The lady in bed 9

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Medical simulation… There is a lot of money being spent on it. It does have some benefits. But it seems very clear to me that the benefits are now being exceeded by the desire to simply sell a new toy to make money for dubious benefit. Although it might not be a bad idea to put one or 2 in a prison recreation yard.

This fine piece of “simulation technology” has just demonstrated that beyond doubt…

http://dangerousminds.net/comments/meet_patrick_the_robotic_proctology_simulation_ass

But as I was making fun of this on Facebook this morning, one of my friends and medical colleague was kind enough to post this:

http://www.pennstatehershey.org/web/educationalaffairs/home/aboutus/services/standardizedpatient

It sort of made me feel bad for all the people working in strip clubs…They really should look into this form of employment. Not only is it less stigmatic, they could put on their resume they were employed by a medical university…Probably doesn’t pay as well though…

But aside from my off color jokes, it is certainly superior to a plastic ass connected to a tv screen and a laptop.

I eagerly look forward to the setups they market for gynecology and urology… I also wonder if there are any hidden “Easter eggs” programmed in? I can just imagine the response to the voice recognition of “My Patrick, your hips are very firm today.”

I will admit when I was in medical school we did have a couple of hours with some plastic strap on breast designed to teach breast examination techniques and findings. While it was certainly entertaining, the educational quality was dubious at best. There are even some pictures of our “educational” experience that I am sure patients would rather not see.

Not to sound like too old of a guy, but there is no substitute for actual experience no matter what your simulator sales rep or the person getting paid to run your sim center says. I think this clip sums it up well…

https://www.youtube.com/watch?v=MR0yVEqJEYw

Of course when I saw this simulator this morning on several pages, I made several of the comments you see here. But I was also reminded of an experience I had when working at one of my favorite jobs. It is also one of the stories I can actually tell at parties without making people think I am psychotic or throw up.

I worked the weekend night shift at the time, 12 hours from 1900 to 0700, Friday, Saturday, and Sunday, every week. For those of you who never worked night shift, we are a different breed. Political correctness and proper decorum are relevant. We are self-reliant and generally goal oriented. (With one of the goals being to make sure we do not burn down the building before all of the “normal” people get back to work in the morning. As such we are also a very tight group. In fact, no matter where you go in the world, night-shifters see eye to eye and even share the same jokes and virtues.

I was at work one summer night, I don’t remember the exact day, but I would bet it was sometime in July, for reasons that will become evident. Trauma season was in full swing. Motorcycle accidents, shootings, beatings, rock concerts, you name it, a majority of the shift was spent in the trauma bays. “Lunch” was usually a piece or two of cold pizza left in the box because nobody else wanted to be the person who took the last one.

As I was returning from a trauma patient to the main part of the emergency department to see what backlog of non-trauma tasks I could help with, I walked past room 9. The door was closed and the curtain was drawn. I was tired and I heard a lady scream. I paused for a moment, attempted to rationalize to myself that I was not assigned to room 9, and that one of my colleagues was probably in the room or knew more about it than I did. I then heard the scream again. Whether it was the desire to provide aid and comfort to a person in need, a duty to help all patients in the department, perhaps lend a hand to a comrade in arms, or just morbid curiosity, I could not say. But ignoring my experienced skill of walking with my head down and moving with a purpose, pretending not to see or hear that which did not immediately concern me, I opened the door and peered behind the curtain. My eyes were met by a middle-aged lady laying in the bed wearing only a hospital gown, her legs spread wide apart, and her looking at me like I was the only one in the world who could save her now. Standing next to her was a person wearing the sky blue surgical scrubs from surgery or that we in the ED would frequently “borrow” from surgery. This person was wearing a surgical mask with a face shield and had an open Foley catheter kit on a tray and the actual catheter in his hand.

I did not recognize this person at all, which is highly disconcerting given that our colleagues at work are also our friends outside of work. We go to breakfast together after work, we went drinking together, went to parties and events at each other’s houses, and there were more than a few couples formed. In my all business like, goal oriented tone, I simply asked “who are you?”

