Friday, 5 November 2010

Kudos to you, Mr GP.

Overheard in the supermarket today:

Mildly coryzal staff member: I've had this cold for 4 days now, and it's pissing me off. I went to my GP, and the idiot refused to prescribe antibiotics.

Other staff member: Seriously?? That's awful. You should change doctors.

Mildly coryzal staff member: Oh you better believe I will. I gave him a piece of my mind and told I won't be back to his crappy surgery ever again. He didn't care, though, and pretty much told me it was my perogative.

So, there you go. Props to that unnamed, unsung hero of general practice.

The future MRSA patients of the plant thank you :D

Dr. T

Friday, 29 October 2010


Dear baby Jesus. Why.......

1) do the sickest kids have the most difficult veins?

2) do the the kids with nothing wrong with them have the most anxious parents?

3) do doctors forget all non-bone related medicine as soon as they become orthopaedic surgeons?

4) do the kids with cancer always come from the nicest families?

5) are people not bothered when the doctor looking after their unwell kid has worked more hours than a pilot or lorry driver are legally allowed?

6) do we employ doctors from developing countries, when we know children in their home nations die in their droves for want of medical attention?

7) do the politicians always know better than us when it comes to health policy?

8) do we laugh when a baby pees all over us, but rush to change our clothes when Albert on the geriatric ward does the same thing?

9) do some parents oppose vaccination so strongly, while parents in poorer countries routinely watch their children die of tetanus and pertussis and other preventable diseases?

10) are physiotherapists and occupational therapists so much hotter than the general population?

If you can answer these questions (and any others posted in the comments section), Lord, then I shall return to church :D

Many thanks for your time,

Dr Thunder.

Thursday, 23 September 2010

Long hours? Or a long time training?

I’m not a fan of too much work. Over the years, I’ve done my fair share of long shifts, nights, weekends, public holidays, and combinations of all the above.

I don’t function well when I’m tired and hungry and thirsty. And most patients don’t want to be seen by an overworked, sluggish, grumpy doc whose priority is a bed and some food. Certainly, I wouldn’t have wanted any member of my family to have depended on care from me after working 27 hours straight.

I always thought my colleagues agreed with me. Enough miserable faces on the corridors of the various hospitals I’ve worked in made me feel a collective yearning for better conditions.

I thought, therefore, that there would be widespread endorsement of the European Working Time Directive (EWTD) when it came into force in Ireland and the UK. The EWTD is designed to limit the working hours of doctors within the European Union. Depending on the stage of implementation, it can mean working a maximum of 48-56 hours per week.

Of course, here in Australia, they’ve managed to do that without relying on international law. Down under, the rules for doctors’ hours seem to be enforced on a regional basis. In fact, from what I can gather, the rules seem to be MADE locally too. But, by and large, it works. Sure, I’ve been miserable and tired and hungry working in Oz, but I’ve never had to work 72 hours on the trot, let alone do it on a regular basis, as happens in Ireland.

Forgetting for a moment that the Irish government has decided to simply ignore the EWTD, and continue to make their juniors work ridiculously long hours, I was amazed to learn that there are significant groups of doctors in the UK and Ireland who oppose the implementation of the EWTD.

These doctors argue that registrars, like me, and other junior staff, need to be exposed to lots of cases in order to become proficient consultants. They argue that patients come to harm at the hands of tired doctors, but also from inexperienced seniors.

I can see their point. However, I don’t buy it. I can’t accept that dangerously long hours are the only way, especially when urban Australia manages fine without total burnout of their medical staff. There has to be a middle ground.

My take on the long hours culture is as follows:

1) If we juniors want to reduce our hours then we have to expect it to take longer to become consultants. Everything in medicine is being streamlined these days, and that needs to stop. We need to return to 5/6 year medical degrees, and long apprenticeships as house officers and registrars.

2) A lot of doctors' time is taken up doing admin work that anybody could do (chasing xrays, filling out blood forms, chasing blood results on the computer etc). These tasks should become the work of someone else, so that doctors actually spend their time doctoring. I remember as an intern working out that about 60% of my tasks could be done by a competent member of admin staff.

3) Our training is important. But so are our lives outside medicine. I sympathise with the wannabe surgeon who wants to work all hours, learning how to do craniozygomatic surgery. But, there are those of us who have wives, girlfriends, kids, and a family life. I want to be a good consultant. But I doubt I’ll look back from my deathbed and say “I’m glad I worked so much”.

4) Patients need to do more. Relatives, friends, patients and strangers are almost always sympathetic towards me, regarding the plight of junior doctors. But how many have ever raised the issue with a canvassing politician? I don't expect the public to have our interests forefront in their mind at election time. But this is about patient safety, as much as it is about modern day slavery. As things stand, the politicos and the media often betray us as greedy and as a vested interest group, and very little of that gets refuted.

