Two Weeks on a Trolley

Vote Mick!!!

2011-03-28T06:05:00.004+01:00

Don't vote Pedro, Vote Mick.

This post is a shameless plug for my friend Mick Molly, who's running for the Seanate in Ireland. Mick is the kind of guy we need in politics.

He's a doctor, who's worked in A+E for a long time, so he's knows all about Ireland and the problems facing our crumbling health system. He's been the president of the Irish Medical Organisation, and has been on the board of a regional health authority, so he also knows how health WORKS. he's been working in Harvard over the last 2 years or so, and has served on a pan-European body, representing the interests of junior doctors, so he knows how to navigate the global health environment.

As a person, he is incredibly helpful, incredible bright, and incredibly dedicated.

The Senate will hopefully start up Mick's career in politics, specifically in area of health politics.

For years, clueless politicians have run healthcare in Ireland.

This can change. Make sure that you check out Mick's site www.mickmolloy.ie and make sure you give him your number one.

This is my 100th post, and I'm glad to use it to endorse Mick for the position of Senator, representing my family and I. Voting is now open, so go and vote :D

Dr. Thunder

The downside of being down under.

2011-02-13T10:28:00.003Z

This blog, and many others are full of the joys involved in a move to Australia and New Zealand. A region where work/life balance is (usually) possible, and where we don't have to routinely watch patients die while they wait for outpatient appointments, or operating theatre slots.

The weather is decent, there's lots to do, and our political masters don't seem to exist purely to screw up our education. Most doctors who come here never regret it.

But there must be a downside, right? Of course, and many of them. So, here is the Dr Thunder MD official "Downside of being down under" list:

1) Trying to get here: NIGHTMARE to get registered as a doctor. Very slow process, and they've outsourced the verification of medical qualifications to the USA!! This, of course, only prolongs the process.

2) Patient expectation is higher: In my opinion (and I've been disagreed with on this topic on the blog before) Australian patients are more aggressively demanding than those in Ireland or the UK, often to the point of being unrealistic. Having said that, I think it's because they're used to a health service of a high standard. Whereas in Ireland, especially, we accept that we'll wait in A+E for 16 hours before seeing a doctor.

3) Residents often rotate every 4 months: As opposed to 6 months in the European model. I don't think they get a good grasp of some of the specialties in 4 months. In fact, 6 months often isn't long enough for these junior doctors to get enough experience.

4) Cost of living: In my experience, it's higher than in most places in Ireland and the UK. Though I found New Zealand much more reasonable. There will obviously be some regional variation here.

5) It's a long way from home: Don't underestimate that side of it, especially if you're not used to living away, or if you're coming out for a long time. One of my grandparents passed away not so long ago, and I didn't get to say goodbye or go to the funeral.

6) There's a craziness about cross-recognition of exams: We have a lot of very highly qualified paediatric doctors who come to Oz, and they have to re-sit all their specialist exams, because Australia won't recognise the UK/Irish ones (and vice versa), which is madness. We're all developed countries, and someone who has their postgraduate paediatric exams in the UK should be given exemption from those exams in Australia (and, again, vice versa).

7) The place is full of GAMSAT course students: We won't go into this, as it's been covered to death on this blog, but we probably need to make the medicine course longer, not shorter, and I personally think that's reflected in the quality of many of the medical students. Though this is almost as much of an issue in Ireland too, as of recent years.

8) Primary care: In contrast to the UK, primary care here is basically a business model. GPs can (and usually do) charge more for a consultation than the government pays. They also usually insist on patients paying cash up front and then reclaiming the money themselves. I'm not having a go at GPs. Anyone who reads this blog will know I have much love for GPs. But they are forced into becoming business people, and the financial realities of that inevitably mean that our poorer patients often can't afford to see their doctor, and get poorer follow up. It also means paediatric A+E is like a GP surgery, with a huge amount of "primary care types" of problems showing up. This will come as a bit of a shock to UK doctors in particular, who are used to a free-at-the-point-of-care NHS.

9) Patients?: Not over here. Seems every second person is now referring to them as "clients". I heard some psych person call a patient a "consumer" the other day. I don't know why, but it boils my piss.

10) The bloody chocolate: it's DISGUSTING!

So, leave your comments below for the benefit of the hordes of UK and Irish docs fleeing their jobs. Remember, no positives. We've done them to death. This is all about the misery :D

Dr T

the family doctor Vs the FAMILY doctor

2011-01-06T16:00:00.002Z

I hate being the only doctor in the family. Aunts, grannies, nieces and friends of theirs all seem too keen to show me their bumps and bruises at any opportunity, in the hope of getting a quick diagnosis. I even had a relative show me his penis recently!

I hate this. Not because I don't understand their frustration at being stuck on a waiting list, or having to pay to see a GP. I hate it because I'm worried I'll get something wrong.

There's a meddling lady who lives near our family home, who brought her child around to my house when I was a 1st year medical student, and asked me to look at her injured shoulder. She'd fallen off a trampoline and landed on it. I'd never seen a broken shoulder before, and told her that.

"But what do you THINK might be wrong?"

I buckled and told her it didn't LOOK broken to me. But I told her I didn't know for sur, and that she should get it checked out in the emergency department.

IN her head that became "this shoulder is most definitely NOT broken, and there is no need to seek medical care for this child". Obviously, the pain persisted for a few days, and she got an x-ray....diagnosis = "broken" shoulder.

To this day she tells everyone who'll listen that it's a crime for me to be doing paediatric emergency medicine, as I can't even diagnose a broken shoulder.

So, today when my gran rang me to say she's getting "funny turns" I told her to see a doctor and she seemed disappointed that I wasn't offering a diagnosis. I don't want want to be that guy who can't even diagnose granny with x, y or z.

So, to the families of doctors out there, I ask you, on their behalf, to treat them like the clueless mucker you grew up with, and not as the professor of brain surgery that they actually are.

Happy new year to you all.

Dr. T

Kudos to you, Mr GP.

2010-11-05T10:15:00.002Z

Overheard in the supermarket today:

Mildly coryzal staff member: I've had this cold for 4 days now, and it's pissing me off. I went to my GP, and the idiot refused to prescribe antibiotics.

Other staff member: Seriously?? That's awful. You should change doctors.

Mildly coryzal staff member: Oh you better believe I will. I gave him a piece of my mind and told I won't be back to his crappy surgery ever again. He didn't care, though, and pretty much told me it was my perogative.

So, there you go. Props to that unnamed, unsung hero of general practice.

The future MRSA patients of the plant thank you :D

Dr. T

Why?

2010-10-29T10:27:00.004+01:00

Dear baby Jesus. Why.......

1) do the sickest kids have the most difficult veins?

2) do the the kids with nothing wrong with them have the most anxious parents?

3) do doctors forget all non-bone related medicine as soon as they become orthopaedic surgeons?

4) do the kids with cancer always come from the nicest families?

5) are people not bothered when the doctor looking after their unwell kid has worked more hours than a pilot or lorry driver are legally allowed?

6) do we employ doctors from developing countries, when we know children in their home nations die in their droves for want of medical attention?

7) do the politicians always know better than us when it comes to health policy?

8) do we laugh when a baby pees all over us, but rush to change our clothes when Albert on the geriatric ward does the same thing?

9) do some parents oppose vaccination so strongly, while parents in poorer countries routinely watch their children die of tetanus and pertussis and other preventable diseases?

10) are physiotherapists and occupational therapists so much hotter than the general population?

If you can answer these questions (and any others posted in the comments section), Lord, then I shall return to church :D

Many thanks for your time,

Dr Thunder.

Long hours? Or a long time training?

2010-09-23T05:07:00.006+01:00

I’m not a fan of too much work. Over the years, I’ve done my fair share of long shifts, nights, weekends, public holidays, and combinations of all the above.

I don’t function well when I’m tired and hungry and thirsty. And most patients don’t want to be seen by an overworked, sluggish, grumpy doc whose priority is a bed and some food. Certainly, I wouldn’t have wanted any member of my family to have depended on care from me after working 27 hours straight.

I always thought my colleagues agreed with me. Enough miserable faces on the corridors of the various hospitals I’ve worked in made me feel a collective yearning for better conditions.

I thought, therefore, that there would be widespread endorsement of the European Working Time Directive (EWTD) when it came into force in Ireland and the UK. The EWTD is designed to limit the working hours of doctors within the European Union. Depending on the stage of implementation, it can mean working a maximum of 48-56 hours per week.

Of course, here in Australia, they’ve managed to do that without relying on international law. Down under, the rules for doctors’ hours seem to be enforced on a regional basis. In fact, from what I can gather, the rules seem to be MADE locally too. But, by and large, it works. Sure, I’ve been miserable and tired and hungry working in Oz, but I’ve never had to work 72 hours on the trot, let alone do it on a regular basis, as happens in Ireland.

Forgetting for a moment that the Irish government has decided to simply ignore the EWTD, and continue to make their juniors work ridiculously long hours, I was amazed to learn that there are significant groups of doctors in the UK and Ireland who oppose the implementation of the EWTD.

These doctors argue that registrars, like me, and other junior staff, need to be exposed to lots of cases in order to become proficient consultants. They argue that patients come to harm at the hands of tired doctors, but also from inexperienced seniors.

I can see their point. However, I don’t buy it. I can’t accept that dangerously long hours are the only way, especially when urban Australia manages fine without total burnout of their medical staff. There has to be a middle ground.

My take on the long hours culture is as follows:

1) If we juniors want to reduce our hours then we have to expect it to take longer to become consultants. Everything in medicine is being streamlined these days, and that needs to stop. We need to return to 5/6 year medical degrees, and long apprenticeships as house officers and registrars.

2) A lot of doctors' time is taken up doing admin work that anybody could do (chasing xrays, filling out blood forms, chasing blood results on the computer etc). These tasks should become the work of someone else, so that doctors actually spend their time doctoring. I remember as an intern working out that about 60% of my tasks could be done by a competent member of admin staff.

3) Our training is important. But so are our lives outside medicine. I sympathise with the wannabe surgeon who wants to work all hours, learning how to do craniozygomatic surgery. But, there are those of us who have wives, girlfriends, kids, and a family life. I want to be a good consultant. But I doubt I’ll look back from my deathbed and say “I’m glad I worked so much”.

4) Patients need to do more. Relatives, friends, patients and strangers are almost always sympathetic towards me, regarding the plight of junior doctors. But how many have ever raised the issue with a canvassing politician? I don't expect the public to have our interests forefront in their mind at election time. But this is about patient safety, as much as it is about modern day slavery. As things stand, the politicos and the media often betray us as greedy and as a vested interest group, and very little of that gets refuted.

5) We have to be wiling to take industrial action. End of. I would be very reluctant to do so in oz, as my job is busy, but tolerable. But if a pregnant junior doc in Ireland who is working 48 hours solid, with no scheduled breaks, isn't entitled to strike, then who is. the media would love it. They would betray us as lecherous public servants trying to bleed the state dry. The media and politicians would distort the facts to make us look greedy. But screw them. I bet we could hold out longer being abused by tabloid readers then they could hold out with no doctors. Obviously, I would never advocate withdrawing acute services. But a work-to-rule or skeleton staffing would cause some browning of pants in the corridors of power.

The Australians do a good job of it (well, in the cities they do, their rural healthcare provision can be pretty piss poor). Ireland and the UK should learn from them. Mostly we’re rostered on for a 38 hour week. We do on-call and out of hours, of course. But those shifts tend to be interspersed with good weeks, where we can catch up with friends and family This is not the case in Ireland and the UK.

I know from experience that some Ozzies will post comments here telling me that they work terrible hours too. And of course that can be true. I once did a paeds emergency medicine job here where my partner was getting seriously worried about my health. I was literally exhausted all the time. I was grumpy, and never seemed to have any joy in my life. That’s not the way to live. And it’s not the frame of mind I want the doctor in when I bring my sick kid to see them.

I know everyone is an expert when it comes to public sector reform. Just look at the comments section of any newspaper article or blog on the issue. So I’ll keep my ideas about system change to myself. But Ireland, the UK and Australia need to wake up to this issue. More complex issues have been dealt with in the history of mankind.

All three countries have started the process of saturating us with medical school graduates. In Ireland and Australia especially, every man and his dog can become a doctor. Of course, there hasn’t been a sufficient expansion in the number of hospital training posts to cope with all these new graduates.

That will have the desired effect of making our young doctors accept crappy conditions, as it’s likely to be the only route to a scarce training post.

Perfect solution, if you’re an administrator or politician. Tough luck if you’re a doctor or patient.

Sadly, doing anything about it is a catch 22 situation. There are those who have tried. But what’s the most common response when you ask local juniors to engage on this issue, and stand up for their rights? Yep, you guessed it....”Sorry, I’m just too tired”.

Hi, I'm Dr. Thunder. What's your f*cking name, you little ****?

2010-09-08T05:37:00.005+01:00

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.

2010-08-28T03:56:00.004+01:00

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?

2010-08-06T12:14:00.005+01:00

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)

2010-07-03T06:29:00.002+01:00

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!

2010-04-02T06:25:00.006+01:00

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.

2010-03-06T03:45:00.007Z

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.

2010-02-10T10:21:00.002Z

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.

2010-01-29T11:28:00.004Z

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......

2010-01-22T21:49:00.004Z

......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

2010-01-07T17:12:00.003Z

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.

2009-12-30T18:52:00.002Z

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.

2009-12-26T21:34:00.006Z

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

2009-12-20T16:27:00.002Z

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.

2009-12-09T11:48:00.005Z

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.

To work in Ireland, the UK, Australia or New Zealand?..the choice facing thousands of junior doctors

2009-12-05T02:25:00.000Z

Posted by Dr. Thunder:

As a registrar, who has worked in Ireland, the UK, Australia and New Zealand, I thought it might be useful to share my experiences here, in the hope of helping other doctors decide whether they want to trek halfway across the world in order to ply their trade.

I've included my thoughts on each of the countries below, and what they're like to practice medicine in:

Ireland: Oh Jesus. Juniors are still working shifts up to 48 hours. The European Working Time Directive will be implemented shortly, which will reduce the working week of doctors to 48 hours. In order to maintain a service, while halving the hours of medical staff, the Health Service Executive have decided they will simply ask the overworked juniors to work twice as hard while they're on the job. Simple.

They will also be docking 30 mins per day from the wages of junior doctors for their lunch break. Just ask any junior doc if they get a lunchbreak. Even if they do, they're not allowed leave the hospital, and they still have to carry their pager. It's a total joke.
Another disadvantage of being a junior doctor in Ireland is that the media, and consequently the public, think you're overpaid and lazy.

The standard of medical care in Ireland is also likely to fall, as the universities adopt GAMSAT and PBL with gusto. It used to be very difficult to get a place at medical school in Ireland. Now, about 1 in 3 of those sitting GAMSAT get offered a place. Call it elitist if you like, but when I'm old and have a complex medical condition, I want someone who works hard and is brainy as hell treating me. To stop these GAMSAT graduates doing too much damage, nurse prescribing is also being introduced, which required the nurse to do about 6 weeks training to convert themselves into a doctor. Good times.

Patients also routinely wait several days in the emergency department corridors on trolleys for treatment, as there are not enough beds.

In the "pro" column, my family and oldest friends are in Ireland. So, I'll probably end up returning someday. But I'm doing postgrad qualifications so I can hopefully get a post in a university, or be based in Ireland whilw working for an aid agency.

The UK: Also not a great life for a junior. Here you will find an imaginary 48 hour working week. In fact, they monitor you to make sure you're not working extra hours, by getting you to fill out an "hours diary". Essentially, you are expected to lie on this form, so your employer can ignore the fact that you work an extra 10-20 hours per week for free.

My biggest peeve about working in the UK, was the famous "4 hour waiting time". This is possibly the greatest con in the history of medical politics. Essentially, what happened was the labour party government got tired of people complaining that they had to wait 12 hours in an emergency department to get treated. So, they announced

"From this day fortwith, no man, women, child nor beast shall wait more than 4 hours in an emergency department".

WOW, we all thought. That's going to require a hell of a lot of investment into acute services. Right?....Eh, yea,...sure.
Obviously there was minimal extra invgestment. So, what happens is....the patient turns up to a crowded A+E department, and is seen about 3 hours later. So, they have some blood tests taken, which won't be back until 4 hours are long gone. You'd like to get a specialist down to see the patient in A+E, but they won't be able to make it before their 4 hours is up.

The head nurse hassles the junior A+E doc to get this person home or onto a ward. "But I need to get the bloods to see what's going on". Doesn't matter. They cannot be here longer than 4 hours, or the whore-child of Satan shall rise and engulf the hospital in his flames of jizm.
So, you have to send them home and hope to God their bloods/xrays etc don't show anything untoward. Or that the pain doesn't return when the pain killers wear off after they go home. Or you hassle the admitting doctor on the ward to take them, even though you've no clue what's wrong with them.

So, the patient usually ends up getting admitted at 4 hours. Nothing serious wrong with them. But they now have to stay overnight because they've been "admitted".
Every doc who's worked in acute care in the UK will have had a nurse coming in to see them while they're seeing a genuinely unwell patient to remind them that there's someone much less sick outside who needs to be seen NOW as they're going to "breech" the 4 hour target. It's not the nurses' fault. They get it in the neck if these people wait more than 4 hours. Some units improvise, by removing the wheels from the patient's trolley. So, they're no longer "waiting on a trolley" in A+E, they're admitted in a "bed". It's genuinely soul destroying.

What's also soul destroying is the way jobs are allocated to juniors. I still don't fully understand it either. All I know is some amazing doctors are unemployed because of it, and some real muppets are doing well because they can tick the right boxes in their "self assesment portfolio" or whatever it's called. It seems juniors in the UK are rewarded for being good at paperwork, rather than being good at medicine.
Oh, and everyone in the NHS is now a "consultant" of some sort. Everyone is taking on a doctor's role on the cheap, and healthcare is going down the pan.

Most consultants are not interested in the plight of juniors, so it's a lost cause.

It breaks my heart to write the above, as the principles upon which the NHS is based should make anyone proud to live in a country where free good quality healthcare for all used to be a reality.

New Zealand: Lovely place to live. Lovely place to work. My experience was in a hospital that was off the beaten track. But the consultants would come in and help immediately if you have any dramas. Colleagues were supportive, and standard of living was good. Managers actually spoke to us, and consultants backed you up.
I ended up looking after some pretty sick people who should have been moved somewhere else, but they were too unstable to go the long distance. This is a recurring problem in this part of the world, because of the geography. I saw it as an opportunity to improve my critical care skills, and, as mentioned earlier, consultants were generally very supportive, so I never felt out of my depth

Highly recomment NZ as a working environment.

Australia: Great place to work, by and large. If you stay for any length of time, you'll probably end up working in an understaffed remote hospital with minimal senior support. But working in a city is well worth it. Great hospitals. Reasonable workload. Supportive consultants, by and large. Nice atmosphere too. Generally first name terms with your seniors. Hours are not too onerous, unless you work remotely, when you can end up doing 24 hour on-calls.
I usually got a l;unch break in oz, and when I finished late I got paid for it.
On the downside, their politicians tend to use health as a political pawn, as is the case in most countries. For example, the recent swine flu response was 50% medicall driven, and 50% political, which was disheartening.
But, while Ozzie politicians are the same as any others, I'd still recommend it as a place to work.

Major downside is that the universities recruit a LOT of GAMSAT students. IN my opnion, and it's only an opinion, these students are simply not that good. MANY og my colleagues share this view. But it's a quicker way to train, so it will be a case of standards being sacrificed to save money.

Hope that helps. feel free to add your own opinions in the comments box.

Dr. Thunder.

2009-12-03T08:28:00.003Z

Posted by Dr. Thunder.

Well, they said it couldn't be done......

A conference without drug company sponsorship.

It was a small gathering, but I was there. Last week I went to my first ever "pharma-free" conference. It wasn't big. It wasn't fancy. There was no breakfast provided. Lunch was a few sandwiches and a slice of cake. There was a dinner afterwards, which you could attend at your own cost.

The experts were mostly local. Nobody was flown halfway round the world on a first-class flight and put up in a penthouse suite.

But the information presented was pretty much as good as that presented at any other conference I've ever been to. The meeting was based in a large capital, so there's plenty of research going on locally to present. A couple of times, research was discussed that hadn't been conducted by the presenter, in a "new developments in....." format.

It was great. Nobody was trying to sell anything. Nobody was trying to con us into presecribing their new decidedly average wonder drug. The cost of attending hardly ate into our budget at all.

It was just doctors talking about the best science. I loved it.

I have real problems with the pharmaceutical industry. I have no problems with them developing lifesaving drugs. Let's be honest, we'd have much worse outcomes without the pharmaceutical advances of the last 10 or 20 years.

But the way they try and peddle their drugs, regardless of how effective they are, gets very tiring, and ultimately erodes any trust in them.

This was a small conference, though, and only a small step in the right direction. As things stand, there's a world of work to do in order to limit the interface opportunities between drug reps and healthcare professionals.

BUt this was one step that was supposed to be impossible. BUt it' wasn't.

Dr. Thunder.

A health-y appetite for the finer things in life.

2009-10-18T11:43:00.005+01:00

Posted by: Dr Thunder.

Two of the most important people in Irish health circles are Mary Harney, the Minister for Health, and Professor Brendan Drumm, the CEO of the Health Service Executive (HSE).

The HSE is, essentially, responsible for the day to day running of the health service. These are the head honchos. The buck stops with them.

For years, doctors and nurses in Ireland have felt anger at both these public figures. They have lectured us on cost cutting, and the need for increased efficiency. In fact, professor Drumm is one of the main reasons why I chose to continue working in Australia, rather than going home to Ireland. I was visiting my family around christmas two years ago, and he came on the radio at my parents' house. He was giving a rousing oration, where he told the public how the front line staff in the Irish Health Service need to look at themselves, and to work harder, and to work more efficiently.