This person then lowered the catheter and his mask, and stated the most obvious fact of the night to me “I don’t work here.” I thought the patient was going to faint, but he continued on…”I am from surgery, I am one of the new residents, and I am not very good at putting in Foley catheters so my attending physician (consultant for the UK folks) told me to come down here and practice.”

My next question to this doctor was “does anyone know you are here?” With a look that seemed like he did not grasp the importance of this question simply said “no, why?” After what I would say was “politely” informing him that he cannot wander around to different departments performing procedures on patients at his leisure, he seemed a bit shocked by my revelation. Being focused on him, with my bullshit tolerance level running low, I can only imagine the look on the face of the patient who was witness to all of this.

Seeing this as just another problem to be fixed this evening, I told him not to touch anything or anyone until I got back. I left the room to find one of the boss-type people to inform them there was a stranger in the department dressed in scrubs, and let them know I would take care of it. The only person I could find was one of the emergency attendings, so I simply informed him there was a surgery resident in the department for procedures and I will take care of it. His response was basically, “do what you need to do.”

I returned to room 9 to find both the patient and the doctor frozen in the exact same positions I had left them in. So I first told him to go ahead and throw out the used catheter still limply dangling from his hand. I went and got a new kit explaining to him that now the old one was contaminated and some time had passed, we would have to start again. He looked extremely upset about what he perceived as the wasted kit. Next I asked him to explain step by step what he was going to do. He expertly talked about how to remove the lid of the kit, maintain sterile technique, scrub the site, etc. feeling comfortable he at least knew what he was talking about, I gave him the ok to begin. He did everything right without coaching under my watchful eye, and was now ready to insert the catheter. Before he did, I asked him to identify the landmarks and tell me exactly where he was going to insert the catheter before he did.

This is where things got complicated…

He described to me what I thought were superfluous landmarks, like labia, because what I was focused on was if he knew which hole was the correct one. He then identified the vagina and the clitoris, and I was just about to give him the go-ahead, but for some reason decided to ask the redundant question “where are you going to put the catheter?”

Thus far having been successful with no guidance or coaching he very confidently used his free hand to point to the hood of the clitoris.

In the split second it took my mind to process this, I immediately knew why I had heard the screaming.

This young surgeon was trying to insert a Foley catheter into the patients clitoris. But in one of those moments where I am tired, hungry, and my BS tolerance has run out, rather than say something educational, constructive, or even helpful, in my deadpan voice and sideways glare, I just blurted out “You don’t spend too much time down there do you?”

To which he bowed his head and shook it, indicating, “no” he did not have a lot of experience with female genitalia. The patient started to laugh uncontrollably. I took this as a good sign. A laughing patient never complains.

I then took the catheter from his hand and told him that he just needed to watch this one. After I had put the catheter in, he stated with amazement “it didn’t even look like there was a hole there!” and again I deadpanned, “that is why the urine stays in.” The look on the patient’s face was relief. The look on his face was awe and admiration.

After this I went on to draw him the anatomy, explain to him the common variances, problems he might encounter in both males and females, as well as what to do when they happened. We made sure with the charge nurse if any patient needed a Foley for the rest of the night, we would be called to do it. By the end of the shift, our young surgery friend could reliably insert Foleys into men or women. I was proud of my student, and everyone else just went about their business as if nothing was out of the ordinary.

Just another day, “living the dream.”

On my way home though, I remember thinking. That guy was a doctor. A surgery resident. He went to medical school, passed human gross anatomy, did years of clinical rotations. Probably used more than a few simulators, including the very same ones I learned my skills on! But in the end, when it was time to perform the skill on a real person, he could talk through every movement of the procedure, but not only could he not do it, he didn’t even understand what he was actually looking at.

But I also realized that the reason was not because of his individual ability. It could have been anyone; it could have been me, learning a procedure for the first time. The problem was not him or his deficiency, the problem was that there is no substitute for experience in medicine.

There are still things that I am not very good at. I need more practice. More experience, on real patients. One thing I have never done, but I am sure will not benefit my career or ability, is get real time feedback on my performance inserting my finger into a rubber asshole. But I bet somebody will spend a lot of money to make sure others get to do it. Oh well, at least they might take away where the hole actually is…

Let’s end this with a song?

