Blame Culture

Today we woke up to the news that the GMC has won its appeal to the High Court, and has struck off Dr Bawa-Garba.

Imagine, if you can, returning to your job after a prolonged leave of absence (maternity leave in this case), beginning your role afresh in a new environment with which you are not familiar, and being told that your colleague couldn’t be in today, and could you please do their work too? Additionally you find out that your boss is uncontactable, the other members of your team all started 2 weeks ago and are just finding their feet, and the IT systems are down. Someone else, in a different team, makes a mistake for which you are punished, and at the end of a gruelling workday you make an entirely avoidable mistake, which leads to catastrophic consequences. Are you no longer qualified to do your job? Do you lack the qualities and experience necessary to carry out your day to day duties? Or are these exceptional circumstances, and an entirely understandable lapse in judgement?

This is what happened to Dr Bawa-Garba. She made a mistake, on the back of incredibly hard working conditions over the course of a 13 hour shift, and a 6 year old boy died. Initial investigations into the case found that her mistake may not have influenced the end result of the resuscitation effort – the outcome may well have been the same. As so often happens in medicine, the SUI team found multiple contributory factors leading to this horrific outcome, and ruled that no specific person was at fault. However, Dr Bawa-Garba was convicted of manslaughter, suspended from the GMC register for a year, and has now been completely struck off.

We hold clinicians to a higher standard than most. It is understandable – our mistakes carry higher stakes. There are horrendous consequences to our failings. However, can we blame individual doctors for an outcome that has occurred in a working environment that no sane person would find acceptable?

We, as doctors, often work shifts where you go 13 hours without eating, drinking, weeing, or sitting down. I have often joked, whilst on call, that I am treating a patient for hypoglycaemia or acute kidney injury, but that my blood tests may well be worse than theirs. We prioritise the need of our patients consistently above our own basic, human needs. We work in conditions that you would be sued for trying to impose on any other profession. And the worst thing is, we impose those conditions on ourselves. We consistently state that our working arrangements are unsafe, no one in their right mind would think that staffing a 500 bed hospital overnight with a medical team of 3 people is a good idea. Wards of 30 beds go from a team of 3-5 doctors during the day, to sharing the 3 on call doctors with the other 470 patients in the hospital. Even on days when the rota is fully staffed and all the systems are working, it is a disaster waiting to happen. Medical ward cover consists of running from one fire to the next, never feeling like you are winning. How are you supposed to prioritise your need to eat when a succession of patients are, literally, trying to die on you?

But hungry, exhausted, overstretched doctors make mistakes. It should not be news that we aren’t at our best when our last meal was 12 hours ago. I remember clearly finishing one day on call on the maternity ward, and passing out on the walk to my car. On reflection, I hadn’t had a meal since dinner the previous night. I was concerned about my ability to drive, and called a cab home. 45 minutes previously I had been responsible for resuscitating a patient, solo.

During my time as an intensive care doctor, I frequently covered a ward of 14 critically unwell patients, with no Consultant cover on site. I started the job, on a night shift, with no induction to the computer-based notes system, no idea how to review medications or change doses. No understanding of how the filtration machines or ventilators worked. The fact that both I, and the patients, survived those on calls is testament to the incredible standard of nursing care. The nurses on that unit saved me more times than I can recall. But it should not be the responsibility of the nurse to educate the doctor. By that logic, there is no point in me being there. I reflect on that unit, and the fact that nobody died as a direct result of my lack of training or experience is frankly baffling.

The GMC has gone on nothing short of a witch-hunt. Bowing to tragically bereaved parents, making an example of someone who did nothing more wrong than any one of us has done on countless occasions, but got away with due to circumstance. The CEO of the GMC released a statement following the outcome:  “We are totally committed to engendering a speak-up culture”.