This, to me, was a disgusting thing for a fellow doctor to say, while Irish doctors (including pregnant women) were still working shifts up to 48 hours long. I decided then that I would never work for a service with a man at the helm who was more concerned with populism and passing the buck than he was with the overworked demoralised staff doing their best in crappy conditions.

Here is a man who has lost touch with the grass roots.This is a man who gave up his job in the understaffed specialty of children's oncology to earn big money running the HSE.

Also, and this is VERY important.....professor Drumm spoke out criticising excessive bonus payments for senior HSE staff back in 2007/8. This fact will become important later.

Then there's Harney, our erstwhile Minister. She has achieved a degree of popularity recently by "taking on" the "professional elites" such as doctors, pharmacists and nurses. In fairness, I do owe her a degree of gratitude, as her treatment of junior doctors mean I no longer feel homesick in Australia, as there are as many Irish doctors working here than I've ever worked with at home.

One of Harney's favourite pastimes involves telling the public how healthcare workers are costing us too much.

So, here we have Professor Drumm telling us we're not doing enough for our money. And Harney tells us we get too much money.

Now, you would expect this pair of reformists to lead by example, if they're going to tell the workforce in a third world health system to tighten their belts and work harder.

However, in a shocking development, which will rock the very foundation of the state, it has emerged that both Harney and Drumm are.......

Talking out of their asses.

We all know that expenses and bonuses are part of both political and business life. I expect a servant of our country to be able to fly first class, so they can do their work on the plane. I expect them to stay in a hotel with a business centre when they're away. I even expect people running the health service to get a bonus when things are going well.

So, what do we know about Harney and Drumm's financial package?

Well, we know that Harney and her husband (!?!) ran up a bill of almost 70,000euro over 3 years in JUST hotel and limousine costs. That's about 23,000 euro per year. On hotels and limousines!!!!!! How often was she going away???

Then it emerges that she refuses to travel on commercial jets when going overseas. Instead, she insists on using the government jet. So, over the same period she ran up a ill of 750,000 euro on flights. That's a quarter of a million euro every year! This jet costs 7,000 euro per HOUR to run. This only the information that is available. The Freedom of Information Act in Ireland is so difficult to navigate that it is almost impossible to discover the full extent of the financial laxity within government and senior civil service ranks.

Sweet Jesus.

Now let's look at Brendam Drumm. He's just been awarded a 70,000 euro bonus for doing so well in navigating our country towards a world class health service. This is the man who gets 430,000 euro per years as a basic salary. This is a man who was so critical of HSE bonuses before they were dangled under his nose. This is a man who has presided over a HSE which treats its junior doctors as glorified slaves, and has closed children's services in our major kids hospital.

In Ireland, there are half a million people unemployed. The self employed who built the country get no social welfare when their business goes bust. Those lucky enough to get some government support are entitled to 204euros per week. There are little children who desperately need spinal surgery, and have been told we can't afford the service.

I don't know how these people sleep at night. But I guess the presidential suite at the Waldorf,or a flatbed sleeper on a government jet helps.

Dr. Thunder.

So, will that swine flu vaccine give my kid mumps or what?

2009-10-14T07:38:00.004+01:00

Posted by: Dr. Thunder.

I've just had my umpteenth conversation with a concerned parent about the swine flu vaccine. I'm starting to sound like a broken record now.

Parents have every right to ask questions, when we consider what's been in the media, regarding this jab. It's a minefield of information, and it's difficult enough for those of us who work in healthcare to get our heads around it.

I get asked a lot of questions about this vaccine. Some sensible. Some truly bizarre. I've had the crackpot conversations already, with the truly paranoid. We discussed mandatory vaccinations, and the big pharma conspiracies.

"This vaccine has been made to give us all swine flu"

"This vaccine has been made to stimulate the world economy"

"I've heard this virus was released accidentally from an American army lab, and they're trying to wipe it out, so unfriendly countries dn't get their hands on it".

These people must live truly terrifying lives, if they're so convinced that government is out to get them.

At the normal-ish end of the paranoid spectrum, I've had some unusual questions. But nothing prepared me yesterday for a previously sensible parent asking me, in hushed tones, whether I thought there was a risk of Anthrax from this vaccine!!!!!!!!

Jesus H Christ!

"It's just that I read it on a website".

I tried to keep it calm. But I'm sure my face cracked a little, as the laughter tried to escape. I reassured Harvey's dad, and he was accepting of my explanation.

Having said that, the concerns expressed to me have been, by and large, fairly reasonable. And those that are a bit crazy, have generally come from respectable looking websites, which are essentially conspiracy theory sites, or are peddling alternative meds. There is something ironic about these people claiming a big pharma conspiracy on hand, and trying to sell you expensive vitamin D "anti-flu" tablets at extortionate prices on the other

I feel I should put up a list of the common concerns here, and make an attempt to address them. Cleverer people than me might want to add some extra info too.

1) This vaccine was rushed through the safety checking process: There's no doubt that the swine flu vaccine was made quickly. If there was a new vaccine on the market. it would take years to reach the market. But the swine flu jab isn't really new.

Every year, we have different strains of flu circulating. We usually detect these many months in advance, and make a vaccine against them. The way we do this is by taking a vaccine mixture that is shown to be safe, and adding in the virus particle that is circulating this year. The virus particle is the bit that immunises you against a specific strain of flu. It is a part of the surface of the virus that your body will recognise. It is not live virus. This year one of the strains of flu is swine flu. We didn't know about it early enough to include it in the yearly flu vaccine, so we've had to make a new one. But it's almost identical to the seasonal flu vaccine that people get every year. It is very likely to be included in the normal flu vaccine next year.

2) I don't need it as I don't have an underlying medical illness: Depending on the country we look at, we're seeing 30-50% of swine flu deaths and admissions to ICU in groups with no risk factors. Plus, vaccines are not designed to protect individuals. They're designed to protect communities. If you don't catch it, you can't pass it onto a baby, or someone else who will be less able to fight it.

3) I read about it making people sick in 1976: There was swine flu in the USA in 1976, and there was a vaccination programme. About 40 million people were vaccinated, and 25 died from Guillain-Barre syndrome. This is true. But when you look closely at the figures, there were about 1 case per million people more than would have been expected in a normal year. That's still high, but it's not a huge risk. No cause has ever been found for these cases. But vaccines weren't as pure as they are now, and this is thought to have been a contributory factor.

Bear in mind, though, a good chunk of those people would survie today, as GBS is better treated. Also remember that influenza infection is a big cause of GBS.

4) This is only a mild disease: True. In most cases. 1 in 200 people who get swine flu end up in hospital. A third of these end up in ICU. Usually for about 2 weeks. 1 in 1000 patients die from it. Though in some countries this figure is much higher. If 1 million people catch swine flu in Ireland, that's 1,000 deaths we're facing, and about 5,000 hospitalisatoins. That will wreak havoc on an overstretched health service this winter.

Everyone has their own choice to make. It's not for me to tell anyone what to do. But, whatever your decision, make it based on facts. Speak to your doctor or nurse. Don't look at the quack websites.

I had mine the other day. Had a bit of nausea the next day. But otherwise I was fine.

Feel free to comment. Feel free to disagree. But please don't scaremonger.

Dr. Thunder.

Who are the trade unions kidding?

2009-10-10T09:45:00.002+01:00

Posted by: Dr Thunder.

I think most public servants are underpaid.

We all have the chance to work in the private sector, for more money and better conditions. We stayed with the public sector during the boom times, when all kinds of people were earning crazy money in the private sector.

We have had to listen to the private sector telling us we were fools for staying put, for the sake of our patients, when there was big money to be made elsewhere. Now we have to listen to them telling us that we're overpaid and that our perks are too lucrative.

I think, to an extent, the public sector have to suck it up. You take your risks in the private sector. When times are good, you earn big. But when things go bad, they go VERY bad.

I have to say, though, the Irish trade union, SIPTU, have left me speechless recently. This trade union represents various public sector healthcare workers. Mostly nurses and paramedics. Oviously, these two groups do a vital job. A job that most private sector workers wouldn't have touched during the boom years in Ireland. But they stick with it, loking after the most vulnerable memers of society, under very trying conditions.

They don't get a Christmas bonus. There was no free staff night out at Christmas for them. there is no health insurance.

So, now their trade union has asked for a 3.5% pay rise for these workers.

For those of you reading this from overseas, Ireland is in trouble. I mean BIG trouble. Think Iceland-Lite. I know there's a global recession. But Ireland is suffering a global recession, plus a national recession. There's just no money left. I wrote recently about how children's surgical services are being closed down because the piggy bank is empty. Unemployment is skyrocketing, and hundreds of thousands of familes are trying to survive on their weekly 204Euro social welfare payment, in one of the most expensive countries in the world.

The people are fed up. They've seen politicians spend crazy money on lavish expenses, and they've seen the bankers bailed out with huge financial packages, while the self-employed don't even qualify for the dole when their businesses fold.

The dole office is so busy, it's taking 3 months for applications to be processed.

This is not the time to be asking for a pay rise.

Healthcare workers continuously come out top of public opinion trustworthiness polls. There's a good reason for this. Healthcare workers are supposed to care more about the people than about money. I think that still holds true. But I think the trade union are trying to play hardball with the government.

But how can we expect the public to have any respect for us if we're demanding pay rises in the current climate? The cost of everything is going down, so it's difficult to justify on the basis of inflation.

For a nurse on 35k per annum, a 3.5 pay rise works out at about 20 euro per week extra, before tax. That is not worth alienating the public for.

I hope common sense prevails. I hope our nurses and paramedics are rewarded when the economy turns a corner. I, and they, know that won't happen, though.

But, in the run up to a very lean Christmas for most of the country, it's time to put the begging bowl away for now.

Dr. Thunder.

Official stement from the Kim Jong-IL school of public relations.

2009-06-27T12:35:00.004+01:00

Posted by: Dr Thunder.

Now, I've never been a big fan of the HSE. The Health Service Executive is essentially the arm of the Irish department of health that runs our pretty shoddy health service.

In Ireland, despite having recently had over a decade of unprecedented economic growth, we still have a third world health service.

Expensively trained Irish healthcare professionals can be found all over the world, as they make their escape from an environment which is one of the most demoralising in the developed world in which to work.

Patients still languish on trolleys in emergency departments, as they wait for one of the precious beds in our understaffed, filthy, crowded wards.

As a doctor it's frustrating to see healthcare being run into the ground by people who have lost touch with what it's like at the coalface. Talk to people who have worked in emergency departments when there's a ministerial or departmental visit. Patients who have been lying on trolleys for days are suddenly found beds. Exhausted staff are kept out of the way. The sycophants are wheeled out for a meet and greet.

Against a background of spectacular cockups, it wasn't a huge surprise when I heard the HSE will be closing down a part of their spinal surgery services in Our Lady's Hospital, Dublin. This is one of the finest children’s hospitals in the country, and provides essential services for children with scoliosis in Ireland.

Scoliosis is a curvature of the spine. Its effects can be devastating. It leads, in many cases, to significant disfigurement. The curving spine can also impinge on vital internal organs, such as the kidneys, to stop them from functioning properly.

However, we are in the fortunate situation, whereby scoliosis can be treated, or at least managed. Sometimes surgery is the answer. Sometimes a cast is fitted to help the spine grow back straight.

Time is of the essence in these case. Because as the child grows, the curvature gets worse if not treated.

Because of the economic crisis, the HSE need to save money. They need to cut back on wages. So, they had a look around at potential targets.

Admin people? No.

Political advisors? No.

Government trips overseas for St Patrick's day? No

"Hey, what about the only people looking after kids with scoliosis in Ireland?". Great idea.

So, operations have been cancelled, and appointments have been binned. Casts won't be applied. Operations won't be performed. Curvatures will get worse, and these children will go from being able to live a normal life, to being a burden on the state.

Unsurprisingly, the weary Irish public have asked the HSE to explain this decision. So, they did. Oh, sweet Jesus, they did. The statement released to the press said:

"The incidence of children with scoliosis in Ireland is different to other countries, as termination of pregnancies that have a prenatal diagnosis of spina bifida, or other conditions that may develop spinal curvature, is not legal in Ireland".

Christ on a bike!

Why oh why oh why would they say this??? There is a technical point of some sort being made here. But what is it? Are they saying these children should never have been born?

Will they say to all the parents of disabled ex-premature babies "Sorry. If it wasn't for the fact that our doctors are obliged under law to treat your sick kids, then we wouldn't have these problems to deal with. So, we'll be withdrawing all future cerebral palsy care".

There some things that may be technically true, but imply a judgment of sorts. In this case, it's hard to read the statement as saying anything other than "You really shouldn't have had these kids".

There's a lot of offended parents out there.

I've seen too much of this type if nonsense to be surprised.

The HSE are thought to be better at PR than actually managing the health service. If that's the case, we're all screwed.

Dr. Thunder.

Don't worry, doc. I've brought a load of people to have a look at your sick kid. I can get more if you need them!

2009-06-12T14:58:00.005+01:00

Posted by: Dr. Thunder.

I find it ironic that, nowadays, when I see someone keeling over, it often makes me want to go in the opposite direction. Very fast. Especially when I'm already busy as hell. But, it's fair to say that's not the case for 99% of the general public.

People love a good old collapse. Nothing draws the crowds like a wham-bam-outa-nowhere-keeling over. It's one of my pet hates. If someone is unfortunate to become unwell in a public place, they can be guaranteed one thing.....that a lot of people will have a good look.

The people I always feel sorriest for are those who have seizures in public. Imagine it. You drop suddenly. Next thing you're waking up on the main street in on a saturday afternoon in your urine soaked trousers, with blood gushing from your bitten tongue, confused and just wanting to sleep. But that can't happen, as someone ALWAYS takes it upon themselves to make sure you don't fall asleep. Like in the movies, where if you let an injured person fall asleep they die. In about 50% of cases, the misery of the unfortunate "seizee" is compounded by someone ramming a spoon in their gob. Gotta make sure they don't swallow that tongue! Swallowing a spoon, or tooth fragments is fine. But keep that tongue firmly in their mouth, at all costs.

Just picture yourself waking up in that situation. Number one rule when dealing with a sick person in public...make sure they have some privacy.

I'm writing about this as I was in a similar situation about 2 weeks ago. I was doing an outpatients clinic, so I definitely wasn't in "emergency mode". I was strolling towards my little room, eating a hearty breakfast of one slighly over-ripe banana enroute. The only thing on my mind was whether it's dangerous to eat a banana that's more black than yellow.

And then then it happened. The 11 year old girl walking ahead of me just dropped. Her mum started shouting for help, and I looked around hoping some nice person was going to sort this kid out. Then I had that "oh yeah...I'M the doctor" moment that every medic will have had at some stage in their career.

Anyway, I made my way over to the girl an her mum, and worked out reasonably quickly that she'd just had a faint. I was on my knees beside her, just talking quietly to her, reassuring her that she was going to be fine. I didn't really notice what was going on around me. Until I turned around to see if I couild find someone who could call the emergency team.

I was looking for one person. There were at least 15. Whoa!!! All these people just having a look at the poor kid.

They were staring at her. She was staring at them. She looked horrified. They looked fascinated.

So, I said "OK, guys, we're fine here, thanks". No-one budged. "Eh, could we please have some privacy here, please?".

Two, maybe three or four, people walked away. The rest just kept staring. This girl looked so embarrassed, and I couldn't blame her. So, I became more forceful, and stood up. I literally forced these grown adults away from her, and into the foyer. The emergency team came with a trolley, picked her up, and took her away. All was well with the world again.

So, why do people do this? I can understand the odd punter offering you their phone if you need to get help, or their first aid skills. But why just stand there and gawk? It's embarrassing for the patient, and it SHOULD be embarrassing for the person watcing.

I remember once looking after a guy in a burger king, who'd keeled over. The problem was so bad, that the excellent and ballsy security guard just decided to empty the store. He just threw every single solitary person out of the restaurant, and shut the big glass doors. When the incident was over, there was still a massive crowd, faces pushed up against the glass, desperate for a glance at this poor guy on the ground.

Has anyone else experienced this phenomenon? It's more of a concrete legs than a rubber neck situation, I think.

As someone who has been part of the mob of medical students turning up unannounced to the bedside of sick patients hundreds of times, I shall continue to take the high moral ground on this issue :D

Apologies for the lack of blogging lately. I'm exceptionally busy in work and real life at the moment, and am likely to be for the next few months. So, please bear with me.

And thanks for the emails reminding me how slack I've been. You're an unforgiving people :D

Dr. Thunder.

Inefficiencies in the Irish Health Service: The "First Dose".

2009-03-14T18:13:00.006Z

Posted by Dr. Jane Doe

The ongoing campaign against NCHDs in the Irish health service has recently accused us of "inefficient work practices". Over the next few posts I am going to illustrate some major ineffiencies in the way the health service runs in relation to our job, and the effect this has on patient care. These inefficiencies are not of our making, and are usually stupid, irritating and inefficient ways of doing things that make our job difficult, the nurses job difficult, and the patient's life difficult.

So today, boys and girls, I'm going to talk about a very inefficient and stupid work practice that occurs in every hospital in Ireland, and as far as I am aware, nowhere else in the world.

The First Dose:

In Ireland, for some reason that no-one knows, the first dose of any intravenous medication is required to be given by a doctor. Usually this falls to the intern, or occasionally the SHO. There is no evidence base for this practice. Nowhere else in the Western world has this practice. I have no idea why it exists, nor does anyone else. People stumblingly explain when asked by the frustrated patient waiting for hours that this is "in case you have a reaction" but this is bollocks, as I'll explain in a little bit.

Now, the "first dose" is not limited to antibiotics. Oh no. It can mean first dose intravenous corticosteroids, IV vitamins (such as Pabrinex to treat alcohol withdrawal), IV vitamin K, first dose IV morphine, anything.

And get this. This'll really crack you up. This is just beautiful. Even if the patient has had IV Augmentin 1000 times before on previous admissions, if they get readmitted, the "first dose" principle applies all over again, and only a medic can administer it!

Ah. The flawless logic of our health system astounds me yet again.

So deconstructing this tower of imbecility, I will explain why the "In case you have a reaction" explanation is bogus in extremis. If a patient has an honest to God anaphylactic reaction when I give them an IV medication, what the hell am I going to do? I'm going to put out an emergency call so that the anaesthetist will come and be ready to intubate, and I'm going to give IV antihistamines, IV hydrocortisone, and administer subcutaneous epinephrine,which should be done first, readily available in the form of an EpiPen, or whichever one the hospital has in stock.

Now nurses are allowed to administer subcutaneous meds, and they usually know how to put out the emergency/arrest call faster than the intern/SHO would as they are the ones that usually do it. So the two first, and most important steps, namely 1)calling for help and 2)administering subcut epinephrine do not necessitate a medic at all. Now, if someone other than a doctor was able to administer the IV hydrocortisone and IV antihistamines, say, one of the ward nurses on receipt of a verbal order, then before the emergency team ever got to the patient, most of the treatment would have been instigated and the anaesthetist could then assess the airway etc. and the medic can manage as appropriate thereafter. So the patient would actually get FASTER treatment, and faster is usually better in emergencies.

If a reaction occurs that is NOT anaphylaxis, then the doctor can be bleeped and review the patient as appropriate.

The whole concept of the first dose is mind-bogglingly stupid anyway. The first dose will likely sensitise you to the drug. The next dose might be the one that gets you, if it is going to, in all probability. Or maybe the third. Or fourth. In fact, you have as much chance of having a reaction every time.
Also, the number of cases of reactions to IV medications on the first administration is exceedingly rare. I have never seen one. Nor has any other doc I know. We have occasionally seen angioedema, and very, very rarely anaphylactic shock, but never after a first dose IV med.

In addition, medics are required to make up the first dose IV med before they give it. Now this is where it starts getting dangerous. You see, as it's not really a doctor's job to do this, we obviously don't receive any kind of instruction on it ever. Some drugs are incompatible with normal saline, some are incompatible with dextrose. Some have to be diluted a certain way, some made up under aseptic technique, some vials have to shaken after the solvent is added, some cannot be shaken or the compound will be ineffective.
Some have to be diluted to a certain volume, so that a certain amount can be administered over a certain time. Nurses receive ample training on this. We are not even shown how to put the connecting tube into the bag, or put it through the infusing machine, let alone set it. Occasionally a kind hearted nurse will show you, but the machines change all the time, are different in different hospitals, and in different wards.

Pharmacists know all this stuff. Nurses know all this stuff. Doctors don't have a frigging clue. The majority of this stuff is usually done by the interns, who, having completed 5-6 years of training to know how to prescribe these meds, the indications for doing so, the intended effects, the potential side effects, and long term complications of therapy, now get to use none of that taxpayer funded training as they instead do a job that they were never trained to do and are unfamiliar with.

You tax dollars at good work, people. Once,as an intern, I was called to do anti-TNF alpha infusions. I had never done one before. There was no-one around to show me, so I made it up with the water for injections which the nurse had thoughtfully left out for me. It wasn't dissolving, so I gave it a good firm shaking. As I was doing so, the nurse came in, and turned pale. "STOP SHAKING IT! NEVER shake it! That's about 800euro worth of Remicade gone!"
Shite.

Also, doctors are not based on one ward. Or even one floor. We have to go everywhere, all the time. Routine administration of IV medications is a bit down the list most of the time, as it is relatively non-urgent. So patients are waiting. Waiting for antibiotics to start to treat their pneumonia. Waiting for IV frusemide to ease their breathing and decrease the swelling in their legs. Waiting for IV hydrocortisone to stop their wheezing. Waiting for IV antiemetics to stop their nausea and vomiting.
They wait, and get uncomfortable and frustrated. So do their families. They get mad, usually at the nurses, whose hands are tied, and they in turn get mad at us for not being there-but we have to be eight other places and what can we do? Nurses hate the first dose malarkey as much as we do, they will, after all, be giving all the other doses, and it does not say much for confidence in their professional training either.

