Friday, October 31, 2014

Obelisk of Light

One of the few things I do which doesn't involve work and makes me happy is playing football. Now I'm no professional but I played for a Sunday league team for 5 years in various positions . I was more upset about leaving the team behind when I moved than most other things about leaving Northampton. The thing I liked most about it, was the fact that it was a Sunday league football team that wasn't completely populated with angry, hungover meatheads. We were probably the politest team I've ever seen. This was both good and bad for results!

So the first chance to go back and see how they are doing I took last week. In the time I have played for them they went from 2nd division also-rans to being in the top Sunday league. They mostly achieved this without my help as we recruited young talented students to replace the old timers like me. So it was sad to see them bottom of the league and in trouble of going under.

A number of reasons behind their fall from grace. Firstly the students who carried us to glory have  all graduated and left the team. Secondly, it is very difficult to run a Sunday league team with any sort of sustainability. You need to recruit, organise games, pay officials, buy & wash kit, organise training, liaise with league officials. You also need to chase up players for money to fund all of this.

Now once this was done by one group of people and over time it was taken over by another group of people. I think the amount of work involved became too much and they have fallen by the wayside.

It is very sad and I wish I had enough time to take over and sort it all out.

I'll add it to the  list of things I can't do due to work!

Monday, October 27, 2014

4 hours in A&E

Much is made of the 4 hour waiting target for A&E departments in the UK and various hospitals' adherence to the target as well as methods hospitals use to fudge the  numbers to make it look like they adhere to the target.

The Mary Seacole Program which I have just completed exists as a direct  result of the Francis Report trying to improve education and leadership in the NHS workforce. Something mentioned in the Francis Report was the fact that Mid Staffs were placing adherence to targets  above the need for safe patient care.

I understand that fast care should result in improved patient safety and satisfaction and targeting time spent in the A&E department should bring about improvements. Unfortunately imposing arbitrary and artificial restraints on a system will mean that the system will adapt to nullify the effect of the restraint. This took the form in mid Staffs of holding wards, inappropriate discharges, boarding patients in inappropriate places and generally harassing staff who were there to see the patients. In my experience I've seen all of these in one form or another in the various places I have worked. I would like to share an example of the unwavering adherence to the 4 hour rule and how ludicrous it can make us look.

It was a Saturday night and I was on call for Urology. I was called to a very busy and rowdy A&E department to see a patient with a painful urological problem which whilst distressing was quite easy to fix and would result in complete resolution and discharge from hospital immediately after the procedure. It was uncharacteristically quiet in theatre so I proceeded to A&E without delay to be met at the entrance with a clip board wielding band 8 nurse who was "site manager" for this shift. This is hospital speak for "enforcer of 4 hour wait rule"and the extent of her first interaction with me that evening boiled down to:

"Majors 12 has been here 3 hours 55, Send him home now or he is going upstairs [to the admissions unit]"

Firstly, I was referred the patient at 3 hours 50 minutes and expected to sort them out in 10 minutes. Secondly, having reviewed the patient quickly I was confident the short procedure would send him on his way home. This would probably take about 5-10 minutes to perform, but would take him over 4 hours in the department. This obviously couldn't do.

After confirming the problem, I left the room to get a pair of gloves and the piece of equipment needed to help the patient out, having applied some local anaesthetic to the area in question and leaving the patient in a compromising position in the private room. In the 10 seconds I took to get the gloves, a porter and "site manager" had gone into the room and wheeled him out (still in a compromising position) in order to transfer him to the admissions ward.

My protests fell on deaf ears:

Me: "I'm only going to take 5 minutes, he doesn't need to go upstairs"
Manager: "He is about to breach, whatever you are doing it can wait until the admissions ward."

So it takes half an hour for patient to be transferred and admission paperwork to be completed before the patient is in a room able to do the procedure. I have a very irate, embarrassed patient who has been paraded in front a department with his pants down. It takes less than 5 minutes to do the  original procedure yet he has been admitted, had an admission nurse fill out a booklet full of paperwork and been subjected to a humiliating trip. All so he didn't breach the 4 hour target.

