16 December 2006

Killing people

Dr Grumble does not like killing. For Dr Grumble the worst sort of killing is judicial execution. What could be more premeditated than that? The founding fathers of that renegade group in the New World banned cruel and unusual punishment. Dr Grumble wonders what they had in mind. Because nothing seems to Dr Grumble to be more cruel and unusual than what goes on across the pond. Waiting for years to be executed with imminent bookings for the execution chamber being punctuated by court intervention seems pretty cruel to Dr Grumble. Not that he would favour a speedier dispatch either.

A particularly nasty part of the execution process has been the medicalisation of the procedure. This seems to have been devised more to sanitise and help sanction the process than to make the procedure better for the victim. A witness to the first such execution commented, "With the medical paraphernalia - intravenous tubes, a cot on wheels, and a curtain for privacy the well lighted cubicle might have been a hospital room." Exactly what was intended, thinks Dr Grumble. It doesn't seem to bother that many Americans. Even some American doctors would be happy to help out at executions. Odd. There are third world countries that have not executed anybody for decades.

Dr Grumble has not been able to bring himself to study the latest botched execution in Florida but, inevitably, he has heard accounts on the radio. To understand what may have happened we need to know what drugs they use in this process. Dr Grumble understands these to be thiopentone, pancuronium and potassium chloride. Pancuronium is, essentially, arrow poison. It paralyses muscles. You remain fully conscious - but not for long because you can't breathe. Not too pleasant really. That's why they give thiopentone, a rapidly acting barbiturate. But it's effect doesn't last long. That's why they give the potassium. It stops the heart. But these agents are all supposed to go in intravenously. If they don't death could be prolonged and painful. Dr Grumble thinks that in the latest botch up the executioners failed to obtain proper IV access. As a result the victim would have been paralysed by the pancuronium - but rather slowly and incompletely. The Pentothal would not have worked too well either so consciousness would have been maintained. And the potassium injected outside the vein would have caused severe pain to the partly paralysed victim. How civilised societies can do this sort of thing Dr Grumble has no idea.

Where Dr Grumble trained they used to use bodies from executions for dissection. Even in those days executions were not reliable. But for Ann Green there was a happy outcome.

26 November 2006

Patient Dignity

Dr Grumble does not want his male and female patients milling around together on the same ward if they are not happy with that. But the average NHS ward does not always make it easy to fully separate the sexes and Dr Grumble would sooner see the sexes together than not have a bed for his patient. And with ever decreasing bed numbers this is the choice our managers have to make.

Dr Grumble does not like having to ask patients about private matters behind some flimsy curtains which just play lip service to privacy. Read the books about how to convey bad news to a patient that is hard of hearing and it is unlikely that it would advise you to shout this information to the patient in an open ward. But these are the realities of today's NHS. Who gets the blame? Sometimes the doctors. But it's not our fault. It's the environment in which we are forced to work.

If our managers were genuinely concerned about patient dignity wouldn't they provide patients with something better than the typical hospital gown? What function do these things serve? What's the betting the hospital managers claim there is some special clinical need? If Dr Grumble wants to examine a sick man in one of these ghastly garments he has to first sit him up, then undo tightly knotted ties then somehow lift the sick patient's bum off the bed and so on. In short, it's a real struggle to expose the patient's chest. What might the patient wear otherwise? Pyjamas perhaps? What could be easier? Unbutton the front and everything is accessible. Sit the patient forward and lift the pyjama top up and the back of the chest is there for auscultation. As for the abdomen, that too is easily accessible if the patient is in pyjamas. Oh and they cover the patient's bum for when they want to walk about. Come on managers, help us a bit! Buy in some pyjamas!

19 November 2006

Georgi Markov

The case of Alexander Litvinenko who is alleged to have been poisoned with thallium reminds Dr Grumble of the story of Georgi Markov. Georgi was a Bulgarian who defected in 1969 and settled in London. In the late 1970s he turned up at a hospital where Dr Grumble used to work claiming that he had been shot in the thigh with an umbrella. He was extremely ill and clinically it appeared that he had septicaemia. Within a day or two he was dead.

