Beyond fucked 

Beyond fucked 

Everyone has their own ideas about what constitutes being totally fucked, by which I mean that level of gubbedness that is unsalvageable and not worth even trying. There are various ways of thinking about it,  you can do a P-possum, check their base excess and pH, look at them from the end of the bed, but one thing is sure. There is rarely a return to health from being totally fucked. It can be depressing.

Bighospital is totally fucked just now….

We have 8 nurses off sick on my ward alone; 5 with either flu or vomiting and 3 with stress and this situation is repeated everywhere.

We have no beds for elective operating as we are full of unwell medical patients. We do physically have beds, but we have no staff to open them.

We have an A&E that is full and overflowing with staff at the ends of their tethers. Patients are being told they have inappropriately attended and should have waited 2 hours to speak to NHS 24 and then 6 hours for a GP to come.

We have trainees (entitled and snowflakey in a way I never was) being taken off on call and moved to elective operating lists in case they complain in their GMC survey and we lose them entirely. Newsflash to anyone who thinks like this: this isn’t school, you get a salary, start delivering some value for money.

We have some consultants who won’t do anything that isn’t in their job plan and obstruct and hinder attempts to improve service. “I’m a consultant surgeon, nobody can tell me what to do”…you’re a salaried employee, not a deity.

We have managers who can’t manage. Leaders who can’t lead.

Bullying, misogyny and bitching are endemic.

Patients on the ward are sometimes not washed or fed because nurses are filling in endless paperwork and “magic stickers”* for every problem that must be completed or some nurse manager will explode.

I can’t get the elderly and dependent patients out of Bighospital because there are no carers to look after them in the community. They remain there, pathetic and heartbreakingly vulnerable, not having been home for weeks. These people haven’t seen the sunshine or felt the wind on their face, and they bear it politely and impassively in a way I could not.

We are beyond fucked. It is the same everywhere, I’m not sure it can be fixed and I suspect that our conservative government doesn’t care if it dies.

*magic stickers are Bighospital’s response to all problems. For any target or goal or other utterly unnecessary nonsense that trained nurses and doctors do anyway there is a sticker. For example; a doctor is asked to review a patient with a low blood pressure. The patient is 17 and weighs 50kg and is asleep, her BP is 80/50mmHg. It was similar to this when she was awake. This is normal, but the nurse has to mention it to the doctor. A year ago we could say “that’s fine. Thanks, I’m ok with that” now the junior must complete a fucking sticker and a complete assessment and stick it in the notes.

Men: desist from this thing immediately please

Men: desist from this thing immediately please

Imagine the scene, you’re sitting listening to a speaker opine on a topic and when they reach their concluding slide instead of a great slide summing up their message they have a picture of their children. Pause for us all to admire Thomas and Em’s extreme cuteness. Then they make some annoying reference to their progeny being way smarter than they are or some other shitey humble brag. 

A certain subset of men then make reference to their amazing wife (a stay at home mum) who keeps them in clean shirts and feeds everyone. I don’t know how she does it! 

I feel the more kids they have the more likely they are to mention it. 

Why do they do this? Women don’t. Is it to brag about their overall successfulness? “not only have I conducted a randomised controlled trial but I have fathered three children”? It’s vile. If I ever get to the point where I am important enough to be chairing meetings I’ll start telling the offenders that it is pathetic. 

Take the slide of your kids out. Don’t ever make reference to them again in a talk. Nobody cares about your children. 

Teaching is not about me 

Teaching is not about me 

Something has occurred to me recently, something that should have occurred to me years ago, and it’s that the teaching sessions I deliver are not about me. It may sound terribly self absorbed (it’s a flaw of mine) but for the last near 20 years I’ve been worrying about what I was going to say and how I was going to say it. Wrong! God what a vain and stupid cow I am. It’s about what they are going to learn and how they are going to learn it. 

Recently I’ve learnt the basics of how to teach and I can’t stop proselytising away about learning objectives and types of learners. It culminated in a session this afternoon (impromtu) in endoscopy when the nurses said at the end “that was great, what a brilliant teaching session, I’ve learned a lot too and how you did it was so clever”. I could not have been happier. 

