Tuesday, February 15, 2005

Quotes of the Day

"It's a good basic axiom that if you take a quart of ice-cream and a quart of dog faeces and mix 'em together the result will taste more like the latter than the former."
"You do not have to be a fundamentalist to admit that it is unlikely that the Holy Spirit supports guiding the Church into denying His existence."

Monday, October 18, 2004

The Big Match

Not really being a sports fan I never really 'get' the exitement of world cups, Europeans cups, qualifying matches and the like. I certainly don't choose to watch sport on TV. If I ever do I'll probably start with women's beach volleyball and ladies gymnastics, though the former is arguably closer to soft porn than real sport.

The closest I ever get to understanding what excites sports fans is at political election time. We are told the coming US elections could be the most significant in living memory, and Bush and Kerry are virtually neck and neck. There's all to play for and everything to loose. I'm unashamedly a Bush man, I intistinctivly warm to a man who reduces liberals to such incoherent, incredulous apoplexy. I'll certainly be staying up to watch the results on election night.

I've discovered this US election poll tracker on the BBC, which I'll use to keep track of the latest poll information. I'm no supporter of the BBC either, but they are good at charts, and elections aren't elections without Peter Snow jumping up and down like a four year old needing the toilet.

Friday, October 15, 2004

Charlotte Wyatt; A rotten precedent

I’ve been thinking a lot about the case of Charlotte Wyatt and now Luke Winston-Jones over the last few days, and the implications of the case are still being talked about at work.

One of the things that has struck me about the case is the considerable consensus across the political and religious spectrum that it is, firstly, a tragedy and, secondly, that everybody involved in the case is motivated to do what is best for Charlotte. Laban Tall, here and here, seems to be a lone voice of outrage, while spokespeople such Josephine Quintavalle of Comment on Reproductive Ethics and the Pro Life Alliance, and Peter Smith , RC Archbishop of Cardiff, seem to have considerable sympathy for the position of the doctors, even if they fall short of endorsing the judge's decision.

Yet I’m moving towards agreeing with Laban. I’m not as ready as him to question the Christian credentials of Mr Justice Hedley. I’m a pro life, evangelical Christian too and taken in isolation I suspect that his decision is, at least on the balance of probabilities, best for Charlotte, even if it isn’t for her parents. He’s certainly not advocating her termination. The law demands he act in her interest not theirs. Certainly the duty of care owed by hospitals is owed to patients first, and only then to their relatives (although in cases such as this it’s a very close second). This looks a pretty bald statement at first glance, but the needs of parents and patients aren't always the same, and parent, even loving parents, don't always act in the best interests of their children. I think a more than plausible case can be made that quality of life is at least as important as length of life.

I wouldn’t even blame the mess on the NHS. I’m no supporter of our Stalinist healthcare system, but ethical dilemmas such as this this arise under any system, even privatised and mixed ones. Aggressive treatment can cause profound suffering to patients. I’ve carried such treatment out while nursing on adult Intensive Care Units. Aggressive treatment may be worthwhile if it does result is the survival of the patient, but it’s surely less justified if it doesn’t. Providing treatment which leads to patient suffering inevitably has a profound effect on those carrying out that treatment, especially when it becomes apparent the patient will die anyway. Laban might be right on the biased nuances of the word ‘aggressive’, but in this context the opposite of ‘aggressive’ is ‘conservative’ and unfortunately that’s a word with negative connotations too.

So why am I moving towards agreeing with Laban?

That this case came to court at all implies a breakdown in trust between medical and nursing staff and Debbie and Darren Wyatt. Doctors are called on to be calm and professional, and it is they who should bear most responsibility when there is a breakdown of trust. That breakdown might be the caused by a number of factors, but it’s pretty unsatisfactory for everybody if it results in increasing legal involvement in the withdrawal of treatment. Whether Mr Justice Hedley wants it or not, this case does set a legal precedent and doctors will be tempted to resort to the courts more speedily than they did before, especially when dealing with ‘difficult’ families. Evidence over the last thirty years shows that when doctors relinquish a moral high ground, they never retake it. The case of the now widespread availability of abortion and the permitted starving to death of patients resulting from the Tony Bland case being cases in point. A horrifying number of my nursing colleagues agree with euthanasia, and are amazed at my opposition to it. We slide further and further from what is right and we seem unable to return.