5) We have to be wiling to take industrial action. End of. I would be very reluctant to do so in oz, as my job is busy, but tolerable. But if a pregnant junior doc in Ireland who is working 48 hours solid, with no scheduled breaks, isn't entitled to strike, then who is. the media would love it. They would betray us as lecherous public servants trying to bleed the state dry. The media and politicians would distort the facts to make us look greedy. But screw them. I bet we could hold out longer being abused by tabloid readers then they could hold out with no doctors. Obviously, I would never advocate withdrawing acute services. But a work-to-rule or skeleton staffing would cause some browning of pants in the corridors of power.

The Australians do a good job of it (well, in the cities they do, their rural healthcare provision can be pretty piss poor). Ireland and the UK should learn from them. Mostly we’re rostered on for a 38 hour week. We do on-call and out of hours, of course. But those shifts tend to be interspersed with good weeks, where we can catch up with friends and family This is not the case in Ireland and the UK.

I know from experience that some Ozzies will post comments here telling me that they work terrible hours too. And of course that can be true. I once did a paeds emergency medicine job here where my partner was getting seriously worried about my health. I was literally exhausted all the time. I was grumpy, and never seemed to have any joy in my life. That’s not the way to live. And it’s not the frame of mind I want the doctor in when I bring my sick kid to see them.

I know everyone is an expert when it comes to public sector reform. Just look at the comments section of any newspaper article or blog on the issue. So I’ll keep my ideas about system change to myself. But Ireland, the UK and Australia need to wake up to this issue. More complex issues have been dealt with in the history of mankind.

All three countries have started the process of saturating us with medical school graduates. In Ireland and Australia especially, every man and his dog can become a doctor. Of course, there hasn’t been a sufficient expansion in the number of hospital training posts to cope with all these new graduates.

That will have the desired effect of making our young doctors accept crappy conditions, as it’s likely to be the only route to a scarce training post.

Perfect solution, if you’re an administrator or politician. Tough luck if you’re a doctor or patient.

Sadly, doing anything about it is a catch 22 situation. There are those who have tried. But what’s the most common response when you ask local juniors to engage on this issue, and stand up for their rights? Yep, you guessed it....”Sorry, I’m just too tired”.

Wednesday, 8 September 2010

Hi, I'm Dr. Thunder. What's your f*cking name, you little ****?

Maybe I'm getting old. Maybe the kids are getting a bit more ballsy. Maybe it's a bit of both!

This week I've been sworn at more in a single shift than ever before. This was a 10 hour paediatric emergency department stint, and there were 3 "incidents".

Normally a single episode of paediatric-potty-mouth is something you remember for a considerable amount of time, as it's reasonably uncommon. But maybe things are changing.

Episode one: I was putting a drip into an 11 year old. It went in nicely. Job done. Poor guy was a bit traumatised by the experienced, and when he regained his composure he screamed "Jesus fucking Christ, doc, that was fucking painful".

Episode 2: Another drip, this tie in a 9 year old girl. As it was going in, she screamed "SHITTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTTT" continuously. When it was all done, she turned around, with a big happy smile on her face and said "Thank you doctor", and started behaving exactly like a 9 year old girl should.

Episode 3: A teenager who just didn't want to be in the hospital. I came to speak to him, and he just ignored me. I asked his name. Nothing. Not a word. This wasn't unusual teenage behaviour, and it's relatively common. His mother got involved, and napped at him.."TALK TO THE DOCTOR NOW!". In frustration, He shouted "For F*CK sake, my name is Joe*. Happy now????".

You have to laugh, in all honesty. These are scared kids, who are all sick. It's a tough life being an unwell child. But I know I'd have felt an awful lot unwell if I'd sworn at an adult in front of my parents when I was their age!

But, as much as I'm supposed to be disgusted, they were the 3 most amusing interaction of the day :D

*Not his real name, obviously.

Saturday, 28 August 2010

Another GAMSAT snoozefest from the desk of Dr. Thunder.


Yeah I know. I have an unhealthy obsession with GAMSAT. But I'm not just trying to be a bollix. It concerns me that the GAMSAT graduates I've worked with, and the senior GAMSAT course students I've taught, have been, in my opinion, less capable than their tradition course counterparts.

I've expressed that view on here numerous times. Each time the comments section has been filled with people telling me that I'm a dinosaur, and my email fills up with people saying much worse.

So, I decided to have another look through the published evidence to see if I've missed something. Though this entry won't be anything close to a literature review.

For those who have never heard of GAMSAT, it is an admissions test for admissions to medical school. It's used in Australia, Ireland and the UK. Only graduates of other degrees can sit this exam. It tests rational thinking, scientific knowledge and written skills. Looking at sample papers, it's a straight forward enough exam if you put in some work, and have some scientific knowledge. Looking at the message boards on the net, it's pretty obvious that a lot of people are doing very well in this exam after a minimum amount of study. It's also obvious that a lot of entrants to medical school are scoring less in the science section than in the other sections.

