Friday, 7 June 2013

NHS 111

So wait, let me get this straight:

You decide that your existing nurse-led telephone advice service, NHS (re)Direct, isn't producing the appropriate yet safe clinical advice that you would like it to, and you'd like to replace it with a better and cheaper system. Mainly cheaper.

You decide that the best way to do this would be to replace the nursing staff whose job is to triage patients over the telephone with people who have no medical training, and you expect that this will make the clinical advice given to patients safer and more effective. You think that this will help take the pressure off the enormously overburdened emergency departments.

What? We pay you to run a national health system? WE pay YOU to run OUR national health system?

We must be out of our minds.

Thursday, 6 June 2013

Value for money post: the vagus nerve, mathematics, systems theory and bowel movements

To quote Gray's, the anatomy bible:
the vagus nerve is composed of both motor and sensory fibers, and has a more extensive course and distribution than any of the other cranial nerves, since it passes through the neck and thorax to the abdomen.

The spelling of "fibers" and Oxford comma belong to the author, although I do love a good Oxford comma.

For the uninitiated, it carries parasympathetic fibres to the thoracic and abdominal organs. These provide the opposite of the sympathetic 'fight or flight' response; instead, they encourage the body to perform functions suitable for a nice relaxing afternoon. The heart slows down and its muscles contract less forcefully when vagal tone increases, whilst the gut blood flow increases and muscle activity increases to digest food, absorb nutrients from it and pass waste in the form of faeces.

Unfortunately, if you are a youngster in heart failure and you go to the bathroom and try very hard to open your bowels, your vagal tone can increase much more than is good for you, and can instantly put you into a state called cardiogenic shock; your heart is no longer pumping out enough blood to oxygenate you adequately, and you become shockingly unwell unbelievably quickly.

This, it goes without saying, can break up the gentle routine of an afternoon on the ward. Trying to engage your insulin-saddled post-lunch brain into quickly prescribing and preparing a 10 microgram/kg/minute infusion of dobutamine, a task which should be reasonably straightforward (although inevitably double or triple-checked) at the best of times, can suddenly become a feat of mathematical impossibility.

Obviously, as Murphy's law would have it, the protocol for prescribing a dobutamine infusion would disappear at the exact time it was most urgently required. Reason's 'Swiss Cheese Model' suggests defects in multiple layers of protective measures must all line up to lead to disrupt the system; meanwhile, a speaker at a study day I recently attended suggested that "the hallmark of an unsafe medical system is a person at the end of any process who has to perform flawlessly."

Luckily, we have people like that. We call them nurses. "Put x mg into 50ml of saline and infuse at 2ml/hr to run at 10," she told me. I double-checked the maths. It worked.

After all that, the PICU team decided they'd start dobutamine on the unit. Typical.

Wednesday, 5 June 2013

The GMC and social media

Thanks to the ever-wonderful xkcd for this

The General Medical Council claims its purpose is "to protect, promote and maintain the health and safety of the public by ensuring proper standards in the practice of medicine". There are more than 250,000 doctors on the list of registered medical practitioners, each paying a significant annual fee to the GMC. It would be nice if the results of this could be seen in published dramatic and substantial patient safety research, although sadly that's not the case.

The GMC this year published guidance for doctors on the use of social media. It helpfully explained what social media was, to aid the less technogically-savvy doctor (just in case a consultant thought the Twitter app on his new phone was a 'to-do' list to enter confidential patient information into and keep it safe, I assume), and also offered this spectacular piece of guidance:

17 If you identify yourself as a doctor in publicly accessible social media, you should also identify yourself by name. Any material written by authors who represent themselves as doctors is likely to be taken on trust and may reasonably be taken to represent the views of the profession more widely.

I suspect that it is purely coincidental that a lot of anonymously-written and excellent blogs within the blogosphere often criticised the healthcare establishment, whether that be short-term thinking feeding governmental interference in the system, or the GMC's laboured, prolonged and continued response to a rogue Hyde GP playing God for decades. I cannot for the life of me imagine any reason why an organisation would create guidance purely to silence its critics.

Whatever the reasoning behind this guidance, it has led to a dramatic decline in the number of anonymously-written medical blogs from the UK. Some have hung up their witty handles and publicly declared themselves, some have simply stopped writing, whilst some are retired, have little to fear from our erstwhile and conscientious regulators and therefore couldn't care less.

This blog has been neglected for some time now. Well, probably since conception. However, the correct way to counter oppression is to fight it directly, and I have been trained that blowing whistles is an honourable thing, but putting your name at the end of that whistle is a death knell for one's career. This means that I could continue to write as a junior doctor and remain anonymous, but this would mean breaching paragraph 17.

I'd therefore like to declare that I choose not to identify myself as a doctor. To be honest, this is the internet, and so even if I claimed to be a doctor, I probably wouldn't be, or I'd be one of those crazy people who thinks homeopathy is scientifically valid. I shall therefore leave my daytime (and often night-time) occupation to your imagination. Any connection between the views expressed on this blog and the views of the medical profession as a whole are purely coincidental.

I hope that clarifies things. In the meantime, I might as well start blogging again, given that no-one else seems to be.