So the above practice has the following implications:

1) Causes unneccessary waiting for patients and resultant discomfort, frustration and suffering.
2) Is a completely inefficient use of a trained doctors' time and contributes to further delays in other patients' treatment. The reason the docs aren't reviewing your new onset pain may well be because they are tied up giving 15 first doses.
3)Is potentially dangerous as the person reconstituting and administering the intravenous medication is not formally trained to do so and is often unfamiliar with the ward equipment.
4)Is not based on logic or evidence, and thus is a completely useless and inefficient hindrance to patient care that should be eliminated without delay.

But will it? Is efficiency and good value for money in the public sector really what we're aiming for? It never seems like it.......

EU may have finally smelled the Irish coffee.

2009-03-13T09:37:00.006Z

Posted by Dr Jane Doe.

This article is taken from today's Examiner. It is truly remarkable that this issue has taken so long to come to anyone's attention.

"Friday, March 13, 2009

EU to take up issue of junior doctors’ hours
by Ann Cahill, Europe Correspondent

THE European Commission is to take up the issue of punishing hours worked by junior hospital doctors with the Government.

Doctors in training should not work more than 56 hours a week under current EU rules, but a report in December, by the Department of Health, found the 4,800 junior doctors regularly exceeding this, working shifts of 36 hours or longer and no hospital was fully complied with the law.

Dublin Labour MEP Proinsias De Rossa referred this to the EU commission, whose job is to ensure states implement the laws.

The commission responded that they "viewed with concern the report and intend to make contact with the national authorities".

Mr De Rossa said: "This is a very significant development. It is the first indication that the Health Minister Mary Harney is facing the prospect of legal action at EU level, and ultimately EU fines, for refusing to abide by the EU health and safety rules on working time. Incredibly, there are still reports of junior doctors on duty for 36 hour shifts, and sometimes longer."

Dr John Morris, vice president of the Irish Medical Organisation, said non-consultant hospital doctors were the only grade in the health service that work on temporary contracts into their 40s and work shifts of 24, 56 and 72 hours without appropriate breaks. Hours are due to fall to 48 a week from the end of July.

Junior doctors are already in dispute with the HSE having voted overwhelmingly for action over proposed cuts in overtime and allowances. Talks in the Labour Relations Commission broke down when the HSE walked out yesterday."

I would like to draw attention to this particular phrase, which sort of cracks me up a bit. "Incredibly, there are still reports of junior doctors on duty for 36 hour shifts, and sometimes longer."

There are STILL reports of this, huh? Wow. That's weird. Considering that EVERY SINGLE HOSPITAL IN IRELAND OPERATES ON THE 32-36 HOUR SHIFT BASIS AS A MEANS OF STAFFING THEIR POORLY MANAGED SERVICES!

There is, currently, not ONE hospital in Ireland where this isn't the accepted and normal way of working for NCHDs. Weekends can be split into 26-30 hour shifts between two people IF management sanction this, or they can be a 56 hour straight marathon with no sleep and no scheduled meal breaks. Some even do from Friday morning to Monday morning working, an incredible 72 hour shift. Not week. SHIFT.

NCHDs have no choice in the matter as the overtime is MANDATORY, and it is worded that way in their poxy 6 month contracts that they remain on for years and years on end. When I was an intern I did 56 hour shifts at weekends. Once I was so ill with fatigue by the Monday that, alarmed at the state of me, they decided I should maybe not treat patients, and I was sent instead to do photocopying for the day.

End this madness. And give the patients a safe health service, and the doctors a health service they can provide care in, as opposed to exhausted and half hearted troubleshooting.

I need to form an opinion. Can anyone help?

2009-03-05T11:36:00.006Z

Posted by Dr. Thunder.

There's controversy brewing in Ireland. Like many countries, it was decided a while ago to introduce a programme of vaccinations for Irish girls, to help protect against cervical cancer. As most of you will know, there's a jab available that has been shown to be very effective in protecting against the viruses that cause most cases of this disease.

This would be given for free to girls in their early teens.

All was well, and public health/preventative health was back on the agenda.

But then the tough times came along. A load of bankers loaned a load of cash to people with no money, and we were all snookered.

So, as is historically the way of the politician, money was taken away from the population health strategy. They must have already syphoned off their quota from mental health services for the year.

The long and short of all this is that Irish girls were told they wouldn't be getting the vaccine. Well, they wouldn't be getting it for free. So, the rich would still get it.

But the type of people who are really at risk of cervical cancer would be less likely to be able to afford it.

There was a big fuss about this initially. But, like most public health initiatives, the fallout from the funding cut was short lived.

However, now a group of doctors have announced that they will be administering the vaccine for free to 300 12-year old girls in Dublin this week. Local businessmen have paid for the vaccine itself, and the doctors won't be charging for their time.

Word on the street is that the administration of the vaccine would have been outsourced to China if the GPs had asked for payment.

This all looks very noble. Fair play to the local businessmen, and fair play to the GPs.

But is it that simple? Possibly not. One of the GPs is a member of the Irish opposition. Dr James Reilly is not just a member of the Fine Gael political party, but he's their health spokesman.

He claims this isn't a political stunt. But in the same breath he says:

"The fact that the local community, 19 schools, parents associations, teachers, parents, doctors, nurses, and 300 children have indicated their demand for this vaccine should send a loud message to the Minister and this Government and the Minister should take up the baton and continue this programme throughout the country,".

My dilemma lies herein. On the surface, I like this idea. Private business funds overseas aid all the time, so why not give something to Irish people who may not have been able to afford this vaccine.

On the other hand, I'm uneasy because:

A) A politician, and a doctor, seem to be using their patients to make a political point.

B) Let's face it, we are seeing these vaccines being given out because this is a popular cause. It has, and will continue to, attract media attention. Do 12 year old girls need a cervical vaccine right now?? probably not. Could it wait a year or 2 until the country is financially more stable? Yes.

Could we use more counselling/psychotherapy services for the mentally ill? Absoloutely. Would this attract a lot of media attention? Absoloutely not.

Like I said, I'm a fan of this idea on a superficial level. But I also have deep misgivings about it in the context of an overall health startegy.

So, I have decided that, for once in my life, I don't have an opinion that's set in stone. Yet.

Can anyone help me out?

The full story is available at:

http://www.irishtimes.com/newspaper/breaking/2009/0302/breaking43.htm

Dr. Thunder

Pink eye for the homeopath guy

2009-03-01T06:37:00.003Z

Posted by: Dr Thunder

Little Timmy is 7.

He's from a middle class family, and goes to a good school. But he's been ill a few times lately. Mum reports that he's been getting "pink eye" recurrently over the last few months.

Their GP has given them antibacterial eyedrops each time, and has showed them proper "eye toileting", which have cleared it up. But timmy's mother reckons their GP isn't treating the problem properly, because it keeps coming back. I had my doubts, as this GP is known locally as being very reliable. But that's why they ended up in the paediatric emergency department this time. They wanted a "proper opinion" from a paediatrics registrar.

Ironically, their GP used to be a paediatric emergency registrar in our department.

Anyway, I examined the eye, and it looked like pretty straightforward conjunctivitis. So, I took a swab to see if there were any bacteria growing, and sent him off with some antibacterial drops in the meantime.

I phoned Dr. Taylor, their family GP a couple of days later, to tell him that Timmy's swab didn't grow a bacteria. We were talking about the recurrent conjunctivitis, when the GP told me what was actually happening.

One kid in Timmy's class has had conjunctivitis for the last few months. It's an easily treatable condition. But it's HIGHLY contagious. This child's mum doesn't like conventional western medicine. So, she's been bringing him to see a variety of herbalists, and lately he's been going to a homeopath.

Meanwhile, he still has pink eye, and keeps giving it to his classmates. it's just going round in circles.

Dr Taylor is seeing his classmates on a regular basis, and has been giving the correct treatment and advice. But conjunctivitis is difficult to prevent when the "index case" is being treated with magic water.

His mum has told one of the other parents that she's using a homeopathic remedy called "Argentum Nitricum". I cannot find any studies that suggest it works. But, ya know, you don't have to bother with that kind of legwork if it's "alternative" medicine.

The GP is going to talk to the teacher, and ask her to try to persuade them to get the kid to a doctor, as I'm little unsure about the long term effects of untreated conjunctivitis. All this really needs is good cleaning, as it appears to be viral in nature. I've suggested the school ask parents to keep children with conjunctivitis at home.

This is likely to be the only thing that will make the index case's mum get proper medical treatment, as having a kid at home with pink eye is likely to affect her coffee morning attendance abilities.

Cases like this make me mad. People have a right to shun conventional medicine. But surely seeing half the class walking around with inflammed eyes would guilt any reasonable person into getting proper treatment.

I need to go and calm down I think. Now where did I put that herbal tea?........

Dr Thunder.

Spin Doctors are expensive!

2009-02-24T13:46:00.005Z

The front pages of several papers today state that the HSE spent a staggering 51 million euros on SPIN DOCTORS!!!!

I hope they mean the band. They're not great or anything, I find that one song I do know very annoying, but quite frankly it would make more sense. And it would be marginally more entertaining.

So we're slashing frontline staff and services left right and centre-and paying spin doctors money to make it sound like it's all a good thing when if we didn't pay the spin doctors we wouldn't have to slash a lot of the services and this would actually in reality be a better thing and...and......I've gone cross eyed.

Just when you think you've seen it all. You, you know, see some more. And stuff.

Dr. Jane Doe

I believe the kids call it a "facepalm"

2009-02-13T17:48:00.008Z

A facepalm, as pictured above, pretty accurately describes what I did when I heard the news last night.

Mary Harney, the Irish minister for health, has announced the formation of a committee to look at ways of reducing clinical mistakes in hospitals. This will be a panel of experts who will get together and publish a report in 18 months time, apparently.

Incidentally, there is also a "commission on patient safety" in existence in Ireland, whose role would appear to be the same as that given to this new committee. However, the commission recommended the setting up of this new panel back in July 2008. The minister announced it's formation yesterday. Indeed.

But this was what got me. Harney, in her distress at the interminable suffering over the practice of shoddy medicine by Irish hospital staff, admitted she had no figures for medical errors in Ireland. But she does know that "Medical claims were costing the state 60 million euro every year" and that the aim of the process was to "reduce adverse events in the health service, and to reduce litigation". So, eh.....seeing as you admit to not having any statistics for medical errors (despite setting up 2 expert panels to combat the "problem") how are you going to know if your new committee is having an effect, Ms Harney????

Now, Minister, I'm no economist. And I'm no risk analyst. But, and apologies for the bold capitals, I have a suggestion for you, if you want to reduce medical errors in hospitals..................

STOP MAKING YOUR JUNIOR DOCTORS WORK ILLEGALLY LONG HOURS, AND REVERSE YOUR INSANE PLAN TO TAKE AWAY THE BUDGET FOR THEIR TRAINING IN RESUSCITATION AND BASIC SURGICAL SKILLS.

I'm glad I got that off my chest. I'll be here all week. I'm also available for Barmitzvas and public policy.

Dr. Thunder.

The Spin Doctors Against Doctors.

2009-02-11T17:21:00.004Z

Posted by: Dr Jane Doe.

"If you, would like to call me lazy, just go ahead now. And if you, would like to call me greedy, just go ahead now."

The HSE is targeting the most vulnerable group in the health service for extreme cutbacks currently, and disproportionately compared to the cuts being proposed elsewhere.
Among the cuts being proposed are:

• Mandatory 1 hour unpaid meal break
• Suspension of Training Grant and PGMDB Allowance
• Discontinuation of Higher Degree and Diploma Allowance
• Attendance at in-house training no longer paid
• Discontinuation of Living Out Allowance
• Introduction of mandatory unpaid Pre call/Post call
• Overtime payment: Monday to Saturday
• First 9 hours paid at flat time
• Balance of hours T + ¼
• Sunday & Public Holidays T x 2

In addition the HSE is aiming to introduce the following measures:
• Rosters formulated 8am to 8pm
• Hospitals to examine and eliminate unnecessary layers of on-call
• Maximisation of on call off site where feasible
• Cross cover across different specialities to be maximised
• Full roll out of successfully concluded NIG pilots
• Interns employed on 48 hour week from 1 July 2009

In addition to these cuts specifically aimed at NCHDs, as public servants you will also be subject to the Government’s proposed pension levy which will result in between a 6.4% and 8.5% deduction from your overall salary. (I might add that, although the pension levy that NCHDs pay is based on their income PLUS overtime-ie if you make 60K a year you will pay the proportionate levy-the pension NCHDs will accrue is based only on their BASIC pay. Food for thought, no?)

Before the recession hit Ireland NCHDs (Non Consultant Hospital Doctors-ie; interns, Senior House Officers, registrars and Specialist registrars, often called junior doctors despite the fact that many of them are in their forties!) enjoyed wonderful working conditions. Ah the Celtic Tiger. Truly a golden age.

NOT.

The Famous Overtime Pay!

We worked anywhere from 60-120 hours per week. Our hourly rate was about ten euro less per hour than a primary school teacher. We did weekends “on call” which is a silly and grossly misunderstood euphemism for just plain old working, that lasted anywhere from 56 to 72 hours straight-with NO SLEEP BREAKS OR MEAL BREAKS SCHEDULED.
Our so called public service “job security” consisted of having to reapply for jobs and do interviews all around the country every six months to a year, indefinitely. We were shifted from hospital to hospital every three to six months, often in different parts of the country working with a whole new set of people and having to get used to a new hospital. We weren’t given so much as a day off to move house if we were rotated from say, Galway to Dublin, and many NCHDs moved themselves, their possessions and their families to new locations overnight and started a new job the next morning after pulling a change of clothes and their stethoscopes out of the boxes in the hall.

If we became sick while in the middle of a shift that could last anywhere from 32 to 72 hours then we had to keep working. If we were vomiting, had diarrhoea, had a high temperature, whatever. We had to keep working. If you became ill during the office hours of HR and management (9-5 Monday to Friday) then if you informed them they would often get angry with you, following which they would try and bully one of your colleagues to work the “on call” shift instead. Before even attempting to get a locum sometimes. The “on call” shift means that the person, who started work at 8 or 9 in the morning, has to stay on and keep working continuously all day, all night, and then resume their normal duties again the next day as though they hadn’t just been up all night working after working a full day too. 32 hour long shift-minimum. Usually it was more because one was so much slower at everything after already having done 24 hours straight with no sleep.

When we worked weekends, we worked all the next week too. In many hospitals around the country this meant that we came in on Saturday morning to work, and worked until Monday evening. No scheduled sleep break. No scheduled meal break. Even if you dared to have a shower you kept a nervous eye on your bleep. Often for most of this 72 hour shift we were continuously awake, and unfit to drive home on Monday evening. Following this marathon of insanity, we came back to work, bright and early, on Tuesday morning and continued working the week. Often there was another 32 shift ahead of us that week.

Yes, we were paid overtime at rates determined by the Labour Court. Time and a quarter for the first 15 hours after one went over 39 hours in the week, then time and a half thereafter. So after you had worked 39 hours, from hour 39 to hour 54 you were paid time and a quarter. From hour 54 onwards you were paid time and a half.
The Irish media has made quite the sensation of this. However, they forgot one teensy, weensy leetle detail.

IT IS ILLEGAL TO WORK OVER 56 HOURS PER WEEK IN THE EU ACCORDING TO THE EWTD.

IT IS ILLEGAL NOT TO HAVE A SCHEDULED REST AFTER ELEVEN CONTINUOUS HOURS ON DUTY.

The above working conditions have not changed and are still in practice all over the country.

There is currently, in Ireland, not one single NCHD who wouldn’t gladly take a pay cut in exchange for a reduction in working hours that would ensure adequate staffing and not compromise patient care. I for one would gladly never ever work another 32 hour shift with no sleep, if I could work a 40 hour week and be paid my basic wage. But, and this is the really big but, these OVERTIME HOURS ARE MANDATORY AND IT IS A BREACH OF CONTRACT TO REFUSE TO WORK THEM. We are contractually obligated to work an unspecified number (ie. however much they tell you to) of hours of overtime in addition to the normal 39 hour week. In addition, were we to all work only 48 hours a week, with the current staffing levels, patients would suffer and patient care would deteriorate drastically.

When the media runs these sensational headlines “Junior Doctor in Wherever Earns 100K in Overtime” they don’t seem to mention what the junior doctor was obligated to do to be paid that wage. This amount of overtime means that this doctor was working approx 120 hours a week, and was a registrar or an SpR. This means that he/she was doing 56-72 hour shifts with no sleep breaks at weekends and doing them every second or third weekend. This means that this doctor was chronically exhausted, never saw his/her family, drove a car and endangered their lives and the lives of others on the road while under the influence of severe fatigue. This means that the patients that he/she was treating were being treated by a medical professional who was so tired that their decision making abilities were akin to those of a person who was over the legal limit.

Personally, the unpaid days off pre and post call that the HSE are proposing sound almost humane to me. A 32-36 hour shift with no sleep or meal breaks will become a 16-24 hour shift instead. This is still insane, but more humane. And less dangerous. They will run into problems staffing the wards during the day, to be sure, if several people are off for two days because of a night on call. But overall, it will be preferable. For us.

The working conditions BEFORE the above proposals were already so bad that Irish trained doctors have been emigrating in the hundreds to Australia, New Zealand, the UK, USA and Canada. At earlier and earlier stages in their careers. Making the conditions worse is going to cause a torrential haemorrhage of doctors the like of which will not have been seen since the eighties.

The Mathematics of Overtime:

It often surprises me that people would become incensed by the thought of someone working 100 hours a week and getting paid for them. The fact remains that if ANYONE worked 100 hours a week doing whatever it is that they do and was paid for them, they would make a lot of money. Hell, if you were paid minimum wage, 8.65 per hour, and worked a 110 hour week like a surgical registrar on some crappy rota somewhere with no locum cover who never gets to see his/her family, you would make 951.50 that week. That’s 4281.75 per month. So if you make 20 euro an hour, then you come out with 9900 per month before tax. This is taxed at the high rate, so I don’t know, you probably get a lot less after, but still.

You see my point. If this junior doc with his 100k worked a 40 hour week instead of a 100 hour one, his salary would be nothing to write home about. If my buddy the primary teacher worked 110 hours a week, they would make 3630 per week gross as they’re on a higher hourly rate than an NCHD.

When NCHDs work a 40 hour week and get 100k, then that will be newsworthy. When they work 100 plus hours a week and get 100k that’s called basic mathematics. (If they worked 100 hours a week and got 40k this would also be newsworthy, as it would mean that registrar doctors in Ireland were paid approx 7 euro per hour, and this would be gross exploitation).

I’m not sure how the HSE thought that this spin was going to get the public on their side. Only an idiot would not be able to do the math here. (I used the calculator on my phone, but you take my point!) No matter how many stories they run about NCHDs working illegal unsafe hours being paid for those hours, they aren’t fooling anyone anymore. Maybe they should hire more doctors and divide our hours equally. Hmmm?

The Training Grant-and by extension, the training:

Being an NCHD in Ireland is an expensive business. One pays the Medical Council about 400-500 euro per year to stay on the register. The training grant does not cover this. Medical Indemnity insurance costs another couple of hundred euro, again out of your own pocket.

Things that the grant will cover:

To register your GPT-that is your General Professional Training, now changed to BST (Basic Specialist Training) which everyone has to register in order for their training to be accredited, it costs 2000 euro PER YEAR currently.

To register and pay for you training on the Surgical SHO scheme is currently 3200 per year. The scheme is two years long totalling 6400 euro just to do the scheme. This doesn’t pay for your exams.

The ACLS (Advanced Cardiac Life Support) course is mandatory for all medics working in an Irish hospital and must be redone every two years by every doctor. This course teaches basics like effective CPR, intubation and ventilation skills, defibrillation, and recognising abnormal cardiac rhythms and how to treat them. It costs 550 euro currently.

The equivalent for paediatric doctors is the PALS course (or APLS I believe it’s called elsewhere). Again, 550 euro, and an absolute requirement for work.

ATLS (Advanced Trauma Life Support) aimed at Accident and Emergency doctors-this one may even be more expensive than the ACLS or PALS as it takes longer.

Basic Surgical Skills courses can run from 500 upwards and teach trainee surgeons basics like suturing and operating skills.

The Royal College Membership exams (MRCPs) for General Medicine, Pathology, Psychiatry, Obstetrics and Paediatrics are requirements, respectively, for entry to specialist training schemes to train up the consultants of the future. The memberships have three parts, and each part costs 590 euro currently. So 1770euro to get these exams assuming you pass them all the first time. Which no-one does, believe me.

Prep courses for the membership exams cost 1000-2000 each sometimes. Particularly for the practical parts of the exams, they are vital.

The ACLS and PALS etc, are always on weekends, and hence one must often use one of the only weekends one is not on call in a month to do these courses.

Axing the training grant is, um, not such a hot idea. Doctors who don’t have the ACLS are probably not going to resuscitate you or your relatives properly. Or if the A&E doc didn’t do the ATLS, then all those RTAs wheeled in after hours are in serious trouble. Lack of doctors progressing through the ranks having obtained their membership exams means less staff at senior registrar and SpR level, and these are the most senior doctors in the hospital after hours, and the most knowledgeable.
Deskilling of the steadily decreasing pool of frontline medical staff is about as intelligent as raising taxes and decreasing incomes during a recession. Oh wait, it’s the same crowd as what done the recession in the first place.

Mandatory Unpaid One Hour Long Lunchbreaks:

HAHAHAHAHAHA! NCHDs getting LUNCH BREAKS? Okay. When did we EVER get LUNCH BREAKS? What planet are these people on? I know they probably think this would be awesome spin fodder, eg: “Fatcat overpaid junior doctors paid to just sit around eating”, but the public aren’t that stupid for heaven’s sake. There’s just no spin value to get out of this one, lads. Sorr-ree.