How do you expect to foster a culture of speaking out, when you victimise people attempting to reflect on, and learn from, their mistakes? Doctors are human. We will all make errors in our careers. I have personally made management decisions that have contributed to a patient’s death. We are a cohort of professionals that go into medicine in order to improve people’s health and lives. Nobody can make us feel worse about our failings than we already do. Nobody can berate us more than we berate ourselves. We worry about doctors’ mental health. We worry about a culture where no one wants to accept responsibility or blame. And then we have a doctor, with an exemplary record, who reflected on a difficult case, gave evidence to an investigation panel, and then had her reflective evidence used to bring a court case against her.

We are all Dr Bawa-Garba. I don’t need to know the case specifics to know that similar situations are happening across the NHS on a startling scale. That the people responsible for safe staffing and rostering are not the people living with the effects of shortages on the frontline. That the people who have made a scapegoat out of this doctor get to go home at 5pm each day, and never have to hold a person’s life in their hands while trying to remember the last time they had something to eat.

Paediatric Pearls

Things I have learned so far in kiddies ED:

  1. Bubbles have magical qualities and fix tachycardias ALMOST every time.
  2. There is no such thing as a “quick look” at a child in triage.
  3. Play specialists = HEROES.
  4. Early ametop application in triage is one of life’s greatest gifts.
  5. ALWAYS take a second cap gas because the machine demands one as a sacrifice.
  6. Sometimes kids just get rashes, and we don’t know why.
  7. All children in London are constipated.
  8. Parents never give paracetamol, for fear of us not believing that their child was in pain/hot. We berate them for it, and then don’t believe them that their child was hot at home if they aren’t hot here.
  9. I can now identify which antibiotics someone has been given based on what colour it is, what it tastes like, and what bottle it comes in.
  10. Suctioning bronchy babies and watching them instantly perk up before your eyes is one of life’s great pleasures.
  11. Sometimes a sympathetic face and time to listen is all it takes. Parents’ scope to worry about their children knows no bounds, and reassurance costs nothing. Be patient.
  12. A good number of midwives scales are broken.
  13. If the umbilical cord looks infected, it usually isn’t. When it is, it is a BIG deal.
  14. Getting a line into a 1 day old baby gives you the best high.
  15. Paramedics and GP surgeries NEVER have paediatric sats probes and this frustration will be felt DAILY.
  16. When you get cocky about your abilities you will inevitably do something insanely stupid like glue a child’s eye shut.
  17. When you finally know the doses for paracetamol and ibuprofen without looking them up you feel like a GOD.
  18. SOME babies ARE cute, and you have to remember to give them back to their parents when you are finished examining them.

Find your tribe.

Choosing a specialty is a funny old thing.

We spend a lot of time in medical school, and post graduation, trying to decide which area of Medicine we are suited to. It is an important decision, as it decides your career path and length of training, and although there is some potential for movement, it often entails further years in training if you get halfway down one path and decide you would rather be on another.

Some people are fortunate enough to be certain in their career aspirations, and know which path they want to pursue. I was never like that. I have found myself ambivalent about the specifics of Medicine. Nothing particularly excites or drives me more than anything else. I am generally doing the job because it seems a waste of a medical school education to do anything else.

It is bizarre then, that I have chosen Emergency Medicine. Ostensibly, this is the most stressful, involved, high pressured area of Medicine. You have to know lots about lots of things and for someone unexcited by various aspects of medicine, seeing patient after patient with a cough or a toe injury or a rash is hardly enthusing. Intersperse that with the seriously unwell patients who keep attempting to die on you, and on paper it sounds even less like something I would enjoy doing.

But the people. My God, the people. I remember walking into my first ED job, seeing the nurse in charge rip the shit out of the on call doctor with a crass and frankly too easy joke, and thinking “I have found my tribe.”

I firmly believe that it is not the type of job that you need to base your career decision on, but the type of people you will have to work with. And there is no better bunch than the ED team. Nowhere else in the hospital do nurses and doctors work so closely together. The relationship can be beautiful. You have the opportunity to understand each other, and ED teams become like family (a replacement for the family you have at home that you never see due to an unforgiving rota).

