Thursday, March 1, 2007

Don't bother coming to A+E....

Please don't come this week, unless you really really have to. I'm not joking. Unless you are one of the minority of patients who are actually attending for valid reasons i.e. an ACCIDENT....or in an EMERGENCY situation (yes, it really is that simple, its not rocket science, its on the front door for all to read!). I promise you that "problems" you have which are self inflicted, stupid, chronic or things that "I was going to see my GP but I didnt get round to it" will be met with extra disdain. At the best of times we don't have much sympathy for you coming in with your sore throat which has been there all week and you havent even bothered trying something as simple as going to the pharmacist before taking the plunge and coming into A+E.

This week, and probably the coming weeks are different. Its a very very special time for several reasons.
1) Below-inflation pay rises for NHS staff. Yippee, our job sucks and you want to effectively pay us even less for the anti-social, below par working conditions..I hope the nurses actually do what they threatened and have a strike...then we can also strike with a clear conscience...problem is we're too scared of being seen as the "baddy"....
see this link to read more

2) Most of the doctors working their socks off in the hospital now face the prospect of NO job come August due to a very ridiculous computer-selection procedure which tested creative language skills rather than clinical skills thus throwing some very skilled clinicians with poor writing (read: embellishment/ plagiarism/ assistance) skills. You may have noticed that the doctor treating you has a tear in his eye. No its not because he is so empathetic, its because he is literally on the brink of breakdown because he has spent the last 10 years of his life training to be a doctor, accrued lots of debts, has a mortgage and 2 kids and will possibly be forced to either leave the country to find work, leave medicine altogether (Waste of £250000 taxpayers cash in trainig on both counts). Or go and prostitute himself in some other way to make ends meet. Generally looking quite grim . He certainly won't be sympathetic to you showing him your verucca because it hurts. You probably do not have any idea what real pain and agony is (Unless you have had a heart attack or a baby perhaps). I, being the infamous Dr NoNo with my powers of extrasensory perception and psychic ability saw all this coming a long long time ago and hence am calm in the face of a storm. Bizarre really for a wound up, control obsessed Type A personality....

So, have a heart this week at least. Don't get p*ssed and fall flat on your face then punch your best mate in the jaw and drag your sorry selves into hospital to be seen. Don't dump granny at the moment let her relax a bit under the covers. If you have a temperaure, take some paracetamol and stop calling the ambulance for back pain that you've had for 4 years.
Just for the moment...just don't bother*

[*Disclaimer : If you think you may be having a heart attack, or your bowel is perforated or any other serious complaint along those lines its still acceptable to come in...sympathetic exceptions will be made for you]

Sunday, February 25, 2007

Granny dumping....the nations favourite pastime

You know theres always a small part of a doctor's brain that sighs very loudly when they pick up a patient's notes and see the age of the patient (over 65) and then complaint of either "Collapse query cause". Or "Chest pain". In fact theres a special scoring system which gauges the "heartsink level" for elderly patients. This is how it comes about :-

Level of depression doctor experiences = Age of patient x (complaint vagueness score* + Home Situation**)
- multiplied by 5 if they were brought in by ambulance
- multiplied by 10 if Dementia is listed on the front of the notes
- multiplied by 20 if they were brought by relatives on/prior to a public holiday e.g. Christmas Eve

* complaint vagueness: "Collapse ? Cause" = 2 "chest pain"=3 "fall"=4 and "unwell" =5
** Home situation: Own home = 0 Living with relatives = 5 Residential/Nursing home =8

The reason for this is quite simple. "Young" people just don't like old people. How ridiculous has society become that the elders are not only not respected and looked after properly but are treated quite badly in some instances. Don't get me wrong, I and other doctors actually enjoy the challenge of seeing elderly patients with multiple medical problems (yes we do need to get out more, more on that topic in later posts) but what irritates and saddens most of us are the circumstances surrounding the majority of elderly patient admissions.

The saddest thing I have personally seen (and very naively thought was just a medic-myth) is the phenomenon of Granny Dumping. Let me enlighten those of you not familiar with this concept

Granny Dumping [gra-nee dum-ping] v.
1. To abstain from the responsibility of looking after an elderly relative often because you "can't be bothered", "they smell" , "you want to have fun and go out with your friends" by way of fabricating medical symptoms which guarantee admission to hospital at least for one evening.

2. To relieve yourself of your nursing/care duty for one/several residents for an evening or two by fabricating medical symptoms which guarantee admission to hospital for at least one night often because "they smell", "they are incontinent", "they are confused", "you don't like them" or you're plain lazy and uncaring.

