Friday, 26 February 2010

Making and Appointment

A few months ago I phoned up my GP surgery to make an appointment for my fiancé. The receptionist not for the first time asked me what the appointment was for. Receptionists are not doctors or nurses, and whilst many of them do a very good job deal with the more idiotic elements of the community on a daily basis they have no right or reason to ask why you are making an appointment. Certainly in my surgery the information does not reach the doctor before you see them, they can not suggest you see a nurse or not make the appointment instead, they do nothing with the information. I had a choice, I could explain this to her in a calm and non-confrontational manner or I could take the childish option......

Me: "The patient is a 24 year old female presenting with pyrexia with haemoptysis and epistaxis with intermitted hypertension and tachycardia. No previous relevent medical history or history of recent trauma. Whats your Diagnosis doctor?"

Receptionist: "I'm not a doctor, I'm just a receptionist"

Me: "They train receptionists to diagnose?"

Receptionist: "No I..."

Me: "to triage patient appointments allowing more acutely unwell patients a chance to obtain an appointment?"

Receptionist: "No its first come first ser..."

Me: "Ah so you pass on the relevent information to the doctor so they are prepared for a patient before they arrive?"

Impressively Resilient Receptionist: "No we dont note the information anywhere we arent allowed to write in patient notes or their electronic records...."

Me: "So what times her appointment?"

I dont feel good about the above conversation but I had recenly taken my fill of GP Surgery Receptionists on my community placement who were just asking patients what they were seeing a doctor for out of pure curiousity or "incase the information became useful later". To be fair the last few times I have phoned my GP surgery the receptionists have been very curteous and not asked me for any confidential information, they have simpley done what they are paid to do.

Wednesday, 24 February 2010

Mid-Staffordshire NHS Trust

Many of you have probably already heard about the investigations and subsequent report that has suggested that several hundred more patients than predicted died in the Stafford Hospital emergency department between 2005 and 2008. The report also indicates that staff were uncaring and more focused on saving money than treating patients.

Whilst I do not in any way condone the treatment of these patients I dont blame the nurses or doctors at this trust. They became EXACTLY what the NHS is training us to be. If a patient comes in to A&E we have a four hour breach target. So if the patient is still present on the department four hours after first being seen by a triage nurse the department recieves a fine to its next budget. You have four hours to fully investigate a patient .It can take longer to get blood test results back or find a radiographer to take an xray for you. Add to this the fact you see a lot of the same patients every week who "cry wolf" if you have to save time and money for your department(money that may well be used to pay you) the temptation may be to discharge the same old patients without a complete investigation(I promise you that will be the time they are actually ill).

You then have cost limits on treatment, if a patient needs a dressing we are told to use the cheapest dressings available that are not likely to get the trust or practitioner sued for malpractice. For example if you have a deep pre-tibial lasceration(a deep cut to your shin) we will have to chose a non adhesive layer to prevent the top layer of gauze sticking to the wound bed, realistically there are three options -

1. Release - A sort of thin gauze covered in some kind of oil to prevent it sticking. The oily layer dries within a few hours and the release then becomes stuck to the wound bed, to remove you have to soak the dressing in saline and if you are very very lucky you wont reopen the wound. Very Cheap.

2. Atraumen - A greasy mesh that stays non-adhesive for about three days(at which point the wound should be assessed anyway), doesnt do a bad job. Moderately Expensive.

3. Mepitel - A silicone based mesh that I have never known to dry out while covering a wound, can be used for upto about 18 depending on trust policy. Primarily designed for burns but still incredibly effective as a general non-adhesive, can also be used to draw a wound together in the absence of steri-strips. Does an unparalleled job. Fairly Expensive.

In my trust we are told never to use mepitel and we can only use atraumen if a senior doctor has signed off on it. There is a similar system for anti-emetics(anti sickness drugs) we give cyclizine because its cheap, although it does make patients very light headed and dizzy. I would personally refuse anything except donperidone which does the same job but without the unpleasant and very common side effects.

Fortunately the hospital I work in completely ignores the targets set by people so far up the chain of command they dont even know what a hospital looks like. If we feel a patient is less likely to develop an infection because we have used mepitel we use mepitel, if a patient is clearly distressed by their nausea we will not give them cyclizine, knowing that the secondary effects of cyclizine will distress them further. And I can honestly say I have never discharged a patient without ensuring they have some help in place. Even if I dont believe what they say is wrong with them and they came to us instead of their GP I will phone their gp and make an appointment for them knowing I havent just left them out on their own.

What has happened in Staffordshire is tragic but it is the result of government and NHS target setting and the threat of penalties to any trusts that dont meet these unrealistic targets generated by people who either have no clinical experience or had it so long ago operating theaters floors were still covered in sawdust. The new chief executive of this trust has already proven a massive improvement in care since hiring close to 200 extra nurses.

As a side note if I were to become ill this is now the trust I would want to go to. Given the scrutiny this trust is under it will probably be demonstrating exceptional standards of care for some time, whereas many other hospitals which receive good marks have probably grown complacent.

