Why did the doctors go on strike?

I came across this and had to share – it is written by Dr Ravi Jayaram

I have kept quiet on here until now about the junior doctor’s strike but the time has come to stand up and say what needs to be said. Apologies in advance for the long essay, I will try to keep it simple. This is aimed at those of you who are not medical; those who are will know exactly what I am talking about.

If you simply believe what is said in the media, you might think that this is all about Saturday pay or even that junior doctors don’t want to work at nights or weekends. It is depressing to overhear people express these views but hardly surprising given the public coverage of the issue.

So what exactly is going on? A junior doctor is any doctor who is not a GP or consultant who is in training to be one of those two. Most doctors spend 8-9 years as a junior but many stay as juniors for longer, especially female doctors who may take time out for families, academics who take time out to do research and doctors in specialities where training in two specialties is needed such as paediatric intensive care. I myself spent 14 years as a junior doctor so was still one aged 37. Junior doctors are the doctors you will see first when you go to A&E or get admitted to a ward and will be responsible for delivering your day to day care when you are in hospital. Junior doctors are covering the hospital 24/7, 365 days a year and always have done. And contrary to what you might believe from the papers, they don’t have any choice in the matter, their contracts say they have no choice in working evenings, nights and weekends.

So what is all the fuss about? Well it is about being able to be safe. When I was a JD, I used to work ridiculous hours. In one job in my 1st year, every 3rd weekend I would go to work at 9am on a Saturday and leave at 5pm on a Tuesday. That was 80 hours in a row with sleep grabbed when the chances arose. It was dangerous and dehumanising and the even crazier thing was that I was actually paid at a lower rate for the unsocial hours than basic pay (1/3 of basic in fact).

Fortunately my generation of juniors was amongst the last to have to do that and things slowly changed. Now junior doctors get paid at a higher rate than basic for unsocial hours, that rate determined by the intensity of work in that specialty e.g. emergency room work would be a higher rate than dermatology. Standard hours are defined as 7am-7pm Monday to Friday (which are not exactly standard working hours for most people) and there are rules on the maximum number of hours per week and consecutive hours that can be worked. There are also safeguards in place so that if employers are consistently making juniors work beyond these rules, they can be fined; hence there is a disincentive for employers to overwork junior doctors, therefore they are not tired and dangerous 1990-style.

But work done outside standard hours is NOT overtime. These hours are contracted hours and have to be worked and, quite rightly, are paid at a higher rate than basic pay. In specialties where there is not a lot of emergency work, the majority of work is in routine hours, but areas like A&E, paediatrics, intensive care have a lot of work done in unsocial hours and attract a higher rate of pay for those hours. I stress again that this is not overtime; overtime is work done in addition to contracted hours. All doctors and nurses do overtime – staying late to complete work and ensure patient safety and very rarely if ever does anyone claim for these overtime hours.

But Jeremy Hunt wants to change the contract for junior doctors, his logic being that doing this will help to deliver the “7-day NHS”. Nobody is really sure what exactly this means. It may mean that he wants routine services such as outpatient clinics and planned surgery or scans for non-urgent problems to take place on Saturdays and Sundays, not just Monday to Friday. If this is the case then changing the juniors’ contract is not going to make this happen as without doing the same for (deep breath) consultants, nurses, porters, receptionists, pharmacists, operating department assistants, radiographers, physiotherapists and many other staff these things won’t be able to happen at weekends.

The 7-day NHS may refer to emergency work. If this is the case then it already exists. Junior doctors are already there at night and at weekends. The proposed contract changes are not going to change the numbers who are there as there is no plan to increase the total number of junior doctors. What is proposed is that the definition of normal time changes from 7am-7pm to 7am-10pm Monday to Friday and from 7am to somewhere between 5pm and 10pm on Saturday. This means that employers could make junior doctors work more unsocial hours as they have redefined as standard hours. It is true that the basic rate of pay for standard hours will be increased by 13%, which sounds great doesn’t it? Except that for the emergency specialties as above that routinely have a lot of evening, night and weekend work, what is currently paid at an enhanced rate will be paid at standard rate; even at 13% higher for standard rate, total pay for junior doctors in these specialties will drop considerably, maybe by as much 30% for some. Doesn’t sound so good now really.

