Was he pushed or did he jump.......

I'm back........from my imposed sabbatical as a blogger, and I've got news!

As any regular reader will know I can be quite a grumpy sod but all in all I love being a nurse-boy. I do however have major issues with how the health system in this fair isle of ours is run and the stupid situations we clinical peeps have to put up with day in day out. So a few months ago I started looking around for something new...........

And............

I left ward nursing and all the hospital bollocks for a job as a clinical specialist/advisor/rep for a rather large, nice, progressive company. Thus, you may now understand my enforced absence from the Internet is general.......(Sorry Dr T, i should have told ya!)

My day now consists of trotting around in my car, speaking to nurses, dr's and anyone else who will listen. Educating about medical conditions, nutrition, co-morbidities and what I can do to help. I teach public health nurses best practice and how to get the best outcomes for patients, reassuring people with toes hanging off, that we'll do our best, and looking super freaking sexy in an array of suits.

Did I also mention I've had a pretty decent increase in pay, an expense account and a company car! All for kinda just being a nurse.

What a difference a capitalist sell out can make!

All in all, I'm pretty damn happy I made the move. I get to see some mad shit......burns, cardio, plastics, GI, Colo-rectal you name it. I'm seeing the best and the worst. I'm learning stuff each and every day ( a cardio-thoraic consultant taught me how to read ECG's the other day) and finally feel like the 4 years I spent in college getting a degree is paying off, and getting quite a lot of respect for the knowledge and advice I'm giving. I'm allowed to be pretty autonomous in how I do things, and am trusted to get on with my job........now read back and see the sort of things I used to write on here...........big change methinks.

If nothing else, this gives me another string to my bow, and maybe I'll go back to hospital work in a few years, armed with a bit more knowledge aboout how the bigger badder world can and does operate. But maybe like hundreds of other RGN's, I won't......and thats the shame of it all really. The health service in both Ireland and the UK is hemorrhaging nurses quicker than an arterial bleed on a stab victim.......and what do they do to stop this.........sweet fuck all other than do their best to piss us all off even more!

Don't worry, I'll still post here, tell anyone who wants to listen about the crazy stuff I've been seeing and stuff, but as a final note.......and just in case anyone form the god old Dept of Health down in Hawkins House is reading, take this as a learning point. I've worked hard and well for you guys for a while now. I was pretty decent at my job, and gave you more loyalty and time than you deserved. But I did it for any of the patients that I was looking after. But you fucked it up, you pissed me off so much that I felt I couldn't work or give you anymore. SORT IT OUT lads, and maybe you'll eventually get the good nurses, Docs, physios, OT's etc etc etc etc etc etc etc etc etc etc back again, and give people the health service that they deserve!

Laters

Ain't No Angel

The mental health lucky dip

Posted by Dr. Thunder:

I'm struggling a bit lately. I help run this "Child and adolescent behaviour clinic" once a week at my new hospital. As I've said before on previous posts, I've no real training in this kind of thing. Adults with mental health problems get seen by psychiatrsists (well, they're supposed to), but kids here get seen by the paediatrician for pretty much every ailment under the sun (medical, surgical, psychiatric). It's fine. I'll get used to it. But at the moment, I'm a little out of my depth.

I saw a kid today. A 7 year old girl with Attention Deficit Hyperactivity Disorder. She's got it BAD, to the point where she is pretty dysfunctional. Her brother has mild autism. Both her parents are disbled, and on disability allowances.

So, the little autistic boy goes to a special school, and is in a tiny class, with an individual carer. Quite right, too. The health authority seems to regard autism as an "important" illness. He does well at school, and functions relatively well in her day to day life,within pretty strict parameters.

His sister with ADHD obviosly hasn't got an important enough mental health problem. She has to go to the local state school, which is a very good school. But there's 26 other kids in her class. There's no individual teaching assistant. There is no one-to-one time.

To my mind, the child with ADHD has a better chance of managing to get what we in the mainstream would call "a good education" than her autistic brother. The autistic child is likely to require care for the rest of his life. That is not the case with his sister.

So, Nicola (with the ADHD) is doing badly at school. Her lovely parents are very worried. They came to me with an agenda today. They informed me that if Nicola was diagnosed as being on the autistic spectrum, she would get the financing for a classroom assistant.

