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Archive - Year: 2018

September 23, 2018

Medicine Balls, Private Eye Issue 1479, 21 September 2018
Filed under: #health4all,Private Eye — Dr. Phil @ 9:07 am

Suicide Isn’t Painless

September 10, in case you missed it, was World Suicide Prevention Day. Each year 6,000 people in the UK, and 800,000 worldwide, take their lives so there is clearly plenty of prevention to be done. Each suicide has a profound effect on those it leaves behind, with around forty people severely affected, and more following celebrity deaths. A study which examined news reports covering the suicide of Robin Williams identified a 10% increase in people taking their lives in the months following his death. This places a lot of pressure on the media as to how they report suicide.

My father, a wonderful warm and witty academic chemist, took his life when I was seven and my brother was nine. It was not easy or painless. He used a deeply unpleasant and painful method for reasons I can never know. My mother thought he’d had a heart attack and told us that. When the truth emerged at a post-mortem, we were shielded from it for 30 years. As a result, a young ‘MD’ worried a little about his heart but not about his mind. I made it through medical school, the junior doctor years and as far as a witness at the Bristol Heart Inquiry without any significant mood disorder and no self-harm or suicidal ideation. And then I discovered not only had my father taken his life, but my great grandfather and great uncle.

As a ‘truth-seeking’ journalist, my mother worried I would be angry at having these dark family secrets kept from me for so long, but I’m eternally grateful. I have seen so many patients burdened for life by the suicide of someone close that I feel I had 30 years of freedom to sort my own shit out before having to process the propensity of men in my family to kill themselves. And as a long-term supporter of assisted dying, it made me pause to consider how people can safely make rational decisions about their death, particularly when your mind and your mood changes over time.

Suicide is never simple and often happens for multiple complex reasons. It increases at times of austerity across all populations, particularly amongst men. I do not blame any of the men in my family for taking their lives, not do I use the term ‘committed suicide’ as if to suggest it is a sin or a crime. Those who do it may have been suffering extreme mental distress and/or unbearable pain for some while, or more transiently. What is clear from those who manage to survive life whilst coping with recurrent strong suicidal thoughts is that it may be possible to learn that ‘depression is a liar’ and that such negative thoughts are wrong and can be dismissed. Alternatively, it may be possible to distract yourself until the suicidal thoughts pass, as they always do eventually.

The mental health of NHS staff is particularly poor, partly because of the stress and exhaustion the job entails but also because doctors and nurses somehow like to imagine they are immune to such pressures. I recently met Mandy Stevens who,  despite 30 years as a registered mental health nurse, didn’t notice depression creeping up on her. ‘It was only when I finally cried at work that I realised something was wrong. At the time I was working as an executive director in a London mental health NHS trust. There wasn’t the obvious feeling of being extremely sad – there had just been a slow downhill trundle and loss of enjoyment in life. My range of symptoms included being overly self-critical and a loss of interest in things I usually enjoy. I was tired but not sleeping. Procrastinating and feeling like I was a failure. I was very surprised by the rapid decline in my mental health and how it affected every area of my life so quickly. I went from fully functioning as a director to being almost mute, constantly crying, unable to care for myself and actively wanting to kill myself in 10 days.’

Stevens was assessed urgently and admitted to hospital for her own safety. ‘The care I received through the NHS was first class. The compassionate nurses, thoughtful and careful doctors, and an impressive array of multi-disciplinary team members were consistent, recovery focused, caring and just amazing.’ Stevens describes a strategy one psychiatric nurse taught her when she had suicidal thoughts after her discharge. ‘I had to make a list of ten things I’d previously enjoyed that I had to force myself to do before listening to the thoughts. This included playing music I liked and which reminded me of happier times, going to my favourite café for a coffee and cake, going on a favourite local walk and so on. No matter how strong the suicidal thoughts were, they never lasted beyond number 7 on my list.’  For others, such diversionary tactics may not work and help is needed more urgently. And the treatment works. Mandy Stevens was fully recovered nine months after admission, and back to full-time work a month later. Suicidal thoughts can and do happen to anyone, but suicide itself is often preventable. Zero Suicide Alliance offers excellent, free suicide prevention training. At 56 and despite my family history, I haven’t had strong suicidal thoughts. But I know to seek help if I do

You can call Samaritans on 116 123 at any time





September 18, 2018

CLANGERS FOR ALL, EVERY DAY
Filed under: #health4all — Dr. Phil @ 3:40 pm

Healthy Living Advice for the Whole Family.