Wednesday, 17 February 2010

State of Relax

Immediately after my post the other day explaining my recent writers block in regards to one of my assignments I sat down and wrote over a thousand words. Some of the best I have ever put into an assignment, I really am rather pleased. Whilst the assignment still has a few hundred words to go I am taking some time to relax. Between work, social and family obligations recently I hadnt realised how badly I need to just stop and do nothing.

I'm currently on the healthcare worker diet. This is an involuntary diet all healthcare professionals are on it involves getting up at 0630 every morning, this time being far too early for me to eat(even toast this early makes me feel sick). Dragging myself into work for a strong cup of low quality black coffee(so strong it could easily be mistaken for gravy). Working for eight or fourteen hours without a chance to have a break or even go to the toilet. Leaving work an hour and a half late because the ward is understaffed and you feel somehow obligated to help pick up the slack. By the time you get home you just about have the energy to fall into a hot shower. You drink a huge quantity of water because you have been sweating all day and not had a chance to drink any water. By the time you have consumed an adequate quantity of water you no longer feel hungry, knowing you should eat something you grab a piece of toast and fall into bed, ready to repeat the process in seven hours time.

Thanks to this process I have gone from a starting weight of 106kg(when I started my course) to 86kg. So its not all bad, although my professional opinion is the healthcare worker diet is extremely dangerous.

Tuesday, 16 February 2010


I recently came across a fairly interesting dilema at work, and I truely feel sorry for the doctor who has to sort this one out.

A patient is diagnosed with a disease. Its genetic so there is a good chance the condition will manifest in at least one of his five children or one of his parents(who are both still alive). I cant divulge exactly which disease this patient had but lets pretend its Huntingdons a very nasty, incurable and degenerative neurological disorder. Now here is the kicker, he doesnt want anyone to know, he doesnt want his wife, his parents, his children to know and thus he is preventing any of them being screened. Our obligation is to the patient, and he can rely on confidentiality in this case. Our legal obligation would take priority if this was a very infectious bacterial infection, we would have to trace everyone who came in contact with the patient and screen them. However this is not infectious, the patients family already either have it or they dont the dice have been thrown. So we say nothing.

Now what if the patients son was in RAF Squadron, flying planes with high yeild payloads for a living and he didnt realise he had a condition which severely impairs motor function as a primary symptom. Do we not have an obligation to the greater good then to inform the patients son?

I understand the importance of confidentiality. I also understand that this patient had just recieved the worst news of his life and probably wanted to prevent any of his family worrying about him, he may even have been clear headed enough to realise that if his children didnt know they couldnt get tested and those those of them who surely had this condition could be spared feeling what he was feeling now. Its information that you cant take back, once you tell someone they are going to die in one of the most horrific ways imaginable(and there is no way to sugar coat it) you cant untell them. His children were only young, whilst the condition could strike at any time maybe he was just trying to buy them a few more years of innocence?

In the interests of balance(I have been told I always assume the best in people) maybe he was just a coward who didnt want to face his own fate and thought that by hiding it he could avoid it no matter what the cost to those around him.

What would you do in this situation? would you respect the patients right to confidentiality? or would you inform his family?

Assignments Assignments Assignments

For the last week I've spent several hours a day sat in front of a blank word processing window with the learning outcomes for an assignment due in on friday in my hands. Fortunately its only 1500 words which I could crack out in a few hours however I cant seem to find the motivation to start. I'm not procrastinating, I sit down every day with the intention of writing, I dont get distracted I just cant seem to find the words to start. I'm exhausted and this is a really boring assignment. "A critical reflection of placement three of the interprofessional learning unit"(IPLU). I'm sure you've heard me rant about the futility of this module before however for once, in this third year it has proven constructive.

Our group was made up of a med student, four nursing students(two adult branch like myself), a social work student, a physiotherepy student and two radiotherapy students (one diagnostic one theraputic). We were assigned a task, to audit the correct and safe use of the hospitals Venous ThromboEmbolysm(VTE) (things like pulmonary embolisms and deep vein thrombosis) risk assessment forms. These forms came as standard in the nursing admission packs so in theory all patients admitted to the hospital should have been risk assessed for VTE and any procautionary measures put in place. We had to take samples from different wards, two medical, two surgical, two orthopaedic, reviewing ten patient notes per ward. We were looking for completed risk assessments, patient age, gender and cause of admission so we could identify which groups were being overlooked(not that any should have been). Once we had collected and analysed our data we had to compile a ten thousand word report covering our methods and findings and at the end of the two weeks we were to give a twenty minute presentation to the relevent members of staff.

The work was facinating not in the least because my father died of a pulmonary embolism ruled as medical negligence at the age of twenty-seven. I found this as a refreshing opportunity to reaquiant myself with a leadership role, a role rarely suitable for a student nurse, although we are encouraged to take some leadership responsibilities on clinical placement.

So why am I having such a hard time writing this assignment? the criteria have drained all the fun out of it, I am not to mention the subject matter just the groups interactions and my role in achieving the final objective. I find it hard to write about myself in a critical light at the best of times, I go with the flow of self-loathing and low self-esteem. Another reason I might not be getting this assignment done is because I am sat here, writing this.....which is far more enjoyable and more than a little cathartic after a week of writers block.