3. A selfish act to ensure your party or public holiday is enjoyed to the maximum at the expense of an innocent party who may have been your own carer when you were younger but you have conveniently relinquish all knowledge of the countless times you had your nappy changed and vomit cleaned up. Usual dumping ground :Local hospital

The last 2 years I have had the joy of working on Christmas Day. Not only was I depressed at having to work and make do for lunch with a soggy sandwich or nothing at all but I was made to feel sorry for the high number of "grannies" dumped in a cold-hearted and selfish manner. The stories whether from nursing homes or from relatives practically drooling at the thought of not having to take grandpa to the loo again were strikingly similar. It would always be...He/She was just sitting at the table and then collapsed and was foaming at the mouth. Or He/She was sitting there and then started having breathing difficulties and was clutching his/her chest and looked in agony. Or he said he had chest pains. Or he looked really unwell and vomited.
Problem is with all of these patients they are unwell...they are elderly, frail, with multiple medical problems and risk factors for serious problems such as heart attacks and strokes and these "symptoms" cannot be ignored, even if the patient themselves do not remember it occuring. Sadly it is not only a Christmas-related problem, its year-wide but more apparent at that time.

The worst cases are those coming in from Nursing homes, brought in by ambulance with nursing staff saying they just became "unresponsive" for x amount of time. As all "good" doctors know its very important to get a detailed history about such events, also known as a collateral history.
And here is what happens to me (unfortunately) on a weekly basis.

Me- "Hello there, this is Dr No No calling from Somewhere Hospital regarding a patient of yours, may I speak with someone who looks after them"
Nursing Staff - "Um you want what? Vat Eez it? Who patient?"
Me- I'm a medical doctor looking after Mr Unwell, please can I speak to the nurse looking after him to discuss what happened today
NS - "No you cannot. Dat nurse is gone now. No one here who knows dees tings. "
Me - "What? No one there who knows about this man? But he just came here one hour ago!"
NS -" No, Dey have gone. Sorry"
Me - "Okaaaay, well perhaps you can look in his personal notes there as we did not receive any information. At least tell me what his regular medications are and what he is like normally, you know like how he mobilises and whether he is confused for example...."
NS - (laughing)...."Dey are all confused here, you know Eeez old"
Me -(starting to get slightly annoyed). "Yes I understand that, can you please find some information for me, as it is quite important"
NS - "Well he is only here few weeks we do not have anytings on him- maybe dee manager will come and say it in morning. I cannot get that stuff "
Me - "Not even his medication list and allergies?"
NS - "Oh Dat, let me see I will come back in 1 minute okay?I av to check it"
(I hear rummaging around and 6 minutes later...)
NS - (Triumphantly) "Here it ees. okay he has At...At....ha ha it is hard to read it ateen- ateen-oh""
Me- Atenolol?
NS- Yes dats it fifty oh dee. And den Ato heehee...Ato- voh- state-een Ten"
Me (getting inpatient and frustrated) You mean Atorvostatin? !!.....

And so it goes on, the painstaking task of getting information out of someone who doesnt care, doesnt know the names of the medications she is feeding to someones "loved ones" on a daily basis and just wants you to go away so she can get back to her nap. She is the one that people entrust with the care of their parents in the hope that they will be looked after in a decent and supportive manner. The reality is not always like the Nursing home brochures would have you believe. Half the time no-one will pick up the phone and a lot of the time the people allegedly looking after the patient don't even know what their normal state ought to be, so how on earth they can be expected to pick up on the sometimes subtle changes in a person who is actually sick? Sometimes patients will arrive in hospital so unkempt and soiled that I wonder if they are having any care at all!

I'm sorry to depict the Nursing staff as foreign and inept, but sadly this is often the case and I don't think it has anything to do with their ethnicity [Note I am a second generation foreigner but my family members have excellent verbal communication skills and are respectful and educated and understand the significance of their respective careers and the effects on others- very much lacking nursing home spheres] . It seems that the people setting up some of these residential and nursing homes will take on "cheap labour" from people whose English is just not good enough for the job (Just think most of these people have trouble hearing the perfect pronounciation and English of the newscasters on must be pretty frightening to not be able to communicate any problems or wishes to someone looking after you). The nursing home owners (businessmen and women) don't really think about quality of care of the human aspect of the service they provide. They just make sure that granny looks clean when daughter comes to visit and time the feeding assistance in line with the scheduled relative visits to give the false impression of good care.
Anyways, I digress...the point was that when these "nurses" (I often wonder if some of them have ever had any training...I spoke to one who had never heard of Aspirin recently) get bored or annoyed with cleaning up urine and faeces and feeding then they pull the- "Send them to hospital" stunt....wasting ambulance and hospital time for a patient who is as well as they always were and will be.
Every cloud has a silver lining...and as a result of multiple presentations of dodgy cases from the same homes...something is being done and investigations of some homes are in the pipeline. I really hope they get shut down or fined or something. Its just so frustrating because that shadow of a person lying on the hospital trolley dazed, confused and smelling of a urinary tract infection mixed with faeces is someone/was someone and is entitled to a better life. Its really a sad reflection when you are over the moon when you come across a decent cooperative and well informed member of staff when you call up a home (it does happen from time to time!)