And, of course, there will be the same number of doctors but spread over 7 days rather than 5 so there will be weekdays where there will be fewer juniors than there are now. A great analogy I heard was to imagine that you have a 10-inch pizza cut into 5 slices. You decide that 5 slices isn’t going to fill you up so your mum cuts the same pizza into 7 slices and tells you that you’ll be full with that. But she won’t get you a bigger pizza.

So same number of junior doctors spread more thinly is going to reduce cover on weekdays as compared to now. And weekdays are when not only emergency work but also routine planned work that also needs input from junior doctors takes place so this will have a detrimental effect on waiting lists for clinics and operations as well.

Junior doctors with children will be hit particularly hard, especially those who have junior doctors spouses, as more unsocial hours will be worked. Childcare is generally difficult to get hold of outside of 8-5 on weekdays; the department of health have actually said (with no hint of irony) that in this situation, family members who are non-medical and don’t work evenings or weekends should be asked to provide child care to get over this problem! It is very likely that couples could go several days without actually seeing each other or their families if rotas do not coincide.

But what about the increased deaths at weekends we have been hearing about? Actually, the statistics have been completely misrepresented and even the authors of the research paper that gets quoted regularly have pointed this out. The statistic was that if you are admitted to hospital on a weekend, your risk of dying within 30 days of that admission was higher than if admitted midweek. Your risk of dying is very low anyway and that very low risk is marginally higher (but still very low) if admitted on weekends. This is probably because admissions to hospital in the week consist of not only sick people but also well people coming in for routine things, whereas at weekends you would tend to avoid hospital unless you were desperately unwell and most likely would leave things as long as possible and so be sicker when you got there. Interestingly they also showed that if you were already in hospital on a weekend, having been admitted in the week, your risk of death within 30 days was lower than it would have been. Either way, there is no evidence of cause and effect in terms of numbers of junior doctors around at weekends. The so-called weekend effect has also been seen in the USA and Australia too so it isn’t peculiar to state-funded health as opposed to private insurance-based systems.

Interestingly the misrepresentation of this study has led to ill people actually avoiding hospitals on weekends and delaying presenting till Monday with potentially devastating consequences. Have a look online for the ‪#‎hunteffect‬. Scary.

Another worrying thing about the proposed new contract is that it takes away the safeguards against juniors being made to work ridiculously long hours. Whereas currently there is a mechanism that makes it in the interests of an employer to ensure the hours are not exceeded, the new contract removes these safeguards. It does suggest that each hospital trust has a “guardian” to whom junior doctors can flag up concerns about their hours but this “guardian” will also be a senior member of the trust who has no obligation to actually do anything about these concerns. I think back to my days as an exhausted junior doctor and it scares me to think that such unsafe and dangerous hours could make a return.

The pay scales are also changing. There has been automatic pay progression as you gain experience and seniority until now. The new system means that there are fewer points where pay is raised. This is not necessarily a bad thing as it can be argued that you shouldn’t get a pay rise unless you deserve it. But remember that over 10 years can be spent as a junior doctor in which time you are likely to acquire husbands, wives, children and mortgages; many existing junior doctors have made their financial plans for the next few years based on the expectation that there will be pay progression. One part-time junior doctor who has worked with me told me that if the new contract came in she would no longer be able to pay her mortgage and would have to sell her home. Bear in mind that these are young people who have spent at least 5 years at university accruing debts from both student loans for living expenses and now also £45000 in tuition fees before even starting work. The new pay scales do not reflect the levels of responsibility taken by junior doctors at different stages of their training at all which makes no sense whatsoever. For female doctors who are likely to take time out to have children and then return to work part-time, the consequences on their income will be huge. The department of health actually acknowledged that women would be hit unfairly but suggested that this had to be accepted as an unfortunate consequence.

The BMA junior doctors committee walked out of talks with the department of health because the DH’s definition of negotiation was that they would reserve the right to do what they wanted if they didn’t agree with what the committee was suggested. In other words, they did not want to negotiate so there was not point in the BMA trying. This is why industrial action was proposed because there was no other way to try to get Jeremy Hunt to talk. Sadly, even when negotiations restarted, he could not see that without a bigger pizza nothing was going to improve patient care and in fact things would be worse and so talks stopped. He has now said he is imposing the contract and that is that, he won’t talk anymore. When a strike ballot (of, let’s face it, intelligent reasonable and educated people) has a 75% turnout and 98% vote in favour, it is clear that there is a serious problem with the DH’s thought processes and they need to listen. It is highly improbable that a small bunch of radical lefties have brainwashed 50000 intelligent doctors who have been trained to analyse information and draw conclusions, much as the press like that idea.

