Saturday, April 29, 2006

Sister, I'm Speechless.

I don't know what to say. While surfing, I noticed Kim from Emergiblog's support for the concept of a US National Nurse via a US Congress Bill HR903. I can only presume this is a nursing equivalent of the US Surgeon-General.

Now, I had always thought it a bit odd that the US had a Surgeon-General, but fair enough, that's what they decided on. His or her job is to go around promoting public health. That's great. In fact, the Surgeon-General's specific duties are:
  1. To administer the U.S. Public Health Service (PHS) Commissioned Corps, which is a uniquely expert, diverse, flexible, and committed career force of public health professionals who can respond to both current and long-term health needs of the Nation;
  2. To provide leadership and management oversight for PHS Commissioned Corps involvement in Departmental emergency preparedness and response activities;
  3. To protect and advance the health of the Nation through educating the public; advocating for effective disease prevention and health promotion programs and activities; and, provide a highly recognized symbol of national commitment to protecting and improving the public's health;
  4. To articulate scientifically based health policy analysis and advice to the President and the Secretary of Health and Human Services (HHS) on the full range of critical public health, medical, and health system issues facing the Nation;
  5. To provide leadership in promoting special Departmental health initiatives, e.g., tobacco and HIV prevention efforts, with other governmental and non-governmental entities, both domestically and internationally;
  6. To elevate the quality of public health practice in the professional disciplines through the advancement of appropriate standards and research priorities; and
  7. To fulfill statutory and customary Departmental representational functions on a wide variety of Federal boards and governing bodies of non-Federal health organizations, including the Board of Regents of the Uniformed Services University of the Health Sciences, the National Library of Medicine, the Armed Forces Institute of Pathology, the Association of Military Surgeons of the United States, and the American Medical Association.
So what is the new Office of the National Nurse going to do? According to the bill:
  1. carry out activities to encourage individuals to enter the nursing profession, including providing education on the distinct role of nurses in the health professions and examining nursing issues that would increase public safety, such as issues relating to staff levels, working conditions, and patient input;
  2. carry out activities to encourage nurses to become educators in schools of nursing;
  3. carry out activities to promote the public health, including encouraging nurses to be volunteers to projects that educate the public on achieving better health; and
  4. conduct media campaigns and make personal appearances for purposes of paragraphs (1) through (3).
Now, don't get me wrong, but this seems like a rather self-serving agenda. The purpose is not to promote public health, but to promote nurses. Isn't that why there are lobby groups like the Centre for Nursing Advocacy, sworn enemies of Dr Crippen from NHS Blog Doc?

The Surgeon-General does not go out promoting the role of doctors (or even surgeons). He promotes public health by overseeing the US Public Health Service Commissioned Corps. That team consists of doctors, nurses and other allied health professionals. Is it not enough that nurses are part of a team? If they want to run the team why doesn't a nurse nominate themselves for the office of Surgeon-General? It's pretty clear that you don't even have to be a surgeon.

I don't know about you, but I am not in support of this concept. If a nurse wants to come and show that she can lead a team of health professionals then feel free. This is not a bill for a public-health advocate, or even a patient advocate. This is a bill for an Office of the Nurse-Advocate.

Thursday, April 27, 2006

Let's call a spade a spade

What is it with patient records? Why is it that we can never get it right? I have seen patient cards (with the tiny shorthand doctor scrawl trying to make use of every piece of the card before you have to turn it over), envelopes stuffed full of A4 letters folded in half, manilla folders that everything falls out of constantly, all permutations of colour-coding to hasten the onset of psychedelia, and electronic records where you either have to dictate everything, write everything (and then submit it for scanning), or type everything. Even worse, you have to do all three, and then you cross your fingers that the computer system doesn't go down like it did last week.