NCHDs carry their bleeps at all times and are available to work at all times when on duty. If you are called you have to go. None of us sit down to a nice lunch and coffee every day, or even ANY day. In addition, you can’t leave hospital grounds. Others can go to the bank or post office at lunch. Not us.

I remember many times eating a Snickers going down the hall and this served as my lunch and kept me until about 10pm when I might get a sandwich out of a vending machine and eat it with one hand while writing up an admission with the other.
I guess what they must want is for us to hand our bleeps en masse in to reception and head off downtown for lunch or for a nice hot meal in the hospital cafeteria. Cool! I’m down with that. As long as whoever has the bleep can handle the situations they are bleeped for. But wait! If all the NCHDs are on their (snigger) lunch break, then who will take care of the patients. Or are we not caring about that anymore because there’s a recession?

I suppose there could be staggered lunch breaks, but if they’re staggered then they sure can’t be a whole hour long. Otherwise you will have people going on their (chortle) lunch breaks at 4 and 5pm and such.

If the HSE would bother to engage with NCHDs and try to compromise then they might find that we are willing to help them devise rosters that decrease hours and consequently, overtime and still ensure enough staff are on at any given time to keep patients safe. They might find that we might be willing to limit the training grant to course fees and exam fees only, and forgo the one off laptop and equipment grant. They might even find that we might be willing to agree to a pay freeze. There are lots of ways we could help them to make savings, if we were to work together. In fact, if all health workers came together and we reorganised things a bit, we could still have a reasonable health service. Or maybe I’ve watched one too many Disney films.

But I suppose unilateral imposition of drastic alterations to our contracts without discussion and with lots of spin to try and further their cause is so much more effective. And industrial action and emigration on an EPIC scale of NCHDs trained at the taxpayers’ expense is a much better solution than us all working together to try and make the best of things.

The idiot's guide to "slashing overtime"

2009-02-07T01:33:00.007Z

So, I was listening to Mary Harney on the radio the other day. She's the Irish minster for health, and I liked what I heard. That surprised me greatly.

She said she was going to "slash overtime" for junior doctors. Great. Our Juniors in Ireland work shifts that are up to 72 hours long, with no guaranteed breaks, and no guaranteed sleep.

There's also a shortage of junior doctors in Ireland, which means they can work a lot of overtime.

Now, Mary Harney said she wanted to reduce overtime in order to save money, so her motives weren't pure. But that's fine,a s long as she was committed to cutting their hours.

How shocked was I, then, when I heard that when she says she wants to "slash overtime", she actually means "not paying overtime rates".

Essentially, what used to happen is that juniors would be paid time and a quarter for their first 9 hours of overtime every week. But the new policy will mean they just get paid normal rates paid to them for their overtime.

That's how she wants to slash the overtime bill. I guess it's likely to achieve it's aims.

The alternative would have been to realise a decade ago that we were short of docs, and train enough of them!

Not content with dropping the morale of doctors by making them work overtime at normal rates, she's also slashed the training budgets.

Basically doctors get a subsidy from the government for courses and education each year. The amount is variable depending on the doctor's seniority, but it can be a few thousand euros per annum

Out of this, the doctor is expected to pay for courses in emergency resucitation, and to attend conferences and surgical skills courses etc. These things cost money, but we should be teaching our doctors how to resuscitate people,and we should be teaching our junior surgeons their basic skills. Not any more. No money for it.

Of course, Harney knows that young doctors won't be able to progress up the ladder without dong these courses, so they'll pay for them out of their own pocket, and will do them on their own holiday time. Everyone's a winner.

Of course, many young doctors won't have the time, or the finances to do all the courses they need, so they'll skim. They'll do what they can, but training will suffer in a MAJOR way. I'm concerned that the public don't understand the implications of making no provision for the training of medical staff after the graduate from university. Just think of the difference between a newly qualified intern, and a consultant. The difference isn't simply the result of experience. It's a result of training, too.

Many of my Irish colleagues feel that this will result in the worst post graduate training in Europe. I agree. These will be the doctors looking after you when you're old. That is, if they stay in the country. Many are planning to follow those of us who've been tempted overseas.

There have been other cuts proposed, but the most laughable has to be the announcement of "a mandatory one hour lunchbreak each day". I had to do a double take when I read this. Every doctor in the country knows that most days a junior doc doesn't get a lunch break. They most certainly don't get an hour. A quick rushed sandwich in the canteen is considered a success, as they still have to carry their pagers while on a break. No-one has suggested that someone else will be covering these duties at lunchtime, so they'll still be carrying emergency pagers. They'll still be on-call.

When the one doctor who's working in intensive care gets paged at 1.30pm to tell him Mr. O'Malley in bed 3 is having severe chest pain, is he going to say "sorry, I've a half an hour of lunch still to take"? Of course he's not. He's going to forsake the rest of his break and deal with the patient.

The government know this, and they don't give a hoot.

It would have been more honest for them just to say "we don't care about you. We know your consultants won't kick up a fuss to defend you, and we know you're desperate to climb the ladder. So, we know you'll pay for courses yourselves, and you will go without breaks, and you won't complain. We know you're an easy touch".

But somehow we all know this will turn into greedy doctor propaganda if anyone dares speak out.

Thank goodness for the welcoming Australian healthcare system, I reckon. I suspect I'll be hearing a few more Irish accents on the wards over the coming year.

Doctors. Their hours. The ten year lag.

2009-02-05T03:24:00.006Z

Posted by Dr. Thunder

So, this week the Department of Health in the UK announced that they won't be implementing the European Working Time Directive (EWTD) for junior doctors anytime in the next few years.

The EWTD is a piece of European legislation that seeks to offer employees protection from overwork and exhaustion. The aim was to have no person being required to work more than 48 hours per week.

Now, the UK department of health has asked for a FURTHER extentsion (doctors have already been way behind the rest of the workforce in terms fo their entitlements for years). Despite having a decade to prepare for the implementation of this legislation, the department say that they can't meet the requirement.

With the farcical new method of selecting doctors in britain, many have moved overseas to get better training. In the same breath, the authorities have made it extremely difficult for overseas doctors to come and work in the UK.

And they wonder why there's a problem,?

The interesting thing is that both the Royal College of Surgeons and the Royal College of Physicians (doctors' representative groups) have supported the delay in it's implementation. Bizzarre. I think this is because a lot of the old school doctors who run these organisations believe that the juniors SHOULD spend most of their best years working.

I call shenanigans on that. I think medicine is a job. It's a privileged job, but it's a job nonetheless. More importantly, it's a job where cockups are not acceptable. It's difficult to reconcile this with the long hours culture that exists within our ranks.

I think we should treat our young doctors like we treat our pilots. Pilots have a limited number of hours they can work in a year.

When I get older, I'll be much happier when the guy about to cardiovert me has had his full 8 hours sleep, and statutory lunch break!

In Ireland, things are worse, as per usual. Though the Health Service Executive (HSE), who are responsible for the "running" of the irish health system, are clinging to the hope that their junior docs will be working a 48 hour week by june 2009.

Now, we all know this is either a crock of balls, or they have something up their sleeve that will allow them to fudge the figures, much like they do in the UK.

The HSE are talking about getting around the law by not counting "inactive" hours as "work" when a doctor is on-call. If anyone thinks this will reduce the official hours tally, then they clearly have NEVER done an on-call shift in an acute specialty.

I don't kow what the solution is right now. I know that the Irish and UK authorities and unions have had about 10 years notice of these changes, but they've not prepared themselves.

I know it won't be the people responsible for this mess who'll be working the extra hours, and spending less time with their families because of it, though.

Dr. Thunder

Dr Thunder: The Lazarus Project

2009-01-25T02:32:00.004Z

Posted by: Dr. Thunder

May I take this opportunity to wish you all:

A) A happy halloween

B) Happy Christmas

C) A happy new year.

Retrospectively, of coure.

I haven't been blogging since late October. Not because nothing has happened. Not even because I'm lazy.

I've just been tired, grumpy, overworked, and unmotivated.

We've recently gone through a very busy period in the paediatric department. We were really snowed under, and everyone was pretty miserable. This had the effect of causing 2 of our doctors to resign.

As a result, the rest of us were even more overworked...and grump.....and unmotivated.

I started working every day of the week, with the occasional weekday off. I worked pretty much every weekend, and all my shifts were long and unsociable hours.

So, I guess the blogging suffered because I was miserable in my job, and just didn't want to talk about it.

But things are better now. I'm getting 2 days off a week, and I have some wekeends off, plus we have more staff.

That has had the effect of improving my demeanour somewhat, which is lucky. Lucky because Mrs Wiley turned up with her toddler today. Mrs Wiley is a "heartsink mum". That means that as soon as she walks in the door, everyone looks the other way, and nobody wants to deal with her.

She brought her toddler, James, in to see us, as she has done every couple of weeks since he was very young.

Mrs Wiley is extremely worried about high temperatures in her son. Someone once told her that high temperatures in a little person suggest meningitis until proven otherwise.

So, she takes his temperature every morning and night.

If it creeps above 37.5 degrees, she comes straight to hospital.

So, the consultation usually involved a happy,playful toddler with a temperature of 37.8 degrees, a rageing mum who's angry at having to wait 3 hours with her meningitic son, and a bemused doctor. The key here is that, while the temperatures tend to be just above 37.5 degrees, they're not signiciantly elevated.

I've seen James a few times. Initially consultants got involved, in order to allay mum's fears. We also wrote to her GP, and arranged health visitors. Nothing worked.So now we've given up, and we just see the kid each time.

Yesterday he looked as well as he usually does. I think he's geting to know me, as he offered me a rusk when I was listening to his chest. I politely declined, and continued the examination.

I told his mum that he looked fine, and gave the standard advice about temperatures to her. She wasn't happy. I had a chat to her, and explained the symptoms of serious illnesses, such as meningitis, and explained why i didn't think james was unwell.

She was unhappy because we "never do blood tests". This, to her mind, meant we weren't taking her seriously.

I don't know what else to say. I tell her I'm not going to do blood tests. We argue. She goes away unhappy, and says she's going straight to her GP. I think that's a good thing actually, as I think she could use some help.

It's a difficult situation, and an akward one. But what do I do? Investigating this well child is a waste of resources, and it will just foster the culture of dependence even more.

I rang the GP and told him that James was on his way. Social services are involved in a superficial way, and he's going to broach the subject of counselling.

I hope it works. I hope mum gets some help. But I suspect we'll be seeing alot more of James and Mrs Wiley in the future.

*all names used in this blog are fictional.

Dr. Thunder

Lazy golf-playing, arse scratching Irish docs costing the elderly their health.

2008-10-18T12:28:00.002+01:00

Posted by: Dr. Thunder

I read this yesterday. It's a short article in the Irish independent:

Source: http://www.independent.ie/breaking-n...s-1502090.html

The Tanaiste is putting pressure on doctors to reduce the amount of money they receive to provide healthcare for elderly medical card holders. Mary Coughlan has indicated that if GPs were prepared to take less money, the Government could readdress the abolition of universal medical cards for the over 70s. There has been uproar since the Government announced in the Budget on Tuesday that they would be scrapping the scheme, which automatically entitles every person over 70 to a medical card.The Minister for Health issued modifications to scheme last night.People on the State contributory pension will still qualify, and those over the threshold will receive either a GP-only card or a €400 annual payment, depending on their financial situation.

I think the Irish government are taking lessons in spin from the British government. When I was a paediatric SHO in the UK, all ills were blamed by the government on doctors. We were told we didn't work hard enough. We were told we weren't efficient enough. Patients were told not to let us hold them to ransom.
Then they went to town on the GPs. The Labour government said they were going to sort out those lazy bastards. They told GPs that they'd be paid ONLY for the work they were doing. They had made the assumption that GPs didn't work hard. Everyone working in the NHS knew that was a crock of balls. But I guess people in ivory towers in london don't really get the coal-face view.
Anyway, they paid the GPs for EXACTLY what they did. And it almost bakrupted them. The government soon found out just how productive British GPs are. So, they got paid a lot of money. Not the 250,000 pound salaries that the media talked about. But nonethless the GPs mostly got a payrise, as they were now being paid for work they previously did for free.

So, now the irish government are following suit. Our deputy prime minister (known as the Tanaiste in Ireland) is engaging in a bit of damage limitation. She has had to tell pensioners in Ireland that there's not enough money to provide primary healthcare for them.
But that's bad news. It doesn't look good for the health service when politicians have to make tough decisions that involve curtainling healthcare. That doesn't bode well for the next election.

So, they tell the public that the reason for their piss-poor healthcare provision is that GPs are over paid. They want them to take less money, to help the government out.
Now, I'm not a GP. But if I was, I'd be telling Mary Coughlan to take a jump.
The governement negotiated a contract with GPs, and now suddenly they want to change the terms of that agreement. They know no lawyer is going to be able to pull that off by force, through legitimate channels, so they use this disgusting spin.

"Old people can't get free healthcare because doctors are too greedy". Why are doctors the only group within the health service being asked to take a pay cut? Sure, they have to be paid, but so do lots of other people who are involved in the running of the medical card system. Admin staff, accounts staff, politicians and advisors are all taking a cut.

I would argue they're all less efficient parts of the equation than the GPs.

The Irish government tried this recently with the pharmacists. They decided they didn't like how much they were paying them, so they tried to bully the chemists into taking a big cut in their remuneration. That was equally as cynical, and it didn't work.

My advice to the health service executive is the look at the big picture. If you want doctors to work with you, and cut you some slack when they're senior enough to GPs....then stop treating them like crap when they're juniors.

Who is ever going to feel any loyalty to a health service that breaks them down to the point of emigration??

So, should GPs take a pay cut? Or are there other ways of making the health care system efficient enough to, well, provide healthcare?

Please welcome our newest blogger, Dr. P

2008-10-11T16:38:00.003+01:00

Hi guys,
Dr. Thunder here. Just posting Dr. P's blog entry while we sort him out with a password etc. Dr. P is a medical registrar working in Ireland. Here's his 1st post:

Few things to me seem as naturally paradoxical as locum work.

Condensation builds up on the windscreen of my pride and joy as the clock ambles particularly showly from 8.30 to 8.55. Here goes.
The sympathetic orchestra slowly climaxes in my small intestine as I click my car door shut in the shadow of my place of employment for the next few days.. (or at least the next few hours).
The fear and desire to take flight are in stark contrast with the determination and certainty that won me this short adventure in mercenary medicine in the first place.

I had to regularly update my CV. I had to provide proof that I was Hep B immune(again at least for the next few hours). And most importantly, I had to alert the agency that I would be available to stand in for one of my absent peers.
With lightening fast fingers, I dialed the agency. ‘Hi... Yes I’m available for the job in Portlaoise/Sligo General/St Lukes Hospital… Great… Thanks, talk to you then.’..
Click...

Some say locums get a raw deal. Not necessarily so. Suspicion is much more often bestowed on Medical Mercenaries than any significant level of responsibility. Locums usually carry out the work of juniors.

Studies somewhere would surely show that locums are at least twice as likely to be asked to perform the PR exam that the Reg forgot, roughly 30% more likely to be asked to take the peripheral blood culture that eluded the intern and four times more likely to be holding the SHO bleep for the less sought after portion of the night.
Thankfully, this contrasts with the inflated hourly wage of the Locum.
And the less advance notice the Locum recieves, the more hansomely rewarded he or she is.

But what I find most paradoxical however about my species is the fact that most locums are already overworked in their regular jobs.
Why am I doing this on my week off I think to myself as I walk into a ward I’ve never seen, a list of patients I’ve never met and a barrage of questions I’ll hear over and over again?
‘So where do you work normally?’
‘Do you not need your holiday?’
‘Are you saving for something?’
In a climate where we complain of the hours that we are forced to work, I’m choosing to work just a few more.. Why?
Why not? It’s 80 euros an hour. I’ll take a break on my next week off.

Dr. P

The Dr. Scot Junior saga (2).....are these fuckers for real???

2008-09-13T04:59:00.004+01:00

Posted by: Dr Thunder

So, a lot of people are aware of the "Dr. Scot Junior" saga. Jane Doe's post below outlines a lot of what the case is about. Essentially, a scottish junior surgeon was posting his views on the doctors-only password-protected website http://www.doctors.net.uk/

On one of the mesage boards, he called Dame Carol Black "A shit". This is because Dame Black was heavily involved in the "rearrangement" of junior doctors training in the UK. This training revamp has pretty much destroyed the training of British doctors, and has had huge impacts on their personal life. Pretty much every British junior doctor thinks Carol Black is a shit. Her and her colleagues get called much worse in doctors' scabby tearooms across the country every day.

Anyway, Dame Black's mate, Professor Gillian Needham, up in Scotland, decided to ban Dr. Scot Junior from practising surgery there.

Now, I worked in Scotland for several years. Healthcare there is the pits. There are parts of Scotland where the life expectancy of males is 64. That means some Scottish males are expected to die before retirement!!!!!

The Scottish health service cannot afford to ban doctors. Not because they were a bit cheeky, anyway.

So, there were apologies. Dr Scot regretted his choice of words, and asked for his comments to be removed from the website. Professor Needham had no real choice but to reinstate him and allow him to continue practising. Especially as the Medical Council tells us that doctors should only be banned from working if their actions put patients at risk. There are no rules covering doctors who cause offence to your coffee-morning pals.

But she was pissed. This upstart has mocked her friend. Needham and Black have helped fuck up the lives of junior docs all over the country, by, for example, advocating a sytem which tells married couples with kids and mortgages that they have to move to opposite ends of the country to work until 2010, as part of the "training revamp" This is on top of making lots of doctors unemployed.

I left Scotland to go to Oz because of these gobshites. I will never go back. Scotland isn't exactly overflowing with paediatricians either.

As Prof Needham was angry, she decided she wasn't finished with Dr Scot Junior. So, she's suspended him again!!!!

The poor guy had only been reinstated 3 days!!!!

This time the reason is being kept private, but it relates to something he apparently did years ago, just after he qualified from medical school.

It didn't seem to be an issue before now, until he offended Needham's coffee buddy.

So, while the waiting lists in Scotland are out of control. Be safe in the knowledge that the medical hierarchy are looking after you and your loved ones by suspending the man who might cut out your colon cancer just before it spreads, or remove your appendix before it bursts. Be safe in the knowledge that no man who has the tenacity to call a superior "a shit" will be allowed anywhere near a scalpel in Scotland.

The NHS is in good hands.

Dr. Thunder

When do we stop? Should we stop?

2008-09-02T01:49:00.004+01:00

Posted by: Dr. Thunder

It's 2pm, and the emergency pager goes off. "Emergency, ward 4" flashes up on the screen.

We all drop what we're doing and run to ward 4.

When the emergency team arrives we're greeted by a flurry of nurses running around little Dylan, a 6 year old boy with severe brain damage. Monitors are beeping loudly, there are tubes everywhere, and Dylan looks crap.

He has pneumonia. For the 6th or 7th time this year. This time it's really bad. This happens to him every few months without fail. Now that it's winter, he suffers a lot more than usual.

The problem this time seems to be that he has very severe pneumonia and is struggling to keep his oxygen levels up. After examining him, it becomes obvious that he's punctured one of his lungs now, and it looks like some of the bacteria in his lungs have made their way into is bloodstream, causing septicaemia.

He's a very sick boy.

So, we stick a tube into his lungs, through his chest wall, to drain out the excess air from his punctured lung. We give him a lot of fluids intravenously to help with his low blood pressure. We give him lots of oxygen. We pump some more antibiotics directly into his bloodstream.

This all helps, but it's not enough. Dylan is really struggling to breathe now, and he needs to go on a life support machine. This involves putting a tube into his mouth and pushing it into his lungs, allowing us to take over his breathing for him.

We managed to stabilise him where he is, and transfer him to intensive care. He stayed there for a number of days, and is now back in his old ward. He still has his pneumonia, and he's still very sick. He'll be in hospital for a while. When he goes home, he'll be back within 6 weeks.

The reason I bring up this incident is because there's a number of staff who don't think we should have resuscitated Dylan. This kind of thing happens to him several times a year, and he's always pulled back from the brink.

But in the interval, Dylan has really no functional capacity whatsoever. His mum think she can make out when he's trying to smile, but that's about is. He has no speech. He can roll his eyes around, but he's mostly blind. He gets fed through a tube in his stomach. He can move a bit, but not much. He has seizures most days, and they are almost impossible to control.

His mother remains very calm when he gets sick. She's been asked whether she wants all these intensive measures when he gets ill. She does. But there are a number of people who believe that this choice should be taken out of her hands.

They argue that, in the last few weeks, he's taken up a hospital bed for 4 weeks, and intensive care bed for 4 days, aswell as a stack of staff-hours and medication costs.

Personally, I don't like getting into the realms of deciding who's worthy of resusciation, and who's not. Dylan is a good example of how there are differing opinions. So, I just get on with it, and try not to think about it too much.

But I was just wondering what people thought. Should people like Dylan have a right to the same healthcare as the rest of us? Should the final decision rest with their parents? or does there come a time when the hospital should step in and call time?

The Hours: (not the depressing film about Virginia Woolf, something different entirely. Still fairly depressing though...)

2008-08-31T02:20:00.005+01:00

Posted by Dr. Jane Doe.

Out of hours. This phrase haunts my life. It’s in the papers, as in “GPs don’t provide out of hours cover properly due to golfing commitments”, or “Women doctors won’t work out of hours for fear of breaking nails” or “Out of hours access to such and such a service is shite” etc etc etc.
It’s not a phrase that is misunderstood very often though. Traditionally “out of hours” is taken to mean outside the hours of approx 9am to 5pm. Night work. Weekend work. That sort of thing. People have a fairly good understanding of what it means.

One phrase, however, that people outside medicine do NOT have any kind of understanding around is the phrase I think I hate more than any other phrase in the whole world. “On-Call”.

