Wednesday, 4 June 2008

Dodgy Locums

I'm rather disillusioned with locums at the moment. I'm sure there are some good ones but I've failed to come across any so far.

We have two locums in A&E at the moment who have done nothing to change my opinion and I am actually quite scared for the patients they see. They're both probably in their 40s and Asian and one of the first problems I came across what the fact that I couldn't understand very much of what they were saying. I've had to ask them to review my patients a couple of times and the patients clearly had no idea what they were asking them and I had to translate what I guessed the question was (which I found very embarrassing). One of them kept demanding "any tender here?" while prodding a 3 year old's ankle which created a lot of confusion until I asked her "does it hurt?". I didn't witness the consultations with the patients they saw on their own but I hate to think what happened.

The main problem however is just their lack of clinical judgement. Today was an extreme example when the overnight locum handed over a patient he'd seen about two hours ago who had come in with chest pain. He gave a mostly unintelligable and vague account of the history and when asked what the plan was he said he had referred the patient for admission under the medics but wasn't sure whether he really needed to come in. The day registrar asked what the ECG showed and he muttered something about not having seen it because he was busy with another patient!! Luckily there were no thrombolysable changes but there was some lateral ischaemia which he'd failed to even look at. At that point we gave up trying to get anything useful out of him and the registrar asked me to re-clerk the patient. I found out that he had a very extensive cardiac history including a quadruple bypass and several stents and his angina had been getting progressively worse to the point that he was using GTN more than 10 times every day. I found that the locum hadn't even given the man an aspirin and had basically clerked him (badly) then done nothing whatsoever. His bloods were actually back at this point and he had a raised troponin (only 6 hours after his pain). I called the medical SHO just to let him know the patient would need to go to CCU only to find out the locum had never even referred the patient! AAAGH!

I have heard horror stories of locums in other specialties too including a locum gastroenterology registrar who apparently tried to connect a chest drain to the oxygen on the wall.

I find it really really worrying that the NHS is employing people like this and sometimes wonder whether they actually have a medical qualification at all. The thing that really makes my blood boil is that the reason they even need so many locums is because they didn't create enough training posts and now find they are short staffed (gosh, whoever would have predicted that??).

Thursday, 8 May 2008

Supernumerary = great responsibility but no power

I was really looking forward to my current post as it was listed as being supernumerary. I thought it would be nice to get some experience in A&E without having too much responsibility for sick patients. I really should have known better and am kicking myself for my naivity now I realise what supernumerary really means in today's NHS.

In theory I am not allowed to discharge any patients without them being reviewed by a senior doctor. This seems like a great idea since I would be the first to admit that I have very limited experience, especially in terms of managing the minor ailments that make up the huge majority of our workload. In practice however this is an absolute nightmare. There are never enough doctors around for this to actually work and I spend an inordinate amount of time trailing around trying to find the registrar so I can discuss whether or not I am allowed to discharge a patient with a broken nail. I just find the whole thing a bit insulting really - there are lots of instances where I don't know what to do with a patient but I would certainly have the common sense to ask and would never discharge someone if I wasn't completely certain it was the right thing to do. The fact that they feel the need to enforce the fact that we can't do anything without a senior review really seems like overkill and implies that we are not capable of knowing our own limitations.

I wouldn't even mind having to have all of my patients reviewed if it wasn't such a battle to get someone else to see them. On numerous occasions I have been on my own in minors because all of the other doctors are with sick patients in majors. It's just completely stupid when you have really simple cases like someone with a UTI or low back pain and you know exactly what to do but aren't allowed to just do your job and send them home. The last time this happened the reg ended up saying that I could just write that they had reviewed the patient in the notes even though they hadn't. This obviously puts them in a difficult situation legally if anything were to go wrong but there really is no other option since the staffing is so horrendous.

I am also not allowed to write prescriptions in minors without them being countersigned by another doctor. I don't understand the rationale behind this at all since I can routinely prescribe morphine etc on a normal drug chart without anyone checking it. It seems like a complete waste of everyone's time for me to have to track down another doctor just so they can countersign my prescription for something like diclofenac or codydramol. The registrars all think it's a complete joke too and have now taken to signing whole piles of blank prescriptions so I can do my work with some illusion of independence.

Working in majors is generally better since I have to spend longer with each patient and therefore see fewer and have to chase seniors to review them fewer times. On a couple of occasions I have been stuck seeing someone really sick on my own in resus though which is extremely scary.

