Abstract
As spring threatens to intrude upon the bleak wintery land, Wood’s attention has turned to re-birth and new starts. It is indeed a hard man whose heart is not warmed by daffodils, lambs, hawthorn flowering and Easter eggs but Wood is more than up to the task. With good weather comes many good things but Mrs Wood demanding a Summer Holiday is not one of them. Winter pressures ease and the public turn their attention to drinking heavily in the outdoors and injuring themselves with lawnmowers or on bikes. Pollen reports provide the weather another sponsor and rushing parents divert their attention from aggressively driving 4 × 4 tanks to get the kids to school to smothering their kids in suncream and making them wear ridiculous hats. Making them walk to school would perhaps be a step too far.
Wood and Trees have been reflecting on the recent election fever because they have been told to do more reflecting after their appraisals. Wood thought he could learn a lot from politicians and Trees thinks it best to concentrate on their expenses claims, sex scandals and 1/40th pension arrangements. Wood proposes an “election theme” ward round where they go round the various beds and invite patients and their next of kin to vote in a secret ballot for Team Wood or Team Trees. There would be crowds of sycophants to shake hands with and babies or lambs available to pick up and kiss and certainly in Wood and Trees unit no shortage of individuals to punch a la Prescott or accuse of bigotry believing the microphone is off.
At a hustings, the various policies and pledges could be spelled out and the patients invited to fight it out. Tricky questions around funding which is currently inadequate to cover the agency staff would be met with elaborate calculations and when the poor track record and SMR are highlighted, we could blame this on the joker who was there the day before and that “Wood inherited the largest bed occupancy from Trees of any network ICU …”
Wood
The ICU has four dialysis machines and five of you needing it … I will leave you to think about it. My policy of austerity on ventilators means I have squirrelled away 6 extra bags of CRRT replacement fluid which I would use to get you back to normal U+E’s. The gentleman to the left would squander your dialysis on CPAP and physiotherapy, and their track record shows how they regard enteral nutrition
Trees
My learned friend is being disingenuous and knows very well that lax immigration and failure to control the management has led to this situation. We inherited a shocking ICU with MRSA rates and cleanliness audits the lowest since we made them up. I have raised standards and cut costs, brought smiles to children’s faces and saved the whale etc etc etc …
The whole concept becomes very attractive. Wood and Trees set a unit budget and let the patients decide – until the Director of Finance pointed out that there was no cash to spend until the waiting lists were cleared. Both Wood and Trees weren’t sure if there was a clear understanding that the 80-year-old emergency laparotomy was competing for the cash with the elective cancer and the 40-year-old pneumonia. The families will have a penned off area to allow “robust discussion” and debate and the clan who returns bloodied and bruised after 10 min keeps the echo machine. Wood and Trees are getting carried away – we allocate set amounts to noradrenaline and oxygen and you the voters decide!
We could have a Rupert Murdoch media type character who is in the wings and suggesting who they should vote for in a “lighthearted way” using topless images and exploiting the reader’s prejudice or naivety. Medicine has always lapped up what industry has done and Wood believes this type of man exemplifies “corporate governance” managing to sidestep phone hacking, printing a paper which one major city won’t buy because it is so offensive and holding an unhealthy control over the politicians. Strangely, Wood notes corporate governance seems to have gone off the boil slightly after the banking crisis and no pay rise for a few years but Trees admires the fact that medicine has greater persistence and will continue with it through “enhancement” of the process. Whether this role is best undertaken by management or a colleague who you always quite liked but went a bit “corporate” after taking on the lead role is a perennial. The individual’s name in Wood and Trees hospital has been withheld for legal reasons but you get the idea …
Perhaps, we all should engage with the election more? It is genuinely touching when Wood and Trees point out the real sacrifices made for people to be able to vote; while some polling stations are in pubs, for many it will be the first time they attend a school building. Ever.
Trees considers democracy to be quite a leap of faith. You need to be happy to accept the decision of your fellow man or woman, and buy into “we are all in this together”. Wood’s biggest window on the world is the hospital and he is not entirely happy with the democratic model. Emergency Department waiting times perplex him; where are all the sick patients coming from? We live in an age with unrivalled public health and access to healthcare and one simple question keeps recurring; what did people do 20 years ago when they had a cold or a slightly poorly bottom? Patients exercise choice now and corporate healthcare has become the patient’s friend; large chain opticians may test your ears now as the hospital audiology department is shut down. Your local pharmacy will offer you health advice but their head office may be in Switzerland and they don’t pay UK taxes. The ICU is changing; Mrs Jones in bed 3 wants “everything done”, according to her family, so I guess we should give the alternative private provider a call. Perhaps, the local commissioners have set a few quid aside for this very purpose, although it’s unlikely if it’s at the expense of elective orthopaedics.
Wood can’t help but think that a national treasure such as the NHS should be better cared for. We are all very aware of the abuses from within the system because Jeremy Hunt kept reminding us; but what of the consumer? What if they aren’t keeping their side of the bargain? Just like democracy, when people abuse the NHS they are directly taking it from Wood and Trees and their family; their beneficence, which was rather like the 30 year old “work trousers” gusset, wears a bit thin. Wood sees the outpatient clinic full of six month reviews for lifestyle related disorders as the patient ping-pongs to and fro with a stubborn HbA1C or BMI. Trees tells him it is dangerous to think this way. Wood knows this and, to be fair, so do the politicians; you can’t accuse a voter of not doing their bit on election eve any more than Wood can consider if the patient “deserves” his care when they are in front of him. The trouble is the politicians and Wood and Trees never get round to talking frankly to them when the election is over. “The NHS is failing, in part, because the British public have chosen to use it as a commodity and not preserved it’s fragile existence”.