I didn’t really understand about “on-call” properly myself before I graduated and began working as a doctor. People often get really angry at me when I say this, for whatever reason. They say “Oh you expect us to believe you trained as a doctor without knowing about the working hours.” “You knew what you were getting into before you started so you can’t complain.” And of course, the single most oft trotted out “But you get paid overtime for those hours so you can’t say anything”.
You see, most lay people think that “on-call” is done from the end of a phone, from the comfort of your own home, or perhaps a nice doctors lounge. They think you get called once or twice a night, order some meds per phone, and generally sit around raking it in while doing nothing.

I don’t blame these people, because I didn’t understand about “on-call” before I DID it and I can see where they are coming from.

My very first day as an intern, we all drew straws to see who was doing the first night’s call. I and three other unfortunates ended up doing this. It was at this moment that I really understood that I had come to work at 8am, and would not go home that night, but stay in the hospital working. Not only that but I would be in the hospital starting a new days work at 8am the next day and would remain there until at least 5pm. 36 hours straight in the hospital, working, bleep on.
I felt sick, and most NCHDs will tell you that nauseous feeling of dread you get when you wake up the morning of a day you are rostered on a 36 hour shift, or “on-call” that night cannot be reproduced by any other set of circumstances.
It gets worse though. Oh, so much worse.

I also drew ANOTHER short straw, and that was to do the first weekend also. I asked the SHO what that entailed, and I still remember the shock I felt when I heard her reply.
“Oh”, she said, looking half regretful, half sympathetic. “It’s um, it’s not good here. They don’t split the weekends here. You come in Saturday morning and you go home Monday evening at 5pm”.

I felt the blood go from my face. “That can’t be right”, I said. “Don’t you even go home to sleep? That’s three days and two nights in a row!! Is that legal?”
She gave me a pitying but also amused look, “Probably not, but you can’t do anything about it if you’re a junior doctor.” She saw my face. “Look, at least you’ll get it out of the way, you won’t have another weekend for a while. And you’ll get double time on Sunday”.
I couldn’t have cared less if I got quintuple time on Sunday. And a foreign holiday thrown in. The first “on call” had been bad enough. I had slept for two hours from 4am to 6am, and gone on to work a full day the next day. I remember as I was getting dressed in the tiny hospital residence room saying to myself “I survived.” My eyes were burning all day long the next day. My muscles ached. I was constantly thirsty for some reason. I was emotionally labile-the slightest cross word (and in Irish hospitals junior docs will hear a lot of these) made me want to cry. And the fatigue made every single little job sound like an insurmountable hurdle.

The 56 hour weekends from Saturday to Monday are still happening in Irish hospitals all over the country. I can’t even describe how bad these are. You will have worked all week already, leaving work on Friday evening like everyone else. You then come in on Saturday morning (in some hospitals they make this Saturday at noon) and you pick up your cardiac arrest bleep and get to work. There are no scheduled meal breaks when one is “on-call. You eat when you can and you often have to leave your food to answer bleeps and attend to jobs. Even going to the bathroom is subject to when you can. You have no, I repeat, NO scheduled breaks.
You work all day Saturday doing whatever it is you do, if you’re an intern, doing scutwork and reviewing ward patients, if you’re an SHO, down in the A&E admitting or reviewing sicker patients on the wards, if you’re the registrar, also in A&E, or seeing consults on the wards, or reviewing the sickest people in the whole hospital and supervising the other two when you can. You work all night Saturday night and try to get to bed when/if you can. You may be lucky and get three or four hours total sleep, or you may get none, as is more often the case. You have a shower the next morning and get working again, and do the same all day Sunday, and all night Sunday night. At this stage you are incapable of safely driving a car. You are sick with fatigue. And here’s the killer-the next day, Monday, the start of a brand new week for everyone else-you have to do your day job EXACTLY the same as though you hadn’t just worked 48 hours straight with no sleep. No slip ups in performance will be tolerated. You’re so so slow to respond to anything or do anything at this stage that all your work takes you twice as long, and you usually get home later than you would on an average day.

So here’s where normal people say “Ah, sure at least you’ll have a day off now, yeah?”
WRONG. You’re back into work Tuesday morning, bright and early. You work all that week too. Making a twelve day week with a 56 hour weekend in the middle.

You see, the reason I didn’t really think this would happen before I started work as a doctor was that doctors are meant to be pretty smart people. It takes a lot of points in the Leaving Cert to get into medicine. It takes a lot of academic work and study to get your medical degree. It takes many post graduate exams and continuous courses and study afterwards to become a consultant. I couldn’t really fathom why these intelligent and motivated young people were all doing this. Within minutes given the total number of staff I could whip you out a rota where someone did a week of nights and had a few days off afterwards and spared everyone else this kind of horrific, dangerous and extremely stupid caper. In fact I did once or twice. But no-one will have any of it. And no-one will listen. Why?

A lot of people will say that it is better for “training” to work marathon shifts of 40-60 hours at one stretch. I will say this now-anything I have learned of any value that I remember was from a consultant or senior registrar during the DAY when they had time to teach me and I had any inclination to learn. The fact is that in Irish hospitals “on-call” you end up doing so much work that in any other developed Western country is performed by other staff (staff on shift work, not being paid overtime, which is CHEAPER, by the way) that you learn shag all. The antiquated idea that it “toughens you up” is illogical in the extreme. How? I’ve personally been forced to stay awake for 40 hours straight on average once or twice a week for a few years and all I got out of that was ill health and a vague feeling that I might have PTSD. I think it weakens people, if anything. It certainly makes them leave and go to the UK/Oz/NZ, that much I can attest to.

I wouldn’t want my relatives in the care of exhausted and suboptimally functioning junior doctors like these. I worry about a time, maybe years from now, maybe not so far away, when one of my parents or grandparents may need to be in hospital, and people in the depths of exhaustion, struggling just to live through their own extended shifts, are half heartedly treating them in the night where services are already at a minimum and any mistakes or problems tend to have much worse consequences then in daylight hours.

What’s so bad about doing a week of nights, people?

Here, down under, we still have what we think of as “on-call”. It is also known as “a long day”, from 08:00am to 23:00. You come in, do your days work, and then from 16:00 onwards you do whatever it is you are allocated to do until 22:30, where there is a scheduled supervised handover to the night team in a designated meeting room. Ah. Like a breath of fresh, common-sensical air. Better for training, patient care, and doctors wellbeing.

TRAINING:

Shift work is BETTER for training than the Irish way. Not worse. Here’s why:

In my experience here, from doing acute medical “on-call”, the registrar and SHO admit on average about 15-20 patients from 08:00-22:30.

In Ireland, this would be unthinkably busy. Maybe A&E put in an IV line, maybe they didn’t bother. 15-20 IV lines, making up all those first dose IV meds and giving them and signing for them, taking any repeat bloods that need taking, doing ECGs, resiting the IV lines as they invariably fall out, the hassle and hell trying to organize even one CT scan “out of hours” not to mind getting it read.

Here, IV lines and bloods that need to be done will be done by the IV technicians who come on at 16:30. So will repeat bloods. Just write in the notes what time. ECGs and first doses ALL done by nursing staff. Basically your job is what a doctor’s job is supposed to be. You admit the patients, take histories, examine them, diagnose them, order investigations and follow up as needed. And you see more cases by 23:00 than you would have seen in your 36 hours constantly awake back home. And you aren’t exhausted so you remember them. And you have time to do procedures, and back up if you fail at doing them. Everyone back home has been in the situation of trying to get a lumbar puncture at 4:30 am and calling the reg, who blearily and exhaustedly says “just keep trying”. If people aren’t exhausted, they will do better jobs. Not rocket science.

CONTINUITY OF CARE : As for continuity of care-that is another weak excuse for dangerous working hours and workloads. Unless the same doctor is on the premises 24-7, 365 days a year, there IS no continuity of care. In this day and age, with increasing complexity in medicine and increasing caseload, what is of paramount importance is continuity of information. Formal handovers at designated times and places, supervised by senior staff and co-ordinated by a team co-ordinator minimize anyone “falling through the cracks”. By the way-there are NO formal handovers that I know of for doctors in Ireland. Some may conduct their own informal ones if they are worried about someone.

Also-if your team are on acute medical take here, the patients remain under your team. You know the 15-20 you admitted. Maybe 9 more overnight, nights tend to be less busy. They will have been admitted and thoroughly assessed by a well rested doctor and all you really have to do is read the notes and go see the patient yourself. So what if you didn’t admit them, you can familiarize yourself with them fairly quickly, you are supposed to be able to do that with any patient if you are any kind of a doctor at all, and they will be your patient from now until discharge. Put a well organized summary in the notes for the night/weekend teams and continuity of information and hence preservation of good care are maintained.

In Ireland it is not usual for the registrar and the house officer of the same team to be “on call” on the same night for their own consultant. Some services in good hospitals do try to arrange it like that, but with differing numbers of every grade of staff and rotas made out by management, it is not usually the norm. Hence the pretence of continuity of care being preserved by extended shifts of 40 hours is farcical anyway. You’re on call admitting for a different consultant, and the reg from a different team is also on call for a consultant not their own. What’s so continuous about that?

Surgical services appear to be different, and need more exposure to time in theatre necessitating longer hours than most other services. However, they still go home and sleep for 7 or 8 hours here, and surgical outcomes appear to be just as good as at home.

One final point, (speaking of “hours”, it’s going to take anyone “hours” to read this longwinded post), I feel I must correct anyone who thinks that we should suck it up as it’s only for one or two years and then we’ll be registrars.
You see, a lot of people, I have discovered, think registrars are NOT junior doctors! Even some nurses think this.
Registrars are NCHDs, that is Non Consultant Hospital Doctors, same as SHOs, same as interns. They are required and forced to work the same hours and often more than SHOs or interns. It’s true, they’re not junior in the sense of the word, but their working conditions and entitlements are, and this is all the more shameful. Hence the years spent working dangerous extended shifts can be as long as ten or fifteen years.

I hope this has shed a little light on the antiquated reality of the archaic working practices of the junior medical workforce in a first world Western developed country. It’s embarrassing, frankly. Far from being tough, we are simply not adapting to suit the times and the needs of patients and doctors. And it needs to change.

A Different Way of Doing Things

2008-08-24T06:24:00.005+01:00

Posted by Dr. Jane Doe.

I’ve been pondering the way in which healthcare is delivered here and looking at why it seems to work so well here in comparison to Ireland. I am gradually getting used to the way things are done here, and hence the differences are not always apparent to me anymore the way they were when I first arrived to the Antipodes. However, the recent influx of Irish junior doctors fleeing the system back home have reminded me of ways of doing things and procedures in place back home that I had forgotten about. And one of the things that I had almost forgotten was the difference in the general attitudes and perceptions surrounding hospital delivered healthcare at home. This sounds like it might be a woolly, subjective thing, but actually it is not. The attitudes and perceptions that people have influence them to shape systems and procedures accordingly.

One of those things that struck me here was the attitude of both doctors and patients towards the delivery of healthcare. The perception in Oz/NZ is very much “We will fix the problem you came to us with. The other things must be dealt with in due course, through the proper channels, unless they have direct influence on the outcome of the problem you came to us with.” The doctors make no secret of this, if you are admitted to hospital with pneumonia, we will treat and cure your pneumonia. The gastro oesophageal reflux symptoms you have been having you will need to see your GP for. If he/she thinks it is appropriate, they will prescribe you something and/or refer you for a gastroscopy, at their discretion. The high blood pressure that is somewhat inadequately controlled you should mention to your GP while you are there, and they should adjust your antihypertensives accordingly. We will cure your pneumonia, and then you will go home. We will not see you in clinic in 4 weeks time to check on your chest, make sure you have had a gastroscopy, and check your blood pressure. Your GP can comfortably manage all of those things. If they have a query about anything they are welcome to contact us.

Hospital consultants in both countries, for the most part are specialists who usually participate in acute medical “take” in the interest of service provision ie. they have general medical patients with non-specialist requiring problems admitted under them every few days or so on a rota that they share with other specialists medical consultants. This is essentially how acute hospital based medical care is delivered.

If you employ the attitude above, the “We will fix only what you came to us with” attitude, what you DON’T get is Outpatient Clinics with 50+ people in them every day, waiting and stewing because they have to wait, and getting all upset because they were seen by a junior due to sheer workload and also because they are a return patient with no serious problems. Because the above patient and others like them can be followed up perfectly well by their GP. Indeed, they SHOULD be followed up by their GP for these things-ultimately the GP is going to need to be the most familiar with all of these problems and manage them accordingly.
In addition, the specialist consultant, say, an Immunologist who does medical take, is not seeing return patients with heartburn and high blood pressure in their clinics-they are seeing the people that need to be seen with rare T-cell deficiencies, severe combined immunodeficiency, people with atopic conditions, treatment refractory asthma, etc etc. Hence not too much of a wait for the specialist appointment if you really need one.

In Ireland, usually, most patients that come in under any consultant are booked for follow up appointments in Outpatients to check, basically, that they’re ok post discharge. The attitude among patients and staff is that the patient is going to have an NCT while they’re in hospital. There are a few reasons for this. (For those of you not from Ireland an NCT is a type of car servicing that sorts out the whole car so it can stay on the road-a roadworthiness check)

Every doctor is acutely aware of the waiting times in Ireland for procedures due to understaffing and stretched resources.

Your patient has been having heartburn for the past few months. They’ve lost a little weight but they think that’s maybe because they’re not eating so much because they have heartburn but they’re not too sure really. You ask have they tried anything for it-ah sure they got tablets from the doctor but they’re not really sure, maybe they were for the chest infection.

Hmm. The pneumonia’s gone. Patient is well, and should go home. But there’s the heartburn and the possible weight loss. Their haemoglobin is fine and it sure ain’t urgent. But they’ll be waiting for months and months on the outpatient scope list, so might as well sort it while they’re here as you never know, it could be something. It’ll mean a couple of days more in hospital as the inpatient scope list is pretty busy and your patient is pretty non-urgent but better to keep them in. More nights in a hospital bed that costs 600 euro a night. Their blood pressure’s high too. You’d better tinker around with their meds. Might add in an ACE inhibitor, they’re on all the other stuff already. Now you need to be monitoring their U&Es while they’re in hospital for the next few days.
Well they got their scope after three or four days, and now they’re on their way home. Seeing as how you ordered the scope, know the story, and also tinkered with their antihypertensives, they will need to be seen by your team in Outpatients really. The GP could follow up this stuff, but if there’s anything on the scope they will need a referral to a gastroenterologist or a surgeon, and again, this will happen faster if they are in the hospital system. And this happens to almost all your patients, and hence outpatient clinic lists grow ever longer.

In Oz/NZ if their pneumonia is gone you send them home and send a detailed letter to their GP. The GP makes an appointment for the patient to have an endoscopy which is done in a couple of weeks. There is no real indication for doing it sooner. They adjust the antihypertensives and check the renal function. The patient does not have to return to hospital for an outpatient clinic visit and wait a couple hours. All the stuff that should get done, gets done, in a timely manner. The scope lists aren’t clogged with not so urgent inpatients who need to be sorted before discharge otherwise they will be waiting weeks/months, and paradoxically, this means there is a little less total waiting time for scopes.

I can see why we did things the way we did in Ireland. The waiting lists for things are so long, we try to find ways around them, each one of us, for our own patients. But is this behaviour influencing the length of the lists and having a boomerang effect for us? I don’t honestly know, but thinking about it like that, I fear it might be.

But patients as well as doctors think differently in Ireland too. A large proportion will not be satisfied with you simply curing their pneumonia. I have been called out of clinic or away from ED because they want their antidepressants adjusted or maybe changed before going home. I explain that it’s not really appropriate for me to do that as I am not the doctor that is managing their depression (usually their GP or occasionally a psychiatrist). They become VERY unhappy with me as do their families and I end up having to get a psychiatric consult before they go home. Again-not so urgent-so maybe waiting another night in hospital before they see the psychiatrist. You can’t force someone out of the hospital if they really don’t want to go.

This simply does not happen here. I don’t know why. Patients seem to understand how the health service works here much better, and they tend to understand that certain things are more appropriately followed up by their GPs. But it is also pretty easy to see your GP here. They’re not very expensive, and there are a lot of them and it is really easy to get an appointment as they are not all snowed under. I walked in to a random surgery here one day for a check-up. I was waiting about ten minutes and they apologized for the wait! I’m quite used to waiting myself up to two hours at times back home, and usually bring a book and a drink, or my IPod. It’s expensive to see your GP at home if you don’t have a medical card, and access can be an issue as they are very, very busy.

Here in the Antipodes there is a fair amount of revenue spent on educating the public. There was my personal favourite, the “1-2-3 Where should I be?” campaign a few months ago that explained in an easy to understand, logical and unpatronising manner the difference between your GP surgery, the 24 hours acute care walk in services, and the Emergency department, and gave examples of conditions appropriate to each one as well as numbers to call if unsure. It was on billboards, TV, bus stops- everywhere. I thought again and again how we could do with that back home. How could you always know if you are not a medical person and you are in pain, where you are better off being?

It looks like more staff and resources again are at least one of the answers. The city I live in currently, I swear there are at least three medical centres on every street. GP access-SO not a problem. When I phone to make an appointment for an inpatient I’m given whatever day or time they want, instantly. There are one or two MASSIVE 24 hour GP acute care facilities and they too are easily accessible and uncrowded. If they refer you for a scope, chances are good you will get it in a couple weeks, because there are more resources and staff per capita than at home. Hence uncomplicated hospital discharges stay just that. Specialists don’t have to be hospital based GPs for at least half their clinics. People who need specialist appointments get them faster because specialists aren’t being hospital based GPs for at least half their clinics.

The next answer is more controversial. We need free access to primary care for all our citizens. Cost is a limiting factor in a LOT of people’s unwillingness to attend the GP in Ireland. I am not an economist. I don’t have a lot of ideas how this can be achieved. Practically, I think we may have to accept that we will have to ultimately pay more taxes, but I don’t really know. But it needs to happen.

Public education is another thing we need. Most Ozzies/Kiwis will tell you the names of their tablets, inhalers etc, and can often tell you doses as well. A LOT of Irish patients can’t. Because the time has not been spent telling them. The time, and the staff, often simply aren’t there, or are too busy. I have never seen posters telling people the most appropriate ways to use the public health services available to them back home.

All of the above, unfortunately, cost money. A LOT of money. More staff, more resources, more public health involvement in educating the public, more media campaigns to do so. This isn’t a post on how to save money for once, but a post on how things would perhaps be if there was more money to spend. And I don’t have the answers to that one.
Dr. Jane Doe

Rageing mums

2008-08-10T11:35:00.002+01:00

Posted by Dr. Thunder

There's something in the water over the last week, I've always said that the Aussies are a bit more aggressive than the Brits and Irish, who used to keep a "stiff upper lip" about things. If they had a gripe, they'd complain to their friends and family, rather than to me. That's not neccesarily a good thing by any means, but that's the way it was.

Here in Australia, it's very different. People complain. A lot.

It's one of the few things about life as a doctor over here that's tougher than being a doc in Ireland or the UK. I've definitely been hollered at more (by staff and my patients' parents) here than I ever was in Europe. In some ways it's a good thing. You usually know if people aren't happy with the care you're giving their kids, and you can explain the reasoning behind it. So, in some ways it's actually conducive to a better working relationship.

But in other ways it's just a pain in the arse. Like this week

Parent 1 went to see the paediatric orthopaedic surgeons about an infected wound. The surgeons had put it in a cast, for some reason best known to themselves, and told the kiddy to come back for review in 3 days. At the follow up appointment, the cast was removed, and the wound was still infected. So, they rang the paediatric registrar on-call......me.

"Hi Dr. Thunder. Its Dr. Bone from orthopaedics........blah blah blah.......we think this it's cellulitis., that will require IV antibiotics. Can you come and review?".

"OK", I said "But limb celulitis is something you guys can manage, so can you start the IV antibiotics? I'm stuck in the emergency department with quite a few sick kiddies, so it's going to be about 2 hours before I get there".

"OK, no problem".

2 hours goes by and I ramble onto the ward to see this kid. I walk over to the bed and say "Hi, I'm Dr. Thunder, how are we all doing?".

The torrent of abuse was unforgettable. It's also unrepeatable here. I was lambasted by this indignant mum for taking "2 WHOLE HOURS" to come and see her sick child.

I explained that there were 3 very sick babies in the emergency department, and I simply had to prioritise. Most people can see that kind of logic. But not this lady......"But we've been waiting TWO WHOLE HOURS" she repeated.

So, then I changed tact. I told them that the diagnosis of cellulitis had been made and that the antibiotics had been started, so any delay on my behalf wouldn't affect the outcome, as I was just here for a second opionion (In relaity I had no idea what I was there for, but I'm known in the hospital as someone who rarely refuses a referral for a consult. I'm a soft touch).

"The fucking antibiotics haven't been started yet. That's YOUR fucking job".

She was right. Nobody had bothered their arses starting antibiotics on this kid.

So, I sat there for a few minutes listening to some abuse, while writing in the notes. I have no idea what she said to me. She was screaming at the top of her voice about how I'm lazy and incompetent and the whole hospital should be shut down etc etc.

I walked off without saying a word. I paged the othopaedic surgeon with the following message "I can't believe you sent me into the jaws of hell without warning. Revenge will be mine. And don't think I'm cannlating that kid for you either!".

Parent number 2 rang me directly. She convinced switchboard to put her through to the on-call paediatric registrar. I answered the phone..."Hello Dr. Thunder, paediatrics".

"I want a prescription for Omeprazole 20mg twice daily, salbutamol 2 puffs as required....are you writing this down??.

"Eh, can I ask who's calling?".

"Mrs Smith....I also need some lamotrigine......".

"Hang on just one second. WHO ARE YOU?? Why are you ringing me up to write you a prescription?"