If you have read this far, please take it on board and share with your friends. I’ve tried to keep it simple (even though it may not seem that way!) The public is not getting the full story from the TV and newspapers and if this contract is imposed then we will all be on the receiving end of the consequences eventually.

Inside the dogs open chest…

I spend hours upon hours reading, studying, visualising and learning from what seems like an endless stream of knowledge. Some of it is stuff I know I will never use but must learn (such as slaughter inspection), then there is stuff that will be used commonly (such as dog vaccinations), and finally the stuff that is really interesting that I won’t use unless I end up a specialist (such as heart bypass protocols).

Now whilst a little more common in the UK, a thoracotomy is not really common here – there have only been 2 in the past 18 months and one of these was traumatic performed by a dog attack. A thoracotomy is where the chest is opened – whether that is for heart or lung surgery or something completely different. This was the first time I have assisted on a thoracotomy where it was intentional…

The case today was different; a dog had got a foreign body stuck in its esophagus. We originally tried endoscopy via the mouth as a minimally invasive approach, whilst we could visualise this foreign object in the esophagus, it was too large to be able to grab or move onwards into the stomach. Unfortunately also when an object has been in place for a while it can also weaken the wall of the esophagus around it so moving it can cause rupture so we have to be very cautious around this as well.

So we went into surgery as an emergency to remove this obstruction from the esophagus. Unfortunately the esophagus mostly lies within the thorax (chest) – it enters the stomach just a few cm’s beyond the diaphragm. This meant that to get to the foreign body meant opening the chest.

Opening the chest is not like it is on TV medical drama’s – there are numerous complications that can occur – and its technical surgery to stop the lungs inflating on the side of the surgery so that there is space to work. Also you have to open in the correct space between ribs to give you access to where you need to be. We open the tissue layers above the space we want to use to gain access to the chest, and then open the space between the ribs.

The pink of the lungs inflating is visible before we deflate them on this side to give us the space to operate. This space is still relatively small, it’s only a small dog, and the ribs will not stretch that far apart. We bring in the rib spreaders – this gives us maybe space 4cm wide to work in, though it sounds like a lot the esophagus is in the center of the chest, maybe 7cm deep. Think about having to operate on the bottom of an empty tin from the top… This is where suturing becomes more fun and demanding, or even dissection, the tip of the scalpel has to be used whilst holding the end of the handle instead of the normal curve of the blade.

Looking up the chest where the lungs are deflated I can see the beating heart – however it is the esophagus that we are interested in – we can see the bulge of the esophagus where the foreign body is. Everything is moving though, and barely seems to stay still.

We use stay sutures to hold the esophagus as close to the wall as we can whilst making an incision into it – opening the muscular layer, and the inner mucosa. We delicately manipulate the foreign object (which looks like a chicken head & neck) from the esophagus. It is larger than we expected so we have to make the incision longer to accommodate it, and then it is out. Time to close – we did this in two separate layers – one for the mucosa and then the muscular layer around this.

One of the tricky things about thoracotomy is getting the chest closed and the lung re-inflated and breathing again. A chest drain can help with this so this is placed. We then place all our sutures into the chest wall around the ribs either side and then let the lungs inflate as we close the wall together before tying these sutures. The wall muscles and skin is then closed.

We remove the excess remaining air through the chest drain to ensure the lung can inflate fully. And then move the dog over to recovery which was surprisingly uneventful.

This has taken maybe 3 hours in total, yet my study around the chest is many hundreds of hours. I know where things are – the vagus nerve runs along the esophagus which is essential we do not damage as it controls so much of the body – the heart, abdomen, throat, swallowing. The major vessels of the aorta and vena cava also run close to the esophagus here so we have to be precise. It’s also important how we open the intercostal space so we do not damage the nerve and vessels that run along the rib. The way the respiration of the animal is compromised when the chest is opened is something that needs to be dealt with – we used a ventilator to keep the patient breathing during surgery.

Now with my latest surgery high finally being beaten by tiredness I am going sleep for the new day tomorrow.

Death, the good, bad and ugly…

Death is one of those bad words, that we try to avoid talking about, that we ignore and hope we never have to face.

Yesterday I read a blog post called “The dirty secret about CPR in this Hospital (That Doctors Desperately Want You To Know)”. For me it was nothing new, however it made it easy to understand and got the point across in a way I never could so I would highly recommend checking it out.