Our health is our freedom to live a life that we have reason to value, and our ability to bounce back when our circumstances change and life kicks us in the teeth. Both of these elements of health are more likely to happen if we try to adopt daily habits that are fun, good for us and rewarding. One way to remember them is the acronym CLANGERS, which depicts 8 daily vitamins (and joys) of health.

Try to do your CLANGERS every day, as part of a regular routine 

  • Connect
  • Learn
  • (be) Active
  • Notice
  • Give back
  • Eat well
  • Relax
  • Sleep

In 2008, research by the New Economics Foundation and funded by the government, came up with five evidence-based steps we can all take to improve our mental wellbeing. Connect, Learn, be Active, Notice and Give back (CLANG). I built on this to come up with a plan for ‘whole-body wellbeing’ by adding Eat well, Relax and Sleep. These are the fundamentals of feeling good and, if you can do them at regular times to fit in with your body’s natural 24 hour rhythm (particularly eating, exercising and sleeping), it should improve how you feel and your energy levels.

CONNECT with the world around you. Human beings are social animals. We are leaves on a tree, needing to feel part of something bigger. Reach out to people, pets, plants, places and the planet.These connections are the cornerstones of our life. Take time and care to nurture them. Disconnection and loneliness may be as bad for us as smoking. And don’t forget to connect with yourself. Loving yourself may not always be easy, but are you happy in your skin? Do you enjoy your own company? Can you disappear inside your own head and not mind what you find there? People who like their own company like being on their own sometimes. You have space to think, reflect, explore and relax.

LEARN What do you want to do with your one wild and precious life? A purpose in life often stems from learning about what matters most to you, developing a passion for learning and keeping your curiosity alive. And there is good evidence that the more you learn, the better your health becomes. Try something new. Rediscover an old interest. Sign up for that course. Join a choir. Take on a different responsibility at work. Fix a bike. Learn to play an instrument or how to cook your favourite food. Develop new passions. Set a challenge you will enjoy achieving. Learning new things will make you more confident as well as being fun. And learning with others in your ‘circle’ often cements the skills and gives you confidence to use your new knowledge.

Be ACTIVE, in mind and body. Rediscover activities and passions you left behind, and have the courage to try new ones. Aim for five portions of fun a day, each different, at least one outdoors and one that involved getting pleasantly breathless. Being outdoors in the morning light wakes you up and helps you sleep well later. Gardening, dancing or singing in a choir are all excellent therapy. Physical activity is better for both mind and body than any drug, but keeps you awake if you do it too close to bed time. Choose activities that you enjoy, so you want to keep doing them. Park runs, dancing, singing, cycling and gardening are great examples. And let’s not forget the power of pets. They are usually happy to see you and . give you unconditional love when you are feeling at your lowest and least energized.

NOTICE, and be present in, the world around you. Try to be as still as you can be for fifteen minutes every day, preferably outside. Fill up your senses. Catch sight of the beautiful. Remark on the unusual. Enjoy the everyday. Savour the moment, and your place in it. Life is a balance and being and doing, and the older and wiser we get, we realise that most of the pleasure in life comes from just being. Notice how lovely your partner or children are without judging or diagnosing them. Simply slowing down and focusing on your breathing for ten minutes a day can pay huge dividends. Breathe in for 3, hold for 4 and out for 5. Feel those fabulous human air bags filling up to their fullest extent. Then slowly, slowly let it all out.

GIVE BACK. Helping and caring for friends, strangers and those less fortunate than ourselves is fundamental to good emotional health. It cements us as part of a community and develops more meaningful connections and insights. A friend of mine overheard a dad telling a waiter in the Glasgow hotel that is son was having chemotherapy in the nearby hospital, and that he was going to shave his head in solidarity so they would both be bald when they came down to breakfast in the morning. He wanted to warn the waiters so they didn’t feel uncomfortable. The head waiter said he would pass the message on. When the newly bald father walked into the restaurant with his son the following morning, they looked around and saw that every single waiter had shaved his head. The joy of being human is to be humane.