She sighed loudly, and started to speak very slowly and condascendingly."My son is a patient of the hospital. He gets these drugs. He's run out, so you need to write him a prescription".

Fine. I can do that. It's his own doctor's job, but if he's run out, then fair enough. So, I took his name and patient number so I could get his notes. I told his mum I'd prescribe whatever is in his notes. She said "OK, I'll be in at 11am tomorrow. Bye".

She hung up.

At 11, the pharmacy rang me. "Eh, this crazy lady is ranting and raving because you've prescribed the wrong drugs".

So, I went dowstairs to see her. Apparently her GP had changed a few doses since their last visit to the hospital, and she wanted them prescribed. I told her that I'd have to check with her GP first. At this point she went flipper. "Are you saying I'm lying?? I've been waiting half an hour for a simple prescription. This is outrageous. I'm going to write to the hospital about this".

So, I lost it. I shouldn't have, but I did.

"Listen. I don't know your son. I've never met him. I don't know him or you. I don't know if you're trying to scam drugs out of me, or if his GP did prescribe them for him. But I can tell you this much...you'll either wait for me to check with his GP, or you'll get someone else to write this prescription for you. I'm doing YOU a favour, and I won't be spoken to like this.

I was quite proud of myself.

"But I've been waiting half an hour and it's just a prescription".

Oh sweet jesus.

I phoned the GP. Her story checked out. I wrote the new prescription. I brought it out to her. She just grabbed it out of my hand, and stormed off, as though she'd just dealt with some faceless, obstructive beauraucrat.

You can't win 'em all, I guess. But It would be nice to win once in a while :P

I've posted this not to have a go at anyone. I guess it was merely to point out that it's not all rosey in the garden of Australian healthcare. It's a damn sight better than what you deal with in Ireland and the UK, but we still have a way to go before we have a totally contented bunch of junior doctors.

Dr Thunder

Lets All Hold Hands and Dance

2008-08-09T13:45:00.005+01:00

I'm constantly apologising when I write to this blog, mainly because I never post as much as I want to. In truth thats down to two things........1) I've been so horrendously busy lately with the new job and 2) the Ain't No Angel wedding 2008 is quickly approaching and any free time I have gets taken up by that!

So bear with me folks,

I'm sure you've all been very happy though with the new addition to the team, Dr Jane Doe. Her posts thus far have been insightful and reasoned, much better than the tripe from that old hack Dr Thunder........:)

Joking aside though, its great to have her aboard, may she be the first of many more new team members!

So now for the bit you've been waiting for.....the Ain't No Angel trademarked rant.........

You might be wondering why I've posted a picture of Fernando and Robbie, looking happy and joyous above. Well apart from the fact that signing Robbie is an inspired decision on the part of the GodMan Rafa, I'm using it as a visual illustration of a concept sadly missing from the Irish Health Care System.

Let me explain........

Liverpool football club have many great players, but what we really missed last season was a player to play with Torres to link the midfield genius of Steven Gerrard/Alonso/Mascherano with the blonde excellence of Torres. Sure from time to time Stevie G stepped up to the plate and performed excellenetly, but it was never consistent enough for my liking, and ultimately we relied on Torres to produce a special moment far too much. This is were Robbie comes in, not only can he score many a fine goal himself, but as a player who sits back a little, works hard and links up the play he is one of the best around.

The Irish Health service is very similar. No.....we don't have long haird Spanish goalscoring machines performing colectomies, or emptying bedpans,but what we do have is this.......

All in all our hospitals are pretty damn good. When I say this, I mean from a clinical point of view. Our nurses, doctors and other professionals are well educated bright people. The standard of care once you get into a hosptial bed is good. Sure, there are resource issues etc but taken in isolation our medical care is comparable to anywhere else in the developed world.

When you look at the community setting, things are always so rosey, but certainly improving. Schemes like Hospice in the Home, which allows those patients on the last rung of the ladder, to die in their own home, with dignity and family support, are certainly excellent. I could name more.......the Diabetes Watch Scheme in the North-East, the countless local community day centres and community units.....and not to forget the army of Public Health Nurses covering huge areas of the country on a daily basis. Again, resources are an issue, but if all these things disapeared in the morning, chaos would ensue. I'd go so far as to say that those in the community are most definitely keeping the wolves from the door and playing a very large part in keeping the whole health service afloat.

Anyone see the anaology here.........

The hospital setting ( some world class staff in a system that needs some more basic funding and management)

Liverpools midfield ( some world class players, in a team that needs some more basic funding and improvement)

The community setting ( over-relied upon, over-worked even though they rarely complain and just get on with the jobs that they have to do)

Fernando Torres ( over-relied upon, over-worked even, rarely complains and just get on with the job that he hasto do)

So who is the Health Services Robbie Keane in this long winded and possibily confusuing analogy.......any guesses???

Well that would be a second level, a level between the acute hospitals and the non-acute community setting. A level for those people not quite sick enough for say a bed in St Vincents Hospital but not quite well enough to be home alone go and get sorted. A level where GP's have access to x-rays, scopes and even CT's allowing quick diagnosis and treatment. A level that would speed up the discharge of patient out of the acute sector, preventing the blocking of beds (that happens by no fault of the patient) and cutting the waiting lists and emptying the A&E Departments around the country, as people don't feel that the only place to go when the they feel sick is the local A&E.

In the new job, I'm spending a lot of time following my patients from admission through to their eventual discharge and treatment in the community, and my God it can get complicated! Every region does things differently, the right hand doesn't always know what the left hand is doing and the red tape can be frustrating! In contrast, when I deal with the private health insurers with many of the same aims in mind, its sooooooo easy, efficient and simple.

Spot the difference??

Doctor, heal thyself. And hurry up, for f*$k sake, there’s plenty of work to be done. Posted by Dr. Jane Doe.

2008-08-06T00:05:00.002+01:00

I had intended to continue on with my cost cutting theme and bang out another simple idea for saving money within the health service. However, I’m angry about something and I think I’ll share:

I’m feeling a bit under the weather today. It’s nothing serious, but I am too unwell to work today as I am feverish, my glands are swollen, and I’m fairly miserable. It’s definitely contagious.

Now do I,

A) Suck it up, get my ass into work anyway and work anything from 8 to 36 hours straight with no designated break or sleep taking care of critically ill patients and making important decisions regarding their treatment and diagnosis while feeling terrible myself, unable to concentrate, almost unable to keep going, not to mind give them my full attention, such as it is at the moment? And almost certainly pass on my lovely virus to them? Being old and frail and already ill it might even be the straw that broke the camel’s back. And drive home afterwards in an impaired state and possibly endanger fellow road travelers as well as myself.

OR

B) Recognise that my performance and decision making ability as a doctor is very likely to be seriously impaired today in addition to the fact that I have a responsibility to both patients and other health service staff members not to be at work when I may pass on a contagious illness and affect their health adversely and potentially cost the health service more in sick leave for others. If I become sick while at work, then after notifying my line manager who arranges cover I am expected to get a taxi home at the hospital’s expense if I cannot arrange for someone to pick me up.

I have done both. A) is the course of action you are expected to follow in one of the countries I have worked in. B) is the course of action you are expected to follow in another. In both cases the expectations are those of management as well as your seniors and even colleagues at your own level and you are obligated to follow them to the letter, and if you make the wrong decision, the consequences will be on your head.

Which do you think is the right attitude to have towards your job and responsibilities?
Which do you think is the right attitude to have towards the public service employees you are responsible for? Which do you think is the right attitude to have towards your juniors or colleagues? Which is the right attitude to have regarding patient care?

There is a climate of fear in one of the places, and often if you are so unwell that you physically cannot come to work and you do notify management, they will become angry with you, particularly if you are rostered for a 36 hour shift that day. In some places they make another of your colleagues pick up the shift, and then when you are back at work you have to pay them back in addition to doing all of your own extended shifts that week, rather than attempting to get a locum in. Working a 110+ hour week when you are convalescing is a real picnic, let me tell you.
You notify your colleagues, and you can get a mixed response, but usually they are disappointed and more than a bit angry with you. This is because they are going to have a bloody AWFUL day trying to pick up your work along with their own, and everyone is already stretched to over capacity. They too, feel the absence of a locum keenly as they stay on late that evening trying desperately just to make sure the patients are safely looked after, and stable. They won’t thank you for taking time out. I have heard of doctors working when their temperatures are so high that they are actually hallucinating, and still no-one stops them or makes them go home (or admits them to hospital, at least until they collapse!)
The doctors cannot stand up for themselves. There is no support from any quarter. In many cases there is nothing much they can do at all, and they soldier on. But they suffer and patient care suffers too. And no-one does anything about it at all.

In another of the places there is a climate of honesty, openness and taking responsibility for your actions. You are expected to recognize when your performance may be suboptimal, for any reason, including stress, and take appropriate action and notify the appropriate person when relevant. There are ample provisions in place for the inevitable event of staff members becoming ill, or needing maternity leave, or bereavement leave or even a holiday. A pool of medical and nursing staff employed specifically to cover absence are available in the hospital at all times and are allocated on a priority basis according to the activity levels of the services requiring cover. In the unlikely event of all the pool staff being utilised on the same day, a universal bleep goes out to all other similarly qualified staff in the hospital offering extra money and/or time off in exchange for covering the gap at short notice. This almost always works, and averts the need to attempt to find a locum.

I must emphasise I am not referring in the above post to any specific recognised policies or procedures in place at any specific location. Many countries share the type A) mindset with the place I worked, and many countries share the type B) mindset. Both are a way of thinking put into practice. One works well, and one doesn’t. In the end, one ends up saving more money than the other. The thing is, the one that sounds initially more expensive is the one that in the long run works out much cheaper, and I’m not talking about anything other than money here.

Anyone have any thoughts about which one is cheaper, and why?

The HSE and Cost Cutting Part 2) Getting a blood test done: Posted by Dr. Jane Doe

2008-07-31T02:49:00.003+01:00

“A penny saved is a penny earned.”
“Take care of the pennies and the pounds will take care of themselves.”
“Waste not, want not.”

My grandfather was quite thrifty. He used to love those old chestnuts above. He was a great one for shopping around, and finding a bargain, and loved budgeting etc. Unsurprisingly he was a financial advisor for a large corporation and they loved all the money he saved for them. He grew up in the post WWII days when people were careful with money and businesses kept a hawk eye on the books.

The thing is, even small savings add up over time. Another example that struck me when I first came here was request forms for blood tests. Again, selfishly, I only noticed it because it made my life easier at first, but then I realized how efficient it was and how it must surely be saving money for the system.

In Ireland, every blood test you want to carry out on someone has a different request form. And different hospitals have different forms for the same tests. In Ireland, if you are on a ward round and your consultant asks you to get urea and electrolytes, coagulation screen and a full blood count on someone (this is pretty much a standard admission profile), then in some/most hospitals this requires three different forms. In the first hospital I worked in, the urea and electrolytes went on a blue form, the coagulation on a red form and the haematology on a purple form. There was a green form for miscellaneous things and microbiology requests went on that and sometimes inflammatory markers depending on what ward you were on.

You also had to write in the name of the test you want done, for example if you wanted a thrombophilia screen in a lot of hospitals you had to write in “Anticardiolipin antibodies, antithrombin III, lupus anticoagulant, Protein C, Protein S etc etc” and of course there was one you always forgot to write in.

Sometimes the nurse or occasionally irate phlebotomist would tell you the glycoslyated haemoglobin (HbA1C) went on a miscellaneous form, then the lab wouldn’t accept it because it was supposed to go on a haematology form (the red one). You would be called out of clinic or away from a patient to come and retake the blood yourself and put it on the correct form. “Which one would that be?” you’d ask. Invariably this would take up to half an hour because you’d end up having to run it over to the lab yourself as well as taking it.
Sometimes the ward would have run out of the haematology forms and you could only fill in the biochem forms. You’d have to make time to get one another ward and drop it over later. If you don’t get one in time, the phlebotomist will have come and gone, and you’ll have to take the blood yourself, and run it over to the lab while your bleep goes mad with other “Just to let you know so and so hasn’t had their potassium checked today because you didn’t put out a form” notifications. “Sure I’ll come up as soon as I can. By the way, there weren’t any biochem forms left on the ward today. Would someone be able to order some more please?” Don’t ever say this-the inevitable response will be “That’s not my job.” “I’m not the ward clerk” etc etc. You will get your ass handed to you.

In the second hospital I worked in, haematology requests and coagulation requests were on the same red form. I loved this. So efficient! Now just to fill in the yellow form for the urea and electrolytes. I need to do FSH and LH levels too though, this person looks like they have PCOS. Yellow form? Is that the one? No-it’s the blue form but we don’t keep those here. You’ll have to request one from the lab. The porter won’t get those so you have to run over and grab one yourself and then come back to take the blood because the phlebotomist’s already been and then drop it back over to the lab again.

Hey-this person had a rectal bleed. We should probably do a Group and Hold on him (send a sample for crossmatch and blood typing to the lab in case he needs a transfusion later on). You have to do that yourself. Phlebotomists don’t do those. And you have to drop it down to reception yourself-only a doctor is “covered” to transport those.

AAARRGGHH!!! Anyone remember Michael Douglas in Falling Down? “I’m-having-a-bad-day”.

Down Under, there is one form for all blood tests bar blood bank requests. Want to check glucose levels, urea and electrolytes, FBC, Coagulation, D-dimers (did these go on the red one or the purple one at home? I can barely remember!) and thyroid function tests?

Pick up one of the blood forms. No writing, except for your name and the date. Tick the boxes next to the name of the tests you want. Put it in the box. There are four phlebotomy rounds a day, at 07:30, 11:30, 13:30 and 15:30. The next one will get his bloods done. You check them at noon. His Hb is a bit low, he might need a transfusion. Fill out a group and hold form and stick that in the box. The next phlebotomy round at 13:30 will get it done. He can start his transfusion at 15:00 if he needs it. You haven’t left the ward. No time wasted. All the patients have been seen and blood tested and results checked and acted on appropriately.

Printing off all those different forms and shipping them all off to different hospitals must cost a LOT of money. Three or four different forms for a couple of common blood tests! And all the problems that can cause. All the wasted doctor time, time that you as a patient have to spend sitting in A&E, or Outpatients, or the ward, waiting to be reviewed by a doctor who can’t come review you because they are acting as a phlebotomist despite the fact that we are PAYING phlebotomists so other people won’t have to leave their work to come and take bloods! All the overtime we pay to that doctor who stays late reviewing people who have had to wait all day because of this inefficiency in getting routine things done.

All we need to improve the above situation is:

1) One standardized form for all blood tests in all hospitals all over the Republic of Ireland. Understood by all laboratory staff, and all doctors and all phlebotomists.

2) Several phlebotomy round in a day. Phlebotomists to take all blood tests, Group and Hold samples too. This is not a special God given skill bestowed upon doctors on graduation. You can train anyone to take a blood sample and label it.

Time saved. Happier doctors. Happier patients. Money saved. Over a year or two, maybe quite a LOT of money saved. Enough to pay for at least an extra phlebotomist or two, I’d imagine.

Dr. Jane Doe

HSE cost cutting

2008-07-26T05:12:00.006+01:00

Posted by: Dr. Jane Doe

I'm hearing an an awful lot these days about how the HSE is woefully hard up for cash and needs to cut costs as a matter of urgency. People get very angry about this, as it will, no matter what, affect patient care.

Staff are not being hired, existing staff are being "redeployed" or their positions done away with, and new units and departments are not being opened as there is not the money to do so nor to staff them appropriately. Having worked as a doctor in Ireland for three years before emigrating Down Under for a better life, I can see a lot of ways the Irish health service could improve things for their patients and their staff that would also be very cost effective.

While I was working in the morass of chaos and hostility that is every day as an NCHD in Ireland, I was generally too busy trying to stay awake through 36 hour shifts and just trying to drag myself through the days to really see where the problems lay. Yes, we all had a sense of utter dissatisfaction and knew vaguely that things weren't working well, but qualifying how this was so was often difficult to do. After working Down Under for almost a year now, time and time again it has struck me how efficient the system is. How organized and streamlined. And by extension, how cost effective.

At first, in sheer relief at being away from the Irish health service, all I noticed was how easy it was for ME, to get my work done and done well and how stress free my days were. How I wasn't exhausted and depressed. However, looking closer at the whole picture, the system is designed to be easy for everyone. Other staff, but ultimately and most importantly, for patients. Patients here get fantastic care, from doctors and nurses who are looked after themselves and feel happy in their jobs as well as able to provide a good service in their jobs.

Recently there has been a mass exodus of junior doctors from Ireland, mimicking the 80's almost. In the past month a fair few have come from Ireland to where I'm working now, and I have usually been asked to show them around and orient them. Talking to them, and hearing their shocking stories about the way Irish hospitals continue to run, it makes me furious that no-one is doing anything about it still, after all this time. It used to be that Irish docs, on completing their intern year, did the obligatory rite-of-passage thing and went to Australia for a year, had a blast, went bungee jumping, snogged a surfer or two, and then returned to Ireland to get onto a GP training scheme or medical scheme etc and settle down to get their MRCPs and become a specialist registrar. This has changed even since I graduated. Now they are leaving, and not going back. All the NCHDs I have talked to in the past few days that escaped Ireland have no immediate plans to ever return. Many are expending their studious efforts on getting exams that will allow them to train as consultants in other countries-their USMLEs, Canadian boards, Australasian exams or even MRCP UK. Even many of the GP trainees are leaving Ireland and training over here-and staying. For the first time ever this year, the medical scheme in a certain part of Ireland had to advertise twice-still could not get staff and had to advertise in the UK. The chickens are finally coming home to roost.

I will illustrate example by example over the next few posts how inefficient, disorganized and downright unpleasant it is to work in the Irish health system compared with working in a well run system such as the one down here. What I'll do is give an example of a certain simple task, for example, obtaining and reviewing an Xray, that forms a daily part of any doctor's job. I will illustrate what it takes to do this in Ireland, and what it takes to do this here.

Example number 1) Obtaining and reviewing a chest xray. Scenario: You've decided a patient needs an x-ray, say, of their chest. You think they might have a pneumonia but they're elderly and not spiking a temperature, and have a history of congestive cardiac failure, and you need to differentiate so you can treat them appropriately.

Obtaining and reviewing an Xray in Ireland:

Find an Xray form. You could put it in the outbox to go down to the radiology department after letting the patient's nurse know they are for an xray. The problem with this is you don't really know if it will be collected and dropped down, this varies from hospital to hospital, from ward to ward. Some places have times that porters/orderlies come and collect these things. Some don't. Some require the nurse to bleep the porter to collect it and drop it down. Some porters won't come and some nurses won't bleep.

So it's really better in a lot of cases to run down to the department yourself with the form. This takes about 10-15 mins if you factor in walking down (quickly), after first making sure it's ok with your consultant or registrar if you leave the ward round to do so. This in itself will result in further problems and disruptions during the day-the consultant will order tests you won't know about and in general you won't know what happened with anyone they saw on the round while you were gone, which means you'll get bleeped a lot about things you don't know about until you manage to make time to go up and review the charts of anyone they saw while you were gone. No-one will be understanding about the fact you missed what happened, they in fact will be angry with you.

Anyway: You get down to Radiology and go up to the desk. The girl there tells you that after you register the xray at the desk you have to take it around yourself to the xray department. You do this. Another 10 mins or more, depending on whether anyone is available to talk to you and take the form. (Note: If it is something like an ultrasound, you may need approx another 15 minutes to try and justify to a unimpressed sonographer why your patient should have an ultrasound. They may refuse and you will have to do some more tests on your patient to strengthen your case, and return to them at a later time/date.)

Anyway. You return to the ward round and later during the day you have to check the xray. You go down to the Xray department. You look first in the Xray dept in a box that they keep some of the most recent Xrays in. It's not there. At this point it has been moved to somewhere in the department in some pile and only people who work in the radiology dept could really know where it is. You spend the next twenty minutes looking through piles of Xrays and checking the names on them and asking around and generally getting underfoot. Assuming you eventually find it, you cannot take it out of the department to let anyone else look at it, so if you are unsure about something you see on it-is that a pneumothorax in the left upper zone?? you have to take it to a radiologist to get a verbal report.

This is where you start sweating and feeling nauseous. Radiologists want you dead. They do not want to give you a verbal. They want you out of the dept and out of their lives. This is because they are much too busy and their workload is too great. Any mistakes they make are immortalized in film. The consequences of making a mistake are too great for them, the media typically does not let serious issues like a dangerous workload get in the way of a good old witch hunt when a doctor is involved. So they are weary, and not happy to see you, most of the time. This is where you have to justify why you need a verbal. You had better know ALL of that patient's history off by heart, blood results, everything, because if they ask, and you don't know, it will not bode well for you.

Assuming you get through that part ok, 15-20 mins later, and arrive back up to the ward having a diagnosis of Congestive Cardiac Failure (CCF), you can now treat your patient. You wrote the Xray form at 11 am. It's now 15:30. You think they should have some IV Frusemide to treat their CCF. You chart it. Nurses in Ireland do not give IV medications in the first instance, they only can give them "as per protocol" ie. after the doctor has given the first dose. There is no evidence based reason for this practice, and it is not safer or better for the patient, it just is. Frustrating for doctors AND nurses. So you go to the drug room. The IV press is locked. You ask around for about ten minutes till you get the key. You draw up your frusemide, go and give it and then go to sign for it. Someone has taken the medication chart. You should have remembered to keep it locked tightly under your arm or sign for it before you actually gave it but you forgot because you were drawing up the frusemide. You look all over the ward. Someone has it but you can't find it and your bleep is going mad. You leave and a while later you get a bleep to come up give the Frusemide because the nurse can't give a first dose IV. You explain you've given it but someone took the medication chart and you were called away and couldn't sign for it. You are told to come up and sign for it. You do so. It's now 16:15.