I had one student and then an hour later I had two. I had decided the learning objectives for student 1 when he came in and we were making progress through the three objectives and then  when student 2 came I made student 1 teach student 2 what he’d learned; thus consolidating 1’s learning and freeing me up to do the paperwork.  Rather than me getting in a pickle about the pharmacology of buscopan, a distant and vague memory, we focused on just a few things and we did it well and when we finished they had learned something. It’s genius, and of course very obvious to people who know how. I’ve recently been criticised for my affection for the University’s “Teachometer” (not it’s actual name), as time spent teaching is not an measure of quality. I’m now on a one woman mission to make my teaching time quality time. 

Freeing myself from the terrible sense of fear that I might not know enough about the subject and therefore not be worthy of delivering teaching has been a long time coming. We filmed some of  a course we delivered locally and part of it involved me delivering a small group session. I have realised several things; I have a weird teacher voice, much quieter and softer than my usual speaking voice, I am not as fat as I think I am and nobody knew when I got the order wrong. 

In my perfectionist mind I had planned on saying things in a particular order but on the day, I didn’t, and despite my heart rate rising to 180 and feeling distraught at my failure, it was not at all apparent and didn’t seem like it was a disaster at all. This has helped me considerably to relax and enjoy my teaching because nobody but me knows what I am going to say and when. 

The observation that I get a gentler voice is not because teaching is anything like parenting, Mummy Me these days is a harassed and often shouting individual with little patience. I think it’s because I feel nervous and unsure, although fortuitously this is not how I come across and if I can project a bit more and change the tone back to my normal then it will seem more genuine. 

Anyway, now that I know that it isn’t about me I’m much less likely to get myself in a state mid lecture thinking I’ve ruined everything if I cock up my running order. Having the focus on them rather than me, so simple and so obvious, maybe that’s why nobody told me? 

I have lots of teaching to do this week and now that I am combining enthusiasm with some knowledge, theory and skills it might just be good quality. Can’t wait for the feedback/happyforms…but are they the right measure? Probably not but I’m excited nonetheless! 

Teaching season again..

  I’m not an official academic, I have an honorary contract with the University of Bighospital that means I get an extra badge and a ridiculously grand sounding extra title of “honorary lecturer” when in fact all it means is that I give lectures and teaching for free. 

I do a lot of teaching as I enjoy it and I like talking to young and enthusiastic students. What gets me down is the few who don’t give a shit and think that they are funny and clever because of it. 

I was lecturing last week, a whole year group, sitting in the very lecture theatre where I too was a student. Ninety percent of them were listening I think, hard to tell when all you see is 180 glowing apple symbols from the back of their MacBooks. (I know, students nowadays, they have no idea. I got the bus and used a pen and a notepad). 

There were a few visibily bored, tired and yawning and a few who were determined to talk and disrupt their neighbours. I had spent many hours on this talk and I had come in on a day off to give it. I had tried to make it interesting and intermittently funny. It is not my job to do this, I volunteered because the university are so desperate for lecturers and I like it and of course it looks good on my cv. 

The talking students really annoyed me, in fact they made me feel small and silly. When I was a student I was constantly chatting to my friends and if mobile phones had been around I probably would have been messing about on snapshagger or whatever they are on. 

They have no idea that I am an unpaid lecturer, no idea I have spent  hours preparing this in my own free time and they also don’t care. I wish I wasn’t so upset by their disregard but I am. Maybe I will get used to it, I’ll have to as my teaching schedule is ridiculously heavy this year. 

All they have succeeded in doing is turning me into a reserved and disinterested lecturer who no longer will try and make my talks engaging  or fun, because rejecting the dry facts and talking through that doesn’t hurt me at all. 

It’s going to be a long year…

Top Australian surgeon recommends blow jobs for good jobs!?

Top Australian surgeon recommends blow jobs for good jobs!?

“Top surgeon” Gabrielle McMullins has suggested that surgical trainees should acquiesce to requests for sex from senior colleagues to further our careers. I have to wonder about the context of McMullins comment about the “she should have given him a blow job” was she really serious? They must be an ugly bunch over there resorting to blackmail to get sex, there are usually plenty of stupid women chasing after the sleazy male surgeons regardless of what they look like in most UK hospitals. If you’ve ever been to a surgical Christmas night out you will be familiar with the sight.

Australia must be a place where presumably one person has the power to destroy you if you won’t show him your tits, which is not quite how it works here. I don’t believe that a woman in her position tells her trainees to let a man have sex with you if he is your boss for the sake of your career. If I was, or had been her trainee I would feel deeply insulted and humiliated through association with this woman. She has said something very stupid, but she’s a woman with a book to promote who needs some publicity.

