowed in A&E a few weeks ago, a girl from the year below me in medical school and a guy i used to climb hills with. All independent of each other but all within 2 rows.

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Beyond the day-trip to the rugby we weren’t particularly adventurous, staying in the hotel all evening and having a lovely meal and some lovely whisky, and some even more lovely conversation. Cause we don’t all get together that often we are undestandably insular when we are together.

My lasting memory will be a conversation about the evolved role and position of the human reproductive system. Bert’s justification for the grouping of the waste disposal system with the reproductive system (which has always seemed a tad odd to me) was that it was good to keep all the “occasional activities” in the one place. No Victorian prudery here eh?

In the morning spent so long sitting in the one seat reading the Sunday Times that I briefly developed a pressure sore.

I got through 200 pages of Churchill (quote of the day, on declaration of war on Japan – “some people did not like the ceremonial style, but after all when you have to kill a man it costs nothing to be polite…”) It was certainly a laid back day.

Home with vague plans for next year (having had a group trip two st. paddys’ weekends in a row it is now a firmly established tradition to be maintained in perpetuity) involving cruisers on lough erne or an isolated cottage in the highlands. An established tradition would be most welcome.

We all grow older, and change in lots of ways. We are no longer banter hungry students (though we all remain banter hungry and some even remain students). We are the white collars of society – these people do all kinds of cool things that make me proud even to be in there presence.

There is a (much welcomed says I) increase in couples in the group and a wonderful comfort (at least I think so) in the relationships amongst that horrible created divide between couples and singles.

We are a lot more forgiving and gracious than perhaps we used to be. The usual bit of getting older and realising how important we all are to each other, with the accompanying fear of how easily we could all lose each other.

I think back on what has passed in the interim year for me and it does not generally make for a pleasant read – everything has changed. I am certainly not who I used to be, in most ways not in a good way, but perhaps I am not the one to judge that.

Being surrounded by so many who I know and  love and who know and love me throws your personality and change into sharp relief. It is smothering. In the nicest, most important kind of way. I find the group/social situation difficult and painful in so many ways, though at the same time I would not miss it for the world.

I regret to say that I am better company in the written word than in person.

War on war

I just got invited to join a Facebook group of “people against terrorism in Northern Ireland”. Though I suspect amongst the population on Facebook, being against terrorism is like being against starvation or pain or splinters under fingernails. I’m pretty sure we’re already signed up to that one.

The best way is to imagine if there’s a Facebook group that calls itself “those in Northern Ireland who support terrorism”. Although maybe I should be careful. The internet is an odd place.

Terrorists don’t define themselves as terrorists. They’re freedom fighters or something similar. It’s not like they spend their childhoods thinking they can’t wait to grow up and play with guns and shoot people from a distance and run away or strap bombs to themselves and take out bus loads of civilians with the blast. Whatever brings them to that point (and no doubt it’s complicated and messy) it is surely not hopeful ambition.

Though I somehow doubt Facebook will redeem us from the mess we’re in, perhaps the lack of public and political enthusiasm for the actions of the past few days will let it all fizzle out in peace.

His band and the street choir

Seeing as everyone had an Ulster Hall story I figure I have mine too.

Listening to Bloc Party with Simy open with “So here we are”, one of their “quiet ones’ yet still probably the loudest gig I’ve ever been to.

So anyhow it’s reopened, the Northern Irish music scene wanted to celebrate the fact. Though to call it the Northern Irish music scene is a tad exclusive as it’s nearly all young, skinny guys with guitars and messy hair. Perhaps hardly representative of the music made in this place.

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The idea was to get 14 Northern Irish bands and let them play 2 songs each. One of their own and one cover of a band that they’d seen in the Ulster Hall previously.

Pretty impressive to get 14 bands and near 4 hours of music for a fiver.

The Knights pulled the luck of the draw and ended up first on, some time, it seems, before the sound engineer turned his ears and brain on so the sound was terrible, though the guys completely nailed DC‘s “Something for the Weekend”.

Being first on is never easy, the venue’s only half full, no one is drunk, no is warmed up.

There was Kowalski and Cashier No 9, both of whom passed me by as dare I say it decidedly average. Though at least the sound guy had it sorted by then. Decent version of “this modern love” – mainly notable for the drummer nailing the drum roll near the end.

I love the Panama Kings. Though it’s still killing me that I’m singing their cover in my head but I can’t name the flippin band (Skeeno arrived home and told me it was Ash – most dissapointed in myself)

Foy Vance caused a wee bit of a moment. After opening with “afternoons and coffee spoons” (anyone remember the Crash Test Dummies) in a new hat he played a new one that got so quiet and moving that you could have heard a pin drop in the place. Pretty stunning stuff. By far biggest cheer of the night.