Having said that, I'm a great believer in evidence. In fact, it's become an obsession of mine in the last 2 years since I set up a journal club where I work, got involved in published research and did a masters degree with a significant stats component.

But I just can't find the evidence for GAMSAT. It doesn't seem to correlate with med school results, whereas school leaving exams correlate very well (in the UK where this type of study has been conducted).
I also read another study showing that GPA in a previous degree is a better indicator of med school performance than GAMSAT.
Yet another study shows applicant selected by their GAMSAT results are less empathetic than those who enter via the traditional route.
Then there's the study showing that GAMSAT grads are much more confident in their knowledge of cancer medicine than their tradition counterparts, but they actually know less.

I didn't leave anything out in my search. I assumed there was a sentinel GAMSAT paper, on which the widespread adoption of this exam was based. But I couldn't find it. That doesn't mean it doesn't exists, as I used Pubmed, which is a relatively new plaything for me.

I have to say that all the above rings through with me and a lot of my colleagues. I find GAMSAT grads and students to be extremely confident, regardless of how little they know. I have also long said that they have less empathy than I would have hoped. They themselves tell me the opposite is true, but I have yet to see this in practice.

That is, of course, not to say they're all bad. I've worked with some fantastic GAMSAT grads and students, who will go on to be much better doctors than me.

But I'd like to see a more evidence-based approach to med school applications. Does a degree really give people more "life experience"? I did a degree before med school. But I got more life experience outside of that....playing in bands, being involved in martial arts/boxing clubs, being involved in charities, being ill, being in relationships, summer jobs and my life in general. I don't think a few extra years studying and going on the piss has given me any more life experience.

We're also often told that their extra knowledge of other fields is an asset to medicine. Sure, a recent resident of mine was a previous IT grad, so he could fix the computer when it went down, and we were able to access blood results again. But his 3 years at uni studying computers will mean he spends 3 years less as a paediatric consultant, which would have been more useful to the world in general.

Some of the unis are telling us that their GAMSAT grads are getting higher marks than the youngsters. Maybe they are. But when the traditional entrants reach their age, they'll know a shed load more medicine.

It seems that GAMSAT was actually brought in to widen access to medicine. I think that's fair enough, if we're trying to widen access for ethnic minorities for example. But trying to widen access A) Should not include widening access to people who aren't as bright as they should be to get in and B) Shouldn't happen at the expense of producing quality doctors.

I can't see how it widens access based on socio-economic status, as it requires incurring the extra debt of two university courses. GAMSAT courses in Ireland, in particular, involve course fees of about 100,000 euro.

In Ireland, too, it has had the effect of restricting the expansion of places to those completing secondary school. Those kids work their asses off during their teenage years, while everyone else is pissing about, getting drunk and trying in vain to get laid. It takes a lot of discipline and focus to give up your high school years and hit the books. You've got to be bright, focussed and a bloody hard worker to do it. I want to see more of these people in medical school, not people who blitzed GAMSAT because they have a biomedical sciences degree.

I expect my email inbox to fill up again. But I can cope with that. I'm just hoping one of the emailers might tell me why I should support GAMSAT. I'm not closed minded. We tell students that evidence is so important in medicine. I just want to see us live by our own rules.

Dr. Thunder.

Friday, 6 August 2010

Who remembers their first emergency call?

I think experience hardens us all. Nowadays, when I hear the emergency pager go off I stay pretty calm, and I know what has to be done. I know I have the skills to offer a high standard of care, and I know that I have a world class ICU in the same building to help out.

But this sure as hell wasn't the case when I was an intern. On the nightshift, having only been a doctor for 5 days, the emergency beeper went off. This doesn't necessarily mean a cardiac arrest. It can just mean that a patient is heading for one if something isn't done quickly. Much of a muchness for a scared junior doctor, though.

I heard the odd noise, and realised it was the red bleeper attached to my belt. The one I'd hoped might never go off. "222 ward 12" the screen read. When you get the location of an emergency as an intern, your first thought is "I hope I'm far enough away from this so that someone else gets there before me".

I was on ward 11 at the time. Next door. Dammit.

Anyway, no time to dilly dally. I strode into ward 11, trying my best to look confident as I walked over to the group of nurses surrounding a very very pale looking man in his 70s, who was desperately struggling for breath.

medical school just hadn't prepared me for this. What the hell was wrong with this guy?? I knew a whole load of causes of breathlessness. But he was going downhill quickly, and I didn't have time to do a "medical school" history and examination. You know the ones I'm talking about...the examinations where you listen for renal artery bruits and ask about hobbies in the social history.

First thing I decided to do was speak to him, and try to reassure him. But I couldn't. At least I couldn't get his name right. I kept mispronouncing his relatively simple name. I just got tongue tied. Needless to say, this inspired a world of confidence in me.

