Archive for the 'work' Category

You talk way too much

Sorry for all the quotes but they really are crackers.

From the journal of the college to which i belong – reasons why i find my job stressful and why i don’t sleep so well at night:

The emergency department (ED) is a complex and difficult environment in which to provide medical care and differs substantially from more traditional settings in healthcare organisations. Care is “unbounded” in the sense that the ED is the only part of the hospital where any number of patients can be admitted and held. It is the only “infinitely expansible” part of the hospital. Emergency caregivers typically treat many patients simultaneously and in a much greater variety than do caregivers in other settings; there are no limits on the type of complaint or condition that patients may present with; there are severe time constraints and often a paucity of information.

…This Government-set performance indicator target aims to increase the speed with which the patient moves through the emergency admission system, with 98% of patients being seen, treated and either admitted or discharged within 4 h. This has created huge pressures, not only on the ED but also on our support services and diagnostic services to increase their efficiency.

…Communication and decision-making are arguably the principal activities of emergency staff. In one study, 89% of emergency physicians’ time involved communication

…Observational studies have revealed that staff members working in the ED are dealing with up to 42 communication events per hour, with a third of these being classified as interruptions. Moreover, senior clinicians and nurses have been shown to be subject to the highest levels of communications and interruptions

I don’t even like people. I am so in the wrong job…

The cost

Blogging while sleep deprived and a bit pissed off makes for good reading I expect but perhaps you say more than you meant to. I imagine this is the type of thing I’ll re tell on a comfy leather couch in about 20 years (or months depending on how it goes…)

The problem with medicine (says he, with finger pointed and all eyes watching the figure with the air of authority as he gets ready to put the world to rights…) is not neccessairily the medico-legal responsibilty.

Say that I cock up and kill someone, or miss something big or whatever – then there is a certain medico-legal responsibility that I have been negligent or incompetent and should (though not always and occasionally too often) face some kind of disciplinary action.

I figure I get paid for that kind of responsibility. That seems to be the way things work in the world, the more responsibility and education and learning you have the more you get paid. Like a top class economy crippling banker – you bring the world as we know it to an end and you still get your golden handshake…

[Although that is probably a tad unfair on the old bankers – no doubt they were unscrupulous and greedy but they were merely in the position to be so. Yes they’re bastards but I’m pretty sure we all are. Anyhow the dodgy millions they made are what paid the taxes that fund the whole NHS and now that their incomes (and tax revenues) are falling then the NHS will suffer. Anyhow it’s all a tad more complicated than a quick “bastards are bankers” “bankers are bastards” joke allows…]

Legal responsibility is one thing. Moral responsibility is a whole other kettle of fish.

You see that’s were the problem lies. I don’t give too much of a stuff about whether I’m legally responsible for a patient – fine sue me, see if i care. What I do care about is my moral responsibilty to the patient in front of me. Yes I am that self-righteously pious. It has taken years of practice believe me…

They turn up with their woes and sicknesses and it is to me they come. And me with my mythical diagnostic and healing powers, foisted upon me by a legacy of TV shows, movies and dishonest doctors, is the one that that has to give them some kind of answer and dare i say it – final solution to the whole mess. (No nazi killing reference intended…)

Do not get me wrong. I am not grumpy and moaning. I am not saying “why can’t you blood sucking parasites leave me alone and sort your own lives out and crawl into a corner and die as you best see fit”.

I enjoy the job. I enjoy that position. It is one of the highest honour and priviledges to face and speak to these people who are part scared, part hopeful, part accepting of what may lie before them.

It is the moral responsibility that I carry around with me. The simple notion that these people need sorted and that in essence is my job.

It is also what keeps me up till 3am worrying about all these little broken, sickly creatures wandering around out there in the community. It is what makes me come home and be grumpy with my house mates and my family. When you see me staring into space and grumpy and  uncommunicative I’ll either be thinking about Da or about all the patients I carry around with me in my head.

Without a doubt this is part of what makes me (i think) good at my job. It is also a large part of what makes me walk across the car park each day swearing inwardly at myself, the patients and the way we serve them.

While trying not to be too melodramatic – oh why the hell not… –  they come to me like ghosts, or apparitions, their faces, their names, their x-rays their CT scans, their veins and arteries and wounds all their weeping, worried relatives.

I have this uncanny knack of remembering every patient I’ve ever seen. Well not everyone but a scarily high proportion. I go in the cubicle and ask have i met them before then i’ll remember – you were in cubicle 4 two and a half years ago and you’d hurt your wrist and there was no fracture on the x-ray. Which is all very impressive till the patient says “oh yes but i came back a week later and the consultant said it was broken…” Which always takes me down a peg or two but I could do with that.

