Tuesday, October 31, 2006

Nurses save lives

Some, reading this blog, may think I’m anti-nurse. It is an accusation frequently levelled at doctors, especially those of us who express our doubts about ‘nurse practioners’ and their ilk. We are apparently arrogant, protectionist and power hungry, our concerns having nothing to do with patients and the care they receive.

Funnily enough the ‘dumbing down’ of medicine is happening across the health service and beyond – with nurses replaced by HCAs, teachers by teacher’s assistants although one notes that MPs have yet to be replaced with ‘parliamentary practioners’.
Funnily enough once the boot is on the other foot the nurses are not so happy to see their ‘professional area’ taken over by under-trained upstarts.

Into this debate comes some nursing research. Nursing research is not renowned for its intellectual rigor or applicability to patients, being all too often pseudo-sociological examinations of the condition of ‘being a nurse’. However some good work is done, and Prof Rafferty of Kings in London is to be congratulated on proving what many of us (evil, nurse hating) doctors have suspected for a while- that higher nurse to patient ratios on wards improve outcomes. In fact higher ratios would seem to improve mortality by 26%- which is as good as many medical therapies.

So now the truth is out- nurses nursing patients produce mortality benefits. Nurses playing at being doctors –who knows, but wouldn’t their time be better spent doing what they do best and reducing ward mortality? CAMRN (Campaign for real nursing) is launched here and unlike CAMRA no beards or sandals are required.

Monday, October 09, 2006

Tomorrow's world?

The NHS of tomorrow

Mr Smith has been experiencing abdominal pain for 12 hours, its getting worse so he calls the doctor. Due to changes in ‘unscheduled care’ he is unable to speak to his own GP and is put through to NHS Direct.

Here after giving his details to a telephonist he is put through to a nurse advisor, he asks him lots of questions and follows the computer prompts which result in calling out a paramedic practioner. The paramedic duly arrives, asks many of the same questions and attempts to examine the abdomen. She is uncertain as to what she has found as her training in abdominal examination has been rather scanty and her supervised experience of assessing such patients is slim. Her knowledge of anatomy is also a little patchy, so she calls an ambulance for Mr Smith to take him to hospital.

In A+E the triage nurse, the emergency nurse practioner and an A+E nurse see him. They all agree that he may have something going on his abdomen, so they send for the surgical assessment nurse practioner. The SNP asks many of the same questions, orders some x-rays and takes some blood. He is uncertain as to the cause but thinks it might be appendicitis. He sends for the emergency surgical practioner who agrees that appendicitis is likely and wants to take the patient to theatre.

The Anaesthetic practioner is sent for, she is happy to anaesthetise Mr Smith as he is a fit and well gent who would appear to present no anaesthetic challenges. The patient is taken to theatre and surgery commences. On opening the abdomen the appendix cannot be found as the caecum has been infiltrated with cancer and has perforated. The hemi-colectomy nurse practioner is away on a course so the surgical doctor is sent for. He has not done many hemi-colectomties as the NP seems so very keen to do them all, so his boss is sent for.

The surgery proceeds uneventfully, but at the end of the operation the patient does not start breathing. It would appear that he has had a rare reaction to the paralysing agent used to intubate. The Critical Care practioner is called who agrees to take the patient to ITU, the central line insertion technician is called and lines are duly inserted. 24 hours later the patient is able to be weaned from the ventilator and returns to the ward. He is looked after by a range of nurse practioners and ward nurses until eventually being fit enough to go home.

The NHS of today

Man sees his GP –‘it might be appendicitis old boy’, GP refers to the surgeons, who see him, agree that it is likely to be appendicitis and take him to theatre. He is anaesthetised by a medical anaesthetist. When it is discovered that he has a tumour, the same surgeon continues to resect the lesion. At the end of the op he doesn’t wake up, the anaesthetist diagnoses the problem, inserts the appropriate monitoring lines and takes the patient to ITU. Along side this activity work groups of highly skilled nurses and other professionals who ensure the whole team work smoothly together.

You may think I’m joking……just you wait. Lulled by the ‘logic of the salary cost’ and lobbying by activist members of the nursing profession the NHS of tomorrow rapidly approaches. Under proposed ‘unscheduled care’ changes from the DoH the first part of this scenario (NHS Direct and Paramedic practioners) will be the main ‘access’ route the NHS. Some units are already replacing their doctors with ‘assessment nurses’ who do the initial ‘clerk-in’ of patients. Surgical, Anaesthetic and Critical Care practioners are already in training. Some hospitals already have ‘line insertion nurses’.