In addition there seems to be an increasing suspicion that the NHS routinely withdraws lifesaving treatment for purely economic or ideological reasons. It’s not really a fear I share. I’ve witnessed more examples of patients being given excessively agressive treatment rather than insufficient, but it’s the former that makes the news and resonates with the public. Mostly, I think, because people feel quite powerless over the health service, certainly more powerless than they do over any other commodity they purchase. In the long run we may remember this case as one more brick in the wall of mistrust, though it's worth remembering that there is considerably more distrust between doctors and relatives within the private American system than the NHS.

Another factor is the difference between adult patients dying and children dying. Most patients dying on an adult Intensive Care Unit are elderly, though by no means all. The degree to which a family accepts the death of a loved one is generally proportional to their age. You can accept your eighty three year old mother dying a lot more easily than your twenty four year old husband. Nature has endowed parents with a passionate desire to protect their children, especially when they are very vulnerable, and put their interests first. This sometimes breaks down, but unless there is evidence that it has in this case, it should require more than the balance of probabilities that the doctors know what's best for Charlotte, rather than her parents. This, I think, is the crux of Laban's argument.

This decision may or may not have been best for Charlotte. There‘s a certain irony if it was, because she may have been the only person who does benefit from it. Her parents didn‘t, and neither, in the long run, did the doctors, nor did the population at large. Even the judges may come to regret it. I suspect the judge made the only decision he could, but this case will be used to justify less justifiable cases in the future and that it was made at all sets a pretty rotten precedent.

Wednesday, September 22, 2004

Bloody EU

I notice Tim of An Englishman's Castle comments today on news that the EU Working Time Directive is to be tightened up, making it harder for countries to opt out of the 48 hour working week.

God these people make me angry. What moral right do they have to put themselves above our, or any, national government (even if it is led by Tony Blair). By what arrogance do they think they know better than any work force what is best for them. Through what cowardice do national governments cave in and allow these unelected parasites to boss them about. It really is time to pull out of the EU and leave them to their own devices.


Good Luck with the blogging, Boris

Having been a little beastly to poor Boris Johnson earlier in the week, I notice he's started his own blog, largely on the recommendation of a chap called Tim. Best of Luck there Boris.

I know he's going to end up making me laugh and I hate myself for it already.

Sunday, September 19, 2004

Loaded for Bear

"In Britain last week, MPs voted to ban hunting with dogs, depriving people of the chance to chase foxes armed with nothing more lethal than a pack of hounds. In America, the 1994 ban on military-style assault rifles passed by Bill Clinton has now expired after President George W Bush failed to extend it. Now, all you need if you want to take a walk in the woods equipped like Rambo is about $1,000. In America, it's known as being 'loaded for bear'“ today's Sunday Telegraph

Now that’s what I call fieldsports!

Saturday, September 18, 2004

Life in the Nash

I’m a lucky man. I’ve a job I adore, and not many people can say that. Theatre nursing is technically challenging, but free from much of the emotional stress of nursing on the wards. The hours are congenial in comparison, and the wages sufficient to pay my mortgage. Sooner or later all the world makes it’s way through hospital, and I get to have interesting conversations with many of them as they do so.

One of the things I like most about working for the Nash is that it’s such an international organisation. As I get older I find it harder and harder to enjoy travelling abroad. Give me a weekend in Criccieth any day. The beds are never comfortable, and I get fretful when I can’t make myself understood. I find myself metamorphosing into some kind of sub standard Victor Meldrew, without the wit. I remain passionately interested in world events though, and working for the Nash gives me the opportunity to discuss them with people from the places concerned.

Occasionally spoken English is a problem, but that’s the West Midlands for you. The Filipinos usually understand what is being said sooner or later. A few years ago I worked in Cheltenham, hardly the most multi-cultural town in England. Even there, I counted nine languages spoken by two or more people in the theatre department alone, including Zulu and Afrikaans. I’d guess there are many more where I work now. At the very least it means we never have to get a translator in from outside. Besides, you can’t believe in free trade and not believe in at least some degree of freedom of movement, at least for those with marketable professional qualifications. Still the consequences are interesting sometimes.

I got talking to an Asian anaesthetist from Bradford yesterday. He’s got a face like Uday Hussein, an accent like Geoff Boycott and a wicked sense of humour that’s all Yorkshire. Apparently a couple of days earlier he had been waking up a patient after an anaesthetic when the patient had become more and more agitated. Eventually the patient was awake enough to croak, “Where am I?”

“You’re in Brummagen General Hospital” my colleague replies.

“Thank God for that!” says the patient, with transparent relief, “I thought I’d been kidnapped.”