Why aren't the rest of the arrest team here yet?

I started some nebulisers, and asked the nurse to give him some intravenous steroids. Of course, his cannula wasn't working any more, so I had to put one in. My hands were shaking. My success with inserting drips was patchy at best. But I'd never been under this kind of pressure. I couldn't see a vein anywhere. So, I just rammed the needle into the part of his antecubital fossa where I knew there should be one! Thank god it worked.

But he was still struggling. And I wasn't really sure what to do next.

SURELY the team must be on the way. This guy needs aminophylline and ICU and central lines!!!! And we should probably intubate too!!!!

With that, my Registrar and Senior House Officer (SHO) burst in. Looking at their sweaty, shaking, stammering intern they must have thought something awful was going on. But as I recounted the story, and the SHO examined the patient the registrar said "Ah, he'll be fine. Just keep going with the nebulisers, we'll get a portable chest x-ray, do a blood gas and ring me with the results. That was a nice easy one for your first emergency. Well done, kiddo".

A nice easy one!?! Surely it doesn't get worse than this??

Then the ICU registrar turned up, to see if we needed him. My Registrar said "Nah, it's nothing major. No need for you to be involved".

So, there I was, living an event that will always stay with me. Yet it was "Nothing major" and "a nice easy one" all at once.

To be fair, the registrar was right. In terms of what I deal with in neonatal ICU or in paeds ED, it's not much. But it was one of the scariest experiences of my career.

So, was it just me? Or did anyone else loose half their circulating volume in sweat at their first emergency, and feign a stroke with their inability to speak?

Dr Thunder

Saturday, 3 July 2010

Dr Under (the weather)

Wow, April 2nd was the last post on this blog!

I've been out of action for a long time, and time has flown.

I was actually sick. I was on the other side of the fence, which is why I haven't been up to posting. I won't go into details of my medical condition, as it potentially makes me identifiable, but suffice to say I had pretty big surgery.

I'm well on my way back to greatness now, though!

It's taken several months to get back to some reasonable level of activity. But I'm almost there. I'm back running and cycling (though not much further than 2.5km in any given day). I'm also back to martial arts training, and I'm slowly getting back into boxing. Mind you, with my current fitness levels, 12 year olds are knocking me black and blue in the ring.

But it's all part of the process, and hopefully I'll be back to normal in a month or 2.

But I have to admit it's odd being on the other side of the doctor-patient relationship. Even allowing for the fact that the doctors I deal with usually give me some special attention (calls on my mobile after their clinic t have a chat about a result that's just come in, the surgeon phoning my parents back in Ireland to let them know everything was going well while he was taking a quick break during the operation), it's still not nice being a patient.

Waiting rooms are inhumane! I once waited 3 hours in the waiting room, while a clinic was running behind. The chairs are tiny, and the receptionists are cranky.

I once popped in on my way to work to leave a urine sample into the clinic for a dipstick. The nurse asked me to wait "a few minutes" while she did the test. So, I waited. And I waited. For an hour and a half! I went looking for her, and she was gone. So I just left. Never did get the result!

But, in fairness, however much we grumble about the health infrastructure, we really are very lucky to be able to get the care that we do. Most of the world's population don't have access to the type of surgery I had, or the support afterwards.

I'd like for this to be a learning experience, which could help me empathise with, and improve conditions for, patients. But, as always, I feel powerless to change anything.

So, the post-script to all this is that I think I have a better understanding of what patients go through. I think I have much more of an appreciation of how lucky we are to have the things we have.

But I don't know what to do with this lesson. All ideas gratefully received.

If there are any readers left, feel free to share your patient experiences in the comments section below.

Dr Thunder.

Friday, 2 April 2010

It's been a busy month in healthcare!

I don't know what to blog about today. So many things have happened since my last post that I don't know where to start. So, why don't we have a little round-up of what's been happening:

1) A large teaching hospital in Dublin (Tallaght Hospital) has been found to have 57000 x-rays lying around, that were never reviewed by consultant radiologists. Pretty shocking stuff. Luckily only 2 patients ran into trouble because of it (I believe), though that will be no consolation to those patients and their families. This is a direct result of the lack of staff in the Irish healthcare system. In many countries it would have brought down the government. But in good old Ireland, our trusty health minister, Mary Harney, continued her holiday to New Zealand when the scandal broke!!!

I wonder did she catch up with any of the thousands of disgruntled Irish doctors and nurses working there, while she was visiting.

2) In the same hospital where X-rays don't get read, it seems that GP referral letters don't get read, or even opened, either. 3500 letters were found to be unopened in the admin offices at this large hospital. These would be letters sent by GPs to consultants, asking them to see patients. The request could be for something minor, or it could be on suspicion of a life-threatening illness.

