Bleep-Bleep-Bleep (Part 2)

My recent relationship with the on-call bleep these past few days has been, to say the least, bitter. Having thought about all the calls I received, I've managed to categorise them:

Trash-bleep: "Hi doc, just called to let you know...." . This sentence infuriates me as 80% of the time I'm told some pointless drivel, and mostly it is to shift any responsibility away from the ward staff to a doctor who may know nothing at all about the patient. If you're going to call me, have a legitimate question you need me to answer.

Ghost-Bleep: How many times have you called back immediately and then no one answers? What is the acceptable number of rings before you give up? If you're going to bleep someone, please wait by the phone or be within an immediate 5 second radius! I haven't got time to be waiting for you.

Prank-bleep: "Hi, you're the surgeon, do you cover [insert alternate specialty here]". Just because I'm a surgeon, it does not mean I cover all the surgical specialties! If you don't know who to call, ask a colleague or switchboard first.

Ping-pong-bleep: If you're going to call me to refer a patient, please have all the information to hand, including basic demographics, relevant history and obs. It's just courtesy. If you have to put down the phone to run back and forth somewhere else to answer every question I ask, I will hang up.

Repeat-bleep; Please don't bleep me to ask a question that someone else on your ward/department has already bleeped to ask me. It is a waste of both yours and my time with constant repetition.

The Echo-bleep - Some people feel it necessary to bleep multiple times successively within a space of 30 seconds. Why? If anything, I'm less likely to respond to your rudeness.

I admit, I don't see any feasible solution to overcome these categories. Common sense and lack of team communication will continue to render pointless bleeps. Perhaps we still need to consider a smartphone messaging system as in my Part 1 post.

Code Black

That time of year has once again snowed upon us where the A+E department admission increases exponentially. As the elderly chill in their unheated homes, fall victim to the flu virus, asthmatics have increased attacks and the young continue slipping over in the ice sustaining nasty lacerations - we fight on, ploughing through the cards in the "to be seen" box.

In my hospital, this month has such overuse of capacity that every surgical ward is now littered with acute medical patients - it is what they denote as "Code Black status". Most of November was a "Code Red". Following from my previous post, now the medical teams have to leave their comfort bubble of their home ward and embark unto various surgical wards - but which medical team is responsible for medical patients on the orthopedic or general surgery ward?

Even more interesting is that the medical director feels it is necessary that the surgical SHOs assist the medical take during "Code Black." This is absurd! It is understandable that suddenly, their teams are stretched and now end up with Safari ward rounds. I argue, surgeons have always been doing this. However, asking me to review and manage a medical patient admitted with IECOPD on a background of CCF and CKD is out of my depth. If I prescribe something for a medical patient, what is my medicolegal stance - will the medical consultant support my error? I doubt it. Instead, it'll go back to the GMC and state I'm incompetant and risk losing my license.

Would you want to be seen by a surgeon if you came to the A+E with acute chest pain? Imagine the conversation:

Me: "Hi I'm the surgeon on call today, Mr Steth. I understand you have some chest pain..."
Patient: *horror face- at the thought of needed an operation for his suspected heart attack*

What purpose do I fill seeing such patient in A+E when I have no role in the medical post-take? Surgeons chose surgery for a reason - not to be demoted back to acute medicine. 

Interestingly, I haven't found any regulations regarding the cross-covering of medical-surgical specialties. This is a gray area that will need clarity. I don't deny that managing medical take is a challenging task - but there is a reason I chose to be a surgeon. Being involved in the medical take is not one of them.

My patient had chest pain,ummm

After we graduate, we all go through the same mix of medical, surgical and now, more commonly, general practice placements through the training programme called Foundation Programme. This is meant to equip us with all the necessary basic knowledge and skills to deal with common emergencies and the acutely unwell patient.

Now I've chosen the Surgical career path (or maybe it chose me!?) which means my knowledge of management of "common" medical presentations become more distant. Rarely now do i get called to see a breathless patient, or chest pain. Do i keep up to date with modern protocols of heart failure? No.