It just feels like whoever thought up the concept of me being supernumerary wanted the best of both worlds. They wanted the safety net of not having F1s discharge anyone or write prescriptions but at the same time didn't want the cost of actually staffing the department properly. I woudn't really mind having no responsibility as it would be a really good opportunity to learn but they need to employ enough doctors so that I'm not having to work independently. On the other hand I also wouldn't mind if they just admitted that I would be doing the same job as an SHO due to understaffing but if this is the case they need to let me have enough power to actually do the job properly.

Tuesday, 22 April 2008

Minor injuries and mundane crap

After a rather long time without blogging I'm feeling the urge to rant again...

I'm now working in A&E and as the most junior doctor in the department seem to find myself banished to minors most of the time. Working in minors makes me very frustrated because I'm convinced that at least 80% of the patients I see don't actually need to be there. I have identified 3 main reasons for this:

1. Patients don't realise that the 'A' of A&E stands for 'Accident' and the 'E' stands for 'Emergency'. Feeling 'tired all the time' is neither an accident nor an emergency, neither is leg pain which has been going on for 2 years.

2. It is too difficult to get a GP appointment

3. NHS direct - They should change their name to 'Covering-our-arses Direct' or something similar. There is absolutely no point in calling them because all they ever do is suggest people go to A&E 'just to be checked out'. A classic example would be a patient I saw today with a stiff neck. No history of trauma. No neuro symptoms. Just woke up with a stiff neck. Called NHS Direct who told him to go straight to A&E. Another man a couple of days ago was told to come in because he had a rash despite the fact that he was completely well in himself. WHY???!!!

If people just used their brains before coming in I think admissions would drop by about 50%. All they need to consider is 1. what's the worst thing it could be and 2. what do they want us to do about it. People don't seem to realise that a painful knee with no history of trauma or injury is NOT going to be broken therefore they don't need to go to A&E but could just wait a couple of days and see their GP. So many people come in comlaining of symptoms that have been there for quite a long time but have made no effort to see their GPs. For example a man came in today who'd had chest pain for a week. Why on earth do you put up with something for a week then suddenly decide it's urgent enough to have to go to A&E??

I really feel like we should just be sending patients like this home and telling them to see their GPs. If we keep going through the motions of assessing them they'll never learn. People won't get the message that they're wasting our time with trivial rubbish if we keep being nice to them and don't tell them off for it. I have even seen such classics as a broken nail...

Friday, 7 December 2007

Ward cover

Today was my first evening of ward cover. It's exactly the same as weekend ward cover - being asked to make decisions about patients you don't know and constantly being asked to review patients for no good reason. Here is what I spent my evening doing:

1. Bleeped to go and review a patient with severe abdo pain. Didn't bother trying to get any other details on the phone since the nurse could barely speak english. Arrived to find that the patient had metastatic bowel cancer, she had had the same pain since admission and had been seen by palliative care who had advised PRN tramadol. Looked at the PRN section of the drug chart only to find that no analgesia apart from paracetamol had been give for two days despite the fact that tramadol, diclofenac and morphine had all been prescribed. When I asked the nurse why she hadn't given any of the painkillers that had been prescribed she just looked at me blankly. Wrote tramadol up regularly since the patient just won't get it otherwise. Poor woman.

2. Asked to review a post-op patient with a swollen calf (alarm bells ringing at this point). Arrive to find the patient had knocked her leg on something and has a bit of a bruise on the side of her leg but no swelling, no tenderness, not hot etc. Not in any pain. No action needed. What's more the (lovely) registrar had already seen her a few hours ago and told her that it was just a bruise.

3. Asked to review a patient's regular medication because the doses had been prescribed wrong. Looked for the patient's notes to try to find out the correct doses only to discover they had gone home two days ago.

4. Asked to consider changing several patient's antibiotics from IV to oral despite never having met them and not having a clue why they were even on antibiotics.

5. Asked to prescribe vaccinations for a patient who had a splenectomy and needed them sometime before going home next week.

5. Asked to write TTOs for a patient who might be going home on monday.

6. Asked to rewrite 2 drug charts.

The surprising thing is that this is all within a couple of hours of the normal teams leaving. I'm sure the nurses wait until 5 before looking to see if any fluids need prescribing, drug charts need rewriting etc. I wrote "No - this is a job for the normal team" on a couple of the notes left for me. I was very very close to writing "Fuck off"

Wednesday, 5 December 2007

Miserable Bastard Registrars

There is a huge difference in the way different registrars treat F1s. There are some absolutely brilliant regs who are patient with us when we don't know all of the answers and even take the time to teach us about what we could have done differently when they come to review our patients. This usually earns them the prefix "lovely" before their names when we discuss them between ourselves.