Nicola's parents can't afford an form of extra tuition.

They looked at me, hopefully. They wanted me to diagnose Nicola with autism. I couldn't do it. It's not ethical. But it's tempting. I told the parents this. They're sensible people. They understood. But it didn't stop me feeling like crap for the rest of the day,a s I sent Nicola away with an increased dose of Ritalin.

I shall see her again in 2 months, when her school reports have deteriorated further. I have asked ther social worker to look into their situation, but she didn't hold out much hope.

I see Nicola becoming a pretty unproductive member of society when she leaves school, due to what is likely to a huge educational deficiency. We'll complain about how much benefits the state will have to pay her for many many years. Sadly, the savings would be enormous if we could just give her the money she needs to get some help at school.

Roll on next week's clinic!

Psychiatry services making me crazy!!

It's been a long week. Nothing too out of the ordinary, but there's a lot of sick kids kicking about in my neck of the woods right now.

One in particular is "sick", but not in the way in which we think of sick kids. Sarah has a psychiatric illness. I think. I'm no psychiatrist, but when you're on-call for paediatrics, all kinds of things come your way.

So, earlier this week i took a call from a worried GP. He had just seen Sarah*, who's in her early teens, and had been brought to him by her mother. Mum was worried as Sarah has been becoming more withdrawn over the last few years, and is now at the stage where she hardly speaks. She also suffers from delusions and paranoia.

So, the GP sent her to me as he was having difficulty finding the psychiatrist on-call, plus he reckoned a kids ward would be a more friendly "waiting room" than either A+E or the psych department. I agreed entirely, and told him to send her straight to me.

When I met sarah, 2 things struck me.

1) She has a LOT of issues, and needs psychiatric assessment, and likely psychiatric treatment.

2) She has been neglecting her own healthcare. Sarah has other quite serious medical problems, and is required to take medication every day. Mum reckons she never takes her medicine. In fact, mum is SURE she never takes her medicine.

I had a chat to both of them. I told them that I'll phone the psychiatrist and get him to have a chat. They agreed. Mum was amazed that sarah was open to the idea of psychiatric input, as previously she wouldn't even go to her GP. We had to ride thinsd wave and take the opportunity to get her help while she was willing to be helped.

You could see they were both relieved that something was going to happen.

I phoned switchboard and asked them to put me through to the psychiatrist on-call. "No problem, doctor, one moment".
The phone rings, and a very pleasant lady answers.

I say "Hello, this is Dr. Thunder from paediatrics, are you the on-call psychiatrist?".

"Well, I'm on-call FOR psychiatry".

"Ok, well, I need a psychiatric evaluation of a patient. I'm not sure if she's psychotic. She's a teenage girl who has a 2 year history of ......."

"Can I stop you there, doctor?".

"???"

"I can't assess your patient, i'm a social worker".

"Oh, OK, not to worry, can you put me through to the psychiatrist, then , please".

"No, I'm on call for psychiatry".

"But you're a social worker".

"Yes".

Oh fuck.

After a few minutes of trying in vain to explain my situation, I was put through to "our clinician".

Thank christ.

"So, are you the psychiatrist on-call?"

"Well, I'm on-call FOR psychiatry"

"Are you a psychiatrist?"

"No, I'm a psychologist"

Sweet baby jesus on a motorbike.

Better than nothing, i suppose, and definitely better than me! After finding out that there are psychiatrists around, but none of them are on-call. I asked the psychologist to come and have a chat to Sarah and her mum.

"I can only get involved in conjunction with the psychiatrist".

"OK, can we get the psychiatrists involved then?".

"They're not around today"

I hung up.

So, the question is...what in the name of good is a social worker doing "on-call" for psychiatry??? Is their doctor sitting in the social work office helping people with their housing applications?? It beggars belief.

I let sarah and her mum go home. I spent half a day trying to get them psych input. They really need it. But instead they are coming back to see me at the general paediatrics outpatient clinic next week. I've slotted them in at the end of the day. So, I will try to get them a psych review at 4.40pm next thursday. I don't hold out much hope.