EAT WELL. Food is above all a pleasure. Learn what’s good and enjoyable to eat, and in what quantities. Learn how to grow it, where to buy it and how to prepare it. Set time aside to sit and eat with friends and family. Your gut is like a garden. It contains trillions of healthy bacteria that are as fundamental to your health as your DNA. Many people with chronic diseases have a fairly narrow range of bacteria in the gut. Healthier people seem to have a wider range of bacteria fed from a wide variety of different foods. Eat plenty of plants – vegetables and fruits of many different types and colours, nuts, seeds, whole grains and olive oil. Add in a little bit of what you fancy.  Sustainable fish, lean meat, dark chocolate and  the odd beer or glass of wine (note: alcohol can improve your chat but seriously disrupt your sleep). You can have the odd Pringle but you wouldn’t plant too many in your garden.  Cutting down on sugary snacks and drinks, processed food is a good starting point. Learn to love water as your ‘go to’ drink. And try to do all your eating in a 12 hour period (say 7am-7pm) to fit in with your body clock, give your gut a break and improve your sleep. It also keeps you at a healthy weight

RELAX. Take time to rest and reflect on the day you’ve had, reliving and re-savouring the happy memories and having gratitude for friends and family. Learn to meditate. Be kind to your mind and let it wind down and de-clutter. My Uncle Ron used to have a sitting room that was just for sitting. At the end of the day, he would really happy little things that have happened during the day, and be grateful for the love he had in his life. I used to think he was crazy, but I now know he was practising positive psychology. Our brains are neuro plastic, which means what we focus on is what grows. So if we learn to relive happy moments and have gratitude for the good things, it can actually make us happier. And this happy end of day wind down can really improve your sleep.

SLEEP Good sleep is one of life’s great joys. It’s also essential for mental and physical health, helping you prevent and recover from a whole range of illnesses and improving your energy levels, creativity and performance. The flip side is that sleep deprivation prevents you from recovering from many illnesses, and it’s the first and most important thing to concentrate on. Adults work best on a regular 8 hours sleep a night, adolescents need nine hours if possible and children need more. Half the population in the UK have poor quality sleep and feel more tired, more stressed, less energized and more anxious as a result. If you’d like to find out more about the importance of a normal sleep pattern,  I would recommend Why We Sleep by Matthew Walker or the The Four Pillar Plan by Dr Ranjan Chatterjee. Dr Chatterjee also hosts some excellent podcasts on health.

 

‘CLANGERS’ WHEN YOU’RE KNACKERED 

 The CLANGERS you can do when you’re ill will be very different from the CLANGERS you do when you’re well, but they are equally important

Severe fatigue often happens to previously very active people. As one of my patients put it; ‘It’s like I used to have Duracell batteries but now I have Poundland batteries.’ If you overdo your activity, you can boom, bust, crash and take days to recover, which is why you have to use your energy wisely, and switch to rewarding activities that are less exhausting.

One young man played football for Bristol City but got severe fatigue after glandular fever and had to stop, which was a crushing disappointment. His Dad encouraged him to take up the guitar – a much less energy-draining hobby – and he gradually taught himself to play, finding the strumming very therapeutic. He has now fully recovered, formed a band, played a gig at the Fleece and Firkin in Bristol and made an EP. He sent me a lovely letter saying how much he loved his music and if he’d never have had severe fatigue, he’d never have picked up the guitar in the first place. Sometimes doors close in life, but another door opens.

