Abstract
It is a time of the year where harvesting has been completed and crops stored away, the nights are long and the shortest day has only just swallowed us up. John Barleycorn has been cut down and in times gone by, not so many generations ago, when a bad harvest and a cold winter would have meant likely death, winter and the return of the sun’s warmth would certainly have held a very great significance. Wood has been reflecting on this of late and while not quite at the ‘fully pagan dancing naked around stone circles’ stage, he is pondering whether his declining mood and general lack of energy reflect these ancient biorhythms. It could also be very closely linked to the explosion of Christmas offers in the supermarkets where 24 cans of export strength lager come in at £2.99 and, while Wood rarely touches the stuff (apart from over Christmas of course) he has become a victim of this most modern phenomenon of binge drinking, ASBO’s and preloading. And 200 Marlboro Lights were cheap too although he doesn’t even smoke. Unless it’s Christmas of course. While bemoaning the fact that one-third of his ICU admissions are related to the evil alcohol, it is a well-known fact that health professionals are immune from the damage of binge drinking and dependency, especially around Bank Holidays, and ‘what harm could it do?’
But is there something else in there making Wood turn to the bottle, or multi-pack aluminium can? Is there something about the darkness and solitude of winter which is driving him this way? Trees thinks it’s because he is a rampant alcoholic, but despite working together and almost being friends for 30 years they have never discussed it. Why would we have a festival at the darkest day in the depths of winter if we didn’t feel a hardwired need to get together, eat, drink and be merry? Yuletide seems unlikely to be related to trying to get time away skiing or to get your own back on Twig with the Christmas and New Year rota allocations but then again perhaps Anglo Saxon man shafted his colleagues with the ploughing rota in times gone by? Whatever primitive urges make us celebrate Yuletide and the dawn of the New Year, it seems clear that Wood and Trees need to man up and leave behind the damage done by mince pies, Christmas party sexual indiscretions and an airborne viral pathogen of which details are to be confirmed.
In fact, Wood went to inspect the Christmas turkeys in November and was turned away from the farm due to an outbreak of a bird-based viral disease which required the entire flock to be culled, and sadly not basted and roasted for good measure. As a man of a certain age, this causes the hairs on the back of Tree’s neck to stand up as he remembers H1N1 and we all remember gifts of Coronavirus from the East or SARS from the West; this is why he sent Wood to become the index case and stand amongst the feathery, pecky things and bring him one back too. French peasants apparently referred to February as ‘the month of fevers’ but now with international travel and animal stocks sufficient to feed the planet’s 7 billion, outbreaks of zoonoses seem a mathematical certainty. The fact that one of these will become a pandemic is a likely event, a statistical eventuality with more basis than a never event, regardless of wishful thinking. Recent commemorations for World War I remind us pandemics can rival man’s stupid conflicts for mortality. Wood decided to play safe and left the turkeys on the farm, went back to the budget store and got a nut roast, Dettol and another 24 cans of lager. And more mince pies. Can’t be too careful.
As we enter this New Year, Wood and Trees are concerned about the Ebola outbreak and hope 2015 brings the signs that it is being contained. Wood couldn’t help but think it seemed a curious way to manage world disasters that the Who should approach the ex-leadsinger of the Boomtown Rats and ask him to shake the tin. Having had this disease appear on European and American shores, with little excuse that ‘no one knew’, the worldwide response has been pitiful and oddly enough, the story seems to have moved away from headlines having run its two-week media life cycle. So Bono Vox and Midge Ure have been dusted off to get some cash and while Wood never doubted their sincerity, the world’s response just seems a bit … well rubbish really. But then again neither Wood nor Trees bought the single – mainly because they couldn’t find a Woolworths open to buy the 7 inch. Apparently, now you get a ‘download’ and this seems just the thin end of the wedge as apparently Jimmy Savile doesn’t host Top of the Pops any more. Trees cannot believe a national institution such as the BBC can find itself in as much trouble as the NHS and believes there must have been a ‘culture’ problem with systematic errors and lack of support for whistleblowers, etc. and would have suggested more dignity or candour. He has offered the BBC a series of recently produced reports, with the relevant sections changed from ‘NHS’ to ‘BBC’, in the hope they may get more action there and save generating £millions of lawyer fodder .…
Trees has observed healthcare-related institutional performance closer to home where his Trust has announced their plans for Ebola, in conjunction with a strategy meeting and training. Extensive revisions were required to the first draft which suggested shouting ‘we’re not here!’ and throwing bleach at them if anyone from Africa turned up a bit shivery with diarrhoea. The hospital identified these people as sick and suggested, they come straight to ICU which focused the minds of Wood and Trees as they often agonise over decisions for multiple organ support where 3/10 are expected to survive. Wood was subjected to a hilarious display by his Senior Infection Control Specialist Nurse Practitioner (it’s a BIG badge!) who attempted to don PPE * which was possibly several sizes too small. Having performed the dance of the seven veils (in reverse) in the style of Coco the Clown, it became apparent that infected faeces was probably now rubbed through this individual’s fringe and perhaps the dance routine needs looked at again. Wood and Trees were even happier when a safe room was identified in the ED where the poor individual, who may have turned up with malaria, gastroenteritis or a cold, can be isolated and then exported to a secure site, much like a ‘grey flight’ to Guantanamo Bay. As terrifying as this all is for an affluent doctor like Wood or Trees, they can’t help but think of the entire cities and districts decimated by the condition and social stigma and fear of perhaps having Ebola and wondering if our PPE should have come after we offered some practical support to the centre of the outbreak. He almost clicked to buy a copy of ‘Do They Know It’s Xmas’ on iTunes before becoming aware of what he was about to do, and calmed down with another can of Christmas beer which was only just out of date.
