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.