Archive for October, 2009

Guilty cubicles

I’ve recently cut down to working 4 days a week. I found out i’d been working 8 hours of voluntary over time a week since i started the job. I get paid for it. I just don’t want to do it. So I don’t.

Anyhow. Best decision I made – days off in the middle of the week are immense.

I think i’ve realised how stressed i get in work. I used to think that i never got stressed in work – i presumed stress meant that you made lots of mistakes and cried all the time and hated the job. Which is not what I mean.

What I mean is the continual frustration I find with the busyness of the place, with the compromises in care that I make because of the pressures of time and work load. And most obviously (to me at least) is how grumpy I get with the staff.

Ask me to do too many things at once and I start to get a bit short and snappy with people.  With people I love about things that are important. That can’t be a good thing.

As odd as this sounds – i find myself most relaxed and on form when it comes to the sickies – the people needing resuscitation and emergency treatment (alas making up probably less than 10% of my work). It’s the list of comparatively well chest pains and tummy pains and kiddies with temperatures demanding attention that stress me.

Having a day off a week helps me with that. I sleep better. It is in many ways an acknowledgement of weakness – that I do not cope as well with the job as perhaps i once did. Doctors are a fairly high-performing bunch of people –  it seems to attract that type, and perhaps emergency medicine as much as any. I still love the job as much as ever – i just find it harder.

The other thing I’ve come to understand is why I lie awake thinking about the patients I send home, or the patients who I’m not so clear about what’s going on with.

I’ve heard it called anticipatory guilt by the wonderful Jerry Hoffman on EMA.

He’s one of the anti-test brigade. The idea that we order far too many unneccessary and stupid tests on people who don’t need them. Which gives the impression to the patient of being a thorough and wonderful doctor when actually you’re just a bad doctor making up for bad judgement by ordering too many tests. I’m with him on that.

As an example:

A pulmonary embolism (PE) is a clot in the lung and a potentially fatal diagnosis that thankfully we can treat quite successfully once we know it’s there.

Most of the time people with PE look pretty sick and have quite significant symptoms and signs.

A small proportion will look very well and are easily missed.

We define them into low, medium and high risk groups depending on what else is wrong with them (ie having cancer or just giving birth makes you much higher at risk for PE).

When this risk idea was initially thought up about 10% of the low risk patients who we suspected had PE turned out (after tests) to have PE. Today less than 1% of who we call low risk and who we investigate turn out to have PE. We investigate a far greater number of these patients than we used to.

The implication is that we’re investigating a far greater number of people with no real success. We are also testing far too many. A 1% miss rate is considered acceptable for most conditions –  for example we miss about 2% of heart attacks and that number has remained constant over 30 years despite the huge amount of extra testing we do and the huge increase in spending.

What the numbers about PE suggest is that people who are low-risk are effectively no-risk patients these days.

So why do we keep testing them?

Is it a fear that the well looking patient with a mild cough and a bit of pain in the right side of the chest will come back dead?

Yes and no.

Yes that there’s a fear that the patient will come back dead but no because it’s not really the patient you’re worried about. It’s yourself.

We anticipate the guilt we’ll feel if we miss the diagnosis and it’s that that makes us order the unnecessary test.

The guilt will have some relation to the poor dead person’s family but most of it (and for this i can only speak personally) the guilt is how i will feel for professionally missing something important. For the feeling i have when I know that my peers know that i missed the diagnosis.

This is where the rational reasoning of what we know to be scientifically true meets the emotional fear of personal responsibility. The burden of decisions making (which is effectively what i get paid for, even though i’m not sure i’ve had that much training in it) is what we carry – and it seems all the numbers and science in the world won’t change that.

Crosstown Traffic

Coming back from Maynooth yesterday took a good 2 and 3 quarter hours instead of the usual hour and 3 quarters. Largely due to the huge number of Irish travelling north to take advantage of the public holiday in the south and the favourable euro to pound rate.

Coming into newry was backlogged a good few miles with people queued patiently in both lanes. Till some chancers who obviously felt their need to have fire works and wide screen TVs bought by lunch time led them to drive down the hard shoulder and try and squeeze in further up the queue.  These weren’t men driving their wives to hospital in early labour. They were almost without exception two parent families with 2.4 kids in the back and their SUVs or people carriers.

You could sense the rage rising in the morally self-righteous waiting patiently in the queue.

Until that is, a couple of articulated lorries decided to block the hard shoulder by driving the mysterious middle lane with their trailers half in the hard shoulder.

Justice was done. You could see drivers giving the lorries a satisfied look of approval at their policing of the situation.

Losing my religion

Two things:

First – just finished Malachi O”Doherty’s Empty Pulpits – a look at the decline of traditional religion in Ireland. Largely from a Catholic point of view, looking at the huge change in Catholic Ireland’s relationship with it’s mother church.

There are indeed many empty pulpits, there aren’t that many seminarians coming through St Patrick’s Maynooth as Zoomtard will tell you. As an aside – I used to play in a football league in Queen’s as a student (one of the many ways to avoid actually studying) and we had a good relationship with the Catholic chaplaincy’s team to whom we would sing “you’ve only got one priest” to the tune of “there’s only one (insert famous footballer’s name here).”

He rightly points many of the deficiencies in the church and our relationship to it – both in the past glory days and in the present times. Worth reading – if not necessarily always agreeing with. I understand Catholicism poorly so it was good for me.

