Wednesday, 30 December 2009

Time to outlaw the smacking of children. Seriously.

Posted by: Dr. Thunder.

Today I was in "The Square", a large shopping centre in Dublin. A young mother wheeled her trolley past me, and a small child was sitting in it. He was about 18 months old, and mum had let him play with a plastic bottle of milk that she was going to buy. As tiny curious people do, he threw it out of the trolley to see what would happen.

Unsurprisingly, milk exploded all over the floor. Mum was very embarrassed. So, what was the first thing she did? Put the trolley over the spill to stop people slipping in it? Go and get a staff member to tell them?


She slapped this tiny child across the face.

I saw red. I was so angry. If she did that tme, a large male, she wold be arrested and charged. But it's OK to do it to a small toddler.

I wanted to ring the police and tell the security guard. But there was no point. This behaviour is COMPLETELY LEGAL in Ireland.

The baby looked stunned, and cried for a minute. But this obviously wasn't the first time it has happened to him. Will it stop him doing it again? No. He isn't old enough to know why he was hit. He isn't even old enough to know that it's wrong to throw a bottle of milk out of a trolley.

I've been a staunch opponent of corporal punishment for as long as I can remember. I've heard all the arguments. I'm sick of "A smack never did me any harm". Well, smoking didn't do my 90 year old neighbour any harm, but anecdote shouldn't form the basis of policy. Plus some of the people who say it hasn't done them any harm are the most maladjusted individuals I know.

I'm sick of the "I just tap him if he's bold" argument. Firstly a "tap" from a 20 stone man is probably quite painful to a child. And surely a "tap" that doesn't hurt won't have the desired effect.

Aside from the fact that it's wrong for be to be allowed to hit a lid, when it's illegal for me to hit an adult, it's also not effective.

Virtually all of the scientific studies and all of the paediatric bodies come to the conclusion that corporal punishent is the least effective form of punishment, and it can lead to problems in itself. I used to work in a paediatric behavioural clinic, and more problems are caused by smacking children than are solved by them. In fact, getting parents to stop hitting children is one of the first steps in improving behaviour.

Smacking a child tells them A) Violence is an acceptable way t0 solve a problem and B) That their parents are not in control of the situation.

A child who believes either of the above has the potential to be a disciplinary nightmare.

I respect no-one who hits children. I know it's harsh. But I lose all respect for someone when they tell me they hit their kids. It's always followed by a nonsense excuse. But it's still assault in my eyes.

The UK have gone some ways towards protecting their children. And special praise must go to New Zealand where they have banned the smacking of children in all settings.

Sadly, Australia and Ireland (as always) are lagging behind. The Irish in particular have most to be embarrassed about, considering it's still legal to slap kids in reidential settings (though virtually all of these institutions have guidlines for staff advising against it).

Both Ireland and Australia have a pretty shameful history of failing to protect the most vulnerable people in their societies. Outlawing corporal punishent would be a step in showing that we're beginning to take the welfare of our children seriously after all these years.

Dr. Thunder.

Saturday, 26 December 2009

Irish healthcare workers feeling the recession blues.

There's a recession in Ireland.

A really BAD recession.

We've had to stop buying new BMWs and 500,000 euro houses while earning 30k per year. That's no bad thing, it has to be said. But it's meant a pretty lean Christmas for a lot of Irish folk.

So, a budget was called recently, to sort out this mess. This PR (and I mean that in the non medical way) exercise had, and will continue to have, signifcant repercussions for healthcare staff working in our beleagured public service. It was aimed at punishing those with a weak voice (with social welfare cuts) and placating those who tend to vote in greatest numbers (The private sector workers and pensioners).

The public wanted public sector heads to roll, because they were angry at giving up their BMWs and 500,000 euro houses that they bought on credit. There was a bizarre thought process that permeated the private sector regarding the payment of all public sector workers. The logic was that "we've all taken pay cuts, so now it's your turn".

The public sector is too expensive, went the argument, so the public sector workers have to pay to keep it running.

We have hospitals that cost millions to run every month. We can't afford it, so we need money. Fair enough. The whole country uses these hospitals. So, how do we get the money? We take it from those people WORKING in the hospitals. A friend argued that he had already taken a 6% paycut while working for a large accounting firm, so he shouldn't have to pay for the hospitals and the police service and the fire service to keep operating. Only in Ireland.

I'm just back from Australia for a holiday, so I thought I'd missed something. "But you've taken a pay cut so your boss's company can survive. That's exclusively for your company's benefit. But the public sector is used by everyone, so why do only the 1/6th of the workforce who work in it have to pay to save it?"

I've asked this question several times, and have been told the following:

A) The public sector are useless and "bloated". As this is a medical blog, I guess we should be focussing on whether that's true in healthcare. And healthcare workers took the same large cuts that everyone else did. In my experience in Ireland, EVERY SINGLE hospital department I've ever been in has been grossly understaffed. Pregnant doctors have been working 48 hour shifts. It's common to work 24 hours every 4th day. Now THAT is value for money!
My sister used to work in medical records, and came home a shell of herself each evening. Another sister worked at a reception desk in a large hospital, until she got a much more sedate, and much better paid job in the private sector.

B) The public sector are overpaid: This is more difficult to fathom. There are various reports that support this claim. But they compare averages. In the private sector, some people are on pheomenal money, but some people get left to the dogs with appalingly low wages. Averages work best when there's a normal distribution. The private sector has been quick to throw the crumbs to it's lower skilled workers for donkey's years. I don't think that should be applauded. My private sector friends have been almost boasting about how there are people in their offices doing long hours for a pittance while angrily frothing at the mouth thinking about public sector workers earning a fair wage.
Then the comparisons with the UK start getting made (particularly in relation to doctors and nurses) and my eyes start to roll.
People in Ireland look at the NHS as a utopia where fatcat doctors and nurses get paid a smaller wage than they do in ireland. It's probably true. But the morale of the doctors in Britain is unbelievably low (and not just because of their pay). It's probably true that junior docs in the UK DO get less money than their Irish counterparts. But the UK docs don't have to cope with 24-72 hour straight shifts on a very regular basis. Plus the cost of living is much higher in ireland. I get paid less in oz than in Ireland, but I get a MUCh better stanbdard of living for my money (and I live in a big city). Same when I worked in the UK. I used to own a lovely apartment in the posh part of town, but wouldn't have been able to afford a cardboard box on that wage in Ireland. So, there's a context to wages.
I'm just not sure why Irish docs have to be benchmarked against British doctors, when both are treated like dirt by their employers. The only difference is that the Irish docs have been a bit more successful at getting remunerated for it.

Also,and I realise I'm being controversial, getting a place in nursing school in the UK is a LOT easier than getting a place in ireland. Irish nurses TEND to be better qualified in my experience, and to adopt the private sector mantra, we should reward excellence. I have a good friend in the UK who is a qualified nurse who tells me he never learned ANY pharmacology at nursing school!!

But I guess the real purpose of this post is to ask whether anyone can explain to me why public sector workers in Ireland have to pay more for the upkeep of these PUBLIC sectors than anyone else? Are, Irish healthcare workers now more entitled to a hospital bed? or a quicker police response?

Please enelighten me.

Dr. Thunder.

Sunday, 20 December 2009

Quote of 2009

Posted by Dr. Thunder.

I'm just on hoilidays at the minute, in the North of England. Last week I was walking down the street, and noticed a small frail nun standing outside a parish hall, just before their weekly saturday night service began.

Another little old lady, who looked like she's in her 80s, was hurrying home, when the nun waved to her. "Hello Carmel" said the nun.

"Oh hello, sister" she replied in a thick northern accent. "Sorry I haven't been to church recently. But the X-factor finishes tonight, so I'll be able to make it from next week".

And they say it's just kids who've got the X-factor bug!!!

PS...lots of "leaks" on the net tonight suggesting Rage Against the Machine have secured the Christmas number one. If this is true, it will make my Christmas :D

Dr. Thunder.

Wednesday, 9 December 2009

The antibiotic war.

Posted by: Dr. Thunder.

What are we doing wrong?