I have just finished a shift where it would be understandable if I was a broken person going home. Presentations were relentless, the board was out of control, not enough doctors, too few nurses, several angry patients – the usual ED shift. But instead, it was one of the better days I’ve had in a while. My personal life is a little rubbish at the moment and it is nice to be able to come into work, and have a good laugh with a genuinely great group of people. You don’t go into Emergency Medicine unless you are hardworking, sarcastic, fun, and have a thick skin.

I am in my 3rd year of ED training now, and during those years I have had to spend several months out of the department getting experience in other areas of medicine. And each time I have come back to ED I have felt the same sense of relief. Mainly the relief of no more ward rounds, no more clinics, and no more dealing with patients for longer than 4 hours (I have a ridiculously short attention span)! But also happiness that however rubbish the shift, however overworked, underpaid, generally under appreciated we all are, there will be piss-taking and merriment, and, if I have had time the night before, homemade cakes and biscuits. You can’t ask for more than that.

Welcome to A&E

confessionsofajuniordoctor:

I have no idea what it is that I like about Emergency Medicine.

The hours are terrible. The rota is indecipherable. You cannot plan to attend a friend’s birthday or a family gathering. Your social life is non-existent. The patients are largely rude, drunk, smelly and irreverent. There are never enough staff on shift. The urgent care centre referrals are sometimes ludicrous. The GPs send in UTIs as renal colic, PID as appendicitis, persistent patients that they can no longer placate. The specialty doctors think we are either lazy or lobotomised. You spend more time than you should at the centre of “specialty tennis”.

The four hour wait is a travesty. There are never enough observation beds. The pressure is immense. The clock never stops. There is always another patient waiting, another test to order, another result to check. There is always a diagnosis to be made, and treatment to initiate, a conversation to be had. You go from renal colic to brain tumours to heart attacks. You see depressed people, drunk people, old people, children. You see people at their worst. You see time wasters and hypochondriacs and then sepsis and deaths. You don’t have time to process. You don’t have time to think. You see, treat, refer, discharge.

People complain about the waiting time, disagree with your assessment, believe google before they believe you. You go home at night paranoid about the patient you sent home; constantly questioning your decisions, your abilities and your sanity. You see multiple patients simultaneously, you are a porter, a nurse, a cleaner, a friend, a confidant. You tell people good news, bad news, sad news.

You are charged with the unhappy job of treating people’s liver disease from excessive alcohol, lung disease from smoking, diabetes from overindulgence. People expect you to take responsibility for their lifestyle choices. You endure the abusive drunkards, the psychotic schizophrenics, the deranged elderly. You put up with the people who have neither an accident nor an emergency.

You exhaust yourself looking after these people, so much so that you go without food, without bathroom breaks, without the most basic of human needs. You are vilified by the media, who feel you are paid too much for what you do. You are misunderstood by friends and family who watch too much ER and Casualty. You become unacceptably irked by poor resuscitation techniques on TV shows. You complain about unnecessary attendances and then carry out wholly unwarranted tests because you are scared of being sued. You will inevitably have complaints filed against you for merely doing your job. You will make poor management decisions and people will die. You will make excellent management decisions and people will still die. You will defy the odds: CPR will work; the patient will recover from sepsis; be discharged from hospital, and then die at home a week later.

You will miss things. You will be wrong on a daily basis. Everyone thinks they know more than you. You finish a shift and barely have the energy to walk to the car; let alone drive home. You spend at least half of your days off comatose in bed. You don’t see your housemates for weeks due to opposing shift patterns. You do locum shifts during your time off because there are never enough doctors and you know how awful it is to work when they’re short staffed. The barista at Costa knows what sort of day you’re having based on whether you order a medio cappuccino or a double espresso. The packed lunch you brought 3 days ago is still sat in the refrigerator. Once you leave work you are unable to make the smallest of decisions because you have used up all of your brain cells.