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Beyond belief

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The saga with the GMC continues…

For those of you just joining me, the General Medical Council is the agency in the UK charged with regulating doctors and granting licenses to practice medicine in the UK.

I have recently applied for such a license and have been attempting to meet a never ending list of demands from them.

First I had to prove I spoke English by taking an exam that basically said I didn’t because I did not pay the 99 pounds sterling for information on how the test is actually scored prior to taking such assessment of my English language. I was asked to submit further evidence of my language ability. One of the many documents I produced was my PhD dissertation (written entirely in English). I was informed this was not acceptable as the document “did not specify that you wrote it.”

Apparently whatever mouth-breathing monosynaptic fucktard in the UK is “evaluating” my credentials doesn’t understand the whole PhD dissertation thing and who is responsible for doing it.

In order to seek help I searched the internet and found a study about the GMC and its exploits published by 3 prominent UK medical officials. In the document they detailed doctors are actually killing themselves because of the stress the GMC induces. It further goes on to state that the people responsible for investigating or credentialing doctors are not doctors at all.

I didn’t actually believe this, so I called the GMC and asked. I was told that it was in fact correct, and that the GMC had no doctors in their offices at all. So I followed up that question with “what credentials or education do they have?” To which I was told it varies by position, but there are definitely no medical doctors.

But today I received a correspondence and subsequent demand that absolutely defies logic…

They wanted to know how I was able to produce paperwork signed by my employers prior to their requesting this specific paperwork.

Now I must point out, the British do not really understand how to create webpages. No matter what British webpage I have been to, they all have thousands of words that basically say nothing and have links that circle you back to the pages of nothing they have already said. (It scares me to think people actually get paid for this…)

But I actually read the 12 pages of instructions that detailed all the documents the GMC requires for an application. Anticipating I would need the documents on the list of “required documents,” and having to get them from all over the world, I requested them from my various employers BEFORE I submitted my official applications. I even downloaded the official GMC forms off of the official GMC website. Can you imagine?

Apparently it is uncommon for people dealing with the GMC to have their shit together before they try to do something. Given the people who have to deal with the GMC are doctors, it really makes me wonder…

It is so strange, I now have to have my employers (and I am extremely thankful I only had to go back 5 years of my 25 going on 26 year working life) submit paperwork EXPLAINING WHY they signed these documents before they were requested.

I can see why doctors are killing themselves over their ordeals with this bureaucracy. As everyone who knows me can tell you, I have an extremely small tolerance for bullshit and stupidity. The older I get, the lower my tolerance gets. You can only imagine my delight knowing my fitness to practice medicine is not only not decided by UK doctors, but is decided by people who do not understand doctoral dissertations are solely written by the candidate whose name appears on the cover page! I am just going to guess none of them have a PhD in anything…

I am also going to guess that because they are utterly incompetent and unintelligent it may come as a shock to them that us educated folks do not possess the intelligence of a trilobite. In fact, I might actually try to publish a case report that I have discovered that trilobites are not extinct and there is a colony of them in Manchester, UK.

But what amazes me even more than being judged by a bunch of cretins, is their work ethic and practices.

They have decided that it is reasonable and in fact their policy to take 5 days, excluding bank holidays and weekends, to reply to an email. 10 days to respond to a customer service complaint. But wait…There’s more… After taking 5 or 10 days, if they decide they have to escalate the concern to a supervisor, that supervisor then has an additional 5-10 days to respond. So if they send you an email, you reply to that email, they have 5 days to read it. In practicality it works like this: Monday they send an email asking me to clarify something like “How is it possible for you to work more than 1 job at a time?” Within minutes, I reply to this email with a detailed explanation using a level of English language befitting of somebody with an advanced education. On Monday of the next week, they then reply to me, asking me to explain in simpler terms. Upon receiving my reply, they then have 5 days to reply to me.
I am now going on 3 months and counting, for a process that took the Polish Medical Authorities 3 working days. My Polish colleagues are actually very proud of themselves, knowing that in a recently former communist country, world renowned for its bureaucracy, inefficiency, and absurdity, the British make them look like the most efficient and capable people in the world.

