Monday, May 08, 2006
you're a lightweight. you're fired.
dr D&C was skiving on friday.
that's not strictly true. i'm going to be unemployed in august and so i said to the house officers that i would be in at 9.30am because i wanted to hand in a job application at another hospital. i also said to them bleep me if there are any problem because yes ladies and gentlemen my pager not only works in the hospital, it also works at home, it works at my friends' houses, it probably works abroad and when i have left this corporeal existence and ascended to a higher plane of consciousness/the afterlife, i am sure that it'll still be putting through the crash calls at 3am.
anyway i left my friend the bleep/pager switched on and sure enough at about 9.15am it went off. i called the phone number displayed and to my suprise it was the voice of the clinical director that answered.
being called by the clinical director is a rarity. it is also quite frightening. you feel a bit like the generals in that scene on the death star in Star Wars when darth vader announces that the emperor will shortly be arriving. "the emperor is coming here?" reply the assembled generals, terrified faces, poop in their pants.
actually our leader is quite a nice guy. he tutored me as a student and i quite liked him. what on earth could he want though? i briefly scanned my mind of the medical activities i'd been involved in over the past few months. no, i couldn't think of any obvious malpractice.
he asked me if i had a minute. i was buying a coffee so i guess i did. he proceeded to ask me of my thoughts on a radical shake up of the way the hospital works. yes he was asking me about hospital at night.
i won't go into HaN in detail as i have ranted at length about it here. also refer to Dr Crippen for more details. in short the idea is that you only need a skeleton crew to run a hospital overnight and at the moment there are too many doctors doing far too little work.
the wonderful thing about HaN is that it is marketed (in the labour spin world) as something to help us doctors have a smoother time on call. bollocks i say! it is about cost cutting and meeting working time targets. that is what it's about.
at present in my hospital we have two junior doctors covering the wards, splitting the hospital geographically down the middle. what the clinical director was asking was why not get rid of one of the doctors and provide an advanced nurse practitioner with advanced skills (he said advanced twice) instead.
what are advanced skills? i'm not sure really.
bow hunting skills? computer hacking skills?
anyway i said i'd let him know on monday because delight of delights i was to be night shifting across the weekend. and off i scampered into work that night.
the weekend was fine as it happens. people weren't very sick and the stuff i had to do was quite basic... for me. initially i thought about writing back to mr clinical director with "bring on the nurse practitioners and screw you guys i'm going home."
but then in retrospect i thought about the activities i'd got up to overnight. for example prescribing fluids. this is relatively easy but then after three years of medicine i can very quickly assess someone's hydration status, their requirements, factor in their cardiac/renal status, correlate this with their electrolyte results and give them the right fluid at the right speed so that their organs get adequate perfusion and they don't drown in fluid. though it has taken me a long time to get to that level.
so i am a little perturbed at a nurse practitioner rocking up and ploughing 3 litres of gelofusin into a tiny man whose heart has the equivalent pumping function of a small clementine. that could be a disaster.
similarly i had lots of people with chest pain. again you have to worry about the heart. even if you take a careful history and look for (what can be subtle) changes on the ECG it can be a very difficult call. do we want nurse practitioners with no cardiac training to be doing this? i'm not sure (though having said that the CCU nurses i worked with were superb.)
anyway i sent my email back to the big boss saying that i didn't think that we were ready for this scheme. if the nurses had years of medical training and experience (ie were doctors) it would be fine. knowing my hospital they'd do it on the cheap and employ someone who was all talk and no ability.
did he reply? yes he did.
"thanks for the email. take care."
who says i don't make a difference?
[i am listening to the specials]