Did this, on top of the x-ray scandal, bring Mary Harney back from her tax-payer funded holiday? No way! Why come back and provide leadership, when there are junior members of government to take the heat for you.

3) Irish doctors and nurses unions have been in negotiations with the government over terms and conditions: GREAT!!! Does this mean they're discussing 24, 36, 48 and 72-hour shifts? Does it mean that they were going to try and make medicine safer for staff and patients by dealing with the dangerous working conditions that are the norm in Irish hospitals??

Nope. They're negotiating so that frontline healthcare professionals don't have to pay extra to keep the health sector running over the next few years. Basically, the Irish economy is screwed. It's on it's last legs.
So the government didn't have enough money to keep the public sector running over the coming year. They needed extra money, and fast. Most able-minded people assumed there would be a levy of sorts, where the population is charged extra, based on their ability to pay. This would make sense, as we all use the public sector, and we should all pay to keep it running.

But no. The government decided that those who work in the public sector should pay the shortfall to keep the pubic sector running. So, doctors, nurses, unskilled labourers, office workers, police officers,teachers etc all had to take a paycut to keep their sectors running. Despite the fact that we don't use the public sector any more than anyone else, we had to pay for it. Despite the fact that junior doctors around the country are working ridiculous hours for free in order to prop up the failing health service, they were hit with a paycut to pay for the same health service that routinely screws them over.

Of course, the public love it, as most of them work in the private sector, and can't see why the public sector workers are upset about all of this. Sure, the economic conditions have dictated that private sector pay has been reduced in many cases, and profits are down. But the only people taking paycuts for the benefit of the country are those who serve the public. The private sector have taken cuts to keep their businesses afloat, or to maintain their bosses' profit margins.

Truly bizarre. But it's a about upsetting as few people as possible, and that strategy has been successful.

Meanwhile in Australia, things are going pretty well for me. My training budget remains, and I can go to conferences and meetings. If I stayed in Ireland, I would be unlikely to get any meaningful training. I fact, some Irish hospitals are making junior doctors work extra hours for free, and calling it "training". In contrast, I get paid for all my hours over here.

It's now been over a year since i worked a 24 hour shift. Yet my Irish colleagues, including pregnant women, are doing even longer shifts on a regular basis.

I'm very happy in Australia right now, but I'd love to go back to Ireland someday. A lot of my colleagues feel the same. And we plan to go back home when things improve.

But I think retirement may come sooner than that!

Dr. Thunder

Saturday, 6 March 2010

The 6 hour wait. This total con is coming soon to an Irish emergency department near you.

Irish emergency departments are stretched to the limit.

The above statement is no surprise to anyone who lives there. Sick people languish on trolleys for days at a time in crowded hospitals all over the country. The health ministry is the poisoned chalice of Irish politics. We've had the same health minister in place for many years, who has succeeded only in pissing off the staff, and improving some select health indices, while ignoring anything that doesn't fit into a succinct soundbite.

Recently, our esteemed minister has realised how spectacularly unsuccessful her tenure has she tried her hand at deliberately misleading the public. Mary Harney told us that things are grannnnnd, as overcrowding in A+E departments has vastly improved, and that it's confined to a few repeat offender hospitals.


I'm currently working in Australia, where we're fed less nonsense. BUT......we have less need to spin the issues over here. We have well staffed emergency departments, where the staff aren't exhausted, and there's senior support easily available. Australian politicians are as disingenuous as their Irish counterparts, if not more. However, they have no need to explain to the population why their elderly relatives are left to fester on uncomfortable corridor trolleys in overcrowded departments. That's because it doesn't happen.

Back in Ireland, however, there are 3 options available to our political elite:

1) Try a quick fix, in the hope of picking up votes in time for the next election.

2) Do something about it. It might take time, it might take money, and it might not win immediate votes. But by looking at health as a problem that will need a consistent approach over time, it will reap benefits for the population.

3) Lie about it. "Problem? What problem?" Ooohhh look.......a penguin!".

Option 1 has been tried. As anyone with a rudimetary grasp of health would have guessed, it didn't work.

Option 2 is, well, we all know that's never been a viable political strategy for politicians who have to get re-elected every few years.

So, option 3 has been tried. Minister Harney seems to have been chilling in her office one random wintry day, just after we'd reached a national record of having 500 patients in A+E departments around the country who needed a bed, but were instead accommodated on trolleys.

"How can I put a spin on this disaster?". "Is there any way I can get a few votes out of this?".

So, she calls in her PR people: "OK guys. I want you to get in touch with all the broadsheets, and tell them that overcrowding is improving. Tell them it's only a problem in a few hospitals. And tell them it doesn't really matter if the elderly lie on hard trolleys for days, as long as they're being treated. And tell the tabloids that a monkey has been seen on the grounds of Beaumont Hospital. That'll distract them from the issue".