What should have happened is that he would have remained in the department for 4 hours and 5 minutes and he would have gone home happy. This chain of events hindered the nurse on admissions, myself, the porter and most importantly the patient. It didn't help anybody and wasted a lot of time, effort and money. Thankfully other than a complaint, it didn't actually harm the patient. I'm sure there are many other examples that have.

So that's why I don't like the 4 hour target; it makes people do silly things in order to get the numbers correct.

Trauma Services in Westeros

A perpetual state of war is the perfect environment for innovation in healthcare to flourish and nowhere is this more in need than Westeros. Currently trauma services are in disarray with pauper and king alike at risk from mismanagement in the dangerous world of the 7 kingdoms.

Alarm bells began with the peacetime death of Robert Baratheon in a hunting accident. Adequate access to quality surgical and anaesthetic care may have prevented the realm being plunged into chaos in the first place. Given his stability at presentation he had time for a full history and examination including co-morbid conditions of obesity and alcohol dependence. Expedient wound debridement and surgical control of intra-abdominal sepsis with post operative ICU care and prevention of alcohol withdrawal would have probably prevented the War of 5 Kings.

With war on 3 fronts, expert medical care was largely an afterthought with  only the Northern Army having any noticeable care for wounded soldiers. Not that this could save their king in the North from succumbing to a cross bow bolt trauma which could have been decompressed with an intercostal drain and appropriate blood products. Things got worse at the Battle of Blackwater with no recognised Burns unit in the capital leading to thousands of unnecessary deaths barely hundreds of feet from the gates to the city.

The next king to suffer from poor investment in his own healthcare system was Joffrey, appearing to die from poison setting off severe laryngeal oedema. Being in the biggest population centre in the realm would mean prompt management of a threatened airway with access to intubation and in extremis a surgical airway. None of which was forthcoming, which leads to cries of regicide.

Things are little better across the Narrow Sea in Essos where leader of the Dothraki, Khal Drogo has succumbed to wounds inflicted in a minor scuffle. Here, appropriate access to antibiotics and sepsis source control will have negated the need to use poorly defined and non evidenced based therapies used by the Blood Magi. Being Barbarians, they could be forgiven for not having a well developed trauma service, but this must become a priority given how much blood is spilt in their name. They need only look towards slavers bay for an effective surgical practice. Becoming unsullied requires an invasive procedure and the fact there are 8000 survivors is testament to go post operative care and cleanliness.

There are reasons to be optimistic, not least in the survival of the  Kingslayer after a grossly contaminated forearm amputation was promptly managed with haemorrhage and infection control from Masester Qyburn, who whilst spurned by the Maesters in their Ivory towers is producing some promising results in acute care situations, results of his treatment of the Mountain are awaited with some excitement.

So what is the answer? The Maesters and the Master of Coin need to sit down and plan an effective and wide ranging trauma network throughout the 7 kingdoms. This should start with a dedicated level 1 major trauma centre in the capital to serve the population of in excess of half a million people. This should be equipped with access to immediate radiology, general, orthopaedic, vascular and cardiothoracic surgery as well as the opening of the Oberyn Martell Memorial neurosurgery unit. This should be complemented by a hub and spoke system of trauma centres located in the major population centres of the largely rurally populated Westeros. Transportation to the MTC should be provided when patients are stable in view of the  large distances involved. Furthermore, field care should be provided by mobile trauma units following the great hosts of Westeros to war and at Tournament, with a banner befitting their neutral and altruistic nature. Lastly the Maesters need to be up to date with evidence and all must attend an ATLS course as a matter of urgency to learn how to care immediately for the injured in battle or intrigue.

Now is the perfect oppurtunity to improve trauma care in Westeros and only short sighted temporary leaders will prevent this.

Sunday, October 5, 2014

Head above the Parapet

Where I work in RuralTown a vast majority of births are in the hospital. We don't have any home birth midwives as far as I know, and we don't have a birth centre. Our private obstetrician also delivers at the hospital, so women who want a home birth don't have much choice out here. 

From canvassing the opinions of my colleagues I don't think home birth is a big thing in Australia. I don't have much in the way of stats, but something like 1% of births are home births, and this is confined to large cities, indigenous communities and accidents in remote areas where there isn't time to get to hospital. 

So, in ante-natal clinic, a pregnant woman asked me where I'd like my wife to have babies when it comes to her.