Obtaining an Xray and reviewing it Down Under:

Find an Xray form. Fill in the details. Go to one of the fax machines on the ward (there are several so people don't have to wait). Fax it down to the Xray department. Approximately 30 mins later you see, as you continue on the ward round, your patient being wheeled off by a porter that xray sent up to get them.

Approximately 20 minutes later you check the PACS system on one of the ward computers to look at the xray. You haven't left the ward. You think there might be a pneumothorax in the left upper zone, so you turn to ask your reg who is still on the ward with you finishing the round. They tell you there isn't one, and spend a few minutes discussing chest xrays with you and you learn what bronchial cuffing looks like and commit to memory.

You go to chart the IV Frusemide and let the patient's nurse know you have charted a stat dose of something. They thank you for letting them know and you say thank you back. You continue on the ward round. After about half an hour you bump into the same nurse who says how much easier your patient is breathing after all that fluid was diuresed off of their lungs. You are glad the problem was easily solved and that your patient is now comfortable. You thank her/him for letting you know. You bump into the family as they are visiting and update them on the patient's progress for a few minutes before continuing to see the rest of your patients. You faxed the form at 11am. It's now noon. However, you never left the ward.

You know what's happening with all your patients as you were on the round. You were taught several things on the round by your consultant and now you are a little less ignorant. See what I mean? Patient was treated more quickly, less overtime was paid to a doctor, less people were left waiting while the above shenanigans took place which results in quicker and better care for those patients also. Less money wasted. Better outcome. If the HSE wanted to cut costs, all they have to do is attempt to provide an efficient sensible service. It's not hard.

Next week I'll give another example of a simple task and compare its execution in both systems, then compare how caring for patients well is actually cost efficient, something I feel the HSE does not understand.

Dr. Jane Doe

DNUK making me mad!!!

2008-07-25T16:24:00.003+01:00

Posted by: Dr Thunder

I use email a lot. Especially right now. I'm emailing a few people back and forward about registrar jobs for next year. For roughly the last 8 years, I've used the email services at http://www.doctors.net.uk/ for everything.

I went to log in today, as I was expecting some important messages. As I typed in my password I was greeted with the following message...."Your account requires security clearance, please ring our helpdesk".

WTF? I thought. So I rang them. They explained to me how they realised today that I wasn't registered with the General Medical Council of the UK any more. Therefore they were cancelling my account. "But I work in Australia, I haven't been registered with the GMC in about a year" says I.

Them's the rules I was told. But don't worry, we can hook you up with our sister site http://www.ausdoctor/ or something like that. They'll even transfer my emails over for me.

That's not the end of the world I figure. So I ask when this will happen.

"Tuesday", they tell me. Tuesday in the UK will be wednesday over here. That's a lot of potentially important emails to miss. I ask can they reinstate me on their UK site until tuesday, then.

"No".

They're the rules.

"Thanks"

My parents arrive in Oz on sunday for a holiday. They're spending a couple of days up north before meeting me. Their phone won't work here. It's ok, Thunder junior, we'll email you on sunday and arrange everything that way. It's just totally unneccesary. I'm spitting mad here thinking about it.

So, on tuesday (wednesday my time) they'll allow me acces to the oz equivalant of doctors.net.uk and then they expect me to stay with them????

I'll be forwarding all my old emails to whoever my new provider is, and saying goodbye to them.

So, onto the real reason I posted this blog entry.....can anyone reccomend a good email provider in Oz. I've been with the same guys for 8 years, so I'm a bit out of touch!

Thanks in advance,

Dr. Thunder

How are there ANY doctors left in the UK?

2008-07-25T10:10:00.005+01:00

Posted by: Dr. Thunder

So, I'm back from my outback junket.

I'm back practising medicine in a hospital that has actual equipment and specialist staff. It's nice not having to say to any more patients "You need to see a neurologist. There's one visiting from the city in 6 months time. I'll see if there's s space on his list, if there isn't, of you can't make that appointment, he'll be back about 8 months after that", or "Yes, your child needs to se an Ear, nose and throat specialist. There isn't one here. And none visit either. I'll just have to refer you to a general surgeon. He'll probably know something about tonsils".

As I've had no real regular internet access for the last few months, I've been catching up on the world of medical blogging this week. There seems to be one recurring theme coming from the UK. That is http://www.iwantgreatcare.org/. This has managed to annoy the medical fraternity in Great Britain like nothing since the government told them they would be making thousands of junior doctors unemployed "But patient care won't suffer".

So, I had to investigate further. Iwantgreatcare is the brainchild of Dr. Neil Bacon. He's a doctor who set up the excellent website http://www.doctors.net.uk/

Spurred on by the success of that particular endeavour he has now embarked on this new project, which aims to let patients judge their doctors online. So, you go to http://www.iwantgreatcare.org/, find your doctor's name, and give your opinion of him/her. Simple and quick to do, and increasing transparency and accountability. This is what Neil Bacon says anyhow. Obviously, the patient isn't identified. there is no way to verify if they are a patient and there is no right to reply for the doctor.

I have grave concerns about this. It sounds condescending and paternalistic, but patients aren't always the best judge of a doctor's performance. This week a particularly aggressive mum demanded I give her toddler antibiotics for a snotty nose. I refused. I tried to reason with her, but she went home in a huff. I believe I did the right thing. If Iwantgreatcare had a section dedicated to "Irish doctors in Australia", she would no doubt have told the world that I was a crappy doctor who doesn't even know how to treat a runny nose.

Similarly, the lady who went potty at me in the emergency department 3 weeks ago would likely be another customer of Dr Bacon's. Her child had a mild viral rash. The emergency department doctor tried to send her home with reassurance, but she wouldn't go anywhere without seeing a paediatrician. I was called about this very well child while I was stabilising a newborn that I had just resuscitated in the neonatal unit. I said I was going to be a while. I was. It took me about 2 hours before I got to see this rash. The child's mum went crazy. She said she was going to write a letter to the hospital. She may have done, I don't know. I told her that, as the only paediatrician in the hospital, I had to prioritise. A very sick newborn takes priority over a well toddler in the play area with a rash. Two hours was the best I could do. It wasn't good enough, apparently.

She would love Iwantgreatcare. So would many of my patients' parents.

I have an excellent rapport with most of the familes I interact with in work. I don't imagine, though, that they'd go home and look up a website to tell the world that I'm amazing. But those who have a gripe will. Just like the patient on that same website who says his doctor "put his wanger in my ear"!!! Or the doctor who was described as being "like David Brent".

But it's only a hair brained scheme, and it will likely die out soon as no-one in their right mind will regard something like this as being the way forward in assessing doctors. Surely anyone with half a brain will realise that allowing anonymous comments by anyone on the web about any random doctor, without any verification process whatsoever, is not sensible?

Right?

Wrong........

Apparently, senior members so the General Medical Council (The body that regulates medical standards in the UK) and the government support this idea, and are giving this website their backing.

I despair, I really do. We can give patients what they want, or we can use our judgment. I know what i'd rather my doctor did.

May I remind any doctors in the UK who despair at being reapeatedly humped from all sides by a crappy union, an ineffective regulatory body and a shamefully spin-driven government, that it's 27 degrees here, and it's mid winter :D

I look forward to seeing more of you guys out here soon. I'd also be very interested in comments about how we should regulate doctors' standards in a sensible way. Maybe you think http://www.iwantgreatcare.org/ IS the sensible way.

Share your thoughts below.

Dr. Thunder

It's access to health care, stupid.

2008-07-05T01:06:00.005+01:00

Posted by: Dr. Thunder

Hi all. Sorry about the lengthy absence. I've been sent up to a hospital in "rural Australia" to cover staff shortages for a few weeks, so I've not had regular internet access. I shall blog about my outback experience when I'm back to civilisation next week, and have a functioning laptop at my disposal.

But Ain't No Angel's post below inspired me to haul my ass out of bed between 24 hour shifts and put finger to keyboard this morning.

It seems he's been poached away from the coalface by the private sector, like so many good nurses before him. Good luck to him. Given the right opportunity, I'd jump ship too. I wish him all the best. Sadly, the hospital system has lost yet another bright young mind to disillusionment and poor management.

But does it really need to be like this. We have nurses tempted away from the coalface, not by unimaginable sums of money, not by improved status, not by glamour and not by less work. I don't know the details of Ain't No Angel's contract, but it seems he was won over by......."normality".

What I mean is that... what the private sector could offer him, that the public sector can't, is the chance to have a normal life, and human working conditions. In the new job he's well respected, he's properly and promptly trained for the tasks he's expected to perform, and he is allowed make decisions. He also, presumably, has opportunities for promotion, too. OK he gets a pay increase. He also gets a company car, but it's an "on the road" kinda job, by the sounds of things.

My point is that a company car and an extra few quid wouldn't be enough to pry our nurses away from doing the job they were trained for if they had the other things that Ain't No Angel talks about....autonomy, respect, proper training, career progression, reasonable working hours and freedom from bureaucracy.

I have said it time and time again...whatever savings the HSE think they're making in the short time by shafting patients and staff in Irish hospitals is costing them in the long term.

How many agency staff will be employed to cover Ain't No Angel's work? how much will that cost? How much did we spend to train Ain't no Angel? Now the private sector will reap the benefits of our investment. How many nursing students will miss out on his mentoring skills, and how many patients will be worse off for not benefiting from his care?

But then again, this government has never cared about the long term. They can't see past the next election.

Which brings me onto.....well, healthcare in Ireland actually! More specifically access to healthcare in ireland.

This week I have gotten 2 text messages from friends in Ireland asking for medical advice about their ailments. This, I must say, has been a quiet week for the Dr. Thunder health advice line.

Why would an adult risk their health by taking advice via text message from a paediatrician who's in a different hemisphere?

Well, let's look at what you need to do to get a non emergency medical problem dealt with in Ireland.

Step 1: Go to your GP. Take time off work. possibly loose money for it. Then you pay 60 euros for the privilege.

Step 2: Try conservative management first, then come back for a review. Another 60 euro.

Step 3: After an indeterminate amount of GP reviews, you might be referred to a specialist. Waiting list in Ireland are up to 2 years.

Step 4: Specialist sees you, and tries first line treatment. Can't bring you back to evaluate treatment for another 6 months due to lack of appointments.

And so on.
3 years later, you're well on the road to getting an appointment to start the process of recovery!

In fairness, I'd take my chances with a "I have a lump on my head, wot is it plz?" text message, too.

Free access to GP services is what I believe needs to happen. Then, and only then, will those on low incomes be able to take control of their health. Sure, it'll cost a hell of a lot of money. But if people could afford to go to their GP to get their cholesterol checked, to have their blood pressure measured, to talk about giving up the fags, then we could potentially claw back a significant amount of the money, while at the same time improving the nation's health.

But when you have the choice between paying 60 euro to have your BMI measured, or buy the tin of baby formula that your nipper needs, I know which most people would choose.

But what do we expect of a government that has so little regard for public health that it refuses to allow public health consultants to use the title "consultant", and pays them less than half of what their clinical colleagues earn?

Pay peanuts.......and everyone will emigrate to Australia :D

Dr. Thunder.

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

2008-06-27T09:23:00.004+01:00

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

2008-05-30T14:00:00.003+01:00

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!!

2008-05-11T08:40:00.004+01:00

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

2008-04-30T08:58:00.004+01:00

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

2008-04-19T04:11:00.006+01:00

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

2008-04-13T10:06:00.003+01:00

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...........

2008-04-09T15:36:00.006+01:00

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!

Thats fighting talk girly!

2008-04-08T14:59:00.007+01:00

Posted by Ain't No Angel
special mention to Dr Ellie

This post I'm going to discuss the discussion that has come up around my last post. In case some of you didn't know you can add comments after each and every post that the 2weeks team put up here on the interweb.

Following my lastest coffee/nicoteine fuelled rant, a disgruntled Doc has been furiously posting comments and generally venting her spleen on some of the topics I've been mentioning.

Now, this silly doc thinks I might be mad at her.........when in fact nothing could be further from the truth! In fact Ellie, your a kindred soul. I admired what you wrote, it took a bit of balls, (i'm working in urology so maybe I'll get that checked for you), and using some of what you wrote I'm going to add my bit in and maybe we'll come up with something resembling where I'd like nursing to be in a few years time.

Que copious quoting and plagiarism......

I'm an Irish doc who left due to the crap conditions and working hours in
Ireland. I'm currently working in New Zealand, which treats docs pretty well,
and our hours are extremely humane.

Btw, I certainly don't mean to direct this at you! You sound like a really nice
nurse, and the fact that you even KNOW about our working hours, let alone
care, says so much. Most nurses at home were not aware that we were forced
to be on for 36 hours straight and didn't believe us or care if we mentioned
it.

As any regular reader will know I've mentioned this before, and it gets on my you know whats so much. NZ has a rough population of 4,264,871,very similar to Ireland, so we'll assume that it has a roughly equivalent tax take. Using this as a basis, then how come they can run their system without working their Dr's to death? Maybe, what we should do here is totally dismantle all the health service machinery and rebuild it in the image of NZ or another good example? Oh wait...........thats what the HSE idea was about.....whoops!

Nurses here, if a patient complains of chest pain, do an ECG, give GTN,
do a set of obs, and call you unless the patient is clearly crashing. If
they suspect a patient is in retention, they do a post mict bladder scan.
Many take bloods and site IVs, and only call you when they don't get them in. They take verbal orders for meds. They give first dose IVs-that's a BIG one that's always annoyed me intensely. In Ireland, many times nurses would go so far as to make us give the first dose of say, IV Augmentin, even if the patient had already had it on this admission, and we were just restarting him on it.

Thankfully giving first dose antibiotics has more or less gone in most hospitals, most of the time we happily give them with few problems. I'd really only start thinking about not giving something if I was really unfamiliar with it. Most times though, a quick call the the pharmacy dept is the best line, as to be fair, most Docs don't know much about the routes of all the mad scary type drugs anyways! I agree though, that first dose stuff was nonsense of the highest order in all but a very very few cases.

When I was a student, I worked in A&E on a placement for 6 weeks. Standard practice there for nurses to do ECG's, well in the dept I worked in. By the end of the 6 weeks, I was doing the things in my sleep. Now, as a fully qualified registered nurse....... I'm NOT ALLOWED do them..... for those not in the know, ECG's are pretty simple to carry out, in fact apart from Dr's the people who do them most as ECG Technicians, I'm not sure what qualifications they have, but I'd assume its not a PhD. Point is, its not that difficult.

Taking blood is another one. Nurses in general don't do this. There are exceptions alright, but for the main part they don't and aren't trained to do it. Even if I went on the course.......the hospitals won't let me do it, or put in a cannula. In fact, if I did do it, and it got out, I'd probably be disciplined. (BEHAVE!)

This all seems a bit silly doesn't it? But see it relates back to some of the things that I was saying before....

See, if i start taking bloods and putting in cannulas, then I'll end up doing them all, and I'll never get a Dr to do any of them. This takes time, so how am I going to get the time to fill in all the care plans, reports and ticky box bits and pieces of paper that I'm already snowed under with? I'll still have patient ringing the call bell when they need a hand in the toilet, I'll still have patients to help get washed in the morning, or to make sure that your granny eats her dinner. See where I'm going here?

There's no one really below the nurses that can take on the jobs so that we can take on a few of the extra Dr ones. Yep, there are the healthcare assistants being trained up as we speak, but until they actually create a proper job spec for these people, and sort out the area of delegation and the responsibility of the nurses for the HCA's practice, they are going to sit on the shelf and it'll all be another waste of time.

While I've no desire to become a "mini - doctor" I'd certainly feel that it'd make more sense to have nurses performing quite a few of the roles that the NCHD's are now doing. Unlike the private sector though, the public health system doesn't seem to much a fan of innovation, free thinking or change. Until, that realisation hits home, nothing will change, at least to a degree where things for patients and staff will get better.

Just a final point...........Ellie.......I always try to be nice to the Doc's. We are after all on the same side. Sure, I've let rip at a few of the pompous fools but I've made friends with plenty of your lot. The behaviour shown to you though as a female NCHD was a disgrace though, and on behalf of the muppet nurses that were like that......I'll apologise. It happens though, especially if your at least vaguely pretty, make an effort with your appearance or are a bit outgoing. Its jealousy i think, but who knows........just between you and me though, I'm always nicer to the girls than the lads........dammit.....Mrs Ain't No Angel is looking shhhhhhhhhhhhh don't tell her!

The week in review

2008-04-05T12:30:00.002+01:00

Posted by Dr.Thunder

So, it's been just over a week since I started my new job, and so far so good. The people I work with are friendly, and the hours haven't been too onerous.

I guess my main problem is one that many docs will identify with in a new environment. It's the lack of trust that I sometimes face. I'm reasonably experienced in neonatology, and would regard myself as reasonably good at the job. I'm not perfect, but I can do enough to get by.

So, it's a bit frustrating when I outline a management decision to the nurses, and they just run it by one of the other registrars "just to make sure". Some of these registrars are more junior than me, which makes it doubly frustrating. I'm all for teamwork, and I have to admit spending alot of my time asking 2nd opinions from the other docs, because things are often done very differently here in Oz. But when ever decision you make is questioned, it gets a bit tiresome.

I was in theatre the other day for a "high risk" delivery. We go to these deliveries to resucitate the baby if the need arises. Usually ourselves and the obstetricians co-exist peacefully. But today's on-call obstetrician doesn't like new faces. I walked into theatre and started preparing the resus equipment for the impending caesarian section. He walked right up to me and, without introducing himself, said "I don't want a resident here. I want a registar for this delivery". I told him that I was the registrar, to which he replied "I said I don't want a resident, I want a reg".

Indeed.

After I convinced him to let me stay he said "You know this baby is going to the nursery with you, don't you?".

"Well, let's see how the kiddy is. It might be fine, in which case we'll just leave him or her with mum".

This sparked a big argument. He was adamant that this baby should be admitted for observation, regardless of it's condition. I said I wasn't admitting a well baby. He said "Look, I know you're only new here, and you don't know how we do things. But this baby is getting admitted to the noeonatal unit".

I agreed, just so he would hurry up and get this baby out of it's bleeding mother. So, a few minutes later, one completely well baby came into this world. I gave him back to his mum and tried to escape back to NICU, as the obstetrician sutured a uterus, or whatever it is they do.

But I was too slow for his eagle eye. He noticed, without even looking up from the ovaries in front of him, that this deviant paediatrician was trying to leave babyless. The argument flared up again. As far as I was concerned, he doesn't have admitting rights to scarce neonatal beds.

I wasn't trying to be unhepful. I probably admit more babies for observation than I need to. But I'm really very strongly againt the idea of splitting up a mother and her baby straight after a traumatic delivery.

I told him he could call me if the baby showed any signs of being ill. Nope. Not good enough. "I want a consultant opinion", he said. Ok.

"Hi, neonatal consultant on-call. It's Dr. Thunder, your new registrar. I've just been at an emergency c-section for a maternal bleed. They were worried about the baby in utero, but he's totally fine. No resus required. I've given him back to his mum. But Dr Obstetrics wants to observe him in NICU. I've told him it's not neccesary, but he wants a consultant decision".

This is where the 2nd tier of distrust comes into play...

"He can't possibly want an admission for that reason. You must be missing another issue".

Oh sweet jesus.

"No, I'm not. I clarified this with him. The one and only issue is the maternal bleed".

"OK, don't admit the kid. It's not neccesary.....you need to be careful about over admitting. Dr. Thunder. You don't want to seperate mum and baby early on unless you have to. That's not how we do things here".

I NEVER WANTED TO ADMIT THE BABY. I WISH I'D NEVER SEEN THE BABY!!!!!!

So, i went back and explained the situation to a disgruntled obstetrician, who mumbled something about crap neonatal care.

I was glad to get back to the neonatal unit. Back to familiar territory, where I could make decisions about head circumferences, neonatal lung disease and such other familar topics, without a fully formed uterus in sight. Even if those decisions do get run by my more junior colleagues "Just in case".

What's Goin On!

2008-04-03T10:18:00.007+01:00

Posted by : Ain't No Angel

Sitting here on a week off from work following a week of night duty I can get pretty bored. There's me, the cat, Dr Phil and the xbox. Good friends to a man (or cat), but they don't compare to how unbored I generally am at work. Things are usually quite frantic there, eventhough we have a well run shop. Its gotten me thinkin though about what I be doing from one end of the day to the next, and what kind of things it is that seem to keep me so occupied.

So today, I'm thinking that I'm going to share with you all the things that keep me busy in work, along with a little of my thoughts on each.

(This may take a while, its going to be one of those stream of consiousness type posts.....)

1) Patients

Well Duh , I hear you say, and you'd be right. Its primarily the reason I go to work everyday, and most of the time its the patients that make my job so cool, rewarding and interesting. Sure, it'd be great if it was like ICU and they all were asleep all the time, but then I'd miss the banter, the craic and all the good stuff. I'd also miss the tears, the anger and frustration and all the little things.

2) Dealing with Dr's

We're normally not to bad at this. Because we're pretty specialised we have our own teams and everyone gets to know each other pretty well. There is generally someone from the team on the ward all the time, so getting things done is rarely a problem. Things start to go wrong when you are dealing with Dr's from teams that have patients all over the hospital. Even something simple like getting laxatives charted can be a nightmare and take hours. Why? Well sometimes, its because said Dr is a fool/lazy/badly organised, but 99% of the time its simply because they are so so so busy running around the place trying to be all things to all men that they simply can't get to you.

I've posted about how I hate how our NCHD's are treated in this country, particularly interns so I'm not going down that road/rant again, but in this day and age, you'd think someone would come up with a solution that meant Dr's wouldn't have to work for 2 days straight with about 4 hours sleep in-between, if they're lucky.....