Why have we not got the message out there about antibiotics?

How come we struggle to get parents to give their kids life-saving vaccines, but we've convinced them to to demand an antibiotic for their little ones, at the first sign of a sniffle.

I saw a 5 year old boy, Thomas, a few days ago in the emergency department. Thomas had a mildly elevated temperature, a runny nose, a sore throat, and a pain in the side of his head.

"We're here because we can't trust our GP any more".

"Really? And why is that?".

"He told us Thomas IS sick, but he won't give us an antibiotic", mum answered.

As Thomas sat there on the trolley-bed watching his portable DVD player, and laughing loudly at the cartoon on his screen, I began to suspect that A) He did not have a bacterial infection and B) This consultation was not going to end well.

I gave him a good look over, and concluded that he had an improving, self-limiting viral infection. Red ear, red throat, runny nose and a bit of a temperature. He was eating and drinking normally again, and seemed to be on the road to recovery.

I sat down with Thomas' parents, and explained the difference between viral and bacterial infections. I told them that this infection seemed viral to me, and reassured them that their GP had made the right decision.

"Look, can we stop all the side stepping here? Are you telling us he's not going to get an antibiotic?".

"I'm sorry. I'm not going to prescribe an antibiotic because....."

"OK, can we get a second opinion. He gets these infections several times a year, and ALWAYS needs an antibiotic".

I told them I'd happily get the consultant involved, but that this would take some time.

They agreed to wait, and Thomas loaded another DVD to watch.
After about 20 minutes they started to complain loudly to each other, as people do when they're trying to get your attention.

"I told you we should have brought him to the other hospital", dad said to mum, VERY loudly. "At least THEY know what they're doing".
This went on and on, and I ignored them.

20 minutes later, they got up to leave. On the way out, they told random nurses and patients int he corridoor that they were going to find a private doctor "Who bloody knows what he's doing".

The thing is, I suspect they may have.

These parents are very likely to have found a doctor who agreed to give Thomas some Amoxicillin. Then Thomas will have continued to get better, except for his antibiotic-induced upset tummy. In two more days he'll be right as rain, and they'll tell all their friends that the antibiotics cured them, and that the pillock paediatricians at the local hospital haven't a CLUE what they're doing.

It has bewildered me for so long that we give out so many antibiotics without any justification. It's hard not to, and when I was a bit more junior I did so, when I couldn't stomach the fight. I don#'t resent the doctors who prescribe them easily. But I really wish they wouldn't.

Anyone got any thoughts on what percentage of antibiotics given for acute respiratory illness actually result in improvement? I've no idea, but I'm sure it's very low.

Dr. Thunder.

Saturday, 5 December 2009

To work in Ireland, the UK, Australia or New Zealand?..the choice facing thousands of junior doctors

Posted by Dr. Thunder:

As a registrar, who has worked in Ireland, the UK, Australia and New Zealand, I thought it might be useful to share my experiences here, in the hope of helping other doctors decide whether they want to trek halfway across the world in order to ply their trade.

I've included my thoughts on each of the countries below, and what they're like to practice medicine in:

Ireland: Oh Jesus. Juniors are still working shifts up to 48 hours. The European Working Time Directive will be implemented shortly, which will reduce the working week of doctors to 48 hours. In order to maintain a service, while halving the hours of medical staff, the Health Service Executive have decided they will simply ask the overworked juniors to work twice as hard while they're on the job. Simple.

They will also be docking 30 mins per day from the wages of junior doctors for their lunch break. Just ask any junior doc if they get a lunchbreak. Even if they do, they're not allowed leave the hospital, and they still have to carry their pager. It's a total joke.
Another disadvantage of being a junior doctor in Ireland is that the media, and consequently the public, think you're overpaid and lazy.

The standard of medical care in Ireland is also likely to fall, as the universities adopt GAMSAT and PBL with gusto. It used to be very difficult to get a place at medical school in Ireland. Now, about 1 in 3 of those sitting GAMSAT get offered a place. Call it elitist if you like, but when I'm old and have a complex medical condition, I want someone who works hard and is brainy as hell treating me. To stop these GAMSAT graduates doing too much damage, nurse prescribing is also being introduced, which required the nurse to do about 6 weeks training to convert themselves into a doctor. Good times.

Patients also routinely wait several days in the emergency department corridors on trolleys for treatment, as there are not enough beds.

In the "pro" column, my family and oldest friends are in Ireland. So, I'll probably end up returning someday. But I'm doing postgrad qualifications so I can hopefully get a post in a university, or be based in Ireland whilw working for an aid agency.

The UK: Also not a great life for a junior. Here you will find an imaginary 48 hour working week. In fact, they monitor you to make sure you're not working extra hours, by getting you to fill out an "hours diary". Essentially, you are expected to lie on this form, so your employer can ignore the fact that you work an extra 10-20 hours per week for free.

My biggest peeve about working in the UK, was the famous "4 hour waiting time". This is possibly the greatest con in the history of medical politics. Essentially, what happened was the labour party government got tired of people complaining that they had to wait 12 hours in an emergency department to get treated. So, they announced

"From this day fortwith, no man, women, child nor beast shall wait more than 4 hours in an emergency department".

WOW, we all thought. That's going to require a hell of a lot of investment into acute services. Right?....Eh, yea,...sure.
Obviously there was minimal extra invgestment. So, what happens is....the patient turns up to a crowded A+E department, and is seen about 3 hours later. So, they have some blood tests taken, which won't be back until 4 hours are long gone. You'd like to get a specialist down to see the patient in A+E, but they won't be able to make it before their 4 hours is up.

The head nurse hassles the junior A+E doc to get this person home or onto a ward. "But I need to get the bloods to see what's going on". Doesn't matter. They cannot be here longer than 4 hours, or the whore-child of Satan shall rise and engulf the hospital in his flames of jizm.
So, you have to send them home and hope to God their bloods/xrays etc don't show anything untoward. Or that the pain doesn't return when the pain killers wear off after they go home. Or you hassle the admitting doctor on the ward to take them, even though you've no clue what's wrong with them.

So, the patient usually ends up getting admitted at 4 hours. Nothing serious wrong with them. But they now have to stay overnight because they've been "admitted".
Every doc who's worked in acute care in the UK will have had a nurse coming in to see them while they're seeing a genuinely unwell patient to remind them that there's someone much less sick outside who needs to be seen NOW as they're going to "breech" the 4 hour target. It's not the nurses' fault. They get it in the neck if these people wait more than 4 hours. Some units improvise, by removing the wheels from the patient's trolley. So, they're no longer "waiting on a trolley" in A+E, they're admitted in a "bed". It's genuinely soul destroying.

What's also soul destroying is the way jobs are allocated to juniors. I still don't fully understand it either. All I know is some amazing doctors are unemployed because of it, and some real muppets are doing well because they can tick the right boxes in their "self assesment portfolio" or whatever it's called. It seems juniors in the UK are rewarded for being good at paperwork, rather than being good at medicine.
Oh, and everyone in the NHS is now a "consultant" of some sort. Everyone is taking on a doctor's role on the cheap, and healthcare is going down the pan.

Most consultants are not interested in the plight of juniors, so it's a lost cause.

It breaks my heart to write the above, as the principles upon which the NHS is based should make anyone proud to live in a country where free good quality healthcare for all used to be a reality.

New Zealand: Lovely place to live. Lovely place to work. My experience was in a hospital that was off the beaten track. But the consultants would come in and help immediately if you have any dramas. Colleagues were supportive, and standard of living was good. Managers actually spoke to us, and consultants backed you up.
I ended up looking after some pretty sick people who should have been moved somewhere else, but they were too unstable to go the long distance. This is a recurring problem in this part of the world, because of the geography. I saw it as an opportunity to improve my critical care skills, and, as mentioned earlier, consultants were generally very supportive, so I never felt out of my depth

Highly recomment NZ as a working environment.