The government are insisting of ‘patient choice’ it’s a shame that choice doesn’t seem to include being seen by a doctor.

Saturday, October 07, 2006

Do you need to be a doctor?












Doctors?

Apparently large numbers of people are unaware that, in the UK at least, all anaesthetists are doctors. ‘Don’t you ever wish you’d done medicine’ a patient asked me the other day. Some of my colleagues get very exercised about this issue, and the Royal College of Anaesthetists organised a special day to tell people.

Part of the reason lots of folk don’t know we are doctors is because they can’t see why you need a doctor ‘just to put you to sleep’. Simply putting someone to sleep is actually pretty easy, you give someone an anaesthetic agent and off to sleep they go. Of course anaesthesia is not ‘sleep’ and the problem is that inducing it (anaesthesia) removes many of the bodies natural balances (homeostasis). The anaesthetist essentially takes over many of these functions and ensures the patient stays alive.

And that is before the surgeons even start. Surgery is a traumatic insult, like a car crash only a bit more controlled. Keeping the patient alive and in-balance despite the activities of the surgeon is the real challenge. To do all of this requires an in depth knowledge of the sciences of human biology, a comprehensive understanding of drugs and their actions on the body and how the various monitors use work and what they actually tell you.

Many patients are elderly or have multiple illnesses and are on long term medication. These can have an impact on how the patient responds to anaesthesia, surgery and disturbance of their ‘natural balance’.

So perhaps you can see why anaesthetists need to be doctors?

Thursday, October 05, 2006

Training the Noctor II

It has been decreed that the admissions unit nurses should be able to order chest x-rays. This is being done for the best of intentions, as it will speed up the process of assessing them and deciding on appropriate treatment and placement.

But, in order to order a chest x-ray one must be able to examine a chest so as to determine whether an X-ray is required and what it will add to the diagnostic process. Although it may appear to the untrained observer that almost all medical admissions get a chest x-ray this is far from the truth, and an x-ray in isolation will not make a diagnosis.

But the great and the good have decreed that it shall be so. Dr SM got raked into helping ‘teach’ the nurses. Having examined ten chests they were then issued with their stethoscope, presumably to be worn as a badge of a Noctor and henceforth were given the responsibility of ordering a patient be exposed to ionising radiation.

The problem is that the nurses did not know the underlying anatomy and could not distinguish between a normal chest and an abnormal one, let alone the difference between pulmonary oedema (fluid on the lungs) and fibrosis (scarring), pneumonia or a pleural effusion (fluid around the lungs). All noises were described as ‘wheeze’ even if it was not.

This is because they are inexperienced. When Dr SM was a first year medical student he equally wielded his stethoscope with as much ignorance, and it took five years of listening to countless chests under the watchful eyes of his seniors before he was given the responsibility of exposing patients to ionising radiation.

But it looks good on the balance sheet and the nurses get to play at being doctor, so that’s all right then.

Monday, October 02, 2006

The training of the Noctor

I’ve written about Noctor’s before. This seems to be a growth area. Many of our best nurses are being lured into Noctordom with the promise of higher pay and ‘autonomous practice’.

These nurses are often some of the best, but they are being sold a lie. They are being told that the role of a doctor is easily filled and that all they need is a little ‘top-up’ training to bring them up to this level. Like Eddie Izzard says ‘I don’t want top-up I want bloody fill up’ –he’s talking about life jackets but the same principles apply.

To illustrate. A couple of weeks ago a couple of former ICU nurses, now training as hospital at night ‘practioners’, came to see me. Could I teach them how to examine patients? Yes, in theory I could, what system did they want to start with and had they identified any patients?

Noctor ‘we’d like to learn how to examine the whole patient, and we thought we might practice on a dummy’
SM ‘the whole patient, in an afternoon?’(looks askance, eyebrow raised)
Noctor ‘ well we’ve had some lectures on it, we just want to practice it’

Dr SM is in the middle of preparing for his PACES –a higher post-graduate practical examination of ‘clinical skills’ which is needed to become a member of the royal college of physicians (not much to do with Anaesthesia, but that’s another story). To do this I need to be able to examine patients well and detect the abnormalities. I have been examining patients for 9 years and I’m still far from guaranteed a pass in this exam. How on earth these guys thought I could even start to teach them some of these skills in an afternoon is beyond me. They are sensible, intelligent nurses, the opinion that examination skills can be picked up like learning to tie your shoelaces has not been dreamt up by them. Someone has given them this impression, someone who has clearly never properly examined a patient in their lives. I despair. In a few weeks, Hospital at Night will start here – the nurses will be out of their depth and patient care will suffer. But the balance sheet suggests these Noctors will be cheaper, so that’s ok then.