3) Bureaucracy

Now I know everyone, no matter what job has this issue, and in Ireland the HSE has rightly gotten stick for the increasing bulk of admin workers it employs, so lets not beat that horse again. I'm talking about the nonsense I have to deal with directly, not the people in the ivory towers of HSE/DOH-land.

For a start, despite the amount of worthless admin we have, there simply aren't enough ward/doctor/general secretaries around. Our own ward clerk is a legend. Highly organised and intelligent, she can sort out a multitude of things for you but she's a minority. I've worked with loads, who are useless. When she's not around, getting a patients old medical notes from storage can become a Hurculean task, up there with peace in the Middle East.

Why?

Because there's no-one in the records dept free to get it and bring it up.

Never mind that though, what about the litany of paperwork that have to sign, tick or otherwise file on a daily basis on every patient I meet. Add to this mix, meetings, radioographers and their nonsense from time to time, plus the additional hassle of dealing with HR from time to time, porters and finally cleaners (who won't clean or who aren't allowed to clean certain things or areas).

It can all get pretty painful sometimes!

First day in big school.

2008-03-30T17:09:00.003+01:00

Posted by Dr. Thunder

So, I'm a working man.

I've started my new job. Babies everywhere. And I mean EVERYWHERE! It's a huge unit. Much bigger than I'm used to back in the UK

But it's all good. Much better than being bored at home.

It all started slowly enough, with no real action to speak of on my first shift. Day 2 started the same, until Jacob entered this world!!!!

Jacob had reached 28 weeks gestation when he decided he was bored in his mummy's tummy. So, encouraged by the local spell of good weather we've been having, he decided to go on his holidays early.....to the outside world. He was born 2days ago weighing just under 1kg.

We were ready and waiting for this young man when he popped out,though, and the team sprang into action. It all went well. He wasn't too well at first, and needed to be resucitated for about 20 minutes in the delivery room where he was born. This all happened in close proximity to his parents, which is never ideal, but is sadly unavoidable in many cases. Then he was transferred to the special care nursery, where he had a rough ride for an hour or 2 before he was stabilised. He's doing well at the minute. His folks are a bit shellshocked, which is to be expected, but so far so good.

It was good to get the first big resuscitation over and done with early on. Things like that are important when you're trying to establish yourself as an important member of a team.

The team itself are all pretty friendly. There's a very laid back atmosphere in the department, and the consultants are on first name terms with us all.

So, for now, there are no complaints. The hours are infinitely better than back home. When I work overtime I get paid overtime, and I rarely work longer than 8.5 hours continuously.

Of course, some things are the same wherever you work in the world....my swipe card still doesn't work. I still don't have a password for the blood results system, and the coffee is dreadful.

But, overall, the move seems like a good one. Watch this space, though, and see if I still feel the same in a month's time.

Finally registered!!!

2008-03-14T09:19:00.003Z

So, nothing here is straightforward.

I'm now registered with the medical board. Happy days. I applied in October. Was supposed to start my job mid January. So, why am I sitting on my ass mid march, bored out of my head and writing silly "archives" posts to fill space? :P

Registration came to me today, via email at about 5pm. That's all very well, except the conversation with the hospital just hours prior to this went as follows:

me: Any news on my registration?

hospital: Well, the medical board have given us an assurance that you will be ready to go a week from monday.

me: A whole other week? I'm going stir crazy here. I'm considering going away to Cairns for that week to see my relatives, as I can't just keep sitting round doing nothing.

Hospital: Oh yes, there's no way your registration will come through before monday week, got on a plane and have a nice wee holiday.

So, I get off the phone and book a flight to Cairns at 3pm, leaving tomorrow morning.

At 5pm I get an email from the medical board "Dear Dr. Thunder, your registration has been approved. You are free to start work immediately".

It would make the baby Jesus weep!

I'm going to Cairns anyway. There's a locum covering me, so she can have a few extra days getting twice my hourly wage, before I take over.

I'll keep the blog posted about what's happening. if I have access to "an internet" in Cairns, I have one more installment of the Dr. Thunder archives that i want to post. Then hopefully the next time you hear from me, I'll have some interesting stories to tell.

Wish me luck!!!

Dr. Thunder.

The Dr. Thunder Archives

2008-03-06T03:08:00.009Z

So, In the absence of a work permit for the next week or so, blogging has been thin on the ground. I'd hoped to have many varied tales of life and death exploits in the neonatal unit to share with you by now. But sadly not.

Now, I'm assuming nobody wants to read about my daytime-TV-watching exploits, or my latest martial arts injuries. Therefore...ladies and gentlemen....let me present....episode 1 of....

THE Dr. THUNDER ARCHIVES*

Until my work permit comes through, I'm going to reminisce about the good old days (ie the pre-blogging glory days!). I'll be writing about some of the experiences that have shaped me, for better or worse, into the quack that I am today ;)

I was reading the excellent "studying under a palm tree" blog today (http://www.studyingunderapalmtree.blogspot.com/). This is a blog by a young Australian medical student, who is currently coming to terms with putting drips into patients, and taking blood.

This brought back fond memories of a student Thunder enthusiastically learning the noble art of intravenous access. It all started in our 2nd year GP placement. Myself and my colleague were told by the GP tutor to take blood from each other.

We'd both seen each other's manual dexterity on show in the dissecting room, where neither of us had covered ourselves in glory.

"let's just do this, mate. Get it over with, then get to the pub", I said to Pete.

"OK, I'll go first" he replies.

So, I'm sitting there. Pale, shaky, sweaty. I'd not seen anyone looking so nervous in a long time. Until i looked at pete, clumsily clutching a HUGE needle in his tremulous hands.

"Oh Jesus".

Attempt 1: Well, it was in my ARM. Nowhere near a vein, but at least it was the right limb. Oh, the pain, though.

Attempt 2: "er, i think that's my artery"

Attempt 3: "aaaaarrrrrggggghhhhhhhhhhhh"

To this day, the nerve implicated in attempt 3's disaster has never fully recovered.

At this point, pete gave up, and I was all ready to get my revenge. I picked up the needle. Cleaned his arm. Stuck the needle in........

BLOOD!!!!!!!

Sweet baby Jesus, blood is gushing into the syringe.

My GP tutor expertly guided me through the rest of the process. End result..successful blood taking. 1st time. Thank you very much.

So, after a week of being Mr. Cocky around campus, I found myself on the liver ward in the local hospital, under the "supervision" of a very tired intern.

This exhausted girl seemed at the edge of reason as things stood. So, when she was presented with 6 2nd year medical students for "clinical practise training" she almost cried.

"I don't suppose any of you guys can take blood or do cannulas, can you?". In unison, my 5 colleagues said "student Thunder can".

"Oh f*ck".

It seems that, in my attempts to impress a couple of the hotter medical students, I may have told them that I was "competent" in cannulating and taking blood.

"ah good. student Thunder, go and put a drip into the man in bed 4, and take the bloods that are written in his notes".

"Oh sh*t".

"and bring the other students. You can teach them how to do it."

"Oh B*ollocks".

Anyway, in I went, followed by a gaggle of white coats. The patient was the same as every patient I ever came across in liver wards in Scotland...he was an alcoholic, with severe liver disease, and very grumpy as he was in "cold turkey".

"Who the hell are you?"

"Hi sir, I'm student Thunder. I'm going to be putting your new drip in and taking some blood".

"OK, but I hate doctors, I hate paddys, and I hate needles".

So, a good start.

So, I'm ready to go. My colleagues were leaning over my shoulder...far enough behind me to gain protection from this Father Jack lookalike, but close enough to see exactly what I'm doing. So, bear in mind that, at this point, I'd never put a drip into anyone. I'd only taken one total fluke of a blood sample from Pete the rugby player, with his huge veins.

Attempt 1: I place the needle directly into the man's muscle. I don't know which muscle. Probably several muscles, as I went so deep.

"arrrgggggggghhhhh you f*ckin c*nt paddy, what the hell are you doing????".

My sweat levels are rising, my hands are trembling.

Attempt 2: Somewhere near the gentleman's shoulder, if I recall correctly.

"arrrrrggggggghhhhhhhhhh HELPPPPPPPPPPPPP, please HELLLPPPPPPPPPP. There's someone trying to kill meeeeeeeee". The sound of his shrieks would have deafened an elephant.

So, as 2 nurses and a doctor rushed into the cubicle, I'm standing there with a blood covered needle. There's blood all over the patient's arm. He's writhing in agony. This is not a good look for me.

"Get this f*cker out of here. He's a monster. He's trying to kill me"

I got shunted out of the way by the intern, who slided the cannula in effortlessly. The patient said "Thanks doc, I hardly felt it".

One embarrassed looking student Thunder stood outside the cubicle with his colleagues. "I thought you could do cannulas, Thunder?" says hot lady number 1.

"yea but he had really bad veins".

"hmmmmm".

Just as I was trying to escape to the relative safety of the library, I heard the voice of another junior doctor behind me. "Thunder, I heard you saying earlier that you can take blood".

"ehhhhh"

"yea, he's been telling us all week how good he is at it" says hot lady number 2.

"here, take blood from the man in cubicle 3. He's an intravenous drug user, so he hasn't got much in terms of veins. I have to run. Bring the other students with you, and show them how to do it" he says, as he disappears away down the corridor.

A bad, bad day.

I never got a date, and it was another 2 years before I successfully put a cannula in. Thought it would never happen.

But it did. It always does. So "stick" with it, kids :P

Practise on rugby players with huge veins.

And when you get good at it, make sure to tell EVERYONE ;)

*Also known as the Dr.Thunder gratuitous space-filling exercise

Jealous + Cold

2008-03-05T17:40:00.005Z

Ok.......to all out there, apologies from me too. I also neglected the blog, life got in the way, along with a few x-box games and the usual post-xmas slump. I'll echo the word of the good Doc though, in saying that I'll be making much more of an effort!

So, now back in the motherland, we're in the beginnings of the Irish springtime, its wet, mostly pretty cold and windy from time to time. Not at all like Oz.........its going to be interesting when Dr Thunder gets going though, and we can compare and contrast the differing healthcare systems.

Since the last run of posts, things have been fairly turbulent in the world of Irish healthcare.

We've had the embargo on hiring new staff to the service, with a few exceptions. This was supposed to finish in January, but apparently this hasn't happened across the board yet.

We've seen media reports of the health service needing to shave about €300 million off the budget inorder to get close to breaking even this year.

The nurses have been at it again..........the latest round of pay discussions about to kick off, following a governement sponsored report which gave pay increases to no-one apart from a lucky bunch of senior managers across the public sector, pharmacists and consultants are also getting in on the act, though, fingers crossed the consultants have gotten sorted.

And in the middle of all this we've had patients on waiting list for colonoscopies for months, dying in A&E departments while lying on trolleys, contracting MRSA and other hospital acquired infections in pretty overcrowded hospitals and generally making a nusisance by being sick and expecting a decent standard of healthcare services from their government. Some things never change!!

To hear me going on, you'd think it was all doom and gloom! But its not......no.....because, as luck might have it, Mary the health minister got to go to the Superbowl, and we all know how much of an American footy fan she is!

Seriously though, its not all bad. I've had, on a personal level a good couple of months. Wedding plans are proceeding nicely, and the missus hasn't gone mental with wedding stress yet, though I have a few rectal diazepam in a safe place for when it does happen. Work has been busy but good, lots of interesting stuff coming through the door, and not all in our normal speciality which has been cool, and I'm also starting to maybe get plans together for a US working excursion, so maybe in a year or so, your favourite nurse-blogger will be telling it like it is from the good ol US of A, cialis adverts and all.

Thats it for now, I'll be back at the weekend. i've something in mind for a post then,but until then feel free to comment or make requests!

Later

I wish I had something to blog about....

2008-03-04T01:38:00.004Z

.....I really really do!

I've been in Australia 3 weeks now, and my license to practise still isn't ready to go. Seems the ozzies are a lot more strict about who they give work visas to than the New Zealanders were. Anyway, they promise me it should all be sorted in the next week or so. Then hopefully I'll be back to work, complaing about the lack of time off!

I never realised how difficult it is to pass the time when you're essentially unemployed. I mean, daytime TV just doesn't cut the mustard for me.

In a boredom-fuelled frenzy, I've taken up martial arts. A very very sore foot, courtesy of a huge eastern european, is testament to my lack of success in that particular field. I'm also back taking drumming lessons. And I've gotten involved with a local first-aid group.

That's a total of about 8 hours per week sorted, then :P

The good news, though, is that all this free time has given me lots of time to go to the gym, with noticeable gut-reduction already.

Right, time to get up out of bed and....well, do nothing. But at least I'm doing it in the sunshine :D

Wish you were here,

Dr. Thunder

Daily Mail journalist in sterilise-the-promiscuous-bastards shocker

2008-02-20T08:00:00.015Z

Posted by: Dr. Thunder

So my medical license to practise in Australia still isn't ready.

Therefore, I have nothing to blog about on the coalface.

But, this extended holiday does mean I'm spending alot more time online. One of my favourite websites to hang out is http://www.boards.ie/

It's the message-board where this blog got started.

In the "ladies lounge" of boards (which, despite the name, is not a virtual pole dancing club. It's a forum where ladies' issues are discussed) the following Daily mail article has provoked a heated debate.

http://www.dailymail.co.uk/pages/liv...icle_id=514542

It's a bit long, so I've cut and pasted what i thought were the salient points, but you should read the whole article by following the link above.

"Last week, an intriguing proposition was mooted by Government minister Dawn Primarolo.
Teenage girls, she said, could be steered towards what is described as "long-term contraception".
This is now possible thanks to the development of contraceptive jabs and implants which can last up to five years.
In other words, there is a way of effectively sterilising girls for a lengthy period of time.
In 2005, there were 39,804 conceptions by under-18s in England - a rate of 41.3 per thousand.
The trouble for those who would tackle the pregnancy problem is that the very act of warning against pregnancy can be unproductive. "

"A certain proportion of teenagers like to defy fate - and the more you warn them not to smoke, drink, have sex, stay up late, join gangs, the more they will.
Defying authority, not doing what you're told, is, for many, part of growing up - the search for your own identity, a necessary preparation for leaving the nest. Persuasion doesn't work. The instinct to rebel goes too deep. "

"It seems that many of today's girls just like being pregnant, and emotionally and physically - not just practically - have more to gain than lose if they are. Sex education hasn't helped, and may indeed have harmed. "

"The Government says it has tried everything to stop pregnancy rates rising - from school matrons to a blizzard of sex education, to free condoms and morning-after pills.
But it's not working. That's why I think sterilising girls for a few years isn't such a bad idea after all - and, when you think about it, it's a tempting solution for the State, too.
Once you stop your under-20s having babies, there's no end to the social improvements you could make. "

"If girls go on to college instead of minding babies, fewer children overall will be born. The more educated a girl, the fewer babies she is likely to have - education and fertility rates being in inverse proportion.
The maternity services, now so very over-stretched, would be better able to cope. Young mothers would not have the priority they now do when it comes to housing, and accommodation would be set free for those unfortunates clamouring on the waiting lists.
Education would benefit, too. Classrooms would be less plagued by fatherless lads whose ambition it is to cause nothing but trouble.
So the children of teenage mothers can suffer, too. "

"Not having babies takes intelligence, planning, prudence and boring appointments with doctors. So what do we do? Deprive potential children of life by sterilising a few hundred thousand girls society has decided are "too young" to breed, regardless of their biological capabilities?
Go for the quality of child they might produce in their 20s or 30s, rather than the quantity they could create if they start at 14? That, let's face it, is what's up for discussion. "

"There is, I admit, a dreadful gender unfairness in the suggestion that teenage girls should be sterilised. Shouldn't boys under 17 have their tubes tied, too? It takes two to make a baby.
What's sauce for the goose should be sauce for the gander. Perhaps the Government should start thinking about how that would work.
Since science has now devised a way of stopping girls getting pregnant without damaging their longterm reproductive health, the idea of enforcing sterility on girls under 17 seems to me a least worst option

So, I thought I'd see what the blogoratti think of this proposal.

The minister in question, Dawn primarolo, is a Labour party minister in the UK, and minister of State for Public Health.

She has not advocated compulsory sterilisation of the UK's female teenager population. However, this journalist, Fay Weldon, has.

As a paediatrician, I have issues with both of their stances.

Firstly, the issue of compulsory sterilisation. This to me is one of the most outrageous suggestions I have ever heard in my life. I'm no lawyer, but I'd imagine it contravenes human rights legislation?

What would the reaction be if we proposed "tying the tubes" of teenage boys, I wonder?

What makes it worse is that our journalist friend wants us to give an implant, which last 5 years. Considering we (as far as I'm aware) don't have any solid data on the long term side effect profile of these implants in children of this age, I find the suggestion doubly galling.

Dawn primarolo is more restrained in her calls for teenagers to use long term implants, with their consent.

I'm all for greater access to contraception, in the quest to reduce the number of teenage pregnancies.

But I wonder at what age a girl is mature enough to give informed consent for an implant that will make her sterile for 5 years. We have the concept of "Gillick competency", whereby if we deem a teenager competent to make an informed decision about their treatment, then they can make that decision. But this will add a whole new edge to assessing this capability.

At what age can a girl assess the risks of an unknown side effect profile?

Would over zealous parents push their kids into having a 5 year implant, to put their own minds at ease?

Will, as the right-wing always argue, there be an extra level of complaceny amongst teenagers if they're "sterilised". Will this lead to a lack of condom usage, and higher rates of STIs?

Are the type of teenagers who are responsible enough to think about their reproductive health 5 years in advance the ones we should be aiming new initiatives at? Are these not the girls who are already using the shorter-term depot contraceptives, the pill, or condoms?

My take on the issue is that forcibly medicating teenagers is a huge no-no. I don't imagine you would find many doctors willing to do it, either. I would refuse to forcibly medicate most people who are ill, so I sure as hell wouldn't do it to someone who's well!

As for giving the option of 5 -year implants, I'm less sure. I'm not convinced of their benefits when compared to shorter-term injections, and I'm unsure about their safety profile. If I'm not sure about it, with my medical degree, is it fair for me to ask girls in their teens to evaluate the risks Vs the benefits?

I know it's just the ramblings of the usual marginalised Daily Mail types, but it's a topic that interested me a lot.

The original (and best) discussion, from the ladies lounge at boards.ie can be found at

http://www.boards.ie/vbulletin/forumdisplay.php?f=1011

Drop in if you fancy a chat and a pole-dance :P

So, has anyone else got an opinon on this? Is this the way forward in tackling spiralling teenage pregnancy rates? Or is the whole thing ethically and medically questionable?

On the Australia front:

1) It's way too hot here for a pasty paddy like me.

2) People are all very friendly here so far

3) Beware any docs coming out to this neck of the woods..medical registration is taking much longer than before for overseas docs. I've been here on a holiday visa for 2 weeks, and my license still hasn't been processed. I applied in november!

4) For the women: There are a lot of really nice parks and nature reserves here

5) For the blokes: Australian women are HAWT :P

Ask your doctor about starbursts for male pattern baldness

2008-02-17T03:11:00.011Z

So, I've only been in Australia a couple of days, and feel unqualified to comment on their healthcare system as of yet.

However, enroute here from Ireland, I passed though the USA. Thankfully, I had no need to make use of their healthcare service either.

But, I did have ample opportunity to make use of the cable TV in my hotel during a 48 hour stopover in LA.

What amazed me was the amount of adverts for prescription drugs on television. All paid for by the drug companies, extoling the virtues of their particular drug, and usually rolling out some actors who claim to have used these medications.

After the actor (or sometimes genuine patient) tells you how their depression was cured by Sad-Gone, they urge viewers to "ask your doctor" about this wonder drug.

Almost invariably, this is followed by a guy speed-reading a disclaimer "drug X is not suitable for everyone. Side effects include liver failure, kidney failure, yellow teeth, arse falling off, cardiac failure, blindness and spontaneous gingerness".

I was flabbergasted. Evidence? Who gives a flying fuck about evidence when you have a happy post-coital elderly couple lying on a bed thanking humanity for viagra or cialis. They're right there in front of you, ON THE TV FOR GODSSAKE, so it must work.

So, what does the panel think? Is this fundamentally ethically wrong? Or are drug companies empowering patients?

I personally find the concept of a pharmaceutical company peddling drugs to people who usually have no access to data about the drug, or do not have the tools to interpret this data, pretty uncomfortable.

Also, are GPs in the states over-run by patients demanding a drug they saw on FOX TV?

I'd be very interested in peoples' thoughts.

Dr. Thunder

The sorryness

2008-02-16T06:42:00.005Z

I would like to take a leaf out of the Australian Prime minister's book, and make an apology. I apologise for neglecting this blog for the last 2 months or so.

My (lame) excuse consists of a combination of being in hospital for a while, and being on an extended holiday.

I just didn't want to think about work, while I was hiking the length and breadth of New Zealand.

But I'm back.

I'm no longer in New Zealand though. For the next year I'm working in sunny Australia. It's really cool over here, and that's not a comment on the heat! My pasty paddy skin was never designed for 30 degree temperatures and high humidity. This has to be the first time in my life that I've gone IN to a neonatal unit to cool down.

Anyway, it's a little soon to be blogging about the Oz healthcare system, as I'm only in the door. I'll be very interested in seeing how it compares tot he New Zealand, UK and Irish systems.

So far it's looking good. But, for starters, the labour ward, the neonatal unit and the adult intensive care dept are all in the one location. This is something you don't always see in Ireland and the UK. All maternity departments will have a baby unit of some sort attached. But many won't have somewhere to put mothers if they become seriously unwell during their labour. We're heading in the right direction back home, but I'm glad to see the Aussies have it sorted,

I also noticed that I get paid by the hour here!! Like I have a timesheet. Getting paid for overtime will be a new experience for me. Not sure if I'll cope.

Anyway, more posts will follow as I settle into the job. I start with 3 months of neonatology in an enormous unit, so much fun and frolics are sure to follow!

Watch this space..............