Friday, July 21, 2006

The rise of the Noctor

The Noctor is a strange beast, coming in a number of guises. It is known by a number of names – the Advanced Nurse Practioner, the Emergency Care Practioner, the Medical Care Practioner. You’ll notice a similarity in the nomenclature, as most ‘Noctors’ have appropriated the ‘Practioner’ title. This is because the term “Registered Medical Practioner” is the legally protected name for a Doctor.

A Noctor is what you get when you have someone who is not a doctor performing a role traditionally performed by a doctor. These jobs often involve things such as diagnosing diseases and prescribing medications, something which up until recently meant having five years of medical training.

The developing world have had Noctors for years, sometimes known as barefoot doctors. For countries with few resources these people can provide a basic health care system and play an important role. Why the UK, as one of the world’s richest countries, is adopting this third world strategy is beyond me.

A lot of doctors are quite wound up about the rising tide of Noctors. Dr Crippen has chronicled the tide of ‘quacktioners’ here, and here, and here, and here.
It might be because we are a protectionist bunch who want to preserve our earning power that many doctors object to these cunning plans. However I think its because we know how difficult a job medicine can be, and that even with years of training and experience difficult decisions have to be made daily, and if you get them wrong patients will come to harm.

Several recent cases come to mind
1) NHS 24/Direct – nurses with phones. Huge expense for a service which largely directs people to services they would already have attended. However in several highly publicised cases they have got it tragically wrong.

2) Paramedics are increasingly being encouraged to become Noctors, and as a result judging when patients need to come to hospital and when not. Again we have a case where this seems to have gone horribly wrong.

The cases above (septicaemia, ruptured aneurysm) have caught out plenty of doctors in the past. However we all know about this, and it seems likely that if one has a difficult to detect condition with potential life threatening effects then someone with years of medical training and experience is more likely to get it right than a nurse on the end of a phone, or a paramedic with a few months training.

Noctors are a false economy, whilst they may appear cheaper than doctors they are not – more referrals, more follow-up, slower to see patients and if left to make independent decisions outside of narrow protocols potentially dangerous.

Anaesthesia is safe

A lot of patients coming in for an operation are far more concerned about the anaesthetic than the operation itself. I can understand the fear of loss of control, the fear of unconsciousness, the unknown. But the reality is that for most people it is the operation itself that holds the greatest risk. The surgeon will open up a part of the body which was never designed to be opened, often uncertain as to what anatomical abnormality you may have inside you, and then rootle around inside before putting you back together. But many people’s prime concern is the anaesthetic.

Anaesthesia is safe because anaesthetists administer it. After the Moscow Theatre Siege journalists asked how, if an anaesthetic gas had been administered, people died. Simple really, it was released in an uncontrolled manner with no one around to monitor its effects or ensure the people were still breathing.

The quoted death rate attributable to anaesthesia is 1 in 200,000, although in fit and healthy patients it is probably considerably lower than this. To put this in perspective you are over 10 times more likely to die in a road crash travelling to the hospital than as a result of anaesthesia.

Back in the 1950s, when such statistics were first being collated, the risk was around 1 in 10,000. Before that it was even higher. A number of innovations have reduced the mortality, including improved monitoring, better training for anaesthetists and safer drugs. Anaesthesia is often compared to the airline industry, although not everyone agrees the analogy is correct.

When things go wrong, they do go wrong very fast and in an often catastrophic manner. This is why anaesthesia requires long and through training.

Friday, July 14, 2006

Schildbuerger Streich

The Germans have a series of allegorical tales in which the citizens of Schilda (the SchildBuerger) embark on a range of schemes that seem, at first sight, logical but on closer inspection turn out to be totally misguided and pointless.

A famous story runs like this – the Schildbuerger have no salt and so must buy it from the nearest big city. This is expensive and the people of Schilda are not rich. They call a town meeting and decide that something must be done. ‘Surely’ says one man “ if we grew our own salt plants there would be an endless supply for us”. The others agreed that this was a great idea. They set about collecting money from all the people to buy two large sacks of salt from the merchants in the big city.
The salt duly arrived and one of the local farmers volunteered his best acreage as a salt field, greedily hoping that he would get a bigger share in return. The salt was ploughed into the soil and the Schilda congratulated themselves on their superb cleverness.
In autumn they returned to harvest their salt plants, but found only a field of nettles. The farmer could never get crops to grow in this field till the end of his days.

Now this is a fun kids story, right? Except today our politicians have set out on a great ‘Schildbuerger Streich” New Labour decided that doctors were barriers to reform in the NHS. They have been suspicious of doctors ever since Bevan’s famous pronouncements about stuffing mouths with gold. It was determined that doctors were running a closed shop, artificially restricting the practice of medicine to registered medical practioners. This clearly wouldn’t do as the Government is interested in ‘delivery’ by which they mean targets. These targets are not to do with improving the quality of health care, simply increasing throughput.

The mendacious doctors were resriticting the numbers of qualified consultants and general practioners (GP), probably to ensure the private practice market wasn’t flooded and fees remained high –or at least this was government thinking. The key to this was the Royal Colleges These institutions set the training standards for those who wished to become consultants and GPs, prescribing length of training, setting examinations and monitoring the quality of training. Despite having done this for hundreds of years in some cases, they were not felt to be ‘fit for purpose’.