There are also some absolute bastards of regs. I had to deal with one of them today when I wanted to make a referral to another team. I've started a new specialty today so I don't really know the patients but the SHO asked me to refer one of them to respiratory. I spent about 20mins reading the patient's notes, looking up the results of their investigations and checking their obs chart etc so I would know what to say when I called. The patient had pneumonia, they had been started on IV antibiotics and had started to improve.

Thinking I had a reasonable handle on the case I bleeped the respiratory reg and asked if I could make a referral to him. His reply was "well to start with, no you can't make a referral to me, you can only ask my advice and I'll decide whether to see the patient or not" - ok, I thought that was pretty much the same thing but never mind. I then asked very politely whether in that case I could ask his advice about a patient. He then asked where my registrar was and why they weren't calling him. I explained that there are no registrars in this specialty, only me and an SHO who was busy. After a lot of sighing and tutting he agreed to listen to the case.

I actually summarised the case pretty well since I'd prepared myself and could answer all of his questions quickly but as soon as I had finished he started going on and on about how this person didn't need to be referred to respiratory and could be managed by my own consultant. He was annoyed that I had called him when I was only an F1 and seemed to be under the impression that the referral had been entirely my idea (when does that EVER happen?).

It's so annoying because I don't know how the hell medicine works. This is my first day. I can only assume that if one of my seniors asks me to make a referral then this is the right thing to do. I don't know that arsey respiratory regs will only accept referrals from other regs or that not all people with pneumonia are referred to respiratory. When I explained that it was my first day and I was just doing what I had been asked to, his response was "That's not good enough. You're wasting my time". Thanks for the understanding.

Anyway... what a pompous wanker. There is absolutely no need to be so rude. I bet he's either short or ugly. Probably both.

I want to go back to surgery :(

Thursday, 22 November 2007

Annual leave

I get 5 weeks of annual leave this year.

I work one weekend in every four and don't get any time off during the week to make up for it.

I worked out today that this means I work an extra 26 days per year outside a normal 5 day week and get 25 days off.

Therefore my annual leave allowance is minus one day per year.


Tuesday, 20 November 2007

Playing truant

Naughty naughty me. I didn't go to teaching today. Again. I've missed four teaching sessions now and am sure to get a big slap on the wrist in the very near future.

We have teaching for 3 hours every two weeks. It's compulsory and is billed as an important part of the foundation programme. It's all about making us better doctors and helping us achieve our competencies and all of that crap apparently. The glossy and expensive looking 'handbook' they gave us tells me that I am supposed to get "up to three hours per week of protected, bleep-free time set aside for a timetabled learning programme."

Sounds great.

But how exactly is this time protected? The answer, unfortunately, is not at all.

The reason I missed teaching is not that I went home early or did anything fun. The reason I couldn't go was because I had sick patients to look after on the ward and there was nobody else to cover for me. This happens every week. It's actually completely impossible to leave the ward for a whole 3 hours because who will do all of the things I usually do? We are supposed to go to teaching and not bring our bleeps but who the hell are the nurses supposed to call if a patient gets sick? Perhaps the idea is that nobody is allowed to get sick on tuesday afternoons but nobody seems to have told my patients that. It is very inconsiderate of them. Don't they know tuesday afternoons are 'protected time' and they should wait until 5 before having their MI/getting septic/going into heart failure?

We do have an SHO who could in theory cover the ward but in true NHS right-hand-doesn't-know-what-the-left-hand-is-doing style, medical staffing have allocated her to only work a half day every tuesday so she leaves at lunchtime.

We did start off going to teaching but we took our bleeps with us in case there were any problems on the ward. Inevitably there were, and we were bleeped out of teaching repeatedly. This resulted in a lot of tutting and dirty looks from the people teaching us (do they actually think we like being bleeped? Don't they realise we would absolutely love not to have to be at the mercy of our bleeps for 3 hours?) and and in the end we gave up and just went back to the ward. On days when we went to teaching we ended up having to go back to the ward afterwards and working at least 2 hours late in order to get all of the jobs done. There isn't anyone else to do all of the venflons and look up blood results so the work has just piled up by the time we get back.

I'm not sure what is actually supposed to happen. Who is supposed to do the work? Has it even crossed anyone's mind that the work won't go away just because we have teaching?

I'm almost looking forward to the inevitable email asking why I have missed teaching. I intend to tell them exactly why I was unable to go. I genuinely want to ask them in what way they consider this time to be protected. What measures have they actually taken to allow us to attend teaching? Unfortunately I think I know the answer already but I'd be interested to see them try to explain themselves.

This is just yet another example of something that is good in theory but f***ing abysmal in implementation. I would expect nothing less from the NHS.