Australia: Great place to work, by and large. If you stay for any length of time, you'll probably end up working in an understaffed remote hospital with minimal senior support. But working in a city is well worth it. Great hospitals. Reasonable workload. Supportive consultants, by and large. Nice atmosphere too. Generally first name terms with your seniors. Hours are not too onerous, unless you work remotely, when you can end up doing 24 hour on-calls.
I usually got a l;unch break in oz, and when I finished late I got paid for it.
On the downside, their politicians tend to use health as a political pawn, as is the case in most countries. For example, the recent swine flu response was 50% medicall driven, and 50% political, which was disheartening.
But, while Ozzie politicians are the same as any others, I'd still recommend it as a place to work.

Major downside is that the universities recruit a LOT of GAMSAT students. IN my opnion, and it's only an opinion, these students are simply not that good. MANY og my colleagues share this view. But it's a quicker way to train, so it will be a case of standards being sacrificed to save money.

Hope that helps. feel free to add your own opinions in the comments box.

Dr. Thunder.

Thursday, 3 December 2009

Posted by Dr. Thunder.

Well, they said it couldn't be done......

A conference without drug company sponsorship.

It was a small gathering, but I was there. Last week I went to my first ever "pharma-free" conference. It wasn't big. It wasn't fancy. There was no breakfast provided. Lunch was a few sandwiches and a slice of cake. There was a dinner afterwards, which you could attend at your own cost.

The experts were mostly local. Nobody was flown halfway round the world on a first-class flight and put up in a penthouse suite.

But the information presented was pretty much as good as that presented at any other conference I've ever been to. The meeting was based in a large capital, so there's plenty of research going on locally to present. A couple of times, research was discussed that hadn't been conducted by the presenter, in a "new developments in....." format.

It was great. Nobody was trying to sell anything. Nobody was trying to con us into presecribing their new decidedly average wonder drug. The cost of attending hardly ate into our budget at all.

It was just doctors talking about the best science. I loved it.

I have real problems with the pharmaceutical industry. I have no problems with them developing lifesaving drugs. Let's be honest, we'd have much worse outcomes without the pharmaceutical advances of the last 10 or 20 years.

But the way they try and peddle their drugs, regardless of how effective they are, gets very tiring, and ultimately erodes any trust in them.

This was a small conference, though, and only a small step in the right direction. As things stand, there's a world of work to do in order to limit the interface opportunities between drug reps and healthcare professionals.

BUt this was one step that was supposed to be impossible. BUt it' wasn't.

Dr. Thunder.

Sunday, 18 October 2009

A health-y appetite for the finer things in life.

Posted by: Dr Thunder.

Two of the most important people in Irish health circles are Mary Harney, the Minister for Health, and Professor Brendan Drumm, the CEO of the Health Service Executive (HSE).

The HSE is, essentially, responsible for the day to day running of the health service. These are the head honchos. The buck stops with them.

For years, doctors and nurses in Ireland have felt anger at both these public figures. They have lectured us on cost cutting, and the need for increased efficiency. In fact, professor Drumm is one of the main reasons why I chose to continue working in Australia, rather than going home to Ireland. I was visiting my family around christmas two years ago, and he came on the radio at my parents' house. He was giving a rousing oration, where he told the public how the front line staff in the Irish Health Service need to look at themselves, and to work harder, and to work more efficiently.

This, to me, was a disgusting thing for a fellow doctor to say, while Irish doctors (including pregnant women) were still working shifts up to 48 hours long. I decided then that I would never work for a service with a man at the helm who was more concerned with populism and passing the buck than he was with the overworked demoralised staff doing their best in crappy conditions.

Here is a man who has lost touch with the grass roots.This is a man who gave up his job in the understaffed specialty of children's oncology to earn big money running the HSE.

Also, and this is VERY important.....professor Drumm spoke out criticising excessive bonus payments for senior HSE staff back in 2007/8. This fact will become important later.

Then there's Harney, our erstwhile Minister. She has achieved a degree of popularity recently by "taking on" the "professional elites" such as doctors, pharmacists and nurses. In fairness, I do owe her a degree of gratitude, as her treatment of junior doctors mean I no longer feel homesick in Australia, as there are as many Irish doctors working here than I've ever worked with at home.

One of Harney's favourite pastimes involves telling the public how healthcare workers are costing us too much.

So, here we have Professor Drumm telling us we're not doing enough for our money. And Harney tells us we get too much money.

Now, you would expect this pair of reformists to lead by example, if they're going to tell the workforce in a third world health system to tighten their belts and work harder.
However, in a shocking development, which will rock the very foundation of the state, it has emerged that both Harney and Drumm are.......

Talking out of their asses.

We all know that expenses and bonuses are part of both political and business life. I expect a servant of our country to be able to fly first class, so they can do their work on the plane. I expect them to stay in a hotel with a business centre when they're away. I even expect people running the health service to get a bonus when things are going well.

So, what do we know about Harney and Drumm's financial package?

Well, we know that Harney and her husband (!?!) ran up a bill of almost 70,000euro over 3 years in JUST hotel and limousine costs. That's about 23,000 euro per year. On hotels and limousines!!!!!! How often was she going away???
Then it emerges that she refuses to travel on commercial jets when going overseas. Instead, she insists on using the government jet. So, over the same period she ran up a ill of 750,000 euro on flights. That's a quarter of a million euro every year! This jet costs 7,000 euro per HOUR to run. This only the information that is available. The Freedom of Information Act in Ireland is so difficult to navigate that it is almost impossible to discover the full extent of the financial laxity within government and senior civil service ranks.

Sweet Jesus.

Now let's look at Brendam Drumm. He's just been awarded a 70,000 euro bonus for doing so well in navigating our country towards a world class health service. This is the man who gets 430,000 euro per years as a basic salary. This is a man who was so critical of HSE bonuses before they were dangled under his nose. This is a man who has presided over a HSE which treats its junior doctors as glorified slaves, and has closed children's services in our major kids hospital.

In Ireland, there are half a million people unemployed. The self employed who built the country get no social welfare when their business goes bust. Those lucky enough to get some government support are entitled to 204euros per week. There are little children who desperately need spinal surgery, and have been told we can't afford the service.

I don't know how these people sleep at night. But I guess the presidential suite at the Waldorf,or a flatbed sleeper on a government jet helps.

Dr. Thunder.

Wednesday, 14 October 2009

So, will that swine flu vaccine give my kid mumps or what?

Posted by: Dr. Thunder.

I've just had my umpteenth conversation with a concerned parent about the swine flu vaccine. I'm starting to sound like a broken record now.
Parents have every right to ask questions, when we consider what's been in the media, regarding this jab. It's a minefield of information, and it's difficult enough for those of us who work in healthcare to get our heads around it.

I get asked a lot of questions about this vaccine. Some sensible. Some truly bizarre. I've had the crackpot conversations already, with the truly paranoid. We discussed mandatory vaccinations, and the big pharma conspiracies.

"This vaccine has been made to give us all swine flu"

"This vaccine has been made to stimulate the world economy"

"I've heard this virus was released accidentally from an American army lab, and they're trying to wipe it out, so unfriendly countries dn't get their hands on it".

These people must live truly terrifying lives, if they're so convinced that government is out to get them.

At the normal-ish end of the paranoid spectrum, I've had some unusual questions. But nothing prepared me yesterday for a previously sensible parent asking me, in hushed tones, whether I thought there was a risk of Anthrax from this vaccine!!!!!!!!

Jesus H Christ!

"It's just that I read it on a website".

I tried to keep it calm. But I'm sure my face cracked a little, as the laughter tried to escape. I reassured Harvey's dad, and he was accepting of my explanation.

Having said that, the concerns expressed to me have been, by and large, fairly reasonable. And those that are a bit crazy, have generally come from respectable looking websites, which are essentially conspiracy theory sites, or are peddling alternative meds. There is something ironic about these people claiming a big pharma conspiracy on hand, and trying to sell you expensive vitamin D "anti-flu" tablets at extortionate prices on the other

I feel I should put up a list of the common concerns here, and make an attempt to address them. Cleverer people than me might want to add some extra info too.