"Em, excuse me, minister...." a young upstart in her media division may have said, as his more experienced peers shook their heads in despair...."...But last week we saw more people than ever waiting on trolleys in emergency departments, and hospitals that didn't have overcrowding problems in the past are now struggling to find beds. Oh, and there are studies showing that people are more likely to die or deteriorate if they are left on trolleys i overcrowded departments".

"Well, duhhhhhhhhhhhhh. But do you think that would win me any votes?????".

Obviously, that conversation is a figment of my imagination. But it beggars belief how one politician can spout so much nonsense, unchecked by her department.

It's a given that politicians in Ireland are not the people we look to for guidance during tough times. We simply hope that we can survive, despite their interference. I had hoped that we could turn to our professional bodies at times like this. I had hoped they would lobby the health department, and to try and push the minister in the right direction.

But sadly, this hasn't been the case.

In a letter to the Irish Times recently, the president of the Irish Association for Emergency medicine wrote that the NHS in the UK had abolished overcrowding in their emergency departments. The letter can be viewed at

The same consultant went on radio recently, espousing the virtues of the UK system, and claiming the problem was "eradicated" by 2005.

Now, I was working in acute medicine in the NHS in 2005, and the "eradication" of overcrowding is a crock of balls.Yet this is what our senior emergency doctors are pushing for. The British model involved telling the population that they will no longer wait more than 4 hours for a bed when they attend an emergency department. Anyone who works in the UK knows this is rubbish. This was classic Labour party spin, and nothing more.

Sure, the stats say that 98% of people get seen within 4 hours. But that means very little. You might see a nurse practitioner, rather than a doctor. You might have the wheels removed from your trolley, so you now technically have a bed. You might get moved to a different corner of the emergency department, which is called "a ward". You would not believe the strokes that get pulled in effort to convince the British public that the 4 hour waiting period has been a success.

This strategy won't work without extra resources. You can't just announce tomorrow that all patients must now be seen and admitted within 6 hours, without providing new resources. We need more staff to see these patients. We need more nursing home beds for the 1000 inpatients who no longer require treatment in acute hospitals, but just can't be sent home safely.
We need expensive scanners being used out-of-hours, rather than sitting idle for 16 hours a day. People should not be in hospital for days, awaiting only the results of a scan. They should not be in an acute bed, waiting for a nursing home bed to open. And the exhausted staff shouldn't be lumped with more useless targets, without the resources to help them. We already have Irish doctors working up to 48 hours straight, so how are we going to work them harder??

This is all about resources. It's not about targets, and bullying and demoralising staff any more than they already are. But it won't be a quick fix. It may not win votes in the next election. Or the election after that.

Is someone going to step up to the plate and take this bull by the horns? Sadly, this doesn't look likely in Ireland. So, for the forseeable future, those who can afford it will buy health insurance. Those who can't will suffer poorer health. And those who are trained to work in the system will emigrate to Australia.

Dr. Thunder

Wednesday, 10 February 2010

"The internet has improved the public's access to quality health information." Discuss.

I heard a mother talking abut the MMR vaccine the other day. She said her first baby had it "because we didn't have the internet back then". But her subsequent children didn't, due to the "autism risk". Now that the Lancet have officially retracted the infamous Wakefield MMR paper, she says her children will be vaccinated in the near future.

She regards this decision-making process as empowerment. And she's not alone. All over the world, patients come to see their doctor with reams of internet print outs. They say things like "I know what the diagnosis is, so can you write me a prescription for drug X".

Undoubtedly, the internet has helped some people improve their healthcare. There are fora all over the web, where people with troublesome symptoms share stories of their eventual diagnosis, so others may prompt their GP or specialist to think about a similar diagnosis for them. The internet helps people compare GPs, hospitals and health tips. It's a source of support for those having children, or helping a loved one through serious illness. The internet definitely has its uses.

But then there's the flipside. The sheer volume of information out there means the quality information gets lost in a sea of nonsense. Recently I was searching for some good info on thimerosal for a friend, who was worried about its inclusion in the swine flu vaccine. Googling "thimerosal" threw up pages and pages of conspiracy theories. Big pharma was supposedly trying to engineer a pandemic in order to profit off vaccine sales. The Americans were using the vaccine as a vector for microchips, which would be used to monitor the more troublesome members of society. And if you got the swine flu vaccine you'd join the ranks of those who went before you, in an early grave.

This is, of course, the more extreme end of the spectrum. More worrying to anyone with a medical degree, are the amount of people who regard themselves as being well informed because they have delved further than the conspiracy websites. These people have......READ JOURNAL ARTICLES!!!!

The mother I mentioned in the first paragraph told me she has "read many journal articles about MMR and autism" and went on to tell me about some of them. Now, anyone who has ever been on the receiving end of this type of scientific discussion will know that, on the internet, any concept of study quality, p-values, confidence intervals or basic study design go out the window, head first. There's no mention of the hierarchy of evidence and not a hope of comparing it to the existing literature.