However, no matter where I work, medical doctors are territorial and have to be dragged by the ankles to our patient if we deem them to require formal medical input purely because medics work on only their territorial ward. Whereas, we surgeons will jump to any place in the hospital to see a patient, relatively immediately.

Why is this the case? Well surgeons are doctors, and should know how to manage "basic" heart failure and diabetes and COPD, apparently. Therefore, there is a reluctancy for medics to step out of their safe zone onto Surgical wards. I imagine the array of stomas and drains intimidates them. On the other hand, screaming dementia patients, the smell of stale urine and diarrhoea on bed linen intimidates me too.

Where does this leave us? Well, perhaps surgical trainees should be expected to cover the ad-hoc medical on-call to keep up to date with acute medical management, including running cardiac arrest calls. The result? We might eventually harvest the surgeon who dually fills out the role of a medical registrar.

Be The Change

So I recently attended a patient safety conference as a random plan, mostly out of curiosity. The striking thing was actually how many trainees are able to rock the boat and make a significant positive change in their department/Trust.

The underlying message was "find someone you trust" and then take your idea forward. The downside for me in this conference is that everyone was doctors. There should be service managers, CFOs and CIOs etc present to defend their positions but also to facilitate ideas and discussion.

This, however, has inspired me, you can be the doctor who sits and carries on moaning about the system or you can stand up and be the change- engage managers and front line staff to talk and open a floor of discussions to improve quality of care for patients.

Be a leader- be the change!

..... Now to find out who my chief exec is....

"Bleep-Bleep-Bleep.." (Part 1)

We all know it, and rapidly loathe that sound that expels from that plastic box clipped to your waist - yes, the On-Call bleep.

What was once the pinnacle of hospital communications, having established itself over 50 years ago, it still exists as the backbone of inter-specialty communication. Surely, now with the PC/internet and smartphone boom, there must be an alternative method of hospital communication.

In America, some hospitals use a Pager system whereby, one can actually send a text message rather than just a 4-digit telephone extension (which you hope isn't a prank bleep '8008' at 3am). However, this is still obsolete technology.

When staff have technology in their pockets or handbags which are more powerful than these dreaded bleeps, we need to think again.

Some places I've worked have replaced the bleeps with cheap Nokia mobile phones. This works great only in a hospital that isn't lead-walled and has good network reception.

One idea I've been thinking is a whatsapp-like platform. A cross-platform smartphone application integrated with the hospital WiFi which allows users to "log in" as specific roles. Thereafter, calls and text messages can be sent to the individual user. An additional benefit would allow group messaging for team messages

Let's take a scenario (the present):
- Mr Smith in ED is waiting to be seen by the On-Call General Surgical team
- ED Matron bleeps the Surgical SHO to find out when Mr Smith will get seen
- SHO is in a coridoor between wards to assist the FY1 with an unwell patient. Can't find a phone
- ED Matron bleeps SHO again
- SHO gets to the ward, phones are being used already
- ED Matron bleeps SHO again
- SHO goes to the opposite ward to find a phone and call the Matron back to explain he is being delayed as he is attending to an acutely unwell patient on the ward
- ED Matron is now happy
- Suddenly, the Bed Manager notices Mr Smith is now waiting 3hr30m and is close to breaching the ED 4-hour wait and bleeps the SHO to find out if Mr Smith should be admitted
- SHO is now attending to the sick patient so ignores the bleep
......15 minutes later....
- Bed Manager still can't get hold of SHO so calls the SpR who is offsite and enjoying his MaccyD's..
..........you get the point........

My new age scenario:
- Mr Smith in ED is waiting to be seen by the On-Call General Surgical team

- ED Matron messages the "On Call Surgical Team" group to ask when someone from the Team will see Mr Smith

- The SHO replies in the message group that he is "On his way to see a sick ward patient and will attend ED after that"

- The Site Manager, who can also screen the ED Matron messages has seen this conversation so goes on to organise a SAU bed for Mr Smith and messages the "On Call Surgical Team" group with this information

- Now the SHO has saved a life, he can now go to SAU instead of ED to see Mr Smith... 

Now who wants to partner with me and design this infrastructure?

Google Health

Now who remembers the Terminator films? Skynet will rise August 4th, 1997.
A year later, Google was founded.
A decade later in 2007, Android OS was born.
Today, Android exists as a mobile device, laptops, wearables, tv, in-car integration, music. Google have been researching in drones. If you really wanted to, you could control your home security and appliances on Google-based system.

Now that got me thinking, now that Google have established a cloud-presence with a vast number of web tools and data architectures, surely there could be immense advantage if Google invested in the NHS system....

Imagine: gPACS, gPath, gPrescribing. Seamless integration of all data systems powered by a Google cloud backend. Data accessible on desktops and portable devices.

The problem currently, every Trust have invested in independent systems. GE Healthcare for radiology, WinPath in Pathology, ICE for order requests and various Electronic Discharge systems. Let us not forget Cerner Millenium which rose and fell very quickly.

I understand the need for each package, but for the front-end user, the digital age doctor is extremely inefficient.

Integrate these systems with a single front-end  single log-on system that works between desktop and tablet, and now we might have a more efficient doctor.

I can only dream.

RCS - Conflict of Interest Money-maker

I've splashed out on many courses and the exams in the last two years. It makes me wonder if it really does make any real impact on my training - I think not.

£620 Basic Surgical Skills Course
£460 MRCS Part A
£894 MRCS Part B
£600 CCrISP Course
£700 ATLS

This already mounts to £3274 - Equivalent to about 6 weeks full pay. Exams I have no problem paying for, they are our badge of honor and rite of passage entitling us to discard our privelaged "Dr" title and henceforth pedastooled as "Mr". Additionally because every industry has exams one must complete to progress their career.

The courses, however, I've attended and see as a conflict of interest. Every core trainee will I hope, have learnt how to tie knots and hold instruments - if not, they need to consider the GP route or be summoned to the scrub room with 2/0 Ethilon until they can tie a 30cm layered surgeons square-reef knot off the door handle (let's face it, that's how we all learnt at home!) What advantage does BSS offer when I've learnt to anastomose porcine bowel and carried out porcine lap choles in medical school??

CCrISP course should be targeted for FY1s if anything.

Bottom line, these courses shouldn't be mandatory when they are of little use to us except to tick the box at ARCP. Perhaps others will disagree - feel free to comment.

Work-Based Assessments

Ever since medical school, the infamous tick-box proof of your (in)competence is relied upon as the Holy Grail of whether you're performing well enough to progress. In actual fact, however, it is common knowledge that it is a pure numbers game. So what's the point of this ongoing farce?

Having been through General Surgery rotations for the past three years, I still can't place laparoscopic ports. Is that my fault? Maybe. But what I've faced is little interest in my seniors to actively train me because they are Staff Grades or long term locum with a commitment for service provision. I end up holding the camera: "Oh no Steth, I'll show you how to dissect the appendix because we need to finish this case quickly".

Are the consultants interested in training? Sadly, very few nowadays. They are all aware we are trainees and need to be trained - but they acknowledge our limited experience and exposure (EWTD - another discussion) and complain about our incompetence. Additionally, their focus is on the private work load. When your Clinical Supervisor writes in your report "I've never seen this trainee operate" - who is that a failure of?

So where does that leave the validity of WBAs? When I might have done only 5 mastectomies from start to finish whereas peers have done 25 local anaesthetic abscess drainages - who is more experienced surgeon? In the eyes of the Deanery, my peers, sadly. Focus should be on quality, not quantity with Consultants and Registrars under pressure from the Deanery to actively train their trainees.

Hello, I'm your new Surgical SHO

So I've been thinking about starting this site since I was a house officer actually - mostly as a way to share the realities of working as a trainee in the NHS. There is an unheard voice, the unheard struggle, and most of all, the daily ritualistic morning chant of "I need to publish, I need an audit, I need a presentation" aside from actually trying to be a good doctor *sigh*.