Severe fatigue can be caused by many things, such as sleep deprivation, stress, anxiety, low mood or just about any illness, including Chronic Fatigue Syndrome/ME, which is a physical illness that may be triggered by an infection, or repeated infections, or other stressful events. Sometimes there is no apparent trigger, and there may just be a strong genetic predisposition to fatigue. A nutritious diet is essential for all of us but with severe fatigue you may find little and often is easier than eating big meals. Try to do your eating in a 12 hour window, and not late at night. It’s also important to try to optimise your sleep. As a teenager, this means trying to get 8-9 hours good quality sleep at the same time every night, including weekends, and trying to avoid oversleeping (you get no extra benefit unless you are sleep deprived) and afternoon catnaps (which, beyond half an hour, can interfere with the quality of your later sleep). Adults  of all ages function best after 8 hours sleep

Teenagers have it tough because their body clock shifts to make their natural going to be time later (11 PM onwards) but school demands that they get up early (often 6.30 am or before). So many are sleep deprived and stressed-out for no fault of their own. Severe fatigue on top of early school wakening is a double whammy.  It is far more important for your health and recovery to fiercely protect the 8-9 hours sleep and aim to get to school at morning break at the earliest, until you have fully recovered

A high quality sleep routine that fits in with your natural body clock is absolutely vital to recovery. Below are 25 tips for better sleep, not all of which may work for you, but they may start your journey to recovery. A normal sleep pattern can improve memory, energy, pain and many other unpleasant symptoms.

25 TIPS TO TRY TO IMPROVE YOUR SLEEP

  1. Try to go to bed at the same time and – most importantly – wake up at the same time each day, including weekends, even if you have had a bad night. This may not always be possible. Aim for a ‘non-negotiable’ 8 hours sleep every night as an adult, 9 hours as an adolescent. This isn’t easy, so decide which timing works best for you and your daily functioning. You will need to ensure 8.5-9.5 hours in bed to give you adequate nodding off time. Keep a sleep diary if this helps.
  2. If this routine goes wrong, don’t beat yourself up. If you don’t get good, refreshing sleep you will build up a sleep debt that has to be paid off on days off. And if your red (high) energy allowance is set too high, you will sleep longer or more deeply to try to recover
  3. If you are asleep all day and awake at night, treat this like jetlag and cut back your going to bed time and your waking up time by 1 hour each day. Day One: 6 am sleep 3 pm wake Day Two: 5 am sleep, 2 pm wake Day Three:4am sleep – 1 pm wake etc until you wake at the desired time.
  4. Have the right sunlight exposure. Daylight is key to regulating daily sleep patterns. Try to get outside in natural sunlight for at least thirty minutes each day. If you aren’t sensitive to light wake up with the sun or use bright lights in the morning. If you have problems falling asleep, you should get an hour of exposure to morning sunlight and turn down the lights before bedtime.
  5. Enforce a strict ‘no caffeine after noon’ rule. Coffee, colas, certain teas, and chocolate contain the stimulant caffeine, and its effects can take as long as twelve hours to wear off fully. Nicotine in cigarettes and e-cigarettes, and alcohol also severely disrupts your sleep, as can some medications. Check with your pharmacist.
  6. Come off close-up screens and games 60-90 minutes before bed. The blue light and excitement they give off boosts cortisol and blocks melatonin release.
  7. Set an alarm to tell you when it’s time for bed, and stick to it. Alarm clocks in the morning freak out your heart and are best avoided if possible.
  8. Fit blackout blinds in your bedroom. The darker your room for sleep, the better. A black-out mask is a cheaper option
  9. Remove ALL screens from your bedroom, so temptation is avoided.
  10. Consider opening the bedroom window. The perfect temperature for sleeping is around 17ºC/ 65ºF. A cooler room is much better for sleeping than a hot one
  11. Eat earlier in the day, before 7 pm if possible. Don’t snack at night.
  12. Exercise earlier in the day, and outdoors when you can. Exercising 2 hours before sleep time raises your metabolic rate and temperature, and makes it hard to sleep
  13. Socializing is important but don’t do it late at night except on special occasions.
  14. Consider red lights for night-time illumination
  15. Consider amber glasses to filter blue light from screens
  16. Don’t use your phone as an alarm clock
  17. Install f:lux on your e-devices, or switch on ‘night-time mode’ from 6pm
  18. Don’t take catnaps after 3 pm and keep them short, ideally less than 30 minutes. And keep the curtains open. You are not trying to fall into deep sleep as this disrupts the next night’s sleep, but trying to have a quick refresh.
  19. Relax before bed. Don’t overschedule your evening so that no time is left for unwinding. A relaxing activity, such as reading, listening to music, chatting through the day with friends or family or stroking a pet should be part of your bedtime ritual.
  20. Take a hot bath before bed. The drop in body temperature after getting out of the bath may help you feel sleepy, and the bath can help you relax and slow down so you’re more ready to sleep.
  21. If you can’t sleep, counting sheep isn’t as effective as repeating the same word over and over (the, the, the, the…) or filling your mind with peaceful music
  22. Don’t lie in bed awake. If you find yourself still awake after staying in bed for more than twenty minutes or if you are starting to feel anxious or worried, get up and do some relaxing activity until you feel sleepy. The anxiety of not being able to sleep can make it harder to fall asleep.
  23. Keep trying to improve your sleep, little by little. It’s about quality as much as quantity
  24. We all have bad runs of sleep, particularly in stressful times, but if we allow ourselves to get back in synch with our body clock, we may rediscover the joy of a good night’s sleep
  25. Some drugs may appear to help you sleep but your sleep quality will be better if you can manage without them, so try these tips first, keep a sleep diary and ask your doctor or nurse to review your progress.