Granny dumping.....this Christmas, let grandma sit in the corner talking to herself....and maybe feed her a bit of mashed turkey and potato puree. After all...she did the same for you when you were babbling away incomprehensively all those years ago....

Saturday, February 24, 2007

No amount of shouting and screaming will help....

Hospital staff don't take too kindly to being shouted at, threatened, whined at or physically attacked. If you have a problem then the best way is to discuss it is in a polite manner rather than kick up a furore in the waiting room upsetting genuinely sick people. Put it this way, if you're well enough to shout and punch, you can bet your bottom dollar that we won't really think you belong in the Accident and Emergency Department and you will be put to the back of the queue (Screw the waiting times).
Recently a "regular" "patient" who has been known to punch nurses and doctors turned up with a "medical problem" along with their usual drink/drugs problem. Most of us point blank refuse to see him which made it very interesting when calling for others from the waiting room to be met with a growl of "I have been waiting for hours, what about mr **** *****". Now I don't enjoy sweating with fear, nor do I like ushering the frail and injured into the department in a rushed manner but this is what we are reduced to. I refer to the big dream of medical school..."To help others when they are unwell or infirm". I don't remember promising to treat numbskulls with personality disorders brought about by drink and illicit substances, Nor did I promise to do "everything possible" for my patient including risking my own and other colleagues safety yet day in day out this is what we are subjected to. Whatever happened to the good old days where the docs and nurses were respected and idiots were sent away immediately until they learned manners. In Britain we are so scared about being labelled as prejudiced so we treat everyone "equally". The theory for this type of behaviour is great...(see modified Hippocratic Oath for more details). You don't judge your patient on any basis other than their illness at the time. However when faced with the contrast of the elderly patient who has slipped and broken a hip and is genuinely thankful for your time with the twenty-something year old who has been fighting after having one too many down the pub and broken a bone its only natural to make a distinction. I will call both patients "Sir" and arrange all the adequate tests,treatment and pain relief as needed but deep down I want the latter patient to suffer. Why? because he has brought this problem upon himself, he is wasting valuable resources that ought to be used for people who really need the help. Because he is exactly why the moral fibre of this country is wearing thin and gang culture rules. He is why the elderly are afraid to leave their homes for fear of being mugged. In short he is useless wasteful scum and most healthcare professionals would agree(although not openly). I sometimes wonder if we took a "Third World country's" view on this and left these people to learn their lesson the hard way that perhaps they might not be such a pain and make way for the real sickies. After all when we took that Hippocratic Oath thats what we were referring to....

Friday, February 23, 2007

Does A+E really look like a dental surgery to you?

No really? ~
Does it? The answer ought to be " I don't think so". However with the sad state of affairs of the NHS dental system (or lack thereof [read: too many rich/greedy/smart dentists have opted out and gone totally private]) many of you out there seem to think that your tooth problem that has been ongoing the last 2 months and "suddenly got worse" will be dealt with in an appropriate(and more importantly, free ) manner in your local Accident and Emergency Department. As you may have noticed we don't have any of those nice dentists chairs, or drills or pliers or any equipment to look in your mouth properly bar a pair of gloves and a torch. Most of us can spot a swelling or abscess or redness in there, but then so could any half brained 10 year old with a pen torch in their hand. They could tell you about as much as we can and probably not curse you under their breath while doing it. That's not to say we won't help you- of course we will write prescriptions for painkillers or antibiotics as necessary but in reality, you need a dentist. You would never ever go to your dentist with chest pains or problems passing urine because they really can't help. The same is true vice versa. And I can assure you, dentists know a helluva lot more about mouths and teeth than your "regular" doctor, and you may end up not losing that precious pearly white after all....

Thursday, February 1, 2007

Why am I here?

I am a twenty something year old slightly cynical doctor working somewhere in the South of the United Kingdom. To say that I am slightly fed up of my job could possibly be "the" understatement of the century however there are some (albeit minor) perks to the job. One of these is the amazing dinner-party entertaining, jaw dropping, hilarious and sometimes disgusting stories that you come across in your daily routine. (That is if you ever have time off to attend said dinner engagement). The human aspect of the job leads you to develop a certain character and way of thinking which sometimes alienates you from others...namely non-medics.

