Sandman's progress

Nurses save lives

2006-10-31T09:04:00.000Z

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.

Tomorrow's world?

2006-10-09T18:20:00.000+01:00

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.

Do you need to be a doctor?

2006-10-07T19:45:00.000+01:00

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?

Training the Noctor II

2006-10-05T20:31:00.000+01:00

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.

The training of the Noctor

2006-10-02T11:50:00.000+01:00

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.

The NHS actually works (sometimes)

2006-10-01T21:42:00.000+01:00

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.

Pain from the pain team

2006-09-26T11:54:00.000+01:00

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.

The rise of the Noctor

2006-07-21T12:43:00.000+01:00

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

2006-07-21T12:10:00.000+01:00

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.

Schildbuerger Streich

2006-07-14T00:18:00.000+01:00

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.

A great mystery

2006-07-13T18:49:00.000+01:00

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

2006-07-13T18:46:00.000+01:00

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.

Introduction

2006-07-13T18:06:00.000+01:00

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: http://www.flickr.com/photos/pomodrunkard/