Georgi Markov

The story seemed altogether a little implausible but an astute radiologist spotted an opacity the size of a pinhead visible in a radiograph of the right thigh and was insistent that it should not be ignored. Despite what might have appeared to be the mad ravings of an extremely sick man, it eventually transpired that poor Georgi had almost certainly been poisoned with a tiny quantity of ricin.

The tiny bullet which killed Georgi.
Just half a milligram of ricin (about the size of a pinhead) can be fatal.

The name of the radiologist was Jean Dow. Unfortunately her astute observations did not help poor Georgi.

The orginal reports carried in The Times can be read here. And here you can find an interesting interview with Annabel Markov, Georgi's wife.

Dr Grumble is dismayed that, though the cold war is long over, these things still seem to be going on.

30 July 2006

Diarrhoea - or was it?

Dr Grumble has had a tough week. In fact he has been working for 12 days non stop: a normal working week followed by a 168 hour week of medical 'take' when he has been responsible for the acute medical admissions and the sundry other acute medical problems of a large teaching hospital. During this time he has seen some 150 acutely ill patients and been responsible for many more dealt with by a vast array of constantly changing shift workers. In the first draft of this blog he accidentally typed 'shit' workers. Sadly, sometimes this might be true. But last week the junior doctors that supported Dr Grumble were excellent. Mostly anyway.

Does Dr Grumble make a difference or is he there just to rubber stamp and cover the backs of the managers in the process of clinical governance? Actually, he feels he has made a difference. Were any of the changes he made life saving? Possibly. Certainly, some of the changed diagnoses driven largely by the gut feeling of experience were important, very important.

But Dr Grumble doesn't want to crow about these. Not yet anyway. But he does want to tell you about the old man admitted with 'infective diarrhoea'. The care homes around Dr Grumbles hospital are privately run. The have a maximum of patients and a minimum of staff. This means that they cannot cope if there is any deterioration whatsoever. They don't seem to have GPs attached to them any more. We get a note from Matron (yes, they still have matrons in the private sector) describing some (usually exaggerated) symptom and the patient is bundled into hospital. Amongst these poor people are individuals that are dying - slowly. When they deteriorate they should be looked after and kept comfortable and not bundled into an acute hospital. The oldest we had was 105.

But back to the poor old man with 'infective diarrhoea'. Dr Grumble found him in a side room (to help with infection control). He had had no treatment. None of it seemed quite right. There's not much time to examine patients on the post-take ward round but Dr Grumble called for a glove and carried out a rectal examination. He could have got somebody else to do this but he wanted to make a point. It wasn't easy. The patient was embarassed because he was lying in a pool of liquid stool. It wasn't too pleasant for Dr Grumble either. There was no nurse to help. We don't always have a nurse on the round any more in the NHS. Dr Crippen will tell you where they have gone.

The diagnosis was made clear. There was hard faeces in the rectum. This poor man had constipation with overflow. This should have been dealt with in the home. The hospital should never have been bothered with this. And the hospital should have got the diagnosis right from the start.

Dr Grumble broke the news to the poor patient that he was constipated. "I know" he said. There it was. The diagnosis, as always or almost always, was there in the history. In a few days, when the nurses eventually get round to giving him an enema he will be better. High, hot and a hell of a lot was what we used to say. But things have moved on.

Dr Grumble sighs.

06 May 2006

Bring out your dead

Anatomy was never Dr Grumble's favourite subject. Learning anatomy is a bit like committing a very complicated 3D road map to memory. He found it so awful that he very nearly gave up medicine after just a term. But if you are going to be a doctor anatomy is important, very important.

Has the work of Guenther von Hagens put donors off?

Bodies for dissection are now in short supply. Imperial College, better known for technology than medicine, has cancelled hands-on dissection for its first year medical students. In Oxford, when Dr Grumble trained, there were plenty of bodies. At one time they used cadavers from executions though it has to be said that this was long before Dr Grumble's time. One such unfortunate was 22 year old Ann Green who was hanged in the Cattle Yard on 14th December 1650 for the murder of her newborn baby. Her body was then carted off for dissection. As Thomas Willis and his colleagues were about to start work they noticed she was still breathing. They tickled her throat with a feather and she soon made a full recovery. Now you might think that they would have taken her back and done the job properly but Dr Grumble is happy to relate that she ended up being pardoned. Some say she went on to live well into old age which is a nice story but others say she died aged 31.