When you're a sick kid, and you have a "trendy" illness, the whole world wants to know. If you have no hair, and a tube in your nose, then you are worthy of sympathy at the highest levels. Actors and sports stars come and see you in hospital. there is huge govenment funding for new buildings, and no drug is too expensive. Quite rightly, too. these are some of the most vulnerable people in society, and that's who we should be doing everything in our power to help.But, if you're an adolescent with a psychiatric illness, you are also vulnerable. Probably as vulnerable as anyone else in society. But there are very few hospital visits by the rich and famous, and you might not even have access to a doctor. Imagine theheadlines if a child with cancer couldn't get access to a doctor in a developed country.

On a lighter note, I bumped into one of my cardiology colleagues yesterday. It had been a rough day for both of us, as we both chatted in ED. I'd just admitted a septic baby, and a diabetic ketoacidosis. He'd been involved with some clot-busting shenanigans that I don't really understand anymore. It was 2am. We had both been in work since 8.30 that morning.

So, exhaustedly, he says...."I really wish i'd done a specialty like paediatrics instead of cardiology. I'd love to just play with kids all day. I mean, you wouldn't believe how sick people get on my ward".

Indeed. At that point I left to go and deal with the 3 year old having uncontrolled seizures in cubicle 3..............

*As always, I have used a false name.

A needle in giant haystacks

So, I've moved departments...again.

I'm now inhabiting the world of acute paediatrics. This is a world of snotty noses, red ears, high temperatures, and needle fear!!!

I hate needle fear. It's one of the big things you have to get used to when you start life as a paediatrician. In adults, taking blood is a routine procedure for most. Putting drips in means a bit of discomfort for the patient, but most cope with it fine.

With the kiddies, the opposite is the case. Some stoical characters just bite down and accept that you've gotta do what you've gotta do. But most of them, understandably, hate it. It's tough being a sick kid. I never had a drip, but I remember needing eyedrops as a nipper, and nearly tearing the house down in protest. So, I do feel their pain.

James was admitted from A+E this week. 8 years of age, with a bad tummy bug. Big strong 8 year old, so was only just barely requiring an admission to the ward. No real dramas. I thought he would be OK with some controlled oral rehydration, and an overnight stay. But my consultant wanted him on IV fluids. No worries.

James' mum is hyper-anxious. As a result, James is also extremely anxious generally. The thought of having a needle put in her son's arm made James' mum VERY anxious. This, in turn, made James VERY VERY anxious. This sets off a sequence of events that is replicated in paediatric departments the world over, and is intrinsic to the smooth running of the time-space continuum. It goes as follws:

I missed the cannula. Obviously. He jumped as soon as the needle touched his skin. The tiny nurse holding this giant's arm for me was no match for his startled reflexes, and the vein was destroyed. He screamed. This was a scream that only paediatricians and dogs can hear. It is a sound so high pitched that it has the potential to shatter stone. It is the sound that comes from all "treatment rooms" in paeds wards every day.

Mum started crying. Then she got angry. She started asking questions like "have you done this before?" and "are you going to get someone else to try?". There is always a look of shocked disbelief when you tell them you're going to try again. "AGAIN???" they shout? As if the need for intravenous fluids is dependent on your ability to get a cannula in first time. It is important to point out that this NEVER happens when the kid is tough, and accompanied by his even tougher granny. This only ever happens when you're putting a line into a "precious" child.

So, by now, both mother and child are in tears. They are both pissed with me. They both think I'm an idiot. I try again. Success. I remove the sharp bit of the cannula and throw it away. Just need to tape it into place now. James is still wriggling. The poor nurse is slowly losing this battle. I tell him the needle is out, and there's only a soft bit of plastic left in his arm. I tell him the worst is over, and he'll be back in his bed any minute. He doesn't believe me. Hell, his mum has seen me throw the needle away and she doesn't believe me. I am he-who-has-lost-our-trust, after all.

He's shaking. Convulsing. Trying desperately to get that drip out. Backup is summoned in the form of more large, stronger nurses. Too late. He's reached round and grabbed the drip and pulled it clean out.

The baby jesus cries at this point.