Now, I'm not quoting studies or being a vagina-controlling doctor, I just answered her question honestly.

I would like my wife to give birth in quiet, clean, safe environment surrounded by people who care about her, and give her the choice to do whatever she wants.

I would also like to be within a 
cord prolapse distance from a fully staffed obstetric operating theatre, with full obstetric, midwifery, anaesthetic and haematology support. Preferably with a neonatal ICU available, ready to deal with any catastrophe that could arise.

I don't think that the two places I have mentioned have to be mutually exclusive.

I have seen enough women and young babies who are alive because of prompt intervention to make that decision for me. And they weren't all "high risk" women either. All any of us want are healthy mothers and babies and I think with births in hospital the trade off between losing some privacy, choice or seeing the likes of me is outweighed by being in an environment that can deal with an emergency. Some things in obstetrics are too fast to allow a transfer. Fortunately, it doesn't happen often, but when it does it's fairly harrowing stuff.

I also think that there is a reason it is so difficult to get indemnity insurance to be a home birth midwife and there is a reason RANZCOG do not advocate it. For balance, have a look at this 
site to see why doctors are all self-serving control freaks who rely on scaring women into having Caesareans. Now, putting my obstetrician hat on, I would love nothing more than every woman birthing their babies at home in complete safety and ease. But they don't. Which is why I get called at 3am.

So that is why I wouldn't want my wife to have a home birth. She happens to agree with me, and if she didn't I would support any decision she made. 

I'm not cleaning the sheets after a 
PPH though.

Tuesday, September 2, 2014

7 months on.....I sound like a broken record!

So 7 months have passed since my last post, I bet you all thought I had disappeared for ever. No? Don't care? Thought not.

Well a lot has happened I say that much. I now have a very happy healthy one year old son, who is better than anything else so I'll mention him first. He still doesn't have a presence on Facebook which I am happy about and is still doing all the right things for his age.

I have also moved house. Again. Fortunately for my family it isn't quite as far as Queensland this time, but still a good 3 hours up the M1 to West Yorkshire. Once more this was necessitated by my damned need for paid employment.

You see, I didn't get a training number. Again. I am starting to see a pattern emerging here of poor communication skills and a lack of direction in the portfolio. I am going to have to focus more clearly on what I want to do as opposed to hedging my bets as I did this year. I have completed my core surgical training and attempted applications for ST3 in general and paediatric surgery. Having to plan for 2 interviews meant not planning for either enough. Suffice to say I hate interviews at the best of times and probably buried my head in the sand about actual preparedness as I hate practising interview questions and handing over built in answers. It is all so fake and makes my skin crawl, Yuk. It is something I need to get over as that is now 4 interviews I have messed up and it is starting  to affect me.

Anybody who wants a career in surgery should think very carefully. There is not enough spaces for everyone who wants to do it, even those who get into core training at CT1 as per the ASIT website. I feel the whole concept of core training is flawed as more than 2/3 of those in a post will not progress to the next level, as most people who go into it don't go in wanting to do radiology or A&E (or they could do that straight away). I feel it is just a way to save money and fill SHO rotas under the guise of training. What's worse is that ST3 applications now downgrade candidates who have been out of medical school longer (presumably to level the playing field and smooth the flow for candidates straight from core training).Therefore next year my portfolio score will be marked down as I have more experience. Again I wonder about the fairness of this as not everyone chooses to go into surgery straight away or is full time all of the time. Anecdotally from the 18 core trainees that entered my core surgical training deanery in 2012, 5 got training positions. More than 5 are doing some stop gap or research and more than 5 left surgery altogether. I'm doing a stop gap. ST3 posts were released on May 24th and I needed a job by August 5th. Panic stations set in and I knew I didn't want to be someone else's research monkey for 3 years.

I am currently working as a Specialty Doctor in General Surgery at Airedale in Yorkshire. It is essentially a non training registrar staff grade post and is in a wonderful part of the country. We live in a cheap, spacious house with rolling hills and farmland all around, charming towns a short drive and within an hour I can be in Manchester or Leeds. The job itself is pleasant and I'm not working with any egos or idiots. I get more responsibility and the chance to work as a registrar and do my own clinics, ward rounds and teaching (but not theatres yet butterfingers). This has its upside as in it is more rewarding and I'm acting like a doctor and not just a ward administrator and retractor holder but means I get my fair share of problems which I used to send up the chain as an SHO, most notably dealing with difficult patients or having difficult conversations.