Thomas Willis who resuscitated Ann Green.

Things may be bad at Imperial College but they appear to be even worse in Australia. There students can't tell a heart from a liver. Some now think this is part of a dumbing down of training with too much focus on the touchy feely subjects that the politically correct insist on squeezing into an already overloaded curriculum. Dr Grumble could have told them that. But nobody listens to doctors.

Patients should be concerned. Dr Grumble is very concerned.

Dr Grumble was so wrong

Many years ago senior nurses told Dr Grumble that nurses should never be taken away from the hands on provision of basic nursing care. Dr Grumble thought they were crackers. They told Dr Grumble that it would be the beginning of the end of nursing. Dr Grumble took the view that as nursing was becoming more technical and there was a need for nurses to take on technical tasks usually done by doctors, it would be better to get others to do the chores like washing bottoms. How wrong he was. Basic nursing care is important. Nurses, very senior nurses, used to tell that to Dr Grumble. They were right. And basic nursing is, yes, nursing. It is not anything else. It should be done by a nurse and a senior nurse should ensure that it is done properly.

Nursing as it used to be. Note the staff patient ratio.

Now nurses are trained away from the wards. Some are too clever to care, others too posh to wash. See what the lovely Amy Wilkins, [the link is now broken but there are others saying much the same] a student nurse, has to say on this. Her more senior colleagues agree with her. But for how long?

Dr Grumble was so very wrong.

01 May 2006

Thought for the day

Dr Grumble's children have all been educated entirely in state schools. He couldn't have afforded otherwise. But he's glad to support state systems at a time that they are under threat. Today's leader believes that anything that is not run like a market is defective and will not work. This might be right - but it might not be. Just because the Soviet Union fell apart because of its dire economic state does not necessarily mean that you cannot make these systems work. Certainly our leaders are not able to make them work as they should. That's why they want to privatise them. You see privatisation puts some distance between the political masters and the deliverers of the service. Dr Grumble doubts whether this will work in the case of hospitals. If hospitals get closed on grounds of efficiency will the companies running them in the future get the blame or will the government? The answer is clear. Hospitals need to be closed but politicians rarely stand up and say so. Where Dr Grumble lives is a hospital. It's really a sticking plaster station. It may be that it should be closed. But no local politician will ever say so. The local newspaper has horror headlines. No local politician ever supports the closure. Quite the opposite: they pledge maximum support to fight the closure.

A half pulled down hospital.
Half-pulled down because they then decided it was beautiful and left the rest!

One way of making schools and hospitals work is to set targets, keep measuring performance and have audits and inspections. The inspection report for the local state school has just arrived. For parents these inspections tell them what they already know. It must say something that millionaires send their children to the local state school - though most of the local millionaires probably don't. But the fact that some do probably says something.

Two things caught Dr Grumble's eye in the latest Ofsted report. The first thing was the silly mission statement. It reads 'Better education and care'. Why do they have to have these things? There's a hospital in London which has a mission statement pasted onto it's lavatorial white-tiled wall. It reads something like ' Serving the community 24 hours a day'. Goodness knows how much it cost to paste this on the walls. And it tells the people what they already know. Who first dreamed up the concept? Why did management gurus propagate it and tell our masters that we must have these things. And why did our masters listen to them? This, of course, does not matter. That's why nobody runs a campaign against mission statements. If there is one, do let Dr Grumble know because he might just sign on.

It was the other thing that caught Dr Grumble's eye that caused him to think. It was under What the school should do to improve. Well, 'improve further' was what they actually wrote because that's politically correct. So pretty important you might think. This was what was last on the list:
  • Enhance spirituality in the school and meet statutory requirements on collective worship

Now Dr Gumble seems to remember seeing this before so it seems there has been no progress. And the fact that it was last on the list implies that even the inspectors consider it least important. Curiously, a previous headmaster was a man of the cloth so you might think he would have sorted this out long ago.