1) This vaccine was rushed through the safety checking process: There's no doubt that the swine flu vaccine was made quickly. If there was a new vaccine on the market. it would take years to reach the market. But the swine flu jab isn't really new.
Every year, we have different strains of flu circulating. We usually detect these many months in advance, and make a vaccine against them. The way we do this is by taking a vaccine mixture that is shown to be safe, and adding in the virus particle that is circulating this year. The virus particle is the bit that immunises you against a specific strain of flu. It is a part of the surface of the virus that your body will recognise. It is not live virus. This year one of the strains of flu is swine flu. We didn't know about it early enough to include it in the yearly flu vaccine, so we've had to make a new one. But it's almost identical to the seasonal flu vaccine that people get every year. It is very likely to be included in the normal flu vaccine next year.

2) I don't need it as I don't have an underlying medical illness: Depending on the country we look at, we're seeing 30-50% of swine flu deaths and admissions to ICU in groups with no risk factors. Plus, vaccines are not designed to protect individuals. They're designed to protect communities. If you don't catch it, you can't pass it onto a baby, or someone else who will be less able to fight it.

3) I read about it making people sick in 1976: There was swine flu in the USA in 1976, and there was a vaccination programme. About 40 million people were vaccinated, and 25 died from Guillain-Barre syndrome. This is true. But when you look closely at the figures, there were about 1 case per million people more than would have been expected in a normal year. That's still high, but it's not a huge risk. No cause has ever been found for these cases. But vaccines weren't as pure as they are now, and this is thought to have been a contributory factor.
Bear in mind, though, a good chunk of those people would survie today, as GBS is better treated. Also remember that influenza infection is a big cause of GBS.

4) This is only a mild disease: True. In most cases. 1 in 200 people who get swine flu end up in hospital. A third of these end up in ICU. Usually for about 2 weeks. 1 in 1000 patients die from it. Though in some countries this figure is much higher. If 1 million people catch swine flu in Ireland, that's 1,000 deaths we're facing, and about 5,000 hospitalisatoins. That will wreak havoc on an overstretched health service this winter.

Everyone has their own choice to make. It's not for me to tell anyone what to do. But, whatever your decision, make it based on facts. Speak to your doctor or nurse. Don't look at the quack websites.

I had mine the other day. Had a bit of nausea the next day. But otherwise I was fine.

Feel free to comment. Feel free to disagree. But please don't scaremonger.

Dr. Thunder.

Saturday, 10 October 2009

Who are the trade unions kidding?

Posted by: Dr Thunder.

I think most public servants are underpaid.

We all have the chance to work in the private sector, for more money and better conditions. We stayed with the public sector during the boom times, when all kinds of people were earning crazy money in the private sector.

We have had to listen to the private sector telling us we were fools for staying put, for the sake of our patients, when there was big money to be made elsewhere. Now we have to listen to them telling us that we're overpaid and that our perks are too lucrative.

I think, to an extent, the public sector have to suck it up. You take your risks in the private sector. When times are good, you earn big. But when things go bad, they go VERY bad.

I have to say, though, the Irish trade union, SIPTU, have left me speechless recently. This trade union represents various public sector healthcare workers. Mostly nurses and paramedics. Oviously, these two groups do a vital job. A job that most private sector workers wouldn't have touched during the boom years in Ireland. But they stick with it, loking after the most vulnerable memers of society, under very trying conditions.

They don't get a Christmas bonus. There was no free staff night out at Christmas for them. there is no health insurance.

So, now their trade union has asked for a 3.5% pay rise for these workers.

For those of you reading this from overseas, Ireland is in trouble. I mean BIG trouble. Think Iceland-Lite. I know there's a global recession. But Ireland is suffering a global recession, plus a national recession. There's just no money left. I wrote recently about how children's surgical services are being closed down because the piggy bank is empty. Unemployment is skyrocketing, and hundreds of thousands of familes are trying to survive on their weekly 204Euro social welfare payment, in one of the most expensive countries in the world.

The people are fed up. They've seen politicians spend crazy money on lavish expenses, and they've seen the bankers bailed out with huge financial packages, while the self-employed don't even qualify for the dole when their businesses fold.

The dole office is so busy, it's taking 3 months for applications to be processed.

This is not the time to be asking for a pay rise.

Healthcare workers continuously come out top of public opinion trustworthiness polls. There's a good reason for this. Healthcare workers are supposed to care more about the people than about money. I think that still holds true. But I think the trade union are trying to play hardball with the government.

But how can we expect the public to have any respect for us if we're demanding pay rises in the current climate? The cost of everything is going down, so it's difficult to justify on the basis of inflation.

For a nurse on 35k per annum, a 3.5 pay rise works out at about 20 euro per week extra, before tax. That is not worth alienating the public for.

I hope common sense prevails. I hope our nurses and paramedics are rewarded when the economy turns a corner. I, and they, know that won't happen, though.

But, in the run up to a very lean Christmas for most of the country, it's time to put the begging bowl away for now.

Dr. Thunder.

Saturday, 27 June 2009

Official stement from the Kim Jong-IL school of public relations.

Posted by: Dr Thunder.

Now, I've never been a big fan of the HSE. The Health Service Executive is essentially the arm of the Irish department of health that runs our pretty shoddy health service.

In Ireland, despite having recently had over a decade of unprecedented economic growth, we still have a third world health service.

Expensively trained Irish healthcare professionals can be found all over the world, as they make their escape from an environment which is one of the most demoralising in the developed world in which to work.

Patients still languish on trolleys in emergency departments, as they wait for one of the precious beds in our understaffed, filthy, crowded wards.

As a doctor it's frustrating to see healthcare being run into the ground by people who have lost touch with what it's like at the coalface. Talk to people who have worked in emergency departments when there's a ministerial or departmental visit. Patients who have been lying on trolleys for days are suddenly found beds. Exhausted staff are kept out of the way. The sycophants are wheeled out for a meet and greet.

Against a background of spectacular cockups, it wasn't a huge surprise when I heard the HSE will be closing down a part of their spinal surgery services in Our Lady's Hospital, Dublin. This is one of the finest children’s hospitals in the country, and provides essential services for children with scoliosis in Ireland.

Scoliosis is a curvature of the spine. Its effects can be devastating. It leads, in many cases, to significant disfigurement. The curving spine can also impinge on vital internal organs, such as the kidneys, to stop them from functioning properly.

However, we are in the fortunate situation, whereby scoliosis can be treated, or at least managed. Sometimes surgery is the answer. Sometimes a cast is fitted to help the spine grow back straight.

Time is of the essence in these case. Because as the child grows, the curvature gets worse if not treated.

Because of the economic crisis, the HSE need to save money. They need to cut back on wages. So, they had a look around at potential targets.

Admin people? No.

Political advisors? No.

Government trips overseas for St Patrick's day? No

"Hey, what about the only people looking after kids with scoliosis in Ireland?". Great idea.

So, operations have been cancelled, and appointments have been binned. Casts won't be applied. Operations won't be performed. Curvatures will get worse, and these children will go from being able to live a normal life, to being a burden on the state.

Unsurprisingly, the weary Irish public have asked the HSE to explain this decision. So, they did. Oh, sweet Jesus, they did. The statement released to the press said:

"The incidence of children with scoliosis in Ireland is different to other countries, as termination of pregnancies that have a prenatal diagnosis of spina bifida, or other conditions that may develop spinal curvature, is not legal in Ireland".

Christ on a bike!

Why oh why oh why would they say this??? There is a technical point of some sort being made here. But what is it? Are they saying these children should never have been born?

Will they say to all the parents of disabled ex-premature babies "Sorry. If it wasn't for the fact that our doctors are obliged under law to treat your sick kids, then we wouldn't have these problems to deal with. So, we'll be withdrawing all future cerebral palsy care".

There some things that may be technically true, but imply a judgment of sorts. In this case, it's hard to read the statement as saying anything other than "You really shouldn't have had these kids".

There's a lot of offended parents out there.

I've seen too much of this type if nonsense to be surprised.

The HSE are thought to be better at PR than actually managing the health service. If that's the case, we're all screwed.

Dr. Thunder.

Friday, 12 June 2009

Don't worry, doc. I've brought a load of people to have a look at your sick kid. I can get more if you need them!

