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!"
Shite.

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.......

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 are STILL reports of this, huh? Wow. That's weird. Considering that EVERY SINGLE HOSPITAL IN IRELAND OPERATES ON THE 32-36 HOUR SHIFT BASIS AS A MEANS OF STAFFING THEIR POORLY MANAGED SERVICES!

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.

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:

http://www.irishtimes.com/newspaper/breaking/2009/0302/breaking43.htm

Dr. Thunder

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.