I do wonder though, what sort of unpalatable shit she’s had to gulp down over the years to get to the position of “top surgeon” in such a dreadful environment as she describes.

I have to believe that she was joking and wanting to stimulate debate (and book sales) otherwise she has just marked herself as someone not many women will want to work for and as the go to girl for a blow job for every Professor of Surgery she meets.

Surely she is trying to highlight that women in surgery are scared to speak up? I am too scared to speak about the “everyday” sexual harassment, though I hope I would speak up about something more direct. I hate how one colleague pulls my hair, stands too close, holds and moves my arms when he is operating with me or touches my shoulders when I am on the computer. I want to scream at him “get off me you sleazy old git” but I won’t and I can’t and I know other girls find it creepy too.

Shame on me of course because I am contributing to a world where he might one day ask for more from someone else, and she might want to say no, but just like me she’ll just put up with it for the sake of a quiet life and the job. How do you handle these situations? He’s my boss, I know and like his wife, how do I tell him not to do it without making it a big deal? But it is a big deal because he touches me and I don’t like it and it makes me feel uncomfortable.

Perhaps the solution is in McMullins book?

Unlike the myriad of news reports on this I have to believe that she is courting attention and stimulating the debate and her Amazon sales.


Outside the grass was raging

Outside the grass was raging

Ageing is inevitable we hope, good health and a long life is one of the most universal of wishes. Some are not so lucky, they find themselves with a long life and poor health, they may even lose themselves in the process and are left in distress and decay as their physiology keeps them alive when they have long since departed.

At school we studied the poem Old Woman by Ian Crichton Smith. The words are forever ingrained in my mind as when we learnt it I was “volunteering” in a nursing home (as prospective medical students are prone to do to demonstrate their commitment to being a doctor- a frankly ridiculous idea perpetuated by mediocre state schools) and the horrors and indignities that I saw in there whilst simultaneously studying the poem cemented his words.

I hated those Wednesday mornings, I hated the nasty, fat old bags who worked in the nursing home who could see my obvious dislike for my task. They all used to ask me why I didn’t want to be a nurse, as though what we were surrounded by was something that many straight A students aspired to.

They didn’t like my ambition, my confidence that I would not be wiping arses in a nursing home and that I would be a doctor. The city I grew up in is at times the kind of city where people are encouraged to stay in their place, to dream small and not get ideas above their station, and more than 20 years ago that certainly applied to uppity 16 year old girls. I hated what they made me do: feed old people Nice biscuits and thickened tea. It used to make me retch, what a wicked little cow I was. I hated it with a passion and would retch and gag all the way back to school when I smelled Nice biscuits and tea on my fingers and hands.

I have a patient just now who makes me think of this poem. He is paralysed from a massive stroke and keeps blowing up his colon to enormous dimensions necessitating a trip to the endoscopy department every few days to suck shit and gas out of his backside. He eats his water, coffee and tea, he cannot drink it; he has thick and easy (the name is the source of lots of amusement in hospitals) added to every fluid so he doesn’t choke on it. He is fed it on a spoon. He cannot speak, he communicates by raising his eyebrows and looking distressed.

I am not imprisoned in pity and shame like ICS is in his poem, although I have found myself wishing to be away. I am too used to decrepitude to still feel shocked by it. I just feel so helpless; he’s too frail to have his colon removed or fixed and yet he keeps volving and requiring decompression.

I see the students faces sometimes when we are confronted with the naked vulnerability of patients, I see them hesitate to help lift someone’s legs, or wipe the spit from their cheeks or the faeces from their legs or a bit of sick from their hair. You see them visibly recoil from the ugly reality of the provision of care.

Maybe they should all be forced into nursing homes as school pupils. Maybe it does teach them something, because I see the same look on some of my colleagues faces as well as they wait for a nurse to come and wipe or lift or care.

Old Woman by Ian Crichton Smith.

And she being old fed from a mashed plate,
As an old mare might drop across a fence
To the dull pastures of its ignorance.
Her husband held her upright as he prayed

To God who is all forgiving to send down
Some angel somewhere who might land perhaps
In his foreign wings among the gradual crops
She munched, half dead, blindly searching the spoon.

Outside the grass was raging. There I sat
Imprisoned in my pity and my shame
That men and women having suffered time
Should sit in such a place in such a state

And wished to be away, yes to be far away
With athletes, heroes, Greeks or Roman men
Who pushed their bitter spears into a vein
And would not spend an hour with such decay.