Posted by: Dr. Thunder.

I find it ironic that, nowadays, when I see someone keeling over, it often makes me want to go in the opposite direction. Very fast. Especially when I'm already busy as hell. But, it's fair to say that's not the case for 99% of the general public.

People love a good old collapse. Nothing draws the crowds like a wham-bam-outa-nowhere-keeling over. It's one of my pet hates. If someone is unfortunate to become unwell in a public place, they can be guaranteed one thing.....that a lot of people will have a good look.

 The people I always feel sorriest for are those who have seizures in public. Imagine it. You drop suddenly. Next thing you're waking up on the main street in on a saturday afternoon in your urine soaked trousers, with blood gushing from your bitten tongue, confused and just wanting to sleep. But that can't happen, as someone ALWAYS takes it upon themselves to make sure you don't fall asleep. Like in the movies, where if you let an injured person fall asleep they die. In about 50% of cases, the misery of the unfortunate "seizee" is compounded by someone ramming a spoon in their gob. Gotta make sure they don't swallow that tongue! Swallowing a spoon, or tooth fragments is fine. But keep that tongue firmly in their mouth, at all costs.

Just picture yourself waking up in that situation. Number one rule when dealing with a sick person in public...make sure they have some privacy.

I'm writing about this as I was in a similar situation about 2 weeks ago. I was doing an outpatients clinic, so I definitely wasn't in "emergency mode". I was strolling towards my little room, eating a hearty breakfast of one slighly over-ripe banana enroute. The only thing on my mind was whether it's dangerous to eat a banana that's more black than yellow.

And then then it happened. The 11 year old girl walking ahead of me just dropped. Her mum started shouting for help, and I looked around hoping some nice person was going to sort this kid out. Then I had that "oh yeah...I'M the doctor" moment that every medic will have had at some stage in their career.

Anyway, I made my way over to the girl an her mum, and worked out reasonably quickly that she'd just had a faint. I was on my knees beside her, just talking quietly to her, reassuring her that she was going to be fine. I didn't really notice what was going on around me. Until I turned around to see if I couild find someone who could call the emergency team. 

I was looking for one person. There were at least 15. Whoa!!! All these people just having a look at the poor kid. 

They were staring at her. She was staring at them. She looked horrified. They looked fascinated.

 So, I said "OK, guys, we're fine here, thanks". No-one budged. "Eh, could we please have some privacy here, please?". 
Two, maybe three or four, people walked away. The rest just kept staring. This girl looked so embarrassed, and I couldn't blame her.  So, I became more forceful, and stood up. I literally forced these grown adults away from her, and into the foyer. The emergency team came with a trolley, picked her up, and took her away. All was well with the world again.

So, why do people do this? I can understand the odd punter offering you their phone if you need to get help, or their first aid skills. But why just stand there and gawk? It's embarrassing for the patient, and it SHOULD be embarrassing for the person watcing. 

I remember once looking after a guy in a burger king, who'd keeled over.  The problem was so bad, that the excellent and ballsy security guard just decided to empty the store. He just threw every single solitary person out of the restaurant, and shut the big glass doors. When the incident was over, there was still a massive crowd, faces pushed up against the glass, desperate for a glance at this poor guy on the ground.

Has anyone else experienced this phenomenon? It's more of a concrete legs than a rubber neck situation, I think. 

As someone who has been part of the mob of medical students turning up unannounced to the bedside of sick patients hundreds of times, I shall continue to take the high moral ground on this issue :D

Apologies for the lack of blogging lately. I'm exceptionally busy in work and real life at the moment, and am likely to be for the next few months. So, please bear with me.

And thanks for the emails reminding me how slack I've been. You're an unforgiving people :D

Dr. Thunder.

Saturday, 14 March 2009

Inefficiencies in the Irish Health Service: The "First Dose".

Posted by Dr. Jane Doe

The ongoing campaign against NCHDs in the Irish health service has recently accused us of "inefficient work practices". Over the next few posts I am going to illustrate some major ineffiencies in the way the health service runs in relation to our job, and the effect this has on patient care. These inefficiencies are not of our making, and are usually stupid, irritating and inefficient ways of doing things that make our job difficult, the nurses job difficult, and the patient's life difficult.

So today, boys and girls, I'm going to talk about a very inefficient and stupid work practice that occurs in every hospital in Ireland, and as far as I am aware, nowhere else in the world.

The First Dose:

In Ireland, for some reason that no-one knows, the first dose of any intravenous medication is required to be given by a doctor. Usually this falls to the intern, or occasionally the SHO. There is no evidence base for this practice. Nowhere else in the Western world has this practice. I have no idea why it exists, nor does anyone else. People stumblingly explain when asked by the frustrated patient waiting for hours that this is "in case you have a reaction" but this is bollocks, as I'll explain in a little bit.

Now, the "first dose" is not limited to antibiotics. Oh no. It can mean first dose intravenous corticosteroids, IV vitamins (such as Pabrinex to treat alcohol withdrawal), IV vitamin K, first dose IV morphine, anything.

And get this. This'll really crack you up. This is just beautiful. Even if the patient has had IV Augmentin 1000 times before on previous admissions, if they get readmitted, the "first dose" principle applies all over again, and only a medic can administer it!

Ah. The flawless logic of our health system astounds me yet again.

So deconstructing this tower of imbecility, I will explain why the "In case you have a reaction" explanation is bogus in extremis. If a patient has an honest to God anaphylactic reaction when I give them an IV medication, what the hell am I going to do? I'm going to put out an emergency call so that the anaesthetist will come and be ready to intubate, and I'm going to give IV antihistamines, IV hydrocortisone, and administer subcutaneous epinephrine,which should be done first, readily available in the form of an EpiPen, or whichever one the hospital has in stock.

Now nurses are allowed to administer subcutaneous meds, and they usually know how to put out the emergency/arrest call faster than the intern/SHO would as they are the ones that usually do it. So the two first, and most important steps, namely 1)calling for help and 2)administering subcut epinephrine do not necessitate a medic at all. Now, if someone other than a doctor was able to administer the IV hydrocortisone and IV antihistamines, say, one of the ward nurses on receipt of a verbal order, then before the emergency team ever got to the patient, most of the treatment would have been instigated and the anaesthetist could then assess the airway etc. and the medic can manage as appropriate thereafter. So the patient would actually get FASTER treatment, and faster is usually better in emergencies.

If a reaction occurs that is NOT anaphylaxis, then the doctor can be bleeped and review the patient as appropriate.

The whole concept of the first dose is mind-bogglingly stupid anyway. The first dose will likely sensitise you to the drug. The next dose might be the one that gets you, if it is going to, in all probability. Or maybe the third. Or fourth. In fact, you have as much chance of having a reaction every time.
Also, the number of cases of reactions to IV medications on the first administration is exceedingly rare. I have never seen one. Nor has any other doc I know. We have occasionally seen angioedema, and very, very rarely anaphylactic shock, but never after a first dose IV med.

In addition, medics are required to make up the first dose IV med before they give it. Now this is where it starts getting dangerous. You see, as it's not really a doctor's job to do this, we obviously don't receive any kind of instruction on it ever. Some drugs are incompatible with normal saline, some are incompatible with dextrose. Some have to be diluted a certain way, some made up under aseptic technique, some vials have to shaken after the solvent is added, some cannot be shaken or the compound will be ineffective.
Some have to be diluted to a certain volume, so that a certain amount can be administered over a certain time. Nurses receive ample training on this. We are not even shown how to put the connecting tube into the bag, or put it through the infusing machine, let alone set it. Occasionally a kind hearted nurse will show you, but the machines change all the time, are different in different hospitals, and in different wards.

Pharmacists know all this stuff. Nurses know all this stuff. Doctors don't have a frigging clue. The majority of this stuff is usually done by the interns, who, having completed 5-6 years of training to know how to prescribe these meds, the indications for doing so, the intended effects, the potential side effects, and long term complications of therapy, now get to use none of that taxpayer funded training as they instead do a job that they were never trained to do and are unfamiliar with.