Today is a Bank Holiday in the UK. Dr Grumble is normally at work before 7.30am so today he had a lie in. This meant that, unusually, he heard Thought for the Day on the Today programme. Today it was a rabbi. Quite a nice old buffer. Gay so I'm told. Can you be a rabbi and be gay? Apparently so. What the rabbi said really doesn't matter. What does matter is that it was a rabbi. It always seems to be somebody with a religious axe to grind. Why is this? Isn't the BBC funded by, essentially, the whole community. Don't people without a religion have any interesting thoughts? And why is worship, collective worship, a statutory requirement in our schools. This seems to be quite the opposite of what is the law in the US. If Dr Grumble has any US readers perhaps they could inform him on this. Was it the founding fathers that had this far-sighted view?

Dr Grumble is perplexed.

15 April 2006

What's in a title?

One good thing about being a doctor is that you deal with both rich and poor. Many middle class types do not interact with the dregs of society and confine themselves to sanitised interactions with the well-to-do. Dr Grumble has looked after lords and tramps on the same ward round. He considers this a great privilege. It’s not dealing with the rich that he likes but the reality of dealing with a whole cross section of society together. And it is a particular privilege to be working in the UK and offering both groups the same quality of care. Can this be true? Yes it is. Few patients have a private GP and private provision for acute medicine in the UK is woefully lacking. When the chips are down, in an emergency we all go to the same place and get the same emergency treatment.

A lord in his lord's outfit.

So what’s in a title? Quite a lot it seems. Certainly those with money seem to be prepared to spend quite a lot on trying to get one. If you’re in the position to sell titles, this is quite a good way to extract money from the rich. The very rich are used to getting whatever they want but money does not buy everything. This leaves the unfortunate rich ruminating over the things they cannot buy. The most important of these is good health. Titles are not so important. Actually they are not important at all but the rich do not have this sort of insight. Like children they want what they cannot have. So it is no surprise if the unscrupulous exploit them. The unscrupulous bit is selling what is not your to sell. But that doesn’t bother the rich. But it should bother the sellers.

Doctors, of course, have titles. Of a sort anyway. Grumble is Dr Grumble. He would, in many circumstances, like to be incognito as plain Mr Grumble or, better still, John Grumble. The reason he has chosen to be Dr Grumble here is because his being a doctor is an important aspect of this blog. Chosen is the right word for most UK doctors who do not actually have a doctorate. Some of the people Dr Grumble works with have doctorates but are not doctors. Many doctors in the UK call themselves Mr, something which perplexes patients and foreigners alike. Dentists in some parts of the world call themselves Dr and, in recent times, Dr Grumble has been getting letters from UK dental surgeons, without an obvious doctorate, calling themselves Dr. This is puzzling because medically qualified doctors, who are surgeons, generally call themselves Mr or Mrs or Miss or that terrible but rather useful title, Ms. In many hospitals, to add to the confusion, you will also find a few Professors.

Does any of this matter? Dr Grumble thinks it does. Patients need to know whether the person they consult is a doctor or not. They know what a doctor is. They don’t really know what a Mr or Mrs or Ms or Professor is. There are lots of people in hospitals with these titles who are not doctors. And quite a few that are. Unfortunately, there are also a good few Drs that are not what patients consider to be a doctor. It’s all very difficult. If ideas about doctorates in nursing practice take off it may get even more difficult.

Dr Grumble has always wondered what the public mean when they refer to a ‘qualified doctor’ as in ‘John Grumble is a qualified doctor’. What, for goodness sake, is an unqualified doctor? Perhaps an ‘unqualified doctor’ is one of the new breed of practitioners that are being brought in to do doctors’ work. Do the public want to be treated by an unqualified doctor? If the person doing the job can do it to a high standard then it really doesn’t matter though how can this square with the Blair concept of choice? Certainly patients have the right to know if they are being treated by unqualified doctors and it’s time all this was clarified for them. Perhaps they should even be given some choice in the matter. In the headlong rush for an efficiency, which is proving elusive, nobody seems to have given this any thought. Except, of course, doctors. But nobody listens to them in today's NHS. Dr Grumble is worried.