I'm not having a go at these people. I don't blame them for wanting to be informed. But my worry is that so many folk think they are highly informed about whatever drug they want, or whatever disease they may have. When the reality is they have just blindly accepted what's been written on the net by a stranger, rather than blindingly accepting what their doctor says. Is this really progress?

I've been a doc for about 7 years, and I don't regard myself as fully informed on a lot of the stuff that's waved in front of me. But I do have the ability to judge evidence, and to ask the right questions, as opposed to just accept something as fact because of the eloquent prose.

If I could get one message across to the public it is that just because something is a paper in a scientific journal does not mean we should take it as fact. Many (probably most) published papers don't give us "the answer". They give us a step in the right direction. Or the wrong direction in the case of the Wakefield paper.

I think the best thing any member of the public could do in order to become more informed about their healthcare is to pick up an old style paper book on stats.

As my old prof used to say.."If you haven't asked yourself 'how might this author be lying to me?', then you haven't read the paper".

Dr. Thunder

Friday, 29 January 2010

I feel pretty useless right now. Mary Harney should feel the same.

As the title says, I feel pretty useless at the moment.

I've been contacted by a friend of a friend in Ireland. Her baby has an agonising condition, and needs to see an Ear, Nose and Throat surgeon to have it treated. It's an easily fixable condition. Science has seen to that.

But science hasn't found a way to shorten hospital waiting lists for children in my home country. Sadly, we depend on our politicians for that, and they've been found wanting.
This family have been told their 10 month old baby will have to wait roughly 2 years just for an initial appointment.

Then they'll have to get scheduled for any procedure that the child needs, which will take another few moths.

This baby will be a 3 year old child by the time he gets sorted out.

They've contacted me in the hope I can do something. I'm a paediatrician, and I'm from Ireland. Surely I can do something to help...can't I?
They can't go private, as they're on social welfare. It costs almost 200 euros for each private visit, and that's before any surgery has to be paid for. Private care is not an option for these people. They rely on the state.
But there's nothing I can do. I don't know anyone at their local hospital. I've told them I'll have a think about it. But I know I'm just delaying the conversation where i tell them I can't help.

As well as feeling pretty low about the plight of this baby, I feel somewhat embarrassed to be associated (albeit pretty distantly) to a service where babies are given worse healthcare than many animals would receive. I'm reasonably sure that a pet owner or a farmer would find themselves in trouble with the law if they left an animal in pain for 2 years.

Mary Harney is the Minister for health in ireland. Rather ironically, when we consider how many cutbacks have been foisted upon the sick children of Ireland, she is actually the Minister for Health and Children.

I wonder if she feels embarrassed like me. I wonder if she's had trouble sleeping, thinking about these kids in pain, like I have.

Or will she continue to claim that Irish hospitals are failing because of the inefficiency of the staff?

I suspect we all know the answer.

Working in Australia, I'd forgotten about these problems. I'm amazed at the third world healthcare available to those without health insurance in ireland. I'm doubly amazed that the current minister has kept her job for the last 6 years.

I guess this blog entry is just a rant because I feel useless. I don't have answers right now. I don't know how to help this kid. I don't know how to help the hordes of other children in the same situation

I'm not paid to have the answers, though. But I guess I wouldn't be as worried if I thought our political masters genuinely cared. Because anyone who gives a damn about people would do everything in their power to make sure nothing like this happens on their watch.

I'm sorry this isn't well written. I'm sorry it's all over the place. I'm sorry it doesn't flow well.

But mostly I'm sorry I can't do anything to help this kid.

Dr. Thunder.

Friday, 22 January 2010

Before considering medicine as a career......

......have a look at this anonymous post from an Irish junior doctor:

The link is to a post in the health sciences section of a popular Irish discussion forum.

While I think the doc in question has it worse than most, it's an interesting read for those thinking of going down the medical career path. Note the number of responses from other doctors, sharing stories of bullying. I think this is one of medicine's most shameful secrets.

One piece of advice I would give prospective medical students is that you need very very thick skin to be a doctor. I've never had the problems with consultants that the poster in the link had. I've had my share of bollockings, and I worked with a surgeon for 6 months who did, by all industry standards :P, bully me for the duration of the job.

I think I've been lucky, insofar as paeds attracts a type of doctor who's usually patient and caring. But bullying and abuse are most definitely part of the junior doctor package. Senior docs can give quite a lot of abuse (Ireland seems to be worse than anywhere for this...I didn't notice much bullying in Oz or New Zealand), nurses can be very harsh on junior docs (I found Australia and the UK pretty bad for this). Even admin have screamed at me in my time. It might be controversial to say this, but if you are female and from an ethnic minority, you are likely to get it in the neck more often than most (In my experience). But very few juniors get spared.

