The Secret of Medicine

Ah, the joys of plagiarism. 

"Yet the great secret of medicine is that almost everything we see will get better (or worse) no matter how we treat it. Usually better. The human body is exquisitely talented at healing.  If bodies didn’t heal by themselves, we’d be up the creek. Even in an Intensive Care Unit, with our most advanced techniques applied, all we’re really doing is optimizing the conditions under which natural healing can occur. We give oxygen and fluids in the right proportions, raise or lower the blood pressure as needed and allow the natural healing mechanisms time to do their work. It’s as if you could put your car in the service garage, make sure you gave it plenty of gas, oil and brake fluid, and then expect the transmission to  fix itself."

What a fabulous paragraph, even if the article is a couple of years old. Click on the quote above to read the rest of the article by Dr. Thomas A. Doyle. No, I don't know who he is or anything about him either, except for the bit of blurb at the end of the article. But he has some very interesting things to say, don't you think? 

Change "America" for "UK", or anywhere else in the developed world, and I suspect that the same problems are present all over. 

So what do you think? Does he have a point? Are we really a nation of wimps? More to the point, does the medical system here just pander to too much? 

Case in point, particularly after the weekend just gone - The Booze Bus. Look at the photo. A transport ambulance, with a fully trained paramedic crew, loaded with three (that I can see, anyway) people who have nothing wrong with them other than an under-developed sense of responsibility and self-awareness. Should the health system really be paying for what is no more than a babysitting service for people who, a few years ago, would have spent the night in a police cell and woken up to a hangover, a steel door, a charge of drunk and incapable, and a large fine? Nothing's changed since then, except for the fear of litigation, and that in itself is well on its way to bankrupting our health system. 

I know the arguments for and against the concept of the Booze Bus (or, Alternative Response Vehicle, to give it its official title). I understand both sides, and I know that had it have been available last night around where I was working, I would have had four fewer patients. Or at least different ones. But I still feel that society as a whole needs to realise that the days of personal responsibility need to return, that the pot of money is not unlimited, and that sooner or later, whether we like it or not, charges will have to be made on certain categories of patients. I just think that the Booze Bus is as good a place as any to start. 

No Answers

Saturday night, the scourge of all police officers and ambulance crews. These days, all nights are busy, but weekend nights are often like being in a war zone. Trust me. I've done both. Sometimes I think that it was safer in the other one. As I work only nights, my weekend night shifts come round more often than most, and without fail, I regret them.

A list of a weekend night's proceedings often resembles a list of the wives of King Henry VIII. Divorced, Beheaded, Died. Divorced, Beheaded, Survived.

A Saturday night on the street runs something like this: Drunk, Assaulted, Trashed. Drunk, Assaulted, Crashed. The last of these might only appear once a night. If that. If you work in the centre of London, there are probably even fewer. I work out in the suburbs, so there's a chance that once the pubs, clubs and fast food shops have shut, I may actually have to treat someone who genuinely needs an ambulance. By that time, I'm tired, cranky, and struggling to give them my best attention and care. That which they genuinely deserve.

Last night, I tweeted about treating drunks, by asking a simple question. Do you think that people who call ambulances because they've had too much to drink, should be charged?

All dozen or so replies were positive. Some just said "Yes". Someone said "Yes, without a shadow of a doubt". And one even went as far as saying "YES!! YES!!!! A THOUSAND TIMES YES!!!" It seems that I received some support for the idea.

It's a knee-jerk, almost default position by health care professionals, and even some who aren't in the medical field at all: You're drunk. It's of your own doing. You should know your limits, or suffer the consequences. You don't need an ambulance. You don't need to be in A&E. And we most certainly don't want to be the ones who have to clean up all the bodily fluids you emit in your sorry state. Therefore, we all want to charge you. I'm as guilty of it as the next person. Not so much the drunk bit, but the wanting to charge bit. But there's a problem with this thought, once taken to one of its logical conclusions.

We should charge those who overdose on drugs. The heroin addicts who should know their limits, but who take a little more than their normal amount, end up not breathing, and who we administer Naloxone to to get them breathing again, ready for their next hit.

We should charge drunks who wonder out into the middle of a busy road and get hit by the car whose driver had no chance of avoiding them. Or by the same account, charge the drunk driver who's hit the lamp post that's sat on the pavement for years, but suddenly jumped into the middle of the road.

We should charge the wrist-slitters, crying for attention at the age of 18 after being dumped by the love of their lives, and who next week will have another life's love.

We should charge drunks who we convey not for being drunk, but whose drunken state has led to some sort of illness or injury.

We should, therefore, charge anyone who should have had some degree of responsibility for their own presenting condition.

Smokers with emphysema? Charge.

Footballers with broken legs? Charge.

Diabetics with high blood-sugars? Charge.

So how far do we take this knee-jerk reaction, this desire to charge drunks? Is it a question of all or nothing, in which case we charge everyone, or do we continue as we are, charge nobody, and just have to keep putting up with it, whilst we all, as taxpayers, foot the bill? Once upon a time, drunks were taken to police cells, given a mattress to sleep on and sober up, generally ignored, and were then sent home in the morning. Just that cost money.

Now, they get an emergency ambulance, often accompanied by the FRU, as they are frequently supposedly unconscious or not alert. If they're in town, they might get the dedicated "booze bus", a multiple-patient-transporting, baby-sitting service staffed by EMTs and paramedics who are clearly a lot less averse to dealing with alcohol-induced vomit than I am. They get a hospital bed, an overworked nurse, a disinterested doctor, and sometimes a bag of fluids as well. All very often whilst abusing those who are caring for them. And that's if all they have is a serious case of overindulgenceitis. That's a lot more expensive, and a lot more frustrating, which is part of the reason we feel that we want to charge. But is it right? In the overall spirit of the NHS, free to all at the point of treatment, can we really justify it? And if we are going to start charging, who do we charge, what for, and how much?