Looking around the bed my colleague realizes that there’s not a white doctor or nurse among them. “Mind you,” he tells me with a wicked glint in his eye, “I’d still like to have seen his face if I’d said, ”You’re in the Tora Bora mountains, mate.”"

Thursday, September 16, 2004

Is There More to Boris Than Meets the Eye?

Last night’s post on hospital cleaning and MRSA seems to have been accidentally topical, and Boris Johnson comments on Blair’s curious priorities in today’s telegraph.

I’ve got mixed feelings about Boris’ style of writing. On one hand I’m amused by his blend of semi coherent outrage and general bonhomie, on the other I’m not convinced that the genial buffoon he pretends to be would have succeeded in becoming a magazine editor, MP for one of the safest Conservative seats in the country and a shadow minister (even in this Conservative front bench) Nor am I much convinced that the forces of British Conservatism are helped by maintaining an image of Conservatives as bumbling, public school dilettantes. I think there’s more to Boris than meets the eye but I’m still waiting to see if he shows us what it is.

Where did the Smell of Disinfectant go? (Part II)

Operating theatres are full of identically dressed people who don’t wear name badges, forcing staff to guess whether the new colleague they are standing next to is a surgeon, anaesthetist, nurse, operating department practitioner, auxiliary, orderly or cleaner. Chatting to a new colleague today, I find she is a former cleaner who has just become a theatre auxiliary; an unqualified assistant who is able to fetch equipment, instruments and sterile supplies for the nurses and ODPs assisting the surgeon.

My new colleague and I got talking about hospital cleanliness and I shared some observations I had made as a ward nurse about how little time cleaners spend cleaning wards, resulting sometimes in truly filth conditions. Her replies were more than a little worrying and I share them with you now.

According to my colleague cleaners have on average about an hour a day to clean a busy 32 bedded ward. They will cover several wards and as well as cleaning floors and surfaces they wash up the kitchen, hand out and collect meals and do tea rounds for the patients. Feeding patients has historically been a nursing job, for the very good reason that inadequate food and liquid intake leads to malnutrition and dehydration; malnutrition being a growing problem in hospitals, or more accurately NHS hospitals. (I’d bet you money that problem started when nurses stopped taking responsibility for mealtimes, but that’s another story.)

Sadly it’s true, as I was once told, that cleaners aren’t allowed to clean up body fluids, specifically urine, faeces, vomit and blood. Possibly a reasonable proscription if you’re a cleaner in an aeroplane factory, it’s surely foolishness in a hospital where such fluids are the reality of daily life. In practice it becomes the responsibility of nursing staff to clean up the mess. Of course the nurse’s immediate responsibility is to the unfortunate patient whose clothes and bedding need changing, or who needs comforting, or who is haemorrhaging. If the floor needs cleaning it’s going to get done after the patient’s needs are met, and it’s probably going to get done in a cursory way, because by now the nurse will be behind in the other tasks she needs to be doing.

The cleaner’s one hour clean needs to be seen in this context. Moreover, as my colleague points out, that one hour clean invariably coincides with the doctors ward round, or patients being collected for theatre or whatever. Training is apparently derisory, with poorly motivated cleaners being inadequately trained by equally dispirited supervisors.

My colleague isn’t impressed by hygiene in the operating theatre either. Cleaners don’t clean equipment, only floors and fabric (presumably on the ground that the equipment is expensive and cleaners might break it). The result is that the equipment barely gets cleaned at all, and when it does it is in a haphazard and intermittent way. Perhaps what is most frightening is that we are a good hospital, well regarded, and one in which, by and large, I’d be happy to be an inpatient myself. Goodness alone knows what it’s like in the bad ones.

What can be done? I don’t see an alternative outside a significant increase in the priority given to hospital cleaning and to cleaners. There is some evidence that my hospital is beginning to see this (it came out quite badly in recent MRSA figures). Well trained, motivated cleaners are as vital to patient recovery as doctors and nurses (Certainly bad cleaners are as deleterious to patients recovery as bad doctors and nurses) Wards should have their own cleaners and they should not get sidelined into jobs more properly done by nurses. They should be trained and expected to clean up body fluids, and should be on hand to do so. They should also be trained to clean equipment and if they have to be paid more to attract appropriately intelligent staff they should. Short-termism has long been the bane of the NHS but MRSA infection rates, among many other things, show what a poor long term investment this has been. The irony is that in many cases the solution to hospital aquired infections will be a return to practice which was considered normal forty years ago.
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