The standard response from prospective students when you tell them about this issue is:

A) But I know I'll love medicine, so I don't care about the other stuff.

B) I'm going to find it hard to hold my tongue.

Well, I've never met a doc who doesn't care about their working conditions. You spend most of your life in the hospital, and it's important to have a nice atmosphere. All the idealistic stuff doesn't play such a big part in your thinking once you're used to it. But how you spend up tp 14 hours of your day will always be important.
As for holding your's not that hard actually, wen you're embarrassed in front of a crowd of people, and your competence (which most junior docs have doubts about at the best of times) is called into question.

I found that, until I was a registrar, it was open season on me. Anyone in the hospital would speak to me in any manner they choose. I remember what it was like. So, when the nurses on my ward ganged up on a young resident recently, I took them aside and told them to leave her alone or I'd report them all. Just like when my consultant heard about a consultant radiologist who tore up my request form in a rage, and threw it at me..he rang the guy there and then, and told him never to treat me like that again.

I think we all need to stick together. I think senior docs have to watch the backs of the juniors more than they do. If I was advising the guy in the post above, I'd tell him to come to Oz or New Zealand until he's senior enough to defend himself.

Though the fact that I'm even writing this post is a sad reflection on how we treat our juniors.

Feel free to share your thoughts/experiences in the comments section.

Dr. Thunder

Thursday, 7 January 2010

Dr. Ima Toilet

So, what's the worst thing that's happened to you on the wards?

A few of my non-medical friends were remarking recently how nothing can turn my stomach. No matter what we're wathing on TV, or what dead animal we see on the roads, I can just carry on eating, and acting like nothing has happened. I'd never given it much thought, but I was very squeamish as a youngster. Anything gross would have had me dry retching, regardless of where I was or who I was with.

But I guess medicine and medical school gives you an iron stomach.

I guess we are exposed to experiences that a lot of people would regard as abhorrent very early in our careers.
Within days of starting medical school, we were cutting cadavers open. Not many 19 year olds operating within the boundaries of the law have had that experience.

A particularly disturbing moment has stayed with me since the second year of medical school.

We were dissecting an abdomen, which was filled with fatty tissue. To get through fat, you basically have to just pull it out with a massive tweezer and a scalpel. I was busily dissecting through the huge adipose layer, with the enthusiasm of a first year medical student. One of my colleagues was hanging over my left shoulder to try and get a glance. He was quite a keen student, but he hadn't mustered up the courage to get stuck in yet.

So, I worked fervently, and was getting through to the prize that was the adominal peritoneum. As I got closer, I worked quicker. A small piece of fat flew from my tweezers. I watched in horror as it shot towards the guy who was standing behind me, with his mouth open.

I can remember the huge hunk of human fat entering his mouth like it happened in slow motion. I still remember him swallowing reflexly as it landed in his mouth.


And down it went. Jesus H Chist. I had just witnessed a colleague swallowing human fat. He turned white. Then yellow. Then green. Then he ran to the toilets to vomit violently for the next hour.

Poor guy. It didn't help his anatomy phobia. But, bizarrely, he is now a surgeon. So, he must have learned to use a scalpel at some stage.

There have been other moments that would make you grimmace. I remember being an intern on-call in a general medical ward in the UK. I was standing at the nurses' desk writing in a set of notes. Suddenly the back of my leg started to feel warm. I jolted and turned around to see a very elderly man standing behind me, urinating on my leg!!!!

I jumped out of the way and he finished off on the floor, undeterred. But that's life, and I have to say it didn't phase me too much. I just pottered off, and got some scrubs. I was back on-call 5 minutes later.

Paediatrics is full of things that would be gross if adults did them, but are considered cute when kids do them.

I was resuscitating a baby at a delivery a while back, and he came around very quickly. So, as I was leaning in palpating the arteries in his upper thighs, he decided to have a pee. Straight into my eyeball. I was so stunned, it took me a second or 2 to jump out of the way. Like I said, disgusting if an adult did it, but because this was a baby, everyone just went "Awwwwwwwww".

But I had to draw the line, when working in New Zealand, and classify a paediatric toilet incident as "gross". I was in A+E and saw a litte person who was constipated. I asked the nurses to put half a little dissolvable tablet into his bottom to shift the impacted poo. They weren't sure how to do this, as it wasn't a paeds emergency department. So, I said I'd show them.

I leaned in and put the tablet into his bottom. Within a millisecond his bowels decided that A) They were going to work and B) They were going to make up for lost time.

I was drenched in liquid poo. I mean DRENCHED. My whole face was covered in a stinking layer. I wiped my eyes, to see this baby laughing like crazy at his handywork.

I guess you have to laugh. And you're pretty much guaranteed to develop an iron stomach after those experiences.

I can't wait until I'm old so I can exact my revenge. Bring it on!!!!

Dr. Thunder.