I better not catch anyone from the UK making Polish jokes again! I can see why they don’t like Polish people. “These fuckers come to our country, work multiple jobs, and can do in seconds what takes us a week! Everyone is hiring them instead of us! They are taking our jobs! We must get out of the EU lest all these foreigners take over everything here!” The world can only hope they will…

But imagine this from my perspective having made a life in various emergency services?

Dispatcher: “911 what is your emergency?”

Caller: “Oh my god help me, my house is on fire and my children are trapped inside!”

Dispatcher: “Thank you for your inquiry, according to our procedures, we will respond to you within 5 days, excluding bank holidays and weekends.”

5 days later, Dispatcher sends an email: “Hello, this is the fire department dispatcher, can you submit documentation from every previous occupant of the house for 5 years that you in fact live there? Also, could you please submit documentation that the children are in fact your own? Finally, can you clarify how it was possible you called 911 from your phone when your house was on fire?”

Let’s look at another example? Dispatcher: “911 what is your emergency?”

Caller: “Help! My husband is having chest pain and difficulty breathing!”

Dispatcher: “Thank you, please consult our webpage for the required documentation proving you are married to the man you claim is your husband who is currently having chest pain and difficulty breathing. We will respond to this documentation within 5 working days…”

How about in the hospital?

Secretary in the emergency department: “Thank you for coming to A&E, unfortunately, we ask you not to come to our offices in person until you are invited, please send us copies of all the appropriate paperwork we require and we will then extend to you an invitation to appear in person.”

Secretary of the Intensive Care Unit: “Thank you for submitting your documents and appearing after 3 months with your critically ill family member. As you may be aware, we have many requests for service, and we will enter you into our queue and per our policy, see your family member within 5 working days.”

Secretary of the ICU 1 week later: “regrettably, your family member is extremely ill and will require the services of one of our senior doctors. As per our policy, said senior doctor will respond to you within 10 more working days.”

Do you have a complaint? Customer service: “Thank you for your complaint about our services taking 3 months to respond to your house fire where your children were trapped, the paperwork regarding emergency medical service for your alleged husband, admission to and referral for intensive medical care for your critically ill relative, and the delays in these processes. After taking 10 days to respond to your complaint, we feel we must refer you to a supervisor, as per our policy, you will receive a written response within 10 more days, unless our supervisor has to refer your complaint to his supervisor.”

You can see my concern? At least I know why you cannot show up at the offices uninvited… In order to keep up appearances, they probably have to hide all their helmets and clean all of the tongue marks off of the windows. It is hard work for clerks to protect the public from doctors…

But I like to fancy myself as a benevolent person, so… Any GMC employee that needs a doctor to testify for your disability pension, please get in contact with me as soon as you are able.

As per my policy, I usually respond to email within hours and certainly not more than 24. Furthermore, I will sincerely and emphatically support your total disability claim on the grounds you are mentally unfit and a danger to yourself and others.

If remediation or retraining is attempted, I humbly suggest something a long these lines…

What do you tell your kids?

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Anyone who has worked in some form of emergency service, particularly overnight, or on the night shift, knows that when the sun goes down, the world becomes a different place.

“Normal”, “civilian”, “9-5ers” whatever you want to call them or they call themselves. “Day-walker” is my favorite term for them.

Their lives are very mundane. Even “secure.” wandering through their routine like mindless drones. Oblivious.

Bad neighborhoods, violence, prostitution, drugs, people so poor you would think you were in the 3rd world somewhere. Things they cannot imagine.

I am writing about this because currently I am stuck in a bureaucratic mess,  with people who are so worthless, I cannot tell if they are being malicious or are a bunch of window-licking retards who were forced into their job by an unemployment agency. I want to believe the former. At least it would restore my faith in humanity and that we are not about to witness another dark age. I once read “Hope is the denial of reality.” Smart phones and TV. If you wanted to take over the world, you couldn’t hope for better tools.

