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

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.