I have lots of questions when it comes to charging drunks.

I just wish I had some decent answers.

What do you think?

Resolutions

I couldn't leave this auspicious (suspicious?) date, without at least disturbing your day for a short while, so first, allow me to wish you a happy, healthy, successful and prosperous New Year. And if by prosperous it means that you win a huge amount on the lottery, then please remember who your friends are.

*****

In the days leading up to the end of the year, the London Ambulance Service has been doing one of the things it does best. Counting numbers. Specifically, a very large number. One Million to be precise.

That was the magic number we hit at just after 3am on the last day of the year. One million calls dealt with in a single year. It's a significant rise on the year before, and the year before that, and the ... well, you get the picture. The thing is, I'm not so sure that it's a number to be proud of.

There are no more ambulances out there than there were a year ago.

No more man- (or woman-) hours. There are boasts that there have been hundreds of new recruits, but there have been probably an equal number of people leaving. The front line staff, as well as those in control, are being pushed ever harder to meet targets that are at best dubious and ill-conceived, and at worst downright dangerous. Patient care targets are nothing compared to the national time-based targets set by the government, and this is where we have the danger of falling flat on our faces.

Patients don't want to see just an FRU outside, single-staffed, with no ability to convey a sick patient. They want to see it backed up quickly by an ambulance. More than that, they want those staffing the FRU and the ambulance to be at the top of their game. Well-informed, well-trained, professional staff will do a great deal more for not only our patients, but our image too. Demoralised, despondent and harassed staff will do the opposite.

Partly, the blame needs to be placed on the fact that we are, in a way, victims of our own success. We are too good sometimes. We provide too much for too little, and do not do enough in the way of public education. We provide paramedics with extra training who now do the house-calls that used to be done by GPs. We provide ambulances especially geared for non-life threatening calls. We still attend calls that any level-headed person would look at with disbelief. Stubbed toes, broken finger-nails, a three-week runny nose, and many more of the same ilk. We even provide transport, every weekend of the year, so that the public can drink as much alcohol as possible, take the booze bus, and not face up to their social responsibility. Or their cab fare.

This year, I'd like to see the trend reversed. I'd like to see fewer calls. Not because I'm lazy, but because I think that the priorities need rethinking.

I think we need to educate ourselves and the public. I think we need to concentrate on what's important, and not necessarily what's arbitrary.

I think we need to worry more about serving those who really need us, and ensure that we are always prepared for them.

I think we need to go back to the days where ambulances are waiting for calls, and not calls waiting for ambulances.

I love my job. I am passionate and idealistic about it, probably to a fault. I'm one of those crazy people who actually loves getting up in the morning and going to work (ok, ok, so I work nights and go to bed in the mornings). If I have more than two or three days off, I start getting withdrawal symptoms. I'm inspired by my job, my colleagues, even my patients. I know, it's worrying, but this is why I want to see positive changes.

We all have our New Year's resolutions. The Service's should include more public education, higher expectation of their staff, whilst maintaining high levels of morale. It's a tricky balance.

My resolutions are little changed from last year. Always be ready to learn something new every single day. I owe it to my career, to myself, to the Service. Most of all, I owe it to my patients. I hope I can stick to it, and I hope, whether you're a colleague, a manager, or a patient, that you can help me do that. I promise to return the favour.

*****

Happy New Year to you all.

Shock Tactics

It's a change in behaviour that we need to aim at the younger, grass-roots members of society.

Before they start exhibiting that behaviour.

Maybe, just maybe, this is one way of doing it.

Good Luck.

Used and Abused

With apologies to, well, everyone. You really probably shouldn't read this either on a full stomach or an empty one. It's 3 in the morning, and I can't sleep. Again. And I can't use work as my excuse this time. The news is showing endless loops of drunks in public places, private parties, and excruciatingly humiliating themselves. It's led to some sort of worrying muse. However - I have to say, hats off to the boys and girls who man (sorry) the Booze Bus. I don't know how you do it.

*****

The Season has begun.
You know what must be done.
You must go to the office do,
And start off at a run.

To drink all that you can,
Will show you're such a man.
It's just the greatest thing to do,
From pint, to glass to can.

You'll vomit like a tap,
Wake up and feel crap.
Won't remember a single thing,
Was it worth it, dear chap?

No connection - brain to feet,
You'll fall down in the street.
They'll call for you an ambulance,
That has someone else to treat.

You really couldn't care,
Whether it should be there.
The ambulance is there for you,
So your vomit you can share.

We'll cart you in the back,
You'll shower us with flack.
Both words and stomach contents,
A hurtling attack.

You'll wake in A&E,
Desperate for a wee,
And do it in the cubicle,
"The bog's too far for me!"

That's how you'll end your night,
In bright fluorescent light.
A black mark on your record,
And your friends nowhere in sight.

And the crew that you abused?
They're feeling somewhat bruised.
We really have much better things,
For which we should be used.

Booze Bus

I'm still undecided whether the Booze Bus is a good idea or not. On the one hand, should we really be pandering to the needs of a self-harming group of individuals, who have no-one else to blame but themselves? Do we really need to cater for those with self-inflicted "My drink's been spiked", "I usually handle more than this" and other such ailments? Is it really a problem that society as a whole should be paying for?

On the other hand, I guess the Booze Bus does save sending an A&E ambulance to every irresponsible drunk...

One thing's for sure. I do think that anyone who does (ab)use the Ambulance Service in this way, should get charged at least double the cab fare to the nearest A&E department...