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.

Another GAMSAT snoozefest from the desk of Dr. Thunder.

zzzzzzzzzzzzzzzzzzzzzzzz.

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.

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

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.

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

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 been.....so 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.

BOLLOCKS!!!!!!

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 http://www.irishtimes.com/newspaper/letters/2010/0210/1224264109053.html

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

"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