Thursday, June 25, 2009

Rules lure

Thirty-five years ago at the beginning of my consultant career I wrote a ‘Personal View’ for the BMJ. At the time I was frustrated by the inappropriateness of the hurdles I had to scamper over to achieve that status, but full of hope for the future and anticipating the exciting developments that the application of science to medicine would bring. Now that I have retired and become a patient, how does the NHS look?

In many ways there has been a great improvement. The plant that I am being treated in is far superior to the make-do-and-mend Victorian buildings that I practised in at the start of my career. There are many more consultants; for much of my career I had three consultant physician and three consultant surgeon colleagues – now there are more than thirty of each at our District General Hospital (DGH). The imaging departments have been revolutionised, so much so that autopsies have become almost a thing of the past – nobody seems to die undiagnosed – and the exploratory laparotomy is as archaic as the tuberculosis sanatorium.

There has been an enormous increase in regulation, much of it necessary, I am sure. I can think of colleagues who ‘paddled their own canoes’ in the hospital environment, not really caring how it affected their colleagues, who were powerless to influence what they did. The introduction of managers who really managed made a difference. On the other hand many of the innovations that I was able to introduce and the advances that I effected would probably have been impossible under the current regime. They would have been judged inappropriate in a DGH. The time and energy involved in bringing research enterprises to the clinic is certainly excessive now.

Junior doctors are much more junior now and hardly seem to work for any hours. As a Senior Registrar I expected to know everything about every patient under my care, even down to the minutest detail about how long an infusion lasted, what side effects were suffered, and whether the neutrophils were granulated or not. It seems that today that degree of surveillance has been delegated to the nurses and laboratory scientists while the more junior registrars are away on diversity training or maternity leave.

Of course, nurses are not the nurses I knew when I started out. No more ‘mopping fevered brows’ but they really are excellent at running wards. They form a smooth cadre of carers with the Health Care Assistants, and my experience as an in-patient was that things got done on time according to well-designed protocols.

Ah protocols! When I ran a laboratory we had to introduce standard operating procedures (SOP) which ensured that every blood test was done in exactly the same way so that no random variation crept in. There was even an SOP for answering the telephone. (“Good morning, how may I help you?”) I can see that as you deskill the hospital it is necessary to introduce rigid protocols and deskilling has become necessary with shorter working hours, more training and the really bright people being seconded to very complicated tasks, but has that rigidity gone too far?

I give you three examples. In the first the rigid rule was ‘no more than four doses of paracetamol (acetaminophen) in 24 hours’. The patient in question had his post-operative pain well controlled by paracetamol 1 gram four hourly. When he awoke at four am and asked for more paracetamol he was denied because only 23 hours had passed. He could either wait for an hour or have a morphine injection. Now I know paracetamol can be lethal. The fatal dose is around 150 mg/kg. For an 80 kg man (for such he was) that makes the potential lethal dose 12 grams if given over an hour. Even in a man with alcohol problems (which he did not have) there is no way that 5 grams in 24 hours could be harmful. Besides, there is a very effective antidote. Because morphine made him sick (and he was not boarded for an anti-emetic) this patient elected to suffer in silence for an hour.

The second rigid rule was ‘no-one but a doctor is allowed to prescribe intravenous fluids’. In this case it was clearly the junior doctor’s duty to write up the intravenous fluids for the next 24 hours. But guess what, she was too busy. As a recent graduate she found getting through her day’s tasks onerous and she went off duty at 5pm (something that is compulsory these days unless you want a black mark). The ‘hospital at night’ team doesn’t really work unless funded at extravagant levels. Despite being rung on numerous occasions, the F2 (an NHS term for a resident doctor in his second year after qualifying) on duty never turned up on the ward to write up the fluids until 2am. The drip had stopped at midnight and no attempt had been made by the nursing staff to keep the drip open. Why should they? No further intravenous fluids had been prescribed. It took seven attempts from three different doctors and a nursing sister to resite the intravenous cannula. In the past the nurses would have accepted a telephoned instruction or even kept the same fluid regime running or at the very least kept the drip open with slowly running dextrose saline. Now they dare not.

The third rigid rule was ‘blood must not be transfused to patients who are pyrexial’. On this occasion the patient had had major hip surgery and dropped his haemoglobin from 140 g/L to 70 g/L. Blood was prescribed but before it could be given his temperature was noted to be 37.4 degrees C. Obviously blood could not be given! No matter that his pyrexia was almost certainly caused by the presence of several litres of altered blood in his thigh. Never mind someone had some ingenuity. They took the patient to an open window, divested him of his pyjama jacket and played an electric fan on him. When his temperature fell by the requisite 0.4 degrees C they transfused the blood and no, he didn’t catch pneumonia. As an aside, I recently came across a medico-legal case where in a similar situation a haemoglobin of 50 g/L was left untransfused because of a pyrexia. The poor woman became blind from her anaemia and it cost the hospital a lot of money in damages.

These three cases have this in common; in obeying the ‘rules’ nobody was available to think what the rules were there for. Such rules do not have the authority of the Law of the Medes and Persians; they are more like guidelines. They should be a spur to thinking and asking questions. But perhaps the NHS no longer employs thinkers.

1 comment:

Marcia said...

Having been a teacher for over 20 years, I can tell you that it is more difficult to require students to think in classes. No wonder there are no thinkers to hire... Not only do the students not want to be bothered to think, but the required exams do not need much thinking, so why should they learn to think?
I'm glad you are feeling up to posting again. I hope the rest of the treatment is less distressing, but completely effective!