You are stressed out, overworked and rarely thanked. And I can’t think of any specialty that I would enjoy more.

I wrote this post over a year ago. I am now back in ED as a specialty trainee, and the above is just as true as it has ever been.

I have loved this job in the face of so many reasons not to, and it will take more than contract changes or incompetent health secretaries to change that. Do your worst Jeremy, we will be doing our jobs long after you have finished doing yours.

I trained as a doctor, not a discharge coordinator.

My current medical placement is on an Endocrine ward. This basically means that as a firm, we should get all the acute diabetes cases; complications including renal disease, ulcers, hypoglycaemia etc. We also get people who have deranged electrolytes such as a low sodium, which in some cases is an indication of an underlying cancer or other disease. If I was in a tertiary centre (big teaching hospital) then I would be seeing exciting, rare endocrine cases such as Cushing’s, Addisonian crises and the like. As it is, in a district general hospital, there are not enough endocrine cases to fill the ward and as such we become the dumping ground for various other cases.

We take the social care cases, the patients who are awaiting placement, the long stayers, people with no discharge destination, the waifs and strays of the hospital. Whilst this feels like it should be a varied job, it is actually the dullest thing in the world. Within a very short space of time these patients are medically stable and they are in need of physiotherapy, OT input and social services for packages of care. Or they are awaiting transfer to a rehabilitation ward, or to another hospital for dialysis, or amputation. A typical ward round for us consists of maybe three or four patients who are medically unwell, and then about 20 medically fit long stayers.

This makes you incredibly lazy as a physician. It is so easy to write “obs stable, afebrile, no new issues” in the notes several times over and then go get a coffee and spend the day surfing the net. It is incredibly easy to miss a hospital acquired infection because you haven’t listened to someone’s lungs for a day or two, or noticed that their catheter is draining more concentrated urine. These guys go off quickly too, they go from months of medical stability to dead in a day or two.

It is a well known fact that increased time in hospital increases your risk of getting an infection and dying. It drives me crazy the amount of time it takes to get these guys out of hospital. I understand that there is a complicated assessment process involved in setting up placements, for example. The patient has to be needs assessed, placed in the right type of care facility, means tested for funding and then the individual home has to be seen and agreed by either the patient or their family. This can take weeks. What worsens this process is the total inability of any professional inside or outside of hospital to communicate with someone else. Social services will require a checklist. They will not communicate which checklist to the nursing staff. The nurses will fill in an inappropriate checklist, fax it off and it will be declined. The decision will not be communicated back to the ward. The doctors will go on the ward round and write “medically fit for discharge, awaiting placement” for weeks on end without knowing where in the process they are. Inappropriate people will be asked about updates – OTs get asked when the placement will be approved even though it is driven by social services, but social services are never on the ward and frustration leads to apportioning blame for delay to the wrong people.

Every time that someone is discharged from hospital with an existing package of care that needs restarting, a section 5 is necessary 48 hours prior to discharge to give the carers time to set up the package again. Everyone knows this is necessary, we know who comes in with a POC and therefore they will certainly need the same or increased POC on discharge, yet inevitably we will get to the morning of departure and it is news to everyone that the section 5 has not been sent. It is apparently impossible for the different teams on the ward to communicate directly with each other. People write their interactions in the notes and other teams don’t read them and then plans are made on incorrect information.

In order to attempt to coordinate all these things, there is a multidisciplinary team meeting on a weekly basis. This is my least favourite activity of the week. At face value, it is an excellent plan. You can get updates from therapy, nurses, discharge teams and doctors and then everyone is on the same page and we can expedite someone’s discharge. In reality, however, most weeks social services don’t turn up, totally negating the point of the meeting for at least half of the patients, or the sister in charge will have out of date information, or the doctors will spend half the meeting discussing someone entirely medical, thereby wasting the time of every other professional in the room. In complete defiance of their job title, the discharge liaison team neither discharge, nor liaise. The social worker never has an up to date ward list and is always at least 3 weeks behind with information. It would make a brilliant sketch show, it would be hilarious if it was exaggerated. As it is, people sit in acute hospital beds costing the NHS £500 per night doing nothing other than eat shit hospital food, go delirious from a hospital acquired infection, or become thoroughly institutionalised because it takes four months to communicate the need for placement, fill in the correct forms and get approval.