I am nearing completion of my Post graduate certificate in Leadership (Mary Seacole Program). Whilst the contact days have been enjoyable, I have found the whole process a bit overwhelming with having a full time job. Some of the other candidates on the course get 8-12 hours protected time at work to work on it! No such luck for me. I'm sure that would get laughed at if I mentioned that applying to me. My department in Leicester were not exactly helpful in doing the practical project side of things going and I'm glad it is soon to come to an end. I really wish I had enough time to engage more fully with it and not move house 3/4 of the way through it as the programme I feel it is worthwhile.

So time goes on and the same things are happening  to me. I've had to nail my colours to the mast and go all out to be a general surgeon. I really like my current job and actually want to go in this direction as opposed to just being all "meh" and going with the flow. That is not to say I won't change my mind when I'm unsuccessful next year. My difficult to placate ego means I don't think I'll want to be a staff grade for ever, however it is very possible that my talent for surgery doesn't match my ego and I will have to try and climb the medical ladder in other areas. I have looked into the new alternative route of entry into emergency medicine training, which I am eligible for as a surgical trainee. It would suit my desire for action and immediacy but I might not like handing my patients off after 4 hours. I have put a lot of time, effort and money into being a general surgeon.

  • MRCS Parts A (£450) & B (£900)
  • ATLS (£600)
  • CCrISP (£700)
  • BSS (£400) 
  • Basic Laparoscopic Skills (£250)
  • Logbook (£200 per year) 
  • RCS fees (£300 per year)
  • Interview  course (£200)
  • Teaching Course (£180)
  • 6 audits
  • 5 book chapters
  • 3 posters
  • 2 regional presentations
  • 2 service improvements
  • 1 publication
  • 1 weekly teaching commitment
  • 1 mentoring programme
  • 1 post graduate qualification (£5000 - luckily bursary paid for) 
  • Not to mention all the annual leave and rest days I didn't take so I could do more operations.

And because I get nervous when interviewers ask me awkward questions, none of that was enough to get even within 200 places of a job. And my list isn't spectacular, in fact some might consider my CV slightly bare. So, again(!) we will wait and see. Hopefully I get a surgical training job, possibly accept a long term staff grade position, potentially change career entirely.

Or sack it all off and go back to Australia.

Oh, and I'm still really fat. More fat than ever. I seem to coincide starting diets with doing blog posts. I must give my fingers something to do when they aren't stuffing pies down my chops.

Monday, February 3, 2014

A tale of 2 rants.

Rant 1:

Circumcising babies for no medical reason.

I have worked in paediatric surgery for 6 months, so I am aware I see skewed picture. On average we see about one admission a month for complications of the aforementioned procedure. Now I understand it is an important religious rite for some people, but that doesn't have to mean I like it. People who say it is a low risk procedure, have you ever seen a 3 day old baby exsanguinating from the tip of their penis? Or a young boy which a suprapubic catheter because he lost the end of his urethra? It's not low risk, which is why it should be performed by urologists, in hopsitals, with consent forms and machines that go beep, for reasons that are physical not metaphysical.

The WHO suggested that male circumcision should be included in a comprehensive HIV prevention strategy. This is aimed at populations with high rates of HIV, and not at the expense of education and actual prevention. It does not stop transmission of HIV, only a modest reduction in transmission. There is no firm evidence to support its use to prevent UTIs, STIs or HPV penile cancer (which is rare as it is). Safe sex is the only way to actually reduce any of these. A recent paper in JAMA has suggested it is cost effective if used in the USA by reducing these. This is because their government funds the procedure. I'm upset about private procedures having complications that cost the NHS. People compare circumcision with vaccinations in terms of perceived health benefits. There is a large discrepency between the benefits of vaccinations and that of routine circumcision.

The reason it is done privately by GPs in their own rooms is because no right thinking doctor would do it otherwise in the UK. It is done without anaesthesia or pain relief. What really gets me is that these private, unnecessary procedures may only go wrong in a small proportion but the cost is born by the NHS not the privateers. Each baby that has been brought in this year has had to spend a night in observation for it. This indirect cost is not measured in pro circumcision papers.