But i remember them all, the things we got right, the things we got wrong. Each one tells me a story.

I’m not entirely sure if all this psychotic craziness is since Da died or not. Certainly watching one of your own go through it makes you painfully aware of how important all this is. But I think I was like this to start with. Only now more so.

I sometimes I think I have a shelf-life, a period of time that I can pull this off for before it all comes crashing down around me and I end up pulling an into the wild and doing private practice as a dermatologist (awww that’s unfair on dermatologists, sorry…). I hope not.

“a man who has no memory has nothing left to hide… nothing and i like it…”

Thank you for saving me

I got my first bottle of wine off a patient today. Not that I think patient’s should encourage their doctor’s to alcohol or anything, though there could be worse things.

Some people’s office’s and pigeon holes are coming down with thank you cards and pressies from patients – there is a certain speciality bias to that.

People who deliver babies get lots of gifts cause it’s generally a happy event and there’s lots of pressies being bought anyhow.

Surgeon’s get lots cause what they do to the patients is fairly dramatic and occasionally it even works (sorry, no surgeon bashing, sorry…) and you generally see lots of them over a month or two so there’s a certain relationship that develops there.

Anywhere, where you get to develop a relationship with a patient (not in any dodgy “let’s meet for dinner and a movie” type way) then there’ll be opportunities for free stuff.

Unfortunately given the nature of A&E we generally don’t develop too much of a relationship – the majority of what we do is basic management and diagnosis and then referral on for appropriate definitve care. The bit of the job that is truly ours and ours alone is the critically ill and resuscitation. Unfortunately most of our target demographic is nearly dead or technically dead and therefore not big into relationship building.

[Anaesthetists suffer a simiar problem in that they put all their patient’s to sleep and do the cross word till the butcher surgeon is all done.]

So we suffer a somewhat unfortunate lack of biccies and pressies relative the 70000 or so we see a year.

There are exceptions to this. Almost every patient of Gilly’s I review will have “a little something” for Dr Carson. But then he is truly exception as medic, Christian and human being. And he doesn’t even drink the whisky…

5 years I’ve been working now and not one pressie have I got (I once got given 20 quid which I put into the ward fund) – now I’ve got boxes of celebrations dedicated to the ward staff but nothing to me personally. Yes I’m that self-absorbed.

Till today. A young fella who I had blind luck to pick up sarcoid on got me a bottle of vino – even though it was the respiratory team who did all the real work of scopes and scans and biopsies. Seems unfair. But hey I’ll take what I can get –  deserved or not.

I’ve been working

I’m back. I suppose. Whatever that means. I’m back in work. I’m back in my own house. I’m back, for the first time for two years, to what counts for stability and doing the same thing for perhaps slightly longer than a few months at a time. Not exactly the circumstances i would have wished for but it is what it is.

I’m now a fully paid up full-time, permanent contract member of staff in the chaos of the emergency department (as the kids are calling it these days…). It is chaos. It is horrible, it is wonderful. It is what i do.

I’ve made a list of about 20 or 30 things to change in the department, from knocking down walls to bits of equipment i’d like on order. The sisters told me to write a letter to Medical executive Satan Santa and see how i got on.

I’ve come up with a list of new rules i need to follow. I’m one of those people who likes rules. I like these little self-imposed commands that seem to represent some ethic or moral that goes with the conduct of each shift. I’m better at obeying some more than others.

– Be thorough in all aspects of history, examination, notation, treatment and disposal [though this would be supposed to be elementary, the temptation to be slack is constant…]

– Work slower [I work manically and far too quickly, i see a lot of patients. I’m not convinced this is a good thing]

– Fight for the patient [in the sense of annoying and if necessary pissing off other doctors if it’s in the patients interest – how not to make friends or influence them…]

– Always go and see the patient you’re asked about [when you’ve been woken at 4am for advice over the phone, you will almost inevitably say something stupid]

– Pee [15 hour shifts no problem…]

– Eat [easy to forget]

– Do not be afraid to follow up patients on the phone

– Keep a list of all the interesting patients

– Copy x-rays/CTs/ECGs [useful for teaching and remembering the interesting ones]

– Remember dual pathology on X-rays [just cause you’ve seen the broken clavicle on the x-ray doesn’t mean that’s the only break]

– Think laterally, always reconsider the differential despite what may seem obvious [just because the patient, GP and nursing staff are telling you they have appendicitis, does not always mean they have appendicitis]

– Ignore any pressure that is not in the patient’s best interests [4 hour target nonsense etc…]

All very noble and honourable ideals. We’ll see how long it lasts.

