Off with their heads

Grumble dreads being on call over those long public holidays we have at around Christmas. It is not necessarily that he minds working when everybody else is merrymaking. There used to be times when he quite enjoyed Christmas in hospital. In Christmas past there was an invigorating camaraderie. On Christmas Day the consultants would come in to carve the turkey properly kitted out with an enormous carving knife and a starched white chef's hat. Consultants would bring their families along and presents were exchanged. Grumble knows because his father would take him on Christmas Day to several hospitals. He saw how pleased the staff were to see him. He saw the joy of hospital life in those days. His memory is of there being masses of nurses everywhere you looked and there seemed to be very little work going on. Very occasionally, but much less commonly, he would see the junior doctors. He can still remember their pristine white coats. Everything was always spotlessly clean and hospitals smelt like hospitals. To this day Dr Grumble does not quite know what that smell was. It's not there any more.

So why does Dr Grumble dread the long holidays so much? Hospitals are no longer the places of merriment they once were over Christmas. Staffing levels don't allow any downtime these days. Turkeys have mutated into twizzlers and the kitchen was separated from the ward aeons ago. That's the modern world. More nose to the grindstone. Less joy. More a contractual relationship. Less duty. Minimal loyalty. Do these things matter? Of course they do. In the Grumble hospital sickness levels are rising. In the past junior doctors were never ever off sick. It's all about the loss of joy, duty and loyalty in the workforce. You can get a lot of work out of people just by stroking them a bit. They just need to feel valued, to love their work and have a sense of duty and loyalty to their patients and colleagues.

These things matter. They matter a lot but they are not the cause of the dread Grumble feels when there is a long public holiday. What worries Grumble about hospitals and holidays is patient care. As luck would have it, Dr Grumble used to work alternate Christmases. One Christmas he remembers an extremely sick man in his early fifties who was transferred from another hospital for Grumble's care. This was now some years ago but the patient's name is still etched in the Grumble mind. The details don't matter except that the patient was very ill and looked as if he would die. His chest radiograph is reproduced below:

OK. It's not the real radiograph but this is what it looked like.

The patient arrived just before the long Christmas and New Year holidays. Dr Grumble knew that there would be a race against time to try and make a diagnosis because, in hospitals, only the front-line workers work over the Christmas break. Any patient reading this might think that it is just a question of having a few scanners working and a single Dr Grumble to interpret the results but hospitals are much more complicated than this. It's people you need not just scanners. It's the expertise to work the scanner and interpret the results that matter.

For those who cannot read chest radiographs, the image above shows appearances consistent with widespread metastases. In other words the patient looked to be riddled with cancer. It would be wrong to go into any details but as Grumble has said the patient was very ill. It would be a struggle to keep him alive. And, if the cancer was essentially untreatable, keeping him alive would not be a kindness. Whatever we did he would probably die anyway.

But it was nearly Christmas. Dr Grumble needed more information. There were all sorts of options for getting this information but none of the expertise he needed was available over the long Christmas break. What should poor old Grumble do? Should he keep the patient alive on the off chance that there would be some treatment for this poor man? Or should he assume that, on the information available, no treatment was going to help? As luck would have it, on Christmas Eve, Grumble managed to get a CT scan carried out. And he was able to discuss the result with the top chest radiologist in the Grumble hospital. She agreed. The patient was riddled with metastases. Nothing else could realistically account for the appearances.

Dr Grumble would have liked a tissue diagnosis. He would have liked to have known that this cancer was not a sort of cancer that might melt away with the right treatment. But none of this was an option over Christmas. He would have to meet with the patient's relatives and he would have to convey all these uncertainties. Patients don't like uncertainly. Relatives certainly don't. Nor does Dr Grumble.

The case was much more complicated than this and Dr Grumble has no intention of giving you the full details of a real case. His purpose here is only to convey the sort of dilemmas that arise over public holidays when patients just cannot get the urgent tests that they need.

And so, Mr Cameron, you have gone down in the Grumble estimation. Because no Prime Minister should announce a new public holiday on the hoof without thinking through the consequences. Patients will die because of your decision to allow us a day off to celebrate a wedding. Did you check which day the wedding would be held on first? Why didn't you lean on those wretched royals and persuade them to hold their wedding at time when it wouldn't damage patient care quite do much? Did you look to check how many Bank Holidays there are then? Have you seen how few working days the hospitals will have that week? Do you know how difficult it will be for Dr Grumble and his colleagues? And do you know how many of Grumble's patients will die as a result of your decision?

Oh. I nearly forgot. Against all the odds Grumble fought tooth and nail to keep his patient alive over the prolonged holiday period. Some thought it would have been kinder to allow him to die. But Grumble had a clinical hunch that the appearances might all be due to infection. And the happy outcome was that the patient miraculously improved and the cannon ball 'metastases' just disappeared. It could so easily have been otherwise.