Thursday, March 26, 2009

Strutting and fretting

One thing that surprised me about being in hospital was how little the doctors influenced what was going on. When I was in charge of the wards I had the distinct impression that I was running things. Of course, it may be very different in surgery, where surgeons are in essence doing the same thing repeatedly and the whole subject may be protocolized. Standard operating procedures (SOPs) are relatively easy to produce and follow when one case doesn't vary very much from the next. In contrast, hematology patients are very different from each other. About the only leukemia that is at all stereotyped is chronic myeloid leukemia, where an identical molecular lesion produces a very similar clinical condition, but my readers will mostly know how heterogeneous is CLL, and AML or MDS is even more so. Non-Hodgkin's lymphoma breaks down into over 40 separate conditions.

When I was running the hematology lab we majored on SOPs, but then we were doing full blood counts on 750+ samples a day and very few other tests. We even had an SOP for answering the telephone (Good morning, this is the Hematology Lab. How may we help you?). The benefit of SOPs is that relatively unskilled workers can be trained to do complex tasks accurately and reproducibly. The danger of SOPs is inflexibility.

The surgery ward ran efficiently on a cadre of trained nurses and health care assistants (HCAs). There were some things that only nurses could do, like give injections, dole out pills and attach and detach intravenous pumps, but for most of the traditional nursing duties, like making beds, emptying bed-pans and giving bed-baths, the nurses and HCAs were interchangeable. Obviously, the use of HCAs to replace nurses is a cost saving. Many of the HCAs were from Eastern Europe or other foreign countries (though their English was always excellent) but, then, my nurses were also likely to be foreign (Indian, Chinese,) and their training was equally as good as those who were locally trained.

Many of my readers will know the Tom Stoppard play 'Rosencrantz and Guildenstern are dead'. For those who don't the author takes two minor characters from Hamlet and builds a play around them. They spend most of the play discussing the absurdities of life and death, the paradox of freedom and inevitability, of freewill and predestination. Mostly it is a two-hander, but at times the whole Shakespeare play rushes on to the stage and performs their bit of Elizabethan drama before exiting stage left, leaving the two alone, perplexed and totally misconstruing what has just happened.

The consultant ward round is like that. Of course, Hamlet is the main thing and Rozencrantz and Guildenstern mere strolling players in comparison. The great and important decisions are taken by the consultant and his retinue, while we patients are blown about by the forces of destiny.

Everything boxed and coxed, categorized and acted out word perfect without prompting makes for an efficient service where errors of omission do not occur. As long as the out of the ordinary does not come along.

The problem with this inflexibility arose over my drip. The houseman (now called a Foundation year one) has the task of writing up the intravenous fluids for the next 24 hours. At the beginning of March the F1s have only been employed for a couple of weeks and have difficulty in getting their routine work done in the day. In my day you stayed until the work was complete, but today the European Working Time Directive insists that you leave on time. Overstay the 5pm deadline and you get a ticket. Do it twice and you receive a reprimand. Habitual offenders may have to repeat the year.

There is a back up position, though. At night there is an F1 available to cover the whole hospital. Of course, this person does not know the individual patients and apart from catching up on the work left left over from the day she (and these days it is usually a she) has to deal with emergencies as they arise, so it wasn't until 2am that she got around to writing up my fluid chart. By which time the drip had been stopped for two hours and the cannula had clotted. In the old days the nurse in charge of the ward have put up a bag of whatever had gone before rather than let a drip stop, but today a nurse does not have that discretion. She has to obey orders precisely and if nothing is prescribed nothing can be given.

The F1 was very nervous as she tried to resite the cannula, and she failed. She summoned Night Sister and she failed twice. A more senior doctor was called for and she failed three times. Eventually an anesthesiologist was called and she got in first time - but it was the seventh attempt.

The next time I needed a new drip I insisted on an anesthesiologist first time. He turned out to be an old colleague whom I had only met over the telephone. He remembered that I had once done him a favor, and he certainly did one for me.


John Wagner said...

I am finding your comments concerning your hospital and post hospital experiences fascinating. I was devastated when I first read about your diagnosis, but I have been, along with many others, praying for a good outcome for you. I also pray the days of severe pain are behind you.

Anonymous said...

A very sad state of affairs to be sure when patients must endure unnecessary discomfort and or anxiety because simple things are made too complex.

I don't understand why the IV fluid orders weren't written as a continuous order (eg, D5/half normal saline with 20 meq KCL at 85 cc/hr continuously) with the idea that the housestaff could/would adjust them as frequently as indicated.

I certainly find it difficult to understand why the nusring staff cannot take the initiative to run D5W at KVO rate to maintain an IV line when an existing IV order has run least until a physician revies things and can give a new order.

Alas, these things happen in all hospitals and in all countries.

In my days of training ("when Giants stalked the halls") we were there until late in the evening getting everything done when not on call and were up all night when we were on call.

Nowadays, in the US, a houseofficer is excused from work at noon on the day following a night of call and may not see new patients on that morning.

What frustrates me most about this is that this edict includes seeing new consultations which is the bulk of the learning experience available to trainees on my specialty service. They, therefore, lose out on much of the available educational experience on those days. Trust me...they leave at 12:00 Noon sharp, no matter what we might be doing on rounds.

So often when legislation is utilized to address issues draconian rules are laid down that miss the mark. Such is the case with the rules affecting medical trainees in the US and apparently also in the UK!


Anonymous said...

Reading your story reminding me of my experience in the hospital following a back surgery.
I was placed in a room with a stroke victim who was on some kind of machine and was unable to speak.
The machine would go off every couple of hours. Each shift the staff seemed to need to discover the solution to shutting it off. Yep, even in the middle of the night.
It got so I would just screech at the staff: "reset the cassette". Like I knew how to fix it. But, I checked it out with my nurse and that was the answer.
I was pretty anxious to recover and get home under my family's care.

Liz W.
St. Paul, MN