Also, the boys have no say in whether or not they lose their foreskin. I would quite like to be informed if I was going to lose some of my genitals. Female genital mutilation is rightly seen as a ghastly act in most of the world, but if a study advocated its reduction in STIs or HIV would we still want to be using it? I'm aware the risk profile increases with age with the procedure, but waiting a few years or not getting it done at all would be more in keeping with my notion of primum non nocere.

So, if you are thinking of getting your infant son circumcised, firstly the NHS do not recommend it, secondly perhaps you should ensure that the guy who makes a mint out of you to do it, gets invoiced for the bill when it goes wrong.  Whilst you're at it, teach your son that condoms are better than lacking a foreskin at reducing STIs. Not that any of that would happen, because questioning 15,000 year old rituals would appear to be the height of bigotry.

Rant 2

People hating stay at home mothers.

When I tell people that we have a new son, one of the first questions I get is. "When is your wife going back to work?" When I tell them "Not for the foreseeable future." I am met with at best surprise and at worse criticism.

Things seemed to have changed in the world. It seems that it is no longer acceptable for just one partner to do money work and one partner to do child work. Many people including writers for "the newspaper that shan't be linked to" seem to think it's lazy and that people revel in being lazy whilst extolling the virtues of living such blatantly idle lives. It is as if child rearing has suddenly become an easy service that can be outsourced.

Luckily, I have a wage that can support a family of 3 which doesn't necessitate the need for my partner to go back to work to keep a roof over our head. Actually, Luckily is the wrong word, because there is nothing lucky about studying for 12 years passing medical school, post graduate exams and post graduate qualifications and accruing 30K worth of debt in the process. I've worked very hard to be in a position where I can allow my partner to raise our child.

The government seems to want everyone to make as much money as possible and outsource care to make even more money. This is not how I see living my life. I don't want some minimum wage dolt raising my children for over a third of it's life, surrounded by dirty toys and even dirtier children. Surely I trust my wife more than anyone else to raise our children, and she has a vested interest in raising him well as he is her child too!

From a simple economic view the gains do not outweigh the costs. A simple Google search of nurseries in my area puts the cost of a months day care at between 750-1000 pounds per month which does not include unsociable hours or extra curricular activities. If my partner was also a doctor we would have to find time out of hours, overnight, weekends, evenings at a premium rate or rely on parents/family to see us through. My wife's last job before maternity leave paid slightly more than the above quoted figure. Is it worth her working full time to come out with about 25% of her wages at the end of the month.

But wait! What if the government want to pay all of your childcare costs (in whatever fantasy land that will happen in). My wife still misses out on all the positive life affirming aspects of seeing your child grow themselves and not learn 2nd hand from an (NVQ certified!) child care assistant that her son strung a sentence together. Possibly along the lines of "Is it my fag break yet?".

Sure, we made a decision to spawn a being and are paying for it, we are 1000s pounds a year worse off for doing so. But this is our decision based on how we wanted to live our lives. Making a small proportion of it back by sending my wife out to work doesn't make up for the chance to raise the child yourself in an environment you have control over.

But it's sexist! I'm enforcing 1950s gender stereotypes on my wife by forcing her to stay at home! Not really. She has a choice to work or stay at home and she made it. I happened to agree with it. Working 160 hours a month for £300 sounds more exploitative to me. If I was the minority earner in the relationship, you might have found me at home in the day doing the housework and baby changing.

Lastly, being a stay at home mum is fun! Why shouldn't I encourage that. There is a fair share of one on one care work for our son, and then there is time for cake making and such! A lot of the negative criticism comes from simple jealousy that my wife leads a nicer life than slaving at an office to earn a bit of cash for somebody else, missing their child develop. Agitator in chief, you know the woman who quit The Apprentice and was on This Morning, her, the one who doesn't like the name Tyler, decries the coffee sipping, lunch goers. That is because these women are very happy, with partners who don't have to put up with the likes of her!

In conclusion, we pay for ourselves and have a happy, productive home, so you can take your opinions about our childcare arrangements and stick em.