Mum looks at me, with red eyes of rage. I'm the culprit. It's true that i should have had more backup, but I never thought he was going to pull the cannula out while I was taping it into place.

So, at this point, all confidence in me is lost.

As always happens at this point, the consultant is strolling past. She's a friendly lady, so she pops her head in to see if everything is going OK. She sees the mess. The blood, the screaming child, the sobbing mother. The dimwit registrar.

So she offers to take over. I jumped at the chance to get away from a situation i've been in a few times before, but always fail to take control of, or to stop it getting out of control. So, the boss picks up the needle, and slides it effortlessly into a nice vein on James' arm.

Does he cry?? Does he hell. Does he try and pull it out?? Ditto. He smiles at her and says "That was much better than before".

So, all is well with the world. Another registrar has been made to look like a twat, without any damage to the patient. This is one of the main reasons that we are employed.

Interestingly, the procedure stressed James so much that he immediately demanded comfort food in the form of jelly and ice cream. Tolerated it beautifully. Therefore...you've guessed it. No need for IV fluids.

But at least the time space continuum was preserved for another day.

Musings of the sleep deprived

POSTED BY Dr Thunder.

It's a short post this week, as I'm on night shift. That means I'm:

A) Too tired to blog properly

B) Too incoherent to blog properly

When you're on nights, things annoy you, way out of proportion to their importance in the grand scale of things.

For, example, the subject of my whineing on his paricular run of nights is the rather grandly named "lactation consultant" who visits our neonatal unit on occasion.

Now, I'm not sure what exactly a "lactation consultant" does. I know she wears a power suit and talks to mums about breast feeding. I'm not 100% sure why we need her. She looks expensive. From what I can work out, she's a nurse who has some extra training in breasfeeding. So she's there to pass her wisdom onto our new mums. Our excellent nurses in NICU talk to our mums about breastfeeding too. They don't call themselves "Looking after sick baby consultants". I suspect she earns a lot more than them, too. She is, of course, unavailable out of hours.

Anyway, it's not the lack of a freely available job description that has me riled. It's the rubbish that she writes in the notes. Why is it that anyone with the title "consultant" in their job title* thinks the whole world is interested in every minute detail of their "Client episode"? The reason I'm saying this is because our lactation consultant has seen 3 mums today. In each case she has written in the notes "I have empathised with (patronisingly insert the patient's first name, which she uses without asking if that's OK) regarding her sick baby".

I mean who writes that they have empathised with the parent of a sick child?? There is probably an "empathy pathway". There may even be an empathy facilitator, who could be called in for a referral.

*sadly, the exception here are my medical consultants. About half of them never write in the patient notes. They expect the resident (junior doctor) to document their decisions. This is becoming more widespread in my opinion, and I find it very unprofessional. For all the faults in the UK service, our neonatal consultants used to see every patient every day, and write a full plan for every patient every day. Here , in about 50% of cases, the ward round consists of a consultant asking the registrar a few questions, telling us what he wants to do, while the poor junior tries to transcribe his/her ramblings. Your decisions.....your documenation......as far as I'm concerned.

The final thing that's been pissing me off is getting the blame for stuff that ain't your fault. EVERY doc has been in this boat.

This week the senior registrar came to review a very sick patient that I was looking after. He changed the kid's intravenous fluid regime. Sadly, he didn't bother to write up a new fluid order. The nurses are pretty good when we're busy and are usually happy to take verbal orders, within reason. So, the boss noticed on the ward round that the new fluids hadn't been written up, and proceeds to tear me a new arsehole.

I didn't even know the fluid regime had been changed!!!!

I assumed I'd made some kind of a cock up, so I just toook the abuse. I am absoloutely 100% against the idea of ANYONE in the hospital environment (or in any environment) raising their voice to another member of staff, regardless of the circumstances. It's, essentially, illegal, and rightly so. But sometimes you've got to take it.

The senior reg was in no hurry to offer up the fact that it was his cockup.

Then the next day I was on the morning ward round after the night shift. I basically tell the day staff what has happened to all the kiddies overnight, just before I go home. As I was discussing a baby, one of our nastier consultants asked me "has this kid has her MRI yet?".

"No, she hasn't".