“Pray God” he said “we ask you God” he said
The bowed head was quiet, I saw the teeth
Tighten their grip around a delicate death.
And nothing moved within the knotted head

But only a few poor veins as one might see
Vague wishless seaweed floating on a tide
Of all the salty waters where had died
Too may waves to mark two more or three.

Serious inequalities in the provision of elective versus emergency care

Serious inequalities in the provision of elective versus emergency care

If you have rectal cancer, the ideal scenario is that it is picked up on screening (biannual FOB tests from 50 years of age followed by colonoscopy if positive), you then enter into a smooth and well oiled machine of investigation and treatment. Within 14 days of that colonoscopy and biopsy you will have had a CT scan of your chest, abdomen and pelvis, an MRI scan of your rectum and your case will have been discussed at a multi-disciplinary meeting of surgeons, oncologists, pathologists, radiologists and other interested and relevant parties.

You will be given a plan for your treatment and a specialist colorectal cancer nurse who is on speed dial for you with your questions and concerns. You will then begin either long course chemo radiotherapy followed by surgery or proceed immediately to surgery.

Wham, bam, we’ll whip your rectum out before you can say “pain in the ass”. It is as smooth and controlled and informed a ride as it can be, and you can be reassured that at every stage you will be looked after by the right person, who has been trained accordingly and is audited and checked up on.

If, however, you are unlucky and on the days of the FOB testing your rectal cancer isn’t in the mood to bleed, if you ignore the weight loss and the rectal bleeding and you present as an emergency with an obstruction, then your outcome is far from guaranteed. Your survival depends on where you decide to present to, which is terrifying and appalling.

If you were me, or a relative of mine, you would drive to somewhere like Bighospital and bend over one of their beds to present your obstructed rectum to one of my colleagues. The reason you would do this is because a hospital where there are more HDU beds, more ICU beds, that do more CT scans per bed per annum, that have more operating theatres per bed are significantly more likely to get you out of hospital alive than a hospital where that does not happen. (Symons et al 2013. British Journal of Surgery 100:1318-1325). And an early CT is associated with a decreased risk of death (Ng et al. 2002. BMJ:3251387

You wouldn’t be taken to one of these local hospitals with a knife in your chest or following a road accident, no way. Trauma goes to a Level 1 trauma centre because we know that these people die in District General Hospital Land.

You are much more likely to get rectal cancer than have a knife in your chest; and yet off you will be referred in the dead of night, vomiting shit out of your mouth to a tiny little dump that does no CT scanning out of hours and cannot stent your cancer anyway because they don’t have interventional radiologists and has no middle grade resident cover overnight.

This figure shown below is of a funnel chart, the line in the middle is the average mortality for emergency admissions, the dark dots are the badly performing institutions, the empty ones are the exceptional units. Age, social deprivation, comorbidities and female sex all correspond with poor outcomes but there still remains a worrying variety in mortality outcomes across the country. Without being a stats bore, everybody should be inside the funnel, that means you are within the average, some better some worse. It is the outliers outside of the funnel that are concerning or superbly impressive.


If someone published the same data on breast cancer survival, or as happened many years ago on trauma survival, there would be an uproar. We urgently need to reshape and rethink how we organise emergency generally surgical provision and centralise services. We need more acute surgical beds, improved access to out of hours radiology (yes radiology I mean you, get out of your beds) and more HDU and ICU beds for emergency admissions. What we need most urgently, is for surgeons involved in the provision of this care (which makes up half of our workload) to start caring as much about the standard of emergency care as we do about elective care. One ass hole I work with said “what a great year, not a single elective death”, he couldn’t understand why I thought that was not worth bragging about.

The other people who need to listen to us are the politicians who do not allow us to ring fence resources and budgets towards emergency care. They have been beating us with the twin sticks of waiting times in A&E and waiting times for operations for years and it is time that we told them to shut up and show the public that the real problems are in emergency unscheduled admissions. The ASGBI issued a consensus statement to this effect which I would urge interested parties to read, but it failed to ignite a political and media debate on this issue.

This is an exciting time to be involved in general surgery as perhaps emergency care is slowly getting the attention it deserves. The government has to listen to us, we and they have to explain to voters that going to your local hospital might be nice, it might be handy for you to visit Granny, but it means that you have an increased risk of dying that a 30 minute drive can reduce by over half. We managed it with trauma care and we have managed it with cancer care we just have to do the same with provision of emergency surgery.