Medicine Balls, Private Eye Issue 1478, 7 September 2018
Filed under: Private Eye — Dr. Phil @ 7:35 am

Court Unawares

One key lesson from the wrongful erasure of Dr Hadiza Bawa-Garba is that lawyers are even more prone than  doctors to draw wildly contradictory conclusions based on the same evidence. In a rare show on unanimity, the Appeal Court judges Ian Burnett, Terence Etherton and Anne Rafferty, agreed that Lord Justice Ouseley and the GMC legal team lead by Ivan Hare QC had reached entirely the wrong conclusions and hence verdict in the High Court on January 28. The GMC should never have challenged the decision to suspend and retrain Dr Bawa-Garba made by its own Medical Practitioners Tribunal Service, as she was a conscientious doctor who was no more a risk to patients than any other conscientious doctor. Why Lord Justic Ouseley wasn’t able to deduce this is something of a mystery.

Since January, the GMC has been busily doing the rounds trying to blame its draconian pursuit of Bawa-Garba on its legal advice. As retiring chair Sir Terence Stephenson put it; ‘If you take external advice from the QC, and they say the tribunal has erred in law, and if you then don’t appeal, you’re setting a precedent. In that sense you have no choice, because the regulator can’t be above the law. You seek the legal advice – and you can take it or not take it – but I think most people take the advice of QCs, especially if you’re a regulator.’ However, Stephenson and GMC CEO Charlie Massey were warned repeatedly by dozens of senior doctors from February 2017 onwards that its original MTPS decision not to strike her off was correct, not least because her working conditions were so unsafe and she had been fed to the wolves by her consultant. Yet they failed to secure better legal advice.

Stephenson is a Professor of Child Health and should have spotted early on there was something very fishy about the scapegoating of Dr Bawa-Garba and the behaviour of her consultant Stephen O’Riordan, particularly when he quietly removed himself from the GMC register to sign back on in Ireland. And Stephenson should have laughed out loud, as most doctors did, when the GMC QC Ivan Hare tried to argue that a consultant isn’t duty bound to pick up the severity of a child’s illness from being told the grossly abnormal blood results. According to Hare, and presumably the GMC, his duty to review only starts after a specific request from his juniors. A formal, written invitation perhaps?

MD is a lowly associate specialist in paediatrics, but the most telling part of the BBC’s excellent Panorama was Dr Bawa-Garba’s tear-soaked incredulity that Jack should have died so soon after she had seen him sitting up in bed, drinking from a beaker and watching Toy Story. As a GP, MD was taught to treat the whole patient and not the test results. But paediatrics is different because children can get very sick, very quickly. In my first paediatric job, I remember a girl going from happily listening to Snow White to death from streptococcal meningitis in half an hour. She was admitted with  diarrhoea and vomiting and was being treated for that. She had been reviewed by doctors and nurses at all levels of