" rant rant rant rant blah blah blah this is totally unacceptable Dr. Thunder blah blah blah" basically ripping into me. This is becoming a recurring theme.

Now, I'm just the night shift guy. The day to day routine management of this patient isn't my responsibility. That's the responsibility of the daytime team. At night we are running on minimum staff, so we only deal with acute problems that arise. We're not expected to do the routine work. It's just too busy for that to be an option.

I explained this as best I could. It's unit policy, so surely he'd understand?.....

His response.......

"Blah blah blah it' unacceptable Dr Thunder blah blah blah completely unacceptable".

Jesus christ.

The actual team who were looking after him stood beside me in silence. Wouldn't want those references being compromised, would we.

Why are hospitals full of people like this? Answers on a postcard please......

Rough day at the office

Posted by Dr. Thunder


What a horrible day today was. We have, coincidentally, 2 babies in ICU at the moment who have both suffered possible brain damage at birth. Both had their MRI scans and EEGs this morning, and the reports were with me by late afternoon.

Both babies had abnormalities on their MRI and their EEG. So, our team had to go and speak to both sets of parents in turn. It took about 3 hours in total, and was horrible.One of the problems (when I say "problem", I mean in the sense of giving information) is that both these kids could well be fine. They may well have no poblems at all. But they may suffer seizures, learning difficulties, or visual impairment at some point in the future. So, basically, it's a case of talking to the parents and telling them that, because the extent of the damage is difficult to assess accurately, we can only say that their child may run into problems. We can't give percentages, or even ball park figures. Basically, keep watching them until they go to school! I mean, how stressful is it to face into that! 6 years of being on edge all the time.


These were 2 very upset sets of parents. But, to their credit, they were very understanding about what info we could give, and what questions we simply couldn't answer.I always feel crap after these types of conversations. But it goes with the territory, I guess.

On the flip-side..to keep sane, i always convince myself that, in the world of neonatology at least, there's a ying and yang effect. For every bad thing that happens to me, a good thing happens. So, just as I was leaving work, the emergency buzzer went off in theatre. They were doing an emergency caesarian section. Our excellent, but very inexperienced, resident was there for paediatric input. The baby came out purple, and she very sensibly pressed the emergency buzzer, and assessed the baby.The baby wasn't breathing, and had a heart rate of only about 20. The resident tried to initiate bag+mask ventilations, but couldn't seem to get air into the baby's lungs (ie she was pushing air through the baby's mask, but his chest wall wasn't moving).


I arrived in, she explained the story as I was putting on my gloves. Baby was only 50 seconds old at this stage. I readjusted the airway, started bag+mask breaths, and thankfully the chest started to move. The heart-rate came up. Baby became pink, and started breathing himself. Happy days. It's not as difficult a task as it might sound, it's just scary! But, at the end of it we have a totally well baby, who will stay with us in NICU for a couple of days of IV antibiotics, and a chest x-ray, just in case. But no harm done. I've said it before, sometimes medicine can be the best job in the world. Sometimes it's the worst. Some days it's both!

Thanks for listening.

Now.........I'm not gay..........BUT...........

posted by : Ain't No Angel

Look look..........another post..............2 in 2 days, your getting spoiled!!!

This is totally non medical related but I'm so full of happyness and joy and excitement that I felt I had to tell you all, and detail the reason why.

Its quite simple really, and its all caused by one man. You may not be aware but I am actually a bloke nurse. I'm also not gay and happily on my way to marriage later this year to Mrs Ain't No Angel, (Ellie........you've got 6 months!). I am a simple man, who takes pleasure from simple things like beer, music, building random things with power tools and sports. I've never really entretained thoughts about other men...........until now..........because I think I'm in love..........with a man.

And this man is...............

FERNANDO TORRES

This modest unassuming young man has been a revelation since signing for Liverpool, and has been a bright star in the fairly grey skys around the city.

I'm not the only one to be having this problem either. Men up and down the country are having this crisis. Many of us didn't even feel this way about people like Keegan or Dalglish. Its a starange feeling but one I'm more than happy to run with, especially if this blonde bombshelllgets us past Chelsea to the Champions League final of dreams against Man Utd. If that happens and we beat them......I'll love it, I'll love it if we beat them!