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.

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.

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.

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.