Since reading this it has remained stuck in my mind throughout the day, I think being in the veterinary profession gives me the other side of the picture. Unfortunately I have been in the position of watching someone I loved die slowly in a hospital bed – it was never what I expected – I expected to turn up one day and find them in their garden or home after a heart attack. It took several days for the die under the Liverpool Pathway (since then I am much more clued up as to why this may not always be the right thing) however the alternative was open heart surgery with very very very small odds of a meaningful recoveryEven at that point in time, without realising I was thinking about the quality of life and not the quantity – the chance of them doing what they loved and leaving the hospital after this surgery was near zero. The quality of life would be zero, even though the quantity would be increased (if you can consider it as life).

Whenever this person had spoken about death to me I had tried to change the subject as I was scared to think about it. I was scared of losing them. I didn’t want to think about it.

So moving forward 5 years with a lot more education and experience I am writing this. Over the past two years I’ve been seeing practice I have been around death, caused death, and prevented death. Some days it seems to be all I deal with, last Tuesday by the last patient I’d seen so many patients die or euthanized that I was no longer surprised when I confirmed another death.

Let’s talk about some death – from the perspective of a vet student… These have all happened to me…

It is 1am, my phone goes, one word – “torsion” – and I am out of bed and running for the door, 10 minutes after this phone call I am scrubbing into surgery. A torsion (GDV or bloat where the stomach swells up with gas) is a surgical emergency. The dog will die without a vet and surgery. An hour or so later the dog is in recovery, and a few days later it goes home.

Last Tuesday at 6:45pm when I was walking out the door to go to lunch a call came in… “torsion”… the owners were on their way about 20 minutes out. That’s 20 minutes for me to prepare. Operating Theatre set up, preparation for stabilisation, emergency fluids, decompression. Car drives up to the door, owner says I think he’s dead… I’m in the back of the car listening to nothing, feeling no pulse, no breathing. This dog didn’t even make it in the doors.

Is a torsion painful? Yes. Can it be fixed with surgery? Sometimes. Will the dog have quality of life after surgery? Yes. Is it a painful way to die? I would not like to die like this.

I am in surgery, normally opening the abdomen is pretty routine, however this time we are struggling. If I hadn’t opened the scalpel blade myself I would have thought it was blunt and old. Opening the abdomen finally it is like all the organs have melted together… There is nothing there, and nothing that is possible, I am wondering how the dog was still alive. We were not sure what we were going find, however I would have never expected this… The owners chose never to allow this dog to wake up.

We’ve got what is expected to be a pyometra – however there is a large mass in the abdomen along with lots of fluid. The owners know that it may be bad – and are waiting by the phone. I am running anaesthesia, the patient is having some problems to breathe so I have placed them onto a ventilator to help them. The abdomen is opened and the right liver lobe the size of the dogs head is removed from the abdomen – the breathing becomes easier. There are changes to other organs as well – it is not a pyometra however there are tumours on the uterus. We call the owners, and they give permission to euthanise on the table. I administer the drugs that will end this life – and relieve the suffering.

In human medicine – these patients would be closed and taken to recovery – they would be given drugs for pain and potentially kept sedated until they die. There is no guarantee of when this would be, they’d be trapped there in a hospital bed hooked up to machines.

A horse – unable to stand, with fluid on its lungs, anemia. The condition is getting worse… There is no quality of life, and the chance of recovery is very slim. We make the decision to euthanise and administer the drugs to do so. The horse is peaceful, out of pain, and no longer drowning inside out.

In human medicine this patient would be treated – humans are lighter than horses, the anatomy is different, and the lungs are like bags of crisps instead of sacks of potatoes. Its treatable – and there is a chance of recovery to a quality of life.

I will end on a puppy, this puppy had a deformity in its leg that was surgically correctable – however it was not showable and not breeding material. I cuddled this puppy on my lap when it was sedated, and held it when it was given the final injection. Not to relieve its suffering, simply because it was unwanted. We tried to encourage the owners to sign it over to be rehomed, tried to talk about the surgical options. That is the danger of euthanasia – that it can be used for ends other than relieving suffering.

We may not be able to pick when, however you can choose how you want to die. Where you want to die. It’s a conversation that should be had, and you can even find online guides like the Five Wishes (https://agingwithdignity.org/docs/default-source/default-document-library/product-samples/fwsample.pdf?sfvrsn=2 ) to help you.