Wood was halfway to daubing this on the front of the hospital ED. It wouldn’t get many votes and probably would get community service. Trees offered to hold the ladder and had suggested some simple expletives but they were worried the important message might be lost if they were stopped halfway. Yes, clinicians are obsessed with developments and spending more but can we really expect Wood or Trees to not try and improve a service? It’s in their nature. Managers manage business units and save cash and that is in their blood. We are all tribal but what of the spoilt little kid who kept demanding more and more sweets until the money ran out and his teeth rotted? Well they got free extractions on the NHS and a can of proprietary cola afterwards.
In the NHS, it is important to have a business case, options appraisal, competitive tender, risk assessment (and to rather clumsily continue the analogy) this exponential rise in “process” has been mirrored by election pledges and promises. Wood suggests the “I’m sorry” song over tuition fees could also be sung for the connecting for health £6 billion debacle? Thankfully as election pledges have increased and ridiculous NHS processes multiplied, confusion and poor decisions have survived in politics and healthcare despite candour and transparency. However, seizing on people’s optimism and short memories here are Wood’s election promises:
No one will ever die and eternal life is built into the Trust Mission Statement (Trees notes you don’t see “mission statements” as much these days and misses altering keywords e.g. cake for care). All organ failures will be recoverable, especially chronic and established ones with no effective therapy. When granny is discharged weak as water, unable to eat, confused and doubly incontinent, a nursing home will be freely available so as not to inconvenience her family. No next of kin should have to stop smoking, drinking, cancel a mobile phone contract or not have a large off road vehicle to maintain “free at the point of delivery” or present with the slightest disorder, regardless of how trivial or self inflicted. Any condition not getting better is the hospital’s fault and we apologise unreservedly. Please fill out a claim form. All patients shall have “everything done” regardless of how appropriate it is or likely to succeed. Any infection apparent in hospital with initials (e.g. ESBL) will be self reported to the Daily Mail and full responsibility accepted even if we know you brought it in with you on that cardigan. Where required, the case will be escalated to local news and a celebrity will be paid for to look like a kicked puppy and produce a tear. All opinions which differ from those of the ICU team (hereafter known as “the mistaken”) will be assumed to be correct and no treatment decisions will be made until “Uncle Dave” in Leamington has been contacted. By not having seen the patient in 20 years his decision making is impartial and, as he used to run a pub, he is right. Intensive care units will offer 7 day working instead of the shoddy and largely absent current arrangements and a follow up clinic in Boots (the chemist not the suggestive footwear) or Lloyds who are the preferred provider. Staff will wear the sponsor’s logos. While in hospital your ability to use your mobile phone and play Candycrush will be guaranteed by an exclusive contract with a provider with a curious legal standing in the competitive market. No TV should have to be turned down for ward rounds, and amorous couples, one of whom was unconscious hours earlier, enjoying a “re-union” in their ICU bed shall be treated with privacy and dignity and not have a bucket of cold water thrown over them.
Away from politics, Trees felt a review of the literature was needed after finding that resistance patterns were not part of the VE day celebrations. This week, he was mainly concentrating on resuscitating patients with septic shock. Having gone to the cupboard to get out activated protein C, hydroxyethyl starch and steroids, he left empty handed. Even the flaming albumin needs a form filling out and as everyone knows this is “natural”. Damn it all – Hartmann’s is too cheap but it will have to do! How much? Talking to the trainees – not too much or they’ll go into ARDS. Not enough and the kidneys will shrivel up and die. We need Goldilocks. Wood used to love his Swan Ganz catheters as they made him special – like a cardiologist with a cardiology stethoscope. The fact that they did the job quite well measuring lots of things but didn’t get looked at for 3 days because he was now doing a theatre list was in no way a distraction from the drama and prestige of floating the yellow snake. It allowed the trainees to be humiliated with lots of exam questions and physiology and always ended in an absolute certainty of benefit. That is why it would be unethical to run a study… what have they? When? Wood is now being peeled off the ceiling as the cupboard doesn’t even have a PA catheter in there, only some ultrasound jelly. The lithium he found does actually help him feel better.
Now he’s got a cardiac output monitor, which doesn’t seem entirely accurate? The 97 year old in bed 3 with heart failure and faecal peritonitis has a stroke volume, which Mo Farrah can only dream of? Perhaps, the massive M “Mobot” he keeps making above his head means “MUG”? Some of the bright young things keep putting on echo and generating lovely images with colour patterns and whooshing noises but Wood is no further forward. He still gets the scroll like printouts with lactate on but it’s all just a bit, well, dull.
One trainee suggested he should measure the A-VCO2? He suggested she should mind her own business, but then apologised. In fact, measure it with the lactate and you will know how well things are going she continued – I read it. It was in a journal so Wood and Trees were reassured they should do this. It’s trendy and measuring SCVO2 is so passé and 2012 SSC Guidelines. Wood had just reached for the synACTHen to run his test only to find he shouldn’t be doing that anymore, but the hydrocortisone is handy for the dog who seems to be thriving on it, which may be how it all started in sepsis after a few dogs and rats seemed to look a bit better after something or other? None the wiser he sent blood away, got out the calculator and gets the result of 0.8 kPa. So there we have it. Now what to do with it? Trees suggested put it out for a vote which is exactly what they did on the ward round and this new test is now in charge. Until the next election.
This left Wood to pose a question to Trees: “When is it acceptable to bare your backside to the assembled medical and nursing teams in the modern NHS in 2015?”
Being poorly prepared for a question of this magnitude there was no answer forthcoming. Wood helped him out: “When you are on ICU with ARDS. And I tell you, you wouldn’t have got away with that in 2000, eh?!”
It was a satisfactory but contrived joke – thank goodness he accompanied it with a Basil Brush “Boom Boom!” None of the trainees knew who Basil Brush was though.