You tax dollars at good work, people. Once,as an intern, I was called to do anti-TNF alpha infusions. I had never done one before. There was no-one around to show me, so I made it up with the water for injections which the nurse had thoughtfully left out for me. It wasn't dissolving, so I gave it a good firm shaking. As I was doing so, the nurse came in, and turned pale. "STOP SHAKING IT! NEVER shake it! That's about 800euro worth of Remicade gone!"

Also, doctors are not based on one ward. Or even one floor. We have to go everywhere, all the time. Routine administration of IV medications is a bit down the list most of the time, as it is relatively non-urgent. So patients are waiting. Waiting for antibiotics to start to treat their pneumonia. Waiting for IV frusemide to ease their breathing and decrease the swelling in their legs. Waiting for IV hydrocortisone to stop their wheezing. Waiting for IV antiemetics to stop their nausea and vomiting.
They wait, and get uncomfortable and frustrated. So do their families. They get mad, usually at the nurses, whose hands are tied, and they in turn get mad at us for not being there-but we have to be eight other places and what can we do? Nurses hate the first dose malarkey as much as we do, they will, after all, be giving all the other doses, and it does not say much for confidence in their professional training either.

So the above practice has the following implications:

1) Causes unneccessary waiting for patients and resultant discomfort, frustration and suffering.
2) Is a completely inefficient use of a trained doctors' time and contributes to further delays in other patients' treatment. The reason the docs aren't reviewing your new onset pain may well be because they are tied up giving 15 first doses.
3)Is potentially dangerous as the person reconstituting and administering the intravenous medication is not formally trained to do so and is often unfamiliar with the ward equipment.
4)Is not based on logic or evidence, and thus is a completely useless and inefficient hindrance to patient care that should be eliminated without delay.

But will it? Is efficiency and good value for money in the public sector really what we're aiming for? It never seems like it.......

Friday, 13 March 2009

EU may have finally smelled the Irish coffee.

Posted by Dr Jane Doe.

This article is taken from today's Examiner. It is truly remarkable that this issue has taken so long to come to anyone's attention.

"Friday, March 13, 2009

EU to take up issue of junior doctors’ hours
by Ann Cahill, Europe Correspondent

THE European Commission is to take up the issue of punishing hours worked by junior hospital doctors with the Government.

Doctors in training should not work more than 56 hours a week under current EU rules, but a report in December, by the Department of Health, found the 4,800 junior doctors regularly exceeding this, working shifts of 36 hours or longer and no hospital was fully complied with the law.

Dublin Labour MEP Proinsias De Rossa referred this to the EU commission, whose job is to ensure states implement the laws.

The commission responded that they "viewed with concern the report and intend to make contact with the national authorities".

Mr De Rossa said: "This is a very significant development. It is the first indication that the Health Minister Mary Harney is facing the prospect of legal action at EU level, and ultimately EU fines, for refusing to abide by the EU health and safety rules on working time. Incredibly, there are still reports of junior doctors on duty for 36 hour shifts, and sometimes longer."

Dr John Morris, vice president of the Irish Medical Organisation, said non-consultant hospital doctors were the only grade in the health service that work on temporary contracts into their 40s and work shifts of 24, 56 and 72 hours without appropriate breaks. Hours are due to fall to 48 a week from the end of July.

Junior doctors are already in dispute with the HSE having voted overwhelmingly for action over proposed cuts in overtime and allowances. Talks in the Labour Relations Commission broke down when the HSE walked out yesterday."

I would like to draw attention to this particular phrase, which sort of cracks me up a bit. "Incredibly, there are still reports of junior doctors on duty for 36 hour shifts, and sometimes longer."


There is, currently, not ONE hospital in Ireland where this isn't the accepted and normal way of working for NCHDs. Weekends can be split into 26-30 hour shifts between two people IF management sanction this, or they can be a 56 hour straight marathon with no sleep and no scheduled meal breaks. Some even do from Friday morning to Monday morning working, an incredible 72 hour shift. Not week. SHIFT.

NCHDs have no choice in the matter as the overtime is MANDATORY, and it is worded that way in their poxy 6 month contracts that they remain on for years and years on end. When I was an intern I did 56 hour shifts at weekends. Once I was so ill with fatigue by the Monday that, alarmed at the state of me, they decided I should maybe not treat patients, and I was sent instead to do photocopying for the day.

End this madness. And give the patients a safe health service, and the doctors a health service they can provide care in, as opposed to exhausted and half hearted troubleshooting.

Thursday, 5 March 2009

I need to form an opinion. Can anyone help?

Posted by Dr. Thunder.

There's controversy brewing in Ireland. Like many countries, it was decided a while ago to introduce a programme of vaccinations for Irish girls, to help protect against cervical cancer. As most of you will know, there's a jab available that has been shown to be very effective in protecting against the viruses that cause most cases of this disease.

This would be given for free to girls in their early teens.

All was well, and public health/preventative health was back on the agenda.

But then the tough times came along. A load of bankers loaned a load of cash to people with no money, and we were all snookered.
So, as is historically the way of the politician, money was taken away from the population health strategy. They must have already syphoned off  their quota from mental health services for the year.

The long and short of all this is that Irish girls were told they wouldn't be getting the vaccine. Well, they wouldn't be getting it for free. So, the rich would still get it.

But the type of people who are really at risk of cervical cancer would be less likely to be able to afford it.

There was a big fuss about this initially. But, like most public health initiatives, the fallout from the funding cut was short lived.

However, now a group of doctors have announced that they will be administering the vaccine for free to 300 12-year old girls in Dublin this week. Local businessmen have paid for the vaccine itself, and the doctors won't be charging for their time. 

Word on the street is that the administration of the vaccine would have been outsourced to China if the GPs had asked for payment.

This all looks very noble. Fair play to the local businessmen, and fair play to the GPs.

But is it that simple? Possibly not. One of the GPs is a member of the Irish opposition. Dr James Reilly is not just a member of the Fine Gael political party, but he's their health spokesman.

He claims this isn't a political stunt. But in the same breath he says: 

"The fact that the local community, 19 schools, parents associations, teachers, parents, doctors, nurses, and 300 children have indicated their demand for this vaccine should send a loud message to the Minister and this Government and the Minister should take up the baton and continue this programme throughout the country,".

My dilemma lies herein. On the surface, I like this idea. Private business funds overseas aid all the time, so why not give something to Irish people who may not have been able to afford this vaccine.

On the other hand, I'm uneasy because:

A) A politician, and a doctor, seem to be using their patients to make a political point.

B) Let's face it, we are seeing these vaccines being given out because this is a popular cause. It has, and will continue to, attract media attention. Do 12 year old girls need a cervical vaccine right now?? probably not. Could it wait a year or 2 until the country is financially more stable? Yes.
Could we use more counselling/psychotherapy services for the mentally ill? Absoloutely. Would this attract a lot of media attention? Absoloutely not.

Like I said, I'm a fan of this idea on a superficial level. But I also have deep misgivings about it in the context of an overall health startegy.

So, I have decided that, for once in my life, I don't have an opinion that's set in stone. Yet.

Can anyone help me out?

The full story is available at:

Dr. Thunder

Sunday, 1 March 2009

Pink eye for the homeopath guy

Posted by: Dr Thunder

Little Timmy is 7.

He's from a middle class family, and goes to a good school. But he's been ill a few times lately. Mum reports that he's been getting "pink eye" recurrently over the last few months.

Their GP has given them antibacterial eyedrops each time, and has showed them proper "eye toileting", which have cleared it up. But timmy's mother reckons their GP isn't treating the problem properly, because it keeps coming back. I had my doubts, as this GP is known locally as being very reliable. But that's why they ended up in the paediatric emergency department this time. They wanted a "proper opinion" from a paediatrics registrar.

Ironically, their GP used to be a paediatric emergency registrar in our department.

Anyway, I examined the eye, and it looked like pretty straightforward conjunctivitis. So, I took a swab to see if there were any bacteria growing, and sent him off with some antibacterial drops in the meantime.