I’ve never heard of Lafaro before now. I’ll never buy any of their music, but live those guys kick ass. I could listen to loud rock and watch drummers all day as long as its live, I just wouldn’t listen to it in the house. They swaggered with more stage presence than anyone had pulled off so far. They looked like a proper rock band.

Iain Archer had the unfortunate task of following the loudest act of the night with one of the quietest. Him and the pilots playing “songbird” while again the sound guy falls asleep and forgets to turn up the drums. I despair sometimes. The new Iain Archer album is the best thing since sliced bread so I think this didn’t do him justice.

He then had the unfortunate task of introducing Barry Gary Lightbody as one of the special guests of the night. Being actually kind of famous this overshadowed the rest of what Iain Archer did. They played a hugely dodgy version of The Frames “lay me down” which no one on stage seemed to know how to play apart from Phil Wilkinson drumming. Not particularly impressive I must say.

Recovered slightly with a decent version of “chocolate” which is a pretty damn strong song no matter what you do with it. Unfortunately followed by that horrible “chasing cars” song which was always on repeat on the radio in the ICU in NZ so I have horrible associations with it. Plus as a song its a bit shit which doesn’t help.

Somewhere around here I get a bit lost in the order but Neil Hannon turned up with an old battered piano and made my day by not only playing the best Divine Comedy song ever (and that’s saying something) “tonight we fly” but also playing a Pixies song. Both purely on the piano and both purely wonderful. And he got away with a nice Pop Idol joke while he was at it.

Fighting with wire and jet plane landing are both bands I’ve only heard of. There’s certain degree of Belfast-centrism going on in the music scene, so perhaps Derry bands get overlooked a bit.

They did manage to be fairly impressive. Good cover of “you really got me”, and a really good cover of Rage’s “know your enemy” though the slightly chubby, dull looking guy doing the rap was all a bit odd. Never mind the two chaps on stage wearing masks.

Duke Special had a lovely sound though he did manage some ill advised crowd surfing at the end. What was most disappointing was the fact that a fully packed Ulster Hall could keep neither Duke Special nor Foy Vance in the air for longer than 5 seconds. I think crowds are out of practice when it comes to their role in crowd surfing.

Ash were a bizzare almost country trio for the night, with the drummer acting as second guitarist.

I remember Therapy as a band that was sort of famous in Northern Irish circles back when I was first getting interested in music at all. They weren’t my cup of tea then and they certainly aren’t now. Though they certainly have a bit of life about them that’s for sure. And a fruity choice of expletives. I’m sure the BBC will thank them for that.

Simy apparently works with (or did work with I’m not sure) the bassist from Therapy. Apparently he works with computers. How rock and roll. Fame loses all its shine when you’ve been to school with them, or you live with them or they work in Tescos.

There was a huge finale were they got everyone on stage and they all sang “Teenage Kicks” (which had to be sung at some point) and there were even fireworks at the end. It was like a Bon Jovi concert in that respect.

At least they didn’t sing some awful charity song and put their arms round each other and sway.

Whole night was great. Perched on the rails at the sound desk at the back where you’ll always find me. Makes me glad to live in this place.

Came home and heard that a policeman was shot and killed near the hospital. Completely threw me. One episode is something, you have two and you’ll soon have a series of murders. Bastards. And the whole effing show kicks off again. We can’t go back down that road. We simply can’t.

GOD have mercy on us all.

Makes me want to pack up and leave this place.

Wrapped around your finger

OK so i bought a new condenser mic for recording. At the same time I figured i would but a wee drum key for the church drum kit so that I wouldn’t have to keep using wee Philly’s socket set to tune the toms.

So in the huge box shown below arrived the small (indestructible) metal key. And a lot of styrofoam.

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The (delicate, expensive) mic arrived in a bag with some bubble wrap the next day.

Devil in the details

I wonder how Islam felt over slumdog millionaire borrowing “allahu akbar” for the apex of the pursuit of what looked awful like the American dream. Especially when uttered by a dying, lapsed, muslim,money grabbing gangster.

Salvation Tambourine

Just finished A Community Called Atonement.

Wonderful book. Despite coming under the banner of being “emergent” it managed to avoid all that horrible confabulation and neologisms that are so frequent in everything associated with the category. Or maybe I just find it all a bit technical and obscure.

Anyhow.

Take home message – and this is pretty basic here – it turns out that there was more going on in the death and resurrection of JESUS than just substitutionary atonement. I almost feel like a heretic saying it. Even more shocking is the realisation that perhaps I don’t have this thing all sewn up and on a neat little theological plate.

This of course seems staggeringly obvious when i think about it, but for some reason this comes to me as kind of new. I try to blame this on Sunday school –  i try to blame everything I learnt about theology on Sunday school – but that’s kind of unfair. I’m pretty sure it’s not what I was taught in Sunday school but it seems to be what I’ve picked up all the same.

The book says far more useful and interesting things than that, but in my theoogical ignorance that seemed enough to start with.


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March 2009
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