Anyway, as I was attempting to get the paperwork these cretins endlessly demand. (A very good pulmonologist I know would say “the poor creatures, they don’t know any better.)I asked one of my bosses how these people look in the mirror or what they tell their kids?

I won’t post what she said…but I mentioned that I tell my daughter the same thing my dad told me. “smart people only have 2 choices in life. They can help people or take advantage of them. I will love you no matter what you choose, but I hope you choose to help.”

I then reminisced a bit, mentioned that I tell my daughter and show her the pictures of me working as a firefighter. I show her pictures of me working on ambulances (she doesn’t understand what a paramedic is so we leave that title out). I show her the pictures of me in Afghanistan (she understands “when tata went far away to help people”). My daughter then recalls the time she came to visit me at work in the hospital, with “you are pan doktor” (she sometimes mixes Polish and English when she speaks)

I could not imagine having to tell my daughter that I just mindlessly fill out forms all day and in no way make any difference to anyone in the world. That my only purpose in life is to annoy people and check boxes without thought or capacity to make a decision or deviation even as the obviousness of the truth was staring me in the face. I couldn’t even look myself in the mirror. Which is why I am so frustrated as of late. To quote a Stanley Kubrick movie. “I need to get back into the shit.”

But I will entertain you with one of my experiences with day- walkers…

It was a weekend night like any other working at an inner-city charity hospital. Nearly 0200, “last call” or as we would say “the 2 o’clock rush.”

An EMS crew brought in a young white male.   Recognizing the crew as from the local station, and knowing the neighborhood well, it was safe to assume he didn’t get lost taking his library books back. This is the type of place your GPS phone app purposefully steers you away from.

The boy (about 16 years old) was beaten, not too bad, or as Darth Vader would say “He will not be permanently damaged.”

We coaxed out of him that he was from a upper class suburb, and he was in the neighborhood looking for street-walking prostitutes and drugs. There was a disagreement about the price and some pimp beat him up. As he was a minor, we were obligated to call his parents, day-walkers.

When they showed up, he had crafted a completely unbelievable story about getting lost, stopping to ask for directions, getting mugged and carjacked. There are only 3 reasons to be in our neighborhood after dark. Buying sex, buying drugs, or as a guest of the hospital.

I can’t decide if his parents were completely oblivious day-walkers or just didn’t want to admit to why their son was beaten, robbed, and lost his car in this no-mans-land. But they first demanded to know why the ambulance drivers brought him to this hospital and not a hospital in a more respected part of the region. The father especially was completely oblivious to the fact it is highly insulting to call paramedics “ambulance drivers.” He probably didn’t know his injured son was in one of the finest trauma centers in the world. The mother then demanded we call the police at once!  Which we did and they arrived in record time, about an hour and 1/2 later. Apparently the family did not think that was fast enough. They registered their displeasure with the officer. The look on his face was priceless. They then went on to demand the attackers be caught, the car recovered, and their son’s pocket money as well.  They finished with the phrase: “we intend to press charges…”

At which point they turned to the hospital secretary and told her to call their bank and have their son’s credit cards cancelled. I think they were under the impression that the secretary first knew what bank they used and second, had a secret number to call at 4am on a weekend and actually reach somebody.

The father then demanded to file a complaint against the hospital when politely told this was not possible. He was also not happy to hear that he might as well call his insurance company because there was no chance the police would find the car or the money. The father was also very upset the police were not going to make this their top priority; taking the officer’s badge number to file a complaint against him as well.

When his son was finally discharged they all left most indignantly; loudly muttering there was a reason we all worked in such a place and it was surrounded by the type of people living there.

The father was right about one thing. There was a reason we all worked there. I doubt it was the same reason he thought. Whether you are wealthy or poor, black, white, yellow, or whatever color. A day-walker or a vampire; we are there to make a difference in the lives of real people, in their time of desperate need.

That is what we tell our kids. They will never know the feeling of being able to do any of that.

They are poor creatures. I don’t know whether to pity them or be angry at them. But they really frustrate me.