Some things you ought to know about doctors in general

1) Most of us are not that caring, sharing fuzzywuzzy want to give you a hug type of person. We are the cream of the crop of arrogant Type A personality , ultra-competitive , back-stabbing, self centred smartasses who think that having the illustrious title of "Doctor" in front of our name gives us the moral high ground and right to sneer at anyone who isnt a "professional" when in reality we are overworked, exhausted, regretful and highly jealous of associates who managed to make better career choices than us back in high school. The moral and snobby perspective is a defence mechanism...we have to constantly reaffirm ourselves because God knows no one else will. Becoming a doctor was something one did to "prove" that you could- even now it isnt a walk in the park. But why do we do it? Gone are the days of highly esteemed and respected doctors. Most of us are lucky to get through a single day without a verbal insult or two.

2) We may smile at you when we see you and treat you all as equals - our professional codes of conduct tell us to act in this way. You know though that deep down we have an opinion about you, your level (or lack)of personal hygiene, your insight into your illness, your "whine" factor , whether you have the annoying relative who harrasses us every thirty seconds and doesn't allow us to actually treat you. Every word that comes out of your mouth will either work in your favour or against you. Although they like you to think that they aren't judging, nurses are the most judgemental. I hear the most scathing comments about patients before I have even met them from the nursing staff...and oh my word can it be harsh!
NB- Don't worry, if you're a sane person who genuinely needs medical attention and aren't a drunken time waster with an element of neuroticism about you we are generally pleasant and enjoy treating you- honest!

3) If your medical condition has come about as a result of your own stupidity you can be sure that we won't have too much sympathy even if we do keep a straight face when we come to treat you. Medical ethics prevent us from telling all our mates down the pub that Mr Joe Bloggs managed to burn his private parts while trying out his wifes steam facial down there but medics have a terrible habit of telling the story anonymously as a "teaching point" for others. I have even heard the same story told by different doctors because the case was so interesting. The truth is probably that our own lives have become so robot-like and dull that the only interesting aspects are those relating to the amusing things patients have managed to do....

4) The majority of doctors know what they are doing. After all we all had to pass all those gruelling exams and assessments year in year out despite the other trials and tribulations of university life. Rarely there will be one who slipped through the net or actually was a model student but the reality of life as a jobsworth working for the NHS has worn away any element of pride in work and care. These are usually the ones that respond to questions from patients with either an undistinguishable grunt or the ones who walk away and pretend they didnt hear what you were saying. That is usually the latter sort of doctor, the ones who think"...actually you know what? I don't care. See ya!". Most just get on with the work at hand and spend most of their life making the people who have the misfortune of being close to them almost as miserable as themselves by virtue of almost constant whingeing....

5)Most doctors have actually forgotten the answer to that all important question they oh-so dilligently prepared for pre-medical school...."So why do you want to be a doctor?". Personally I never even had an answer for that all those years ago. I lived on my ability to blag (shame it doesnt work much outside of interviews)

6) Working for the nhs is generally very very very depressing. Most of us would rather run away to some obscure country than work here but its like one of those life-sapping parasites. Once you're lumbered with it, its bloody hard getting out again. No matter what you do to try and get out, somehow you bounce back in, and feel worse for it every single time.

7) Being a (junior) doctor in the nhs is akin to being a trained monkey. You actually don't need all that training to do the sort of work you are required to do as a junior. I certainly remember spending hours on end chasing test results, requesting other examinations scans and tests and generally being at the beck and call of my masters (Consultants). I think the taxpayers money would be better spent training a bunch of school leavers to fetch and carry stuff around hospitals, that and learn to take blood....all for minimum wage. Yes Mr Blair I am suggesting ways of reducing the NHS multimillion pound deficit that seems to be burning up any chance we had of good clinical care. I mean whats the point in having highly qualified "professionals" if they aren't allowed to treat patients in a professional way because of financial restrictions?
Back to the point- getting these school leavers in on the act would be great because it would have double effect- hopefully the time they spend at work would a) keep them off the dole (hahaha- yeah right!) and b) keep them out of trouble- perhaps lower that horrendous teen pregnancy rate we have? Lets face it if you don't have a job and everything is a bit dire, what can you do that doesnt cost anything to amuse yourself?! and theres another teen-smoking-buggy pushing-cider drinking micro family sapping the economy for "jobseekers allowance" and the suchlike. Hurrah. Thats why I went to medical school- I remember now- to work myself to the brink of being ill, multiple evenign weekend and night shifts looking after people who didnt care for themselves or others around them and pay a sizeable chunk of my earning to a system which supports these sorts of things....oh yeah, and to amass huge loans that will take me the next 20 years to pay back for 6 years of is good.