Hospital paper records have to take the cake, though. I am used to a standard filing system:
  1. Patient Registration Details
  2. Outpatient and non-admission ED notes
  3. Correspondence
  4. Investigations (Haematology, Biochemistry, Microbiology, Histopathology, Radiology and ECGs at the back)
  5. Inpatient admissions with one tab per admission (most recent at the front)
  6. Split admissions into other volumes if necessary
Not that long ago, I was in New Zealand where the histories are filed:
  1. Volumes split by time period if necessary
  2. Outpatient Notes (including correspondence)
  3. Inpatient Notes
  4. Investigations filed as they occurred during the outpatient or inpatient progress
  5. No specific operation notes, all op notes written in progress notes
Needless to say, I found it a complete mess. Every department had its own staff that would generate its own paperwork that would be inserted into the notes however they liked. Woe betide the unlucky soul who dropped a history and broke the binding!

Having a fairly standardised filing system in Australia has its advantages. I know that if I flip to the back of an admission there will always be a sheet of handwritten paper describing each operation done during that admission. If you are a surgical registrar and you do not look at the handwritten notes in a patient's history, you are in for a lot of surprises.

Unfortunately, my pet peeve for the day is the insistence on calling forms by their "MR number". I understand that the Medical Records staff like to identify each form by number so they know where to file them, but does this jargon need to extend to the rest of the hospital?

If you ask me to fill out an "MR24" how the hell do you expect me to know that you mean the drug chart? And how am I meant to know that an "MR21" is a request for OT assessment? Or that "MR15" is a Progress Note? I am much more interested in whether you can accurately fill out a Fluid Balance chart, not an "MR76"!!!

So for the benefit of any professional form designers out there, anybody who asks me to fill out an MR-something will be met with a blank stare, and "What?". I will feign ignorance until I am told what this form actually is and what it is for. As for forms that have 20 tick boxes and 30 items to circle... I circle or tick the minimum number that will get the job done (usually this involves no more than three). If your form involves more than three selections, then you will get a big black texta mark saying "This form is too complicated". And if you don't like it, you can fill out an MR69 and file it in the round filing cabinet on the floor.

Monday, April 17, 2006

Record Surgery Makes Good News?

This was recently in the news.

Qld hospitals set surgery record
Queensland's two largest hospitals have set records for the amount of surgery they performed last month. More surgical cases were handled at the Princess Alexandra Hospital than at any other time in its history. The Royal Brisbane and Women's Hospital set a March record for the number of surgeries performed this year. Staff at the PA Hospital operated on more than 1,700 patients in March and more than 2,000 patients were treated at the Royal Brisbane.

Let me ask a question - who cares? I feel sorry for the poor administrator / media liaison manager who felt that this was something to be proud of and worthy of generating a press release. Clearly the reporter didn't know what to make of it. Neither do I. Let's just hope that this does not set off a round of "I do more operations that you" comparisons. Before we know it, there will be tearoom arguments at the DHS about it. I'll nominate this week's Bullshit Bingo phrases now:
  • statistical anomaly
  • population-adjusted operation rate
  • minor-major Procedure ratio
  • theatre utilisation
  • staff efficiency index
Don't know what Bullshit Bingo is? Check it out here. All suggestions for medical Bullshit Bingo phrases are welcomed.

By the way, is it just me, or does the ABC news just recycle the same operating theatre photo again and again?

Monday, April 10, 2006

All I need is a knife, spork and foon!

On a lighter note, one of my colleagues is known for not being fussy with his surgical instruments. As a surgical registrar, often you are subject to the vagaries of available equipment at your hospital. In many cases the instruments you want or prefer may have just been put into the steriliser (and thus unavailable for the next four hours), or in use in another theatre, or not on your scrub nurse's tray, or dropped on the floor, or just plain don't exist.

One learns to be versatile, and a pair of forceps becomes a blunt dissection tool, a retractor, and a needle holder. A pair of artery forceps (or, as those surgeons on the other side of the pond call them, "hemostats") becomes a towel clip, a retractor, a blunt dissector, a temporary replacement for dressing tape, and many other uses that only become obvious at the time.

In any case, this colleague was known for saying (when asked, "What instruments will you need?") "A knife, fork and spoon please."

Lo and behold, one day he was handed a sterilised kitchen cutlery set. The nurses were kind enough to open some real surgical instruments after they had finished laughing at their joke.

Having said that, though, a spoon actually does a pretty good job of removing thrombus from the inside of aortic aneurysms.

On the subject of spoons, this article recently came to my attention. I can only say that epidemiologists have a lot of time on their hands.

Sunday, April 02, 2006

We all have to start somewhere!

First Steps by andi2 at currently have the pleasure of my junior registrar being on leave. This is especially so because she has been replaced by an even more junior registrar. In fact, this registrar is so junior that he doesn't know what being a registrar actually means.

Thankfully for him, I do remember what it was like being a registrar for the first time. It is, in fact, just like every other transition that we make in our personal lives and professional careers... learning to trust your own judgement, realising that other people are not always smarter or more knowledgable than you, and accepting that the greater responsibility that comes with being senior means that you have to always keep in mind the "bigger picture". That means that the patient is not your only responsibility.

Perhaps the biggest lesson of all is that there are times when, if you don't do it, nobody will.

While these may seem like very generic observations, they are nonetheless true. As you progress in seniority, they become more and more evident. Unfortunately, there are many health professions where these tenets do not apply.

NHS Blog Doctor's favourite topic at the moment is Nurse Practitioners. I must admit that I think there are some very good Nurse Practitioners out there. They are the ones who know their limitations, and stick to the very straight and narrow area that they are trained in. Unfortunately there are also many who do not, and think that with their protocols and limited clinical skills they can deal with situations that many doctors take years to start to understand.

As a neurosurgical registrar, I had to learn to confidently assess and clear cervical spines. Nobody was going to do this for me. If I made a mistake I had to wear the blame. Perhaps I left a few collars on for longer than necessary, and ordered a few more flexion-extension views than necessary, but that's what it took until I became comfortable with my clinical acumen and responsibilities.

As a vascular surgery covering registrar, I learnt to keep track of my consultants. They changed their on-call rotations regularly, and I could not trust switchboard to keep track correctly. If a AAA came in I had to know who to call, and where they would be. There was little luxury in delay while I tried five different phone numbers.

As a trauma surgery registrar, I had to learn to deal with team conflict. Consultants did not get along, ward rounds were dysfunctional. Politics were rife. Nevertheless, I did my best to smooth things over and ensure that the unit functioned and served its patients well. Was this part of my job description? No, but who else was there to turn to?

As a general surgery registrar, I learnt to deal with private rooms, secretaries, nagging patients from the waiting list, pre-admission stuff-ups, and a barely competent intern going through a divorce. This wasn't part of my medical school training, but one has to accept that as the interface between almost all parts of the hospital and the community, the registrar becomes the non-stop troubleshooting machine.

There have been many other clinical and non-clinical lessons that I have learnt along the way, and it has taken many years to develop my skills and better judgement. Each rotation through an unrelated field, different hospital, different state and different country has only served to teach me how everything can change around me, and yet I am still expected to (and more importantly, able to) oversee every aspect of my patients' care. I can happily say that I can see how "the system" works (or doesn't work) and appreciate the point of view of most other parties in "the system". That doesn't mean that I agree with them, but I think it makes me a better doctor.

I happily admit that my job does not start at 9am and finish at 5pm. That is the nature of being a doctor - or even worse, a surgeon. My responsibilities stay with me when I go home, they carry on for years. Long after I retire I will still be responsible for everything I have done for my patients. If I did not want this responsibility I would never have progressed beyond being a hospital resident. Hmmm... now that is an interesting idea. Perhaps there is a hidden social agenda - given the current need for hospital resident doctors, by scaring them away from becoming registrars and consultants we can increase the RMO workforce? Another topic for another day, I fear.