Some things just aren’t a laughing matter and it seems the CQC are coming to inspect Wood and Trees hospital and this is causing great anxiety. When the hospital underwent is 29th Directorate re-shuffle and Geoff from Surgery swapped with Trudi from Medicine for the third time, things became less clear. So unclear since everything was in a business unit so when Wood wanted to anaesthetise a patient for a tracheostomy that Trees was looking after that day on ICU, he had to take a credit card guarantee and his car keys until the two business units had billed each other. It is now not rare for a given business unit to approach a pay day loan company and ask for an advance if the patient needs a lengthy or costly procedure, in the hope that ICU can sell a ventilator and pay it back. This follows the national financial model of PFI financing and eye watering re-payments. CQC are very interested in ‘domains’ and checking services are patient-centred, safe, effective and the like. Wood has got into big trouble for adding extra domains like ‘sexy and you know it’ and Trees is on an official warning having drawn what can only be described as ‘schoolboy graffiti’ on the selected walls which have been painted. To be fair they needed a touch up after the last Royal visit.
So what do CQC hope to identify and assess in two days? Well, one of the biggest sources of anxiety is among Wood and Trees colleagues who moonlight inspecting other units for CQC because if they fail at home they can’t remain CQC inspectors elsewhere. Wood wonders if CQC know that an £11 grand emergency laparotomy only gets £6 grand back so the business unit they’re in has as tough a job as trying to improve the process? Thankfully, the National Tariff rewards elective orthopaedic surgery handsomely and Wood and Trees have been struck at how many more colleagues they meet over a weekend on call than they used to in the week; this seven-day working seems to be here already? Wood can’t help but think most people expect the hospital to respond rapidly to a perforated viscus discharging faeculence, but it seems young ladies requiring their breasts to be made bigger have pipped them at the post. As Trees observed in true Catchphrase style, It’s good, but it’s not right – even at Christmas.…
Finally, Wood and Trees felt there was a need to resurrect the ICU Journal Club and get looking at the evidence, having been away from it for a few decades. There were a lot of stumbling blocks including trainees on shifts, colleagues in ortheopaedics and no money in the business unit to implement any of the study findings. However, tempted by a free can of the aforementioned lager (there weren’t many left), a group of characters gathered and went through a paper. It was the first one they found in a well respected journal and had the word ‘sepsis’ in the title so 20 copies were printed in less time than it takes to run away when someone shouts ‘CQC’. However, it was clear the photocopyist had not read the paper as it was a trial of goal directed therapy in Zambia. Much of it was quaint and greeted by knowing expressions from Wood, Trees and gathered luminaries that we don’t do things like dopamine, CVP’s or even goal directed therapy any more. Things ground to a halt when they noticed that of 109 randomised patients 80.7% had HIV and most were presenting with pulmonary sepsis and over one-third had TB. Two-thirds died whatever was done for them. Wood and Trees stopped the journal club early because it seemed so unbelievable this would happen in their hospital that the implications for practice were minimal. The medical student had been told by a visiting GUM specialist that HIV was now associated with normal life expectancy thanks to HAART, which seems a curiously confident conclusion having treated young sufferers for less than 30 years.
The medical student was perplexed and asked Wood and then Trees why no one dies of HIV any more in our hospital, but the majority are dying elsewhere in the world? Thankfully they had the benefit of experience and cynicism to explain to a clearly upset and distressed youth that this is just the way it is and life is unfair and mixed metaphors often help make sense of it. Modern medicine seems increasingly about managing the complications of over indulgence and poor lifestyle choice such as Wood’s developing beer habit or Trees obesity and awaited type 2 diabetes. Around the world where conditions are readily treatable, then is it inevitable they are left to struggle and face high mortality and suffering while the WHO and UN look on solemnly? They offered no explanation or justification to the medical student and both Wood and Trees recognised the inequality in what was happening. Thankfully a ‘It’s January and we haven’t been plastered since New Year’ party was on that night; after a few drinks, both Wood and Trees were ejected for fighting with the CQC Inspectors who felt that turning up at the local Hooters bar wearing full PPE and a ‘Kiss me Quick’ hat was inappropriate and neither ‘well led’ nor ‘patient centred’.
The medical student didn’t fancy the party and went home to ponder what the local ICU was doing and who it was doing it for. And then had an epiphany that Homer Simpson would have been proud of. The reason half the world is dying of the fixable is that we would need to give something up to intervene. The natural order can’t allow an orthopaedic cancellation because it is everyone’s right to avail themselves of the boundless generosity and capacity of the NHS, and so there is nothing left in the ‘Africa’ or ‘Asia’ business unit to go round. As we give statins to everyone in the developed world who has a heart, there can never be enough clean drinking water or malaria therapy or HAART. The next day everyone turned up for the ward round and the mood was frankly sombre. Wood and Trees also felt a bit embarrassed and vowed never to do a party again. People were girding their loins to get the ward round completed when the radio blurted out ‘Do they Know It’s Christmas Time at All?’ I guess it depends where you live and if you have got PPE to wear?
Happy New Year!