I don’t know what the answer is, obviously people should be in a place of safety until they can be appropriately discharged, but should that place be an acute ward in a hospital? Arguably not. In addition, most of the patients have come in with relatively minor complaints such as a UTI or chest infection, and got stuck after recovery due to worsened mobility or inappropriate houses for discharge. This job has definitely highlighted to me the importance of trying everything possible in A&E to get these patients safely out of the door. No one wants to take responsibility for discharging a 92 year old with a UTI in case she goes home and falls. But the other option is a 6 month hospital stay, loss of independence and eventual placement. Obviously, if people are unsafe at home I am not suggesting emergency care physicians chuck them out into the cold at 3AM, however, all most people need is a course of antibiotics, or some IV fluids, or plugging in to community services and they will be fine. Alternatively, we saturate our medical wards with people who have no medical problems, and the doctors become deskilled and lazy, and wonder why they bothered going to medical school in the first place.

Frustration

Last Saturday, I cried for the entire journey home.

The day had been hugely stressful, the usual A&E combination of too many patients and not enough staff. It was largely my own fault – I had been hoping for a quiet shift in order to get some revision time in for an exam I was taking the following week. I did not stop from the time I entered the department until an hour after my shift finished when I finally dragged myself home. I had not had food, drink, or a wee for 12 hours. None of this was new. What was different on Saturday was that, for the first time since starting this job 4 months ago, I felt overwhelmed.  Patients with non-urgent problems were saturating the department, and as a result there were too few of us to see the seriously ill patients that required immediate care.

The fact that our current Health Secretary has publicly stated that he takes his children to A&E because GP waiting times are too long, shows us that there is a complete lack of public education concerning appropriate places to seek medical help. There are very few things more frustrating than seeing a patient in A&E who is annoyed at having waited three hours, and then telling them that there is nothing that you can do for them. Sending people back to their GP is a vicious cycle – they most likely presented to A&E because it takes ages to get an appointment, and although their condition is not life threatening, they want it sorted. This is entirely understandable. What the public as a whole do not realise though, is that unless your condition is serious enough to require admission to hospital, or something that can be sorted with a one off course of antibiotics, A&E is the worst possible place to go.

Since the restructuring of the healthcare system, which has put commissioning and budgeting in the hands of GP surgeries, we are no longer able to refer into specialist clinics from A&E. If I see someone who has come with palpitations, I have to send them back to their GP for a referral into a cardiology clinic for monitoring. If I see someone with angina-type chest pain, the referral to the “rapid access chest pain” clinic no longer comes from A&E; it comes from the GP. The problem with this, of course, is that many people still present to us in the hope of circumventing the waiting time at their GP surgery, only to find out that they need to go back there for the necessary investigations.

It is hugely frustrating as an A&E doctor to see someone, know exactly what investigations they need, and essentially have no way of ensuring that they happen. Good GPs, of which there are many, will look at the discharge and arrange appropriate tests. Good A&E doctors will write letters to the GP, which the patient can take with them to explain what investigations have been done and what are outstanding. The frustrating aspect occurs when the GPs are slow, or the communication breaks down, and then the person gets lost out in the community until they have another, non-urgent problem, and present to us again.

We have just changed jobs, and last week was my final shift in A&E for a little while. A lady presented whom I had seen 7 weeks previously, and had discharged home. She was in her eighties, and had probable new onset dementia. When she had first presented, her husband and daughter, frustrated with the lack of access to their GP, brought her to A&E because they were worried about the decline in her cognition. After discussion, we agreed that she did not need admission to hospital; they were coping at home, but were keen for a diagnosis and some social support. We did a basic infection screen, and I wrote a three-page summary of her presentation and the family’s concerns. The husband took the letter to their GP the following day. The crux of situations like this is that you cannot get social support until there is a formal diagnosis of dementia. Until there is a diagnosis, families struggle on by themselves, with inadequate resources, and little understanding of what they are undertaking.