They had to be replaced with a body that would not stand in the way of progress. So in place of the colleges was erected the ‘Post Graduate Medical Education and Training Board”, rapidly abbreviated to PMETB. This body would ensure that training was ‘fit for purpose’ (i.e. rushed to boost ‘consultant’ numbers) and that there were no ‘undue barriers to progress’ (i.e. make the exams dead easy so everyone passes first time). However despite much fan-fare, appointments of ‘lay people’ and the ensconcing in plush offices, no one had bothered to find out how to run post-graduate medical training. Suddenly they realised that a staff of twenty people with no experience could not do the job. But luckily they knew just the folk to help them out, those pesky barriers to reform, the Royal Colleges. So now the colleges set curriculum standards, prescribe length of training, set examinations and monitor the quality of training, PMETB acts as an expensive rubber stamp and everything goes back to the way it was. Truly a Schildbuerger Streich.

Thursday, July 13, 2006

A great mystery

Anaesthetists often say, “We don’t know how these agents work”. Its not to try and make the whole thing more mysterious and keep non-initiates out –its because we truly don’t know why our anaesthetics induce unconsciousness (or Hypnosis to use the correct term). The conventional explanation is that they alter cell membrane fluidity, this being demonstrated by showing that the more fat-soluble a compound the more potent an anaesthetic it is. This also would nicely explain why molecules with no obvious similarity in structure could produce the same effect. To me this all seems a little vague and ‘hand-waving’, a little too much like alternative therapists talking about chi-lines, auras and charkas. It turns out they probably work by binding to certain receptors in the brain, which usually bind Gamma-Aminobutyric Acid (mercifully shortened to GABA). This chemical has an endogenous calming effect, so it is perhaps not surprising that this system is involved. Interestingly alcohol works through the same family of receptors, so our rum toting surgical brethren had something right.

A moral dilemma

Dr SM is working in Intensive Care at the moment. This is where the sickest hospital patients are looked after, using a variety of machines and powerful drugs to support patients’ organ systems whilst we try to fix the underlying problems.

Intensive Care is expensive, around £1000 pounds per patient per day. Each patient is looked after by a single nurse and is reviewed several times a day by senior doctors, whilst a junior doctor is present 24 hours a day. The machines are not cheap, with ventilators, kidney dialysis machines and even the monitors costing thousands.

Intensive care is also expensive for the patient. Being critically unwell is an unpleasant experience; patients often suffer hallucinations and persecutory delusions. Sadly these will often persist after discharge, with between 10 and 20% of patients developing post-traumatic stress disorder. Critical illness leads to severe muscle wasting, pain and joint discomfort, loss of fitness and appetite. Quality of life after intensive care is a major issue. Nearly half of those patients who survive to discharge from intensive care die in the year following it, many of them in hospital.

For these reasons we often have to think carefully before taking a patient to intensive care. It is important that we judge it appropriate to subject a patient to this, that it is done with a realistic hope of survival with a reasonable quality of life. What is a reasonable quality of life? What is ‘realistic’ when talking about chances of survival? These decisions are part of the day-to-day business of working in intensive care.

A recent example. Last week we discharged a young man from our unit to allow him to die at home with his family. James was 23; he had a congenital condition that had left him with significant learning disabilities, epilepsy and physical impairments. He lived at home with his parents who cared for him more or less full time and had done so for the last 23 years. He was admitted with a ruptured bowel and required emergency surgery to fix this. Following this he had difficulties breathing and came to intensive care for ventilatory support. Over the past four or five months James’s physical condition had deteriorated, he was not as strong and active as before, he had to be fed with a tube into his stomach and required help with washing, dressing and toileting.

We had several long discussions with the family, asking for their assessment of James’s quality of life, did they think he experienced pleasure, could he recognise them and his siblings, how did he express himself? We had daily debates amongst the medical and nursing staff about what we were hoping to achieve and whether there was any chance of surviving intensive care.

Over the first few days of admission he made steady improvement and we were able to get him off the ventilator. However he was still very weak and was unable to cough up the secretions from his chest. He developed a pneumonia and his physical condition deteriorated again. We had to make a decision as to whether to put him back on the ventilator and restart aggressive therapy. Further discussions were held with his parents, and we explained that without this aggressive therapy James would die but that even if we restarted he was still at high risk of death and would more disabled than before if he survived to discharge.

The parents asked if they could take James home. Thankfully for once the NHS worked as it is meant to, and we were able to co-ordinate with James’s GP, the district nurses and our own nurses. James was able to go home and died a day later, comfortable and surrounded by his family. Sometimes we can’t save lives, but as in this case we can still act in the patient’s best interest.


So everyone is blogging these days. Lots of doctors are doing it, mostly because we like the sounds of our own voices and think we have something valuable to say. Sometimes we do, and popular culture seems rather taken with medical practice and all things ‘health related’.

I’m an anaesthetic trainee, a very junior one who has yet to sit exams. This blog is intended to chart my way through my training and maybe give some insight into what we do. I also intend to include some discussion about current changes in medical practice and the NHS from my insider’s perspective.

Anaesthesia is a fascinating area of practice. There is no other walk of life where one can render folk unconscious, stop them breathing and stick sharp implements into them hoping to hit vital structures without being arrested. And add to this the ‘victim’ is usually grateful afterwards. It is a direct application of the physiology and pharmacology we spent hours hearing about in dusty lecture theatre’s from even dustier lecturers, sneaking glances at the social scientists frolicking in the summer sun outside.

Anaesthesia is the rendering of a person unaware of their surroundings, inured to pain and not moving. It is this last bit that allows the surgeons to do their work far more effectively than they used to be able to achieve with half a bottle of rum, some laudanum and a leather strap to bight on. In this way it has allowed surgery to move out of the dark ages and so truly ranks alongside the great medical discoveries such as antibiotics, vaccination and the value of good sanitation.

picture from: