No surprises here then

Saw this story originally in the London Lite paper on my way home from work last night, and subsequently on the BBC News homepage. It goes like this...

Junior medics have more 'crashes'.
Junior doctors are being put at increased risk of road traffic accidents because of exhaustion.
A survey of 1,619 junior doctors by the Royal College of Physicians found that one in six had a road traffic accident when commuting in 2004-05.
Returning from a night shift was found to be most risky, although half of accidents happened on the way to work.
The College warned that working patterns were to blame with doctors doing too many night shifts in a row.
The annual survey of specialist medical registrars found that 264 of the doctors questioned had a road traffic accident - 134 when driving to work and 130 when returning from work.
Although more of the doctors who crashed on their way home had been working a day shift rather than a night shift, the overall risk of crashing was far higher for those who had worked through the night.
Doctors only work about one night in 10, but 56 of the doctors who reported an accident on the way home were returning from a night shift and 74 from a day shift.
The introduction of the European Working Time Directive in 2004 means that doctors no longer work more than an average of 56 hours in a week.
But the RCP said despite attempts to reduce working hours, poorly designed rotas left almost half of doctors working seven 13-hour shifts in a row, resulting in a 91-hour week.
It recommends hospitals switch to a nine-hour shift pattern rather than 13 hours, with fewer shifts in succession.

The rest of the article is on the BBC webpage, via the link above.

What gets me, is they actually call this news! Every medic up and down the country knew this and I'm sure it came as no surprise to the families of medics. The European Working Time Directive was meant to be a great rule that would see junior doctors work no more than 56 hours a week and one night shift in 10. Basically it was never going to be possible. Junior doctors are relied on heavily to do on-call work, lots of shifts and the evil over-nighters. They were never going to be tucked up in bed at 10pm with a cup of cocoa even with an EU order over them. Hospitals have found ways round the maximum 56 hour week and junior doctors are still working anti-social, overworked shift patterns. It comes with the territory as a medic.

In other news, I found a job in an Accident & Emergency department in this Southern neck of the woods. It feels bizarre to be back around the area that I trained in, but good because the department is amazing! Fiance is off to the battlefield come the New Year and I'm panicking slightly about that, but I've seen him go off before and return in one piece, so I'm sure this time will be no different.

Sigh...

I have just got back from work, and am wondering how I am meant to sleep when it looks so gorgeous out there. The department was rammed last night, and so hot, even I was nearly melting in a set of scrubs (how elegant they are).

I felt very sorry for the poor old dear who had been brought in my ambulance and her daughter had wrapped her up in a big fleecy dressing gown to "keep out the cold", the paramedics had then put a blanket over her (they always seem to put a blanket on you, do they not realise that the NHS can provide sheets) and then the nurse who had signed her ambulance sheet and put her in a bed hadn't taken either her dressing gown or her blanket off. Said nurse then decided to run through a set of observations (vital signs; things like temperature, blood pressure, pulse etc.) and hurriedly ran across to me to exclaim "I'm a bit worried about the patient in bed 3 as her temps running a bit high". I wouldn't have minded this if she had been extremely pyrexial but her temp was 38.4C, a little high but could possibly be down to the fact that she was wearing enough clothes to go on an Arctic expedition in a hospital that had a more sub-tropical theme to it. My advice? Take the blanket and dressing gown off, put her in a gown and cover her with a sheet, if that doesn't make her feel better in about 5 minutes go and get a fan. The nurse's comment "gosh, I would never have thought of that" in a very sarcastic tone. Well don't ask my advice if you know, I mean I have got other things to deal with.

The patient I was actually dealing with was a 19 year old first year university student (studying something obscure) who was convinced she had failed her first year exams, convinced her parents were going to stop funding her if she got below a first or 2:1 this year adn had swallowed a large amount of painkillers, antidepressants (her own she claimed, but then then also claimed she didn't have a history of depression) and anti-histimines. She was found in her room by her boyfriend who bought her into A&E and then proceeded to berate her at triage and dump her. Good timing. I tried to pick the pieces of all of this up with a girl who won't talk to me, and even if she would she was crying so much she was nearly hyperventilating. She's promptly throws the activated charcoal across the room at my colleague (who has been working for about 15 hours at this point due to a staff shortage) and he doesn't take kindly to having things thrown at him and goes over to "have a word with her". She then decides to run away, hide in the toilets and is found crying in the corner of a cubicle having smashed a mirror and is slicing her arms with the remnants.

We (the nurse who found her and I) got her back into a cubicle, calmed her down, got her to drink the charcoal and ran the necessary blood tests and ECG. They all came back normal/slightly abnormal. She was a bit tachycardic but then she was in an anxious state so the rapid heart wasn't so much of a problem. However, we did still want to keep her in until later today either on CDU or a general medical ward. Trouble was CDU was full and none of the general medical wards would admit her unless she had a medical problem that needed treatment/observation. Time to call in the psychs as she obviously was about to be discharged and I didn't want to send her home without an assessment. Along trot the Crisis Resolution Team (we no longer have a duty psych, we have nurse led 'teams') who carry out the necessary paperwork (i.e. tick boxes 1-18, fill in questions 19 & 20 etc.) and declare that my patient (who is acutely distressed, has run out of the department and been found actively self-harming) is at no risk to herself and is not likely to self-harm again! I couldn't believe it. Anyway, we pushed the boundaries and she's being kept until midday on CDU.

Another fun filled night and now I am off to bed. Goodnight!

Summer Nights

I am on a week of nights this week which I don't actually mind. I hate nights in winter when you arrived at work in the dark and leave work in the dark and because you're working in some goddamn awful NHS hospital (and I note proper 'old style' NHS hospitals, not a new fancy PFI one which looks more like a shopping centre) which has very few windows and ghastly flu-tubes meaning that you never get to see any daylight. No, working in the summer is quite pleasant as the hospital has cooled down somewhat (why do NHS managers seem to think that simply because 'it is a hospital' do we need the heating on when it's 23C outside) and you see some daylight.

Most of the work is the same... alcohol related, poisonings, collapse from unknown cause, etc etc etc. However, you do get to see some different types of patients, such as those with heat stroke or surprisingly there tends to be an increase in the number of poisonings by illicit drugs, so I was relieved to find this article from the 'New Scientist' which clarifies my thinking. Obviously, you see more alcoholism related injuries/illnesses which occur from people sitting outside in the sun for lunch, having a few drinks and then deciding that they can drive home/return to their manual job/construct a garden shed. Also, more dehydration and self-neglect as elderly people (in my observations) don't go out when it is hot, and therefore do not stock up on food etc and it is startling how many say "well my daughter-in-law was meant to go to the supermarket yesterday for me but she rang and said she didn't because it was a nice day so she was going out for a drink with her friends from work". Members of the public, sunny weather does not mean you can neglect your duties, whether this is collecting food from the supermarket for mother-in-law, leaving your kids in the car for "just 5 minutes" whilst you chat to a friend (with no window open and in direct sunlight), doing the same with your dog or neglecting to apply suntan lotion to your child who is about to spend all day outside on a school trip and will come back with very nasty burns (although I sense the teacher should have had some input there, but now I remember that teachers are not allowed to touch children anymore so the child suffers severe burns, dehydration, heat stroke and ends up in A&E... bureaucracy gone mad!).

On another note, I will soon be unemployed in August and have just been informed by my darling fiance that he is moving South with his job (surgical registrar). Currently we both work in the North, me in a city and him in the country, but we are to move. He is an army medic and therefore has to work where there are MDHUs and so we have been told where we are going. I have just had a quick look on the NHS Jobs website and there are a couple of job opportunities that look promising, both Registrar posts in Emergency Medicine. They are both under the scheme where you train 'on the job' for 5 years after being qualified for 3 years and having been considered to have had enough training in a junior role to undertake a more senior role and senior training. I guess I'll have to start applying!

Public Health Announcement

I have a few words of advice for those of you wishing to conduct 'Do It Yourself' projects over the weekend. This comes from my observations over the Bank Holiday weekend of injuries people have caused to themselves.

1) When a set of instructions says that the project requires 2 people, it says this for a reason. This is probably because a wardrobe is a heavy item and one person cannot support it. I don't want to see more people with crush injuries and suffocation from a wardrobe falling on them.

2) Do not walk around the house holding a battery powered drill at a 45 degree angle to the ground (i.e. straight out in front of you) and still have it switched on. The likelihood is that you may bump into someone when you turn the corner and the drill bit will penetrate their lower neck (not pretty).

3) Never think it is a good idea to hold screws/nails/pins inbetween your teeth until they are needed as they can go through your tongue and cause a lot of bleeding. Plus the Max Facs doctors will not like you for it.

4) Place the ladder on a hard, stable surface and not near steps. Ladders have a habit of moving backwards slightly when weight is put on them and if you placed your ladder at the top of a set of stairs, hey presto, you just fell down the entire flight and broke numerous bones in your body.

I think that's it for now. In all fairness, just show some common sense.

It's just been one of those days

Managed to get a short shift today, only 10 hours instead of the usual 12. However, with the sort of day it has been I am glad I didn't have to work the last 2 hours.

It has been one of those days where nothing has gone right. Patients have been shipped in the Clinical Decisions Unit from A&E not because they need further tests which can be arranged by us, or because they need to be observed for a few hours, but simply because A&E has been packed to the rafters and no one has been seen by a doctor until about 3 hours after they booked in. This of course goes against the government's wonderful guidelines that patients should be seen, treated and discharged/admitted within 4 hours of arriving at A&E.

What this ultimately means is that patients who have presented with minor injuries have been told by the triage nurse to make a GP's appointment (for conditions lasting 2+ days), go to a Walk In centre or go to the Minor Injuries Unit. This has weaned out a lot of malingerers but some creep through the net. Usually the ones who claim to be in pain, or insist on having an X-Ray, or have problems that nurse practitioners won't deal with (and don't get me started on the rant there, see Dr. Crippen's blog for some good rants).

I've had some very funny conversations with patients today, including one that went like this. Bearing in mind that the patient had already sat in a cubicle in A&E for 1 1/2 hours whilst nobody treated her. She then got moved to us as she was elderly, dehydrated, had previously collapsed and no one could work out what was wrong with her and no one was prepared to risk discharging her.

Me: Hello, I'm MJ, I'm one of the doctor's here. What seems to be the problem? This being done whilst flicking through her A&E notes.
Patient: I don't know. I felt funny this morning and collapsed. My neighbour found me. I feel much better now, can I go home?
Me: Not yet, we really need to find out what's wrong with you. Are you in any pain? Noticing that in her notes she has been taking dihydrocodeine (a strong painkiller) regularly for 8 months.
Patient: No, no pain.
Me: So why are you taking dihydrocodeine?
Patient: For the pain.

Is there any wonder I want a brick wall to bang my head against at times??

The little things you miss

CDU/obs ward/critical care is absolutely amazing and I am loving it so much despite the severe sleep deprivation I seem to be having at the moment. What is it with locums who don't turn up to complete their shifts? Not on. At all.

However, whilst being totally rushed off my feet I have to say I noted why I missed working nights on MAAU which were a lot more relaxing than here, as nights here seem to be more and more chaotic by the second. It's the actually sitting down for a cup of coffee in the staff room when you want to (if there isn't a patient who needs you) and being able to read a trashy celebrity magazine stolen from the day room in peace. Here I'm lucky if I get to walk off for a cup of coffee without being nobbled to do something else. Not that I'm moaning, I feel a lot more useful here and more wanted. Not just as if I'm the useless SHO who you'll call if the staff nurse/senior staff nurse has a major issue and it can't wait until ward rounds. I feel like part of the team especially as I'm going to take my MFAEM (Member of the Faculty of Accident & Emergency Medicine) soon so people actually want me to work and get experience.

Now I know why I became a medic

After reading Shiny Happy Person's comment about her name being the link for Random Acts of Reality's blog, I attempted to change it. Only to find that when I accessed the template page I had the links up for both Shiny Happy Person and Random Acts of Reality on separate lines and in separate links. So now I am confused (and it does not take a lot really). So instead I have decided to leave it be for the moment and apologies to anyone who gets taken to the wrong webpage but I did try and attempt it later in the week when my brain may be functioning slightly more. Technology has never been a strong point of mine (well at least not computer technology). Anything other than medical equipment tends to fail on me, although I was known on the ward when I was a medical PRHO for having an amazing ability to make a 12 lead ECG machine go totally haywire. Luckily though over the years I have perfected my technique and now only have small problems with infusion pumps and only then because I forget that half the one's in the hospital actually have no battery life anymore and have to remain plugges into a mains electricity supply. Never mind, it's all a learning curve.

What do you all think of the new layout? Personally I prefer it, if only because I can read it more easily without having to grovel around in my bag/coat pocket to find my glasses! I am that blind, which is shocking really and I need to invest in contacts but the mere though of them makes me squearm. In other news I have moved jobs (again) back to critical care. For the next 6 months I am based on the clinical decisions unit and observation ward attached to the A&E department but am accountable to critical care (that is intensive care and high dependency, where I will also spend some time). There is more on the use of CDUs and obs wards here in an article from the BMJ. Personally I think they're just a "push the patient out of an A&E cubicle" solution and in the case of CDUs just an incentive to get patients out before they breach the 4 hour rule. I'm not complaining though, it means I'm going to spend a better 6 months than I did in admissions where I felt my sole purpose was just to stick drips in people, write up painkillers, look at ECG results and tag around with the consultant at ward round writing up his notes.

I'm sure it'll be hell for the first few weeks, although I'll know a lot of the nurses from the rotation I did in A&E earlier in my career so that should be fun as a lot of them are hilarious to be around. It means longer hours which my fiancé is not too impressed with as he's already doing enough hours (as a surgical registrar - mad soul) and thinks that I should become a GP. I hate that typical male sexist view that just because I am a 26 year old woman who has done her basic medical training I should now pack up and move into general practice because it's seen as a more female environment. I don't want to be a GP (no offence to GPs) because I like critical care and emergency medicine, I like the variety it brings along with the adrenaline which you don't get in primary care. You may get the variety but not the adrenaline and no where near the buzz from working in that environment. Plus, I won't just be seen as a female medic who will get married, settle down and have children and become a part-time salaried general practitioner. The whole issue of it annoys me.

There also appears to be a spark of interest in the media at present with self-harm. The Times covered two stories on the issue on Saturday in the health section and on the front page of Sunday's edition. Maybe it is because the government realises what a crisis the NHS is in when it comes to self-harm and many mental health issues in general. I found a large proportion of self-harm when I worked on admissions in the case of overdoses as the patients are admitted overnight and I expect to see a lot more of it now I'm back in critical care through overdoses and self-mutilation. It scares me to see the figures of self-harmers admitted to hospitals these days. I know that when I trained to be a doctor hardly any emphasis was put on self-harm in psychiatry lectures and rotations and a nurse I worked with once who had been an A&E nurse for 18 years said she couldn't remember the proportion of self-harming previously that is seen at present. I took a special interest in it during my mental health module, probably because of my history, and when I worked in A&E I always offered to treat the patients who were in the department because of self-harm or who were deemed to need psychiatric intervention by the triage nurse.

Many doctors take a dim view of self-harmers and I know a lot of my colleagues will be "tut-tutting" at the idea of giving them clean blades to use as it may encourage them to self-harm and therefore they will clog up the emergency departments even more (their views, not mine). It is true that there is a proportion of patients that will attend an A&E unit on frequent occasions having self-harmed but this is symptomatic of the nature of it, it is habitual and often increase in severity the longer it goes on. For the same reason this is why on admissions we had patients who had 6 or 7 piles of notes for previous admissions to the unit following overdoses. However, in the case of clean blades it could be said that prevention is better than cure and preventing infection is paramount, along with education into how to cut safely, thus avoiding major injuries.

Maybe you have to have been there to show the sympathy and empathy that these people need. It is a very vicious circle that I think needs a lot of specialist training to comprehend and unfortunately many NHS trusts don't have the resources (despite the National Institute for Clinical Excellence's guidelines stating all clinical staff should be given training if they come into contact with self-harmers). In the trust I work we are lucky that we have a deliberate self-harm team who assess people admitted following acts of self-harm but that is the end of their remit, they can discharge people, refer them to community mental health teams/psychiatrists, or have them admitted to an acute psychiatric unit, most of which is not what the self-harmer (in my opinion) needs. They need short-term intensive intervention when they are discharged, followed by long-term support. The former to prevent them from self-harming so badly again and not feeling as if they have been rejected and left and the latter to help them understand the condition and any triggers behind it.

Then again I have the experience, I self-harmed, and therefore think I am more aware of the needs and I know NHS trusts are overstretched already and are doing the best they can.