I phoned Dr. Taylor, their family GP a couple of days later, to tell him that Timmy's swab didn't grow a bacteria. We were talking about the recurrent conjunctivitis, when the GP told me what was actually happening.

One kid in Timmy's class has had conjunctivitis for the last few months. It's an easily treatable condition. But it's HIGHLY contagious. This child's mum doesn't like conventional western medicine. So, she's been bringing him to see a variety of herbalists, and lately he's been going to a homeopath.

Meanwhile, he still has pink eye, and keeps giving it to his classmates. it's just going round in circles.
Dr Taylor is seeing his classmates on a regular basis, and has been giving the correct treatment and advice. But conjunctivitis is difficult to prevent when the "index case" is being treated with magic water.

His mum has told one of the other parents that she's using a homeopathic remedy called "Argentum Nitricum". I cannot find any studies that suggest it works. But, ya know, you don't have to bother with that kind of legwork if it's "alternative" medicine. 

The GP is going to talk to the teacher, and ask her to try to persuade them to get the kid to a doctor, as I'm  little unsure about the long term effects of untreated conjunctivitis. All this really needs is good cleaning, as it appears to be viral in nature. I've suggested the school ask parents to keep children with conjunctivitis at home.

This is likely to be the only thing that will make the index case's mum get proper medical treatment, as having a kid at home with pink eye is likely to affect her coffee morning attendance abilities.

Cases like this make me mad. People have a right to shun conventional medicine. But surely seeing half the class walking around with inflammed eyes would guilt any reasonable person into getting proper treatment.

I need to go and calm down I think. Now where did I put that herbal tea?........

Dr Thunder.

Tuesday, 24 February 2009

Spin Doctors are expensive!

The front pages of several papers today state that the HSE spent a staggering 51 million euros on SPIN DOCTORS!!!!

I hope they mean the band. They're not great or anything, I find that one song I do know very annoying, but quite frankly it would make more sense. And it would be marginally more entertaining.

So we're slashing frontline staff and services left right and centre-and paying spin doctors money to make it sound like it's all a good thing when if we didn't pay the spin doctors we wouldn't have to slash a lot of the services and this would actually in reality be a better thing and...and......I've gone cross eyed.

Just when you think you've seen it all. You, you know, see some more. And stuff.

Dr. Jane Doe

Friday, 13 February 2009

I believe the kids call it a "facepalm"

A facepalm, as pictured above, pretty accurately describes what I did when I heard the news last night.

Mary Harney, the Irish minister for health, has announced the formation of a committee to look at ways of reducing clinical mistakes in hospitals. This will be a panel of experts who will get together and publish a report in 18 months time, apparently.

Incidentally, there is also a "commission on patient safety" in existence in Ireland, whose role would appear to be the same as that given to this new committee. However, the commission recommended the setting up of this new panel back in July 2008. The minister announced it's formation yesterday. Indeed.

But this was what got me. Harney, in her distress at the interminable suffering over the practice of shoddy medicine by Irish hospital staff, admitted she had no figures for medical errors in Ireland. But she does know that "Medical claims were costing the state 60 million euro every year" and that the aim of the process was to "reduce adverse events in the health service, and to reduce litigation". So, eh.....seeing as you admit to not having any statistics for medical errors (despite setting up 2 expert panels to combat the "problem") how are you going to know if your new committee is having an effect, Ms Harney????

Now, Minister, I'm no economist. And I'm no risk analyst. But, and apologies for the bold capitals, I have a suggestion for you, if you want to reduce medical errors in hospitals..................


I'm glad I got that off my chest. I'll be here all week. I'm also available for Barmitzvas and public policy.

Dr. Thunder.

Wednesday, 11 February 2009

The Spin Doctors Against Doctors.

Posted by: Dr Jane Doe.

"If you, would like to call me lazy, just go ahead now. And if you, would like to call me greedy, just go ahead now."

The HSE is targeting the most vulnerable group in the health service for extreme cutbacks currently, and disproportionately compared to the cuts being proposed elsewhere.
Among the cuts being proposed are:

• Mandatory 1 hour unpaid meal break
• Suspension of Training Grant and PGMDB Allowance
• Discontinuation of Higher Degree and Diploma Allowance
• Attendance at in-house training no longer paid
• Discontinuation of Living Out Allowance
• Introduction of mandatory unpaid Pre call/Post call
• Overtime payment: Monday to Saturday
• First 9 hours paid at flat time
• Balance of hours T + ¼
• Sunday & Public Holidays T x 2

In addition the HSE is aiming to introduce the following measures:
• Rosters formulated 8am to 8pm
• Hospitals to examine and eliminate unnecessary layers of on-call
• Maximisation of on call off site where feasible
• Cross cover across different specialities to be maximised
• Full roll out of successfully concluded NIG pilots
• Interns employed on 48 hour week from 1 July 2009

In addition to these cuts specifically aimed at NCHDs, as public servants you will also be subject to the Government’s proposed pension levy which will result in between a 6.4% and 8.5% deduction from your overall salary. (I might add that, although the pension levy that NCHDs pay is based on their income PLUS overtime-ie if you make 60K a year you will pay the proportionate levy-the pension NCHDs will accrue is based only on their BASIC pay. Food for thought, no?)

Before the recession hit Ireland NCHDs (Non Consultant Hospital Doctors-ie; interns, Senior House Officers, registrars and Specialist registrars, often called junior doctors despite the fact that many of them are in their forties!) enjoyed wonderful working conditions. Ah the Celtic Tiger. Truly a golden age.


The Famous Overtime Pay!

We worked anywhere from 60-120 hours per week. Our hourly rate was about ten euro less per hour than a primary school teacher. We did weekends “on call” which is a silly and grossly misunderstood euphemism for just plain old working, that lasted anywhere from 56 to 72 hours straight-with NO SLEEP BREAKS OR MEAL BREAKS SCHEDULED.
Our so called public service “job security” consisted of having to reapply for jobs and do interviews all around the country every six months to a year, indefinitely. We were shifted from hospital to hospital every three to six months, often in different parts of the country working with a whole new set of people and having to get used to a new hospital. We weren’t given so much as a day off to move house if we were rotated from say, Galway to Dublin, and many NCHDs moved themselves, their possessions and their families to new locations overnight and started a new job the next morning after pulling a change of clothes and their stethoscopes out of the boxes in the hall.

If we became sick while in the middle of a shift that could last anywhere from 32 to 72 hours then we had to keep working. If we were vomiting, had diarrhoea, had a high temperature, whatever. We had to keep working. If you became ill during the office hours of HR and management (9-5 Monday to Friday) then if you informed them they would often get angry with you, following which they would try and bully one of your colleagues to work the “on call” shift instead. Before even attempting to get a locum sometimes. The “on call” shift means that the person, who started work at 8 or 9 in the morning, has to stay on and keep working continuously all day, all night, and then resume their normal duties again the next day as though they hadn’t just been up all night working after working a full day too. 32 hour long shift-minimum. Usually it was more because one was so much slower at everything after already having done 24 hours straight with no sleep.

When we worked weekends, we worked all the next week too. In many hospitals around the country this meant that we came in on Saturday morning to work, and worked until Monday evening. No scheduled sleep break. No scheduled meal break. Even if you dared to have a shower you kept a nervous eye on your bleep. Often for most of this 72 hour shift we were continuously awake, and unfit to drive home on Monday evening. Following this marathon of insanity, we came back to work, bright and early, on Tuesday morning and continued working the week. Often there was another 32 shift ahead of us that week.

Yes, we were paid overtime at rates determined by the Labour Court. Time and a quarter for the first 15 hours after one went over 39 hours in the week, then time and a half thereafter. So after you had worked 39 hours, from hour 39 to hour 54 you were paid time and a quarter. From hour 54 onwards you were paid time and a half.
The Irish media has made quite the sensation of this. However, they forgot one teensy, weensy leetle detail.



The above working conditions have not changed and are still in practice all over the country.