Second –  just watched William Crawley’s Losing our religion on the iPlayer – charting both his own and Northern Ireland’s changing/declining relationship with religion. (Though you must forgive his James Bond pose on the front page of the iPlayer link)

I remember William from a few church events I played music at where he always played the role of the devil’s advocate and the provoker of deep thoughts and questions about so many basic aspects of faith. I must say I always really appreciated it as a chruch kid who took a while to own his faith.

He now describes himself more as a questioner and on a journey than a believer and has no affiliation with the institutional church. This is no doubt a growing segment in the country but the intellectualism that goes with it will not seem relevant to the majority of Northern Irish punters. Belief in God is still very popular (whether or not that’s a good or a bad thing depends on how you look at it) – though the definition of God is far less precise and people’s engagement with the traditions of religion have declined.

And while critical of our religious institutions (and there is no shortage of that these days – most often with good reason) he remains positive about the idea of faith – and even some of it’s more modern representations.

Northern Ireland’s relationship with religion is no doubt changing. I hope mainly for the better. We have not always been honest with our faith – too many of us choosing nominalism over engagement with a life-changing faith and tradition. Us Protestants have too often busied ourselves with defining what we are not (ie not Catholic), our belief as much a statement of identity as of faith.

Northern Ireland needs the church – in the Holy Catholic Church sense of the term. Though perhaps the decline of its institutions is no bad thing. The decline of the institutions unwilling to take ownership of former and current sin; unwilling to be redeemed and transformed as they would call their members to be –  for these institutions to be left behind is surely no bad thing.

Faith and Christianity will likely be here for the duration. If we lose out on religion as depicted in this book and this documentary then perhaps that is no bad thing.

Worst at the best of times

Most of you who know me will know that today is a year down the line from Da dying. Odd how these arbitrary dates and timings acquire some kind of significance. They do. Whether I want them to or not. You see them coming over the horizon, like a great big box waiting to be ticked.

I was on call overnight and slept poorly and just as I did get over I got rang by work anyhow. Leaves me an excuse for being tetchy and grumpy.

Me and Simy had both booked the day off and we took wee Liz to Castlewellan for the day. With ever present puppy of course. No trip these days is complete without the pup.

We have too many good memories (yes I know that’s a stupid thing, it’s like saying you’ve too much money – oh I’m so sorry for you, it must be so hard…) everywhere you go you remember how happy you were. Not always in a bad way but still it seems tough some how. I suppose you need to be a certain kind of person to get annoyed by happy memories.

Castlewellan is like that. Me and Simy would both (well really just Simy, but if he went I’d keep him company) gladly go back to the late eighties and cycle down from the caravan to feed the ducks in the lake at Castlewellan. We both do the pleasant nostalgia thing.

We did the boundary walk. two and a half hours and saw two people. Great stuff. Found our view point looking over Newcastle and Donard and cracked open a tin of Magners and toasted Ronaldo from plastic cups. Good moment. Good as such a thing can be anyhow.

When we got home Simy produced a DVD from his wedding of Dad’s wedding speech at Simy’s wedding that none of us had seen before.

Weird watching it and have the memories come back.

Number 1 – growing the hair has been such a good move for both me and Simon. I know we may look like prats these days but seriously you should have seen us with the shaved heads.

Number 2 – Dad makes a bloody good speech. Managing foul humour, insults, grace and emotion all in one move. Special kind of gift.

To Ron.

To protect the family name

The college of emergency medicine is a young college. The Royal College of Physicians has been about for donkeys. Most people are members of royal colleges or something or other.

We’re not very royal. We have royal patron but apparently that’s different. Emergency Medicine is still a baby speciality – most people still know the place as Casualty (before my time) or A&E (which I still call it) instead of its preferred title of the Emergency Department.

As such I think everyone still has a bit of a chip on their shoulders. Trying to bustle for significance amongst the big boys.

We now have a logo, Which is kind of disturbing when you look at it close but i suppose it fits.

They were also touting for a tag line – Craigavon Hospital used to have one – caring through commitment. Though I don’t even know what our hospitals preferred name is any more. Maybe caring through incompetence would be better.

Anyhow, not wanting to disappoint there were some rather humerous responses to the appeal for a tag line. These were published in this month’s EMJ.

[incidentally the EMJ has the annoying habit of publishing case reports the week after i see a really interesting case of that just published – ruined my bilateral ICA dissection, posterior SC joint dislocation and my luxation erecta (not what you think). I wanted to try and publish a vertical patellar dislocation but I didn’t have my camera. Such a wasted opportunity…]

Find a sample of the best below

Emergency Medicine…
– it does what it says on the tin
– EM sports, it’s in the game…
– We’re not casualty
– We don’t care first
– The thick bit of the thin red line
– Seeing your referrals cause you’re “too busy”
– We did it when they were dying…
– Dare to care in our lair of despair
– Practical solutions to ridiculous problems

And my favourite two
Emergency Medicine…
– Too clever for orthopaedics, too stupid for anaesthetics
– The sickest looked after by the thickest

I probably would have added
Emergency medicine – go get bent and come back when you’re too sick to

A reasonable mistake

All who drink of this remedy recover in a short time, except those whom it does not help, who all die. Therefore it is obvious that it fails only in incurable cases

Galen 2nd Century


October 2009