Sunday, October 01, 2006

The NHS actually works (sometimes)

The other week an old lady left hospital, walking alone, to stay with her daughter. Not an unusual story you may think, but this old lady had quite a story to tell.

Several months ago I was on call and was asked to come to the Emergency Department to help deal with the victim of a Road Traffic Accident (RTA). The sole victim was an elderly woman whose car had hit a tree at around 60 mph. She had multiple injuries, with a punctured lung, fractured femur and large scalp wound, and her blood pressure was very low despite aggressive resuscitation with blood and fluids. Although it was not clear where the bleeding was, her abdomen was distending rapidly and the surgeons thought she might have internal injuries.

She was taken to theatre rapidly and her abdomen opened. No bleeding point was found, but she continued to require large volumes of blood to maintain her blood pressure. At several points her heart nearly stopped, and her lungs were not getting enough blood to pick up sufficient oxygen. She was, to put it mildly, in a bad way.
There was some collective head scratching as to where the bleeding was, when her chest drain bottle (tube sited to treat the punctured lung) suddenly filled with blood. The cardiothoracic surgeons were called and the lady’s chest opened, where the bleeding vessels were found and tied off.

By the end of this operation this lady had received 27 units of blood, around 4-5 times her circulating volume, as well as litres of fluid and other substances including platelets and clotting factors.

Having been stableised she was transferred to Intensive Care, although no one held out much hope. Such massive trauma combined with a prolonged and major operation would be a challenge for a far younger patient, let alone someone of this age.

But, confounding our expectations, she continued to improve and came back to theatre several times for further operations to fix her broken bones. Eventually she was able to be weaned off the ventilator and was transferred to a normal ward, where I would see her from time to time. She made slow progress, and had some memory impairment but was otherwise remarkably intact.

Two weeks ago she left hospital, and will stay with her daughter. She may never live independently again. But she has regained much of her quality of life. Worth the money? I think so.

Tuesday, September 26, 2006

Pain from the pain team

I’ve not posted anything here for a while. The government are intent on morphing the medical profession into their own image –a grotesque parody of consultants formed under the Modernising Medical Careers (MMC) Farce.

More on this later.

SM has now moved hospitals and is back doing Anaesthetics, following a spell in Intensive Care. I’m genuinely enjoying my job, with one exception –the pain team.

Several years ago it was realised that post-op pain is not well managed, patients were often sore and this delayed recovery as well as being unpleasant for the patients. Anaesthetists, as those with a wide experience of managing analgesia (pain relief) started setting up ‘acute pain services’. Realising that much of the work was routine and fairly repetitive they rapidly got a lot of nurse specialists to do the work for them.

Now these nice ladies (and a few gents) walk about the hospital, Monday to Friday, 9-5 dealing with pain issues. Outside of this time the on-call anaesthetist gets called. About everything. Junior Doctors are no longer deemed capable of running basic devices like morphine pumps, or capable of being educated about epidurals –mostly because the pain nurses give the impression that what they do is highly complex and when they are unsure the Junior doc would clearly be out of their depth –‘Send for the Gasman’ goes out the cry.

But now it seems that even I’m not capable of dealing with these complexities, despite several years of training and the medical degree to boot. Why, because what I suggest is ‘not protocol’.

An example – I went to see a patient who was sore. Simple post op wound pain with nothing else funny going on. He can’t take oral meds because he is feeling sick. He can’t take morphine because it makes him hallucinate. So I suggest an alternative opiate given under the skin. The ward nurses are not happy because this is not ‘the protocol’ and the pain team (i.e. more nurses) don’t do it that way. No amount of explaining by me as to the safety and efficacy of this drug by this route will swing them, I even end up offering to give the injections myself and teach to Junior doc how to do them –but no. Up against the implacable wall ‘its not protocol’.

Sadly many patients do not fit neatly into protocols, and what is best for them has to be judged on an individual basis. Nursing, with its strict rules and protocols, does not have the flexibility to alter this. Medicine, when practiced by doctors, does. This does of course give me the ability to do great harm if I screw up –but that’s what the last 9 years of education have been about trying to prevent.