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...