If the woman had an infection, or was dehydrated, or ill enough to require admission to hospital, the diagnosis of dementia would likely have taken a few days. However, she was able to go home, and things move at a much slower rate in primary care. Unfortunately, in the intervening weeks, none of the investigations happened; no support materialised, and as such the same family represented to A&E on my final shift, after the lady had attempted to assault her husband because she didn’t recognize him anymore, and he had to lock all the doors in the house to stop her running out into the cold.

So, the family is back, again with an inappropriate presentation to A&E, but a presentation out of desperation. By some cosmic cock-up, they are seen again by the very doctor who discharged them into the community last time, with the promise that this would be investigated and they would get the help that they so clearly needed. Again, this lady’s infection screen was normal, bloods were normal, and there was no clear indication to bring her into hospital. I found myself – a compassionate, sensible doctor, advising this family to essentially abandon their elderly relative in a busy A&E department, alone and confused, because then we would have a reason to admit her for investigation. There is so much wrong with that picture that I don’t know where to start. When we, as clinicians, are reduced to hoping for abandonment as an excuse to diagnose an elderly lady and give her home support, it is a glaring example of the failings of our healthcare system.  

We need integration and communication between primary and secondary care. We need education for the general population on where to seek medical help. Lord knows there are enough YouTube videos around advising of where to go when you have the flu/need antibiotics/have run out of medication. I don’t know what the solution is, which is probably why I am not the Health Secretary, although he doesn’t seem to have this figured out either. All I know is that a system that leaves vulnerable people without support is not good enough. We are better than this.  

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Aneurin Bevan is my hero

The NHS gets a bad press. 

As an organisation founded in 1948, it is no wonder that it is struggling to keep up with the growing demands and expectations of an ageing population. The fundamental principle of a free at point of service healthcare system for all, is something that I am immensely proud to be a part of. It is consistently portrayed as a decaying and inefficient system, with no option other than privatisation viable to sustain it. 

I think this is a mistake. 

I have first hand experience of the dedication of NHS staff to ensuring effective and timely management for patients regardless of their social status. With privatisation will inevitably come prioritisation, and we will be in severe danger of losing the ethos of our healthcare system.

Despite the overarching belief that the NHS is an outdated model which needs renovation, England still has the best healthcare system in the world. I think it is pretty spectacular that from first presentation at A&E to diagnosis and initial management of complex diseases such as cancer and heart failure takes on average only 48 hours. And 4 of those will be spent waiting in A&E…

My colleagues and I consistently stay beyond our finishing time in order to update families about patients’ progress, or to deal with emergencies that inevitably seem to occur at 5:30 when you are crabby and tired after a long day and should have left the hospital already. There is a sense of shared responsibility, a sense of duty and an underlying pride at being able to provide the world’s best medical input for people who would be otherwise unable to afford it. Yes, there are days when the inefficiency stifles me, when I get irreparably frustrated with our lack of resources and the dissatisfaction of patients and staff alike, but on these days I try to take a step back and remember the principles that our system is based on, and the ethos we are working for, and then the shortcomings don’t seem to matter as much.

The NHS has become a political model, and as such it is not left alone long enough to gain level footing. Every new government has to have a different plan for saving the NHS, and as such none of them are given time to work. Instead of giving up on it, we need to accept that as an organisation it is always going to require more funding, it is always going to be inefficient (because how can you legitimately price health?)..instead of lamenting this, we should be proud of it. There are few better things to spend our money on than health provision. We should be praising NHS staff, and supporting them, bankrolling them, celebrating them. We still have a reason to be proud of our healthcare system. We should not condemn it just yet.