Here comes the anxiety

I have come home to roost. Back to the world of emergency medicine and waitng times and drunks and crazys and the worried well. With the odd bit of emergency medicine thrown in for good measure.

I love working there. I’m not entirely sure why when I think about it but I do. I tend to work late evening shifts and come home with my head buzzing from all the different patients and spend ages searching uptodate for better diagnoses than I could come up with. And going through all the resuscitations in depth, like little movies on repeat, with all the different things I could’ve done highlighted.

I’ve been doing lots of studying of late and realising that perhaps ignorance was bliss. When my medical knowledge was particularly limited then I had less to worry about. Now that I know a few things, I have a better idea of what can go wrong.

Don’t worry, honestly. I can do all that for you…

Fat Freddy’s Drop

Footy tournaments are wonderful distraction therapy. Watching terrible games twice a day, just in case you miss a cracker (yes I missed Holland-Italy…).

Though in work this has the added advantage of giving me something to do while waiting for the “magic cream” to cook on the kiddies.

Your child, safe in my…oops I dropped him…

Better do Better

epa0966l.jpgI’ve got myself all worked up now into an angry irate blog against the NHS. Well maybe not against the NHS, more of a passionate defence of what we hold dear.

Since arriving back (I’m thinking of dividing my life into BNZ – Before New Zealand and ANZ – After New Zealand) I have become increasingly frustrated with my beloved hospital. Though I suspect none of this is peculiar to me alone.

To be perfectly frank I think all the poor dying, sick people we’re meant to care for are getting a pretty raw deal. I think all the poor kids pulled from car wrecks are getting a raw deal, all the wee grannies dumped to our care get a rough time of it. Even the kiddies, the babies, and the mums are getting a raw deal. Health service has a kind of hollow ring to it.

Now this is of course not universal, lots of people get a great deal from the NHS and will tell of wonderful experiences. But then that’s the whole point – we’re not succeeding on a universal level, we’re  not even succeeding on a passable level.

Basic principles of medicine (these are more mine than Hippocrates, thought up while waiting for the pizza on a Friday night) could go as follows:

1) relieve suffering – because we’re generally crap at actually fixing things. People die, we’re crap at stopping that. We can make the process of human existence slightly more palatable. This is a long way from euthanasia.

2) we occasionally fix people – see note above.

3) deal with people with grace and dignity and kindness

4) understand something of what it means to be in their shoes.

5) ensure patient safety – in other words that it should be the disease that kills the patient, not us.

And we’re not doing great, we’re working in a system, that’s akin to a recently departed horse getting the beating of it’s life.

The NHS is full of people who hate their jobs, at least that’s how they talk. At tea breaks, all people do is complain about how busy their department, how they’re pushed to breaking point, how they’re frustrated with their jobs, their wards and their patients. Everyone sounds like they’re one crisis away from quitting.

I feel sorry for the students, the guys coming through in every discipline. They’re exposed to nothing but stress, pressure and frustration with a system that seems to have no answer.

The depressing tea break conversation is coming from smart, committed, dedicated people. With a desire to do the job right, but seeing no way to do it in the system they’re in.

I love my job, I believe I’m the luckiest guy in the world to have it. I feel it’s nothing but an honour and a privilege to be a part of people’s lives at some of their most significant moments. It kills me to see those around me struggling to feel anything positive about the place. It pisses me off to see patients getting treated like shit all the time.

They get sorted eventually, but they get neither the time, respect nor treatment they deserve.

The NHS will continue to survive on people busting their ass for their patients. But simply surviving doesn’t really count for much.

The dear, brilliant, hard working people (though not everyone in the NHS is up for a sainthood, there’s lazy gits here too) I work with will continue to work in a system that is being continually squeezed in successive efficiency drives to meet targets to fulfill a politicians mandate. No one ever stopped to think whether an efficient NHS is good for the patient. Maybe a hospital works better (for the patient) at 80% capacity (though clearly less efficient)

But anyway, I’m not going anywhere (what else would I do), I continue to love the job, we’ll all keep trucking along to a mediocre standard till a few more people die unneccessairily, and a few thousand more get sub-standard treatment and maybe we’ll start thinking about properly funding the place…


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July 2017
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