There is currently, in Ireland, not one single NCHD who wouldn’t gladly take a pay cut in exchange for a reduction in working hours that would ensure adequate staffing and not compromise patient care. I for one would gladly never ever work another 32 hour shift with no sleep, if I could work a 40 hour week and be paid my basic wage. But, and this is the really big but, these OVERTIME HOURS ARE MANDATORY AND IT IS A BREACH OF CONTRACT TO REFUSE TO WORK THEM. We are contractually obligated to work an unspecified number (ie. however much they tell you to) of hours of overtime in addition to the normal 39 hour week. In addition, were we to all work only 48 hours a week, with the current staffing levels, patients would suffer and patient care would deteriorate drastically.

When the media runs these sensational headlines “Junior Doctor in Wherever Earns 100K in Overtime” they don’t seem to mention what the junior doctor was obligated to do to be paid that wage. This amount of overtime means that this doctor was working approx 120 hours a week, and was a registrar or an SpR. This means that he/she was doing 56-72 hour shifts with no sleep breaks at weekends and doing them every second or third weekend. This means that this doctor was chronically exhausted, never saw his/her family, drove a car and endangered their lives and the lives of others on the road while under the influence of severe fatigue. This means that the patients that he/she was treating were being treated by a medical professional who was so tired that their decision making abilities were akin to those of a person who was over the legal limit.

Personally, the unpaid days off pre and post call that the HSE are proposing sound almost humane to me. A 32-36 hour shift with no sleep or meal breaks will become a 16-24 hour shift instead. This is still insane, but more humane. And less dangerous. They will run into problems staffing the wards during the day, to be sure, if several people are off for two days because of a night on call. But overall, it will be preferable. For us.

The working conditions BEFORE the above proposals were already so bad that Irish trained doctors have been emigrating in the hundreds to Australia, New Zealand, the UK, USA and Canada. At earlier and earlier stages in their careers. Making the conditions worse is going to cause a torrential haemorrhage of doctors the like of which will not have been seen since the eighties.

The Mathematics of Overtime:

It often surprises me that people would become incensed by the thought of someone working 100 hours a week and getting paid for them. The fact remains that if ANYONE worked 100 hours a week doing whatever it is that they do and was paid for them, they would make a lot of money. Hell, if you were paid minimum wage, 8.65 per hour, and worked a 110 hour week like a surgical registrar on some crappy rota somewhere with no locum cover who never gets to see his/her family, you would make 951.50 that week. That’s 4281.75 per month. So if you make 20 euro an hour, then you come out with 9900 per month before tax. This is taxed at the high rate, so I don’t know, you probably get a lot less after, but still.

You see my point. If this junior doc with his 100k worked a 40 hour week instead of a 100 hour one, his salary would be nothing to write home about. If my buddy the primary teacher worked 110 hours a week, they would make 3630 per week gross as they’re on a higher hourly rate than an NCHD.

When NCHDs work a 40 hour week and get 100k, then that will be newsworthy. When they work 100 plus hours a week and get 100k that’s called basic mathematics. (If they worked 100 hours a week and got 40k this would also be newsworthy, as it would mean that registrar doctors in Ireland were paid approx 7 euro per hour, and this would be gross exploitation).

I’m not sure how the HSE thought that this spin was going to get the public on their side. Only an idiot would not be able to do the math here. (I used the calculator on my phone, but you take my point!) No matter how many stories they run about NCHDs working illegal unsafe hours being paid for those hours, they aren’t fooling anyone anymore. Maybe they should hire more doctors and divide our hours equally. Hmmm?

The Training Grant-and by extension, the training:

Being an NCHD in Ireland is an expensive business. One pays the Medical Council about 400-500 euro per year to stay on the register. The training grant does not cover this. Medical Indemnity insurance costs another couple of hundred euro, again out of your own pocket.

Things that the grant will cover:

To register your GPT-that is your General Professional Training, now changed to BST (Basic Specialist Training) which everyone has to register in order for their training to be accredited, it costs 2000 euro PER YEAR currently.

To register and pay for you training on the Surgical SHO scheme is currently 3200 per year. The scheme is two years long totalling 6400 euro just to do the scheme. This doesn’t pay for your exams.

The ACLS (Advanced Cardiac Life Support) course is mandatory for all medics working in an Irish hospital and must be redone every two years by every doctor. This course teaches basics like effective CPR, intubation and ventilation skills, defibrillation, and recognising abnormal cardiac rhythms and how to treat them. It costs 550 euro currently.

The equivalent for paediatric doctors is the PALS course (or APLS I believe it’s called elsewhere). Again, 550 euro, and an absolute requirement for work.

ATLS (Advanced Trauma Life Support) aimed at Accident and Emergency doctors-this one may even be more expensive than the ACLS or PALS as it takes longer.

Basic Surgical Skills courses can run from 500 upwards and teach trainee surgeons basics like suturing and operating skills.

The Royal College Membership exams (MRCPs) for General Medicine, Pathology, Psychiatry, Obstetrics and Paediatrics are requirements, respectively, for entry to specialist training schemes to train up the consultants of the future. The memberships have three parts, and each part costs 590 euro currently. So 1770euro to get these exams assuming you pass them all the first time. Which no-one does, believe me.

Prep courses for the membership exams cost 1000-2000 each sometimes. Particularly for the practical parts of the exams, they are vital.

The ACLS and PALS etc, are always on weekends, and hence one must often use one of the only weekends one is not on call in a month to do these courses.

Axing the training grant is, um, not such a hot idea. Doctors who don’t have the ACLS are probably not going to resuscitate you or your relatives properly. Or if the A&E doc didn’t do the ATLS, then all those RTAs wheeled in after hours are in serious trouble. Lack of doctors progressing through the ranks having obtained their membership exams means less staff at senior registrar and SpR level, and these are the most senior doctors in the hospital after hours, and the most knowledgeable.
Deskilling of the steadily decreasing pool of frontline medical staff is about as intelligent as raising taxes and decreasing incomes during a recession. Oh wait, it’s the same crowd as what done the recession in the first place.

Mandatory Unpaid One Hour Long Lunchbreaks:

HAHAHAHAHAHA! NCHDs getting LUNCH BREAKS? Okay. When did we EVER get LUNCH BREAKS? What planet are these people on? I know they probably think this would be awesome spin fodder, eg: “Fatcat overpaid junior doctors paid to just sit around eating”, but the public aren’t that stupid for heaven’s sake. There’s just no spin value to get out of this one, lads. Sorr-ree.

NCHDs carry their bleeps at all times and are available to work at all times when on duty. If you are called you have to go. None of us sit down to a nice lunch and coffee every day, or even ANY day. In addition, you can’t leave hospital grounds. Others can go to the bank or post office at lunch. Not us.

I remember many times eating a Snickers going down the hall and this served as my lunch and kept me until about 10pm when I might get a sandwich out of a vending machine and eat it with one hand while writing up an admission with the other.
I guess what they must want is for us to hand our bleeps en masse in to reception and head off downtown for lunch or for a nice hot meal in the hospital cafeteria. Cool! I’m down with that. As long as whoever has the bleep can handle the situations they are bleeped for. But wait! If all the NCHDs are on their (snigger) lunch break, then who will take care of the patients. Or are we not caring about that anymore because there’s a recession?

I suppose there could be staggered lunch breaks, but if they’re staggered then they sure can’t be a whole hour long. Otherwise you will have people going on their (chortle) lunch breaks at 4 and 5pm and such.

If the HSE would bother to engage with NCHDs and try to compromise then they might find that we are willing to help them devise rosters that decrease hours and consequently, overtime and still ensure enough staff are on at any given time to keep patients safe. They might find that we might be willing to limit the training grant to course fees and exam fees only, and forgo the one off laptop and equipment grant. They might even find that we might be willing to agree to a pay freeze. There are lots of ways we could help them to make savings, if we were to work together. In fact, if all health workers came together and we reorganised things a bit, we could still have a reasonable health service. Or maybe I’ve watched one too many Disney films.

But I suppose unilateral imposition of drastic alterations to our contracts without discussion and with lots of spin to try and further their cause is so much more effective. And industrial action and emigration on an EPIC scale of NCHDs trained at the taxpayers’ expense is a much better solution than us all working together to try and make the best of things.