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.

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

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

http://www.boards.ie/vbulletin/showthread.php?t=2055799819

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 tongue...it'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

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.

GULP.

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.

Time to outlaw the smacking of children. Seriously.

Posted by: Dr. Thunder.

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

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

No.

She slapped this tiny child across the face.

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

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

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

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

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

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

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

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

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

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

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

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

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

Dr. Thunder.

Irish healthcare workers feeling the recession blues.

There's a recession in Ireland.

A really BAD recession.

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

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

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

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

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

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

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

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

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

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

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

Please enelighten me.

Dr. Thunder.

Quote of 2009

Posted by Dr. Thunder.

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

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

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

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

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

Dr. Thunder.

The antibiotic war.

Posted by: Dr. Thunder.

What are we doing wrong?

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

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

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

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

"Really? And why is that?".

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

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

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

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

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

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

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

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

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

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

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

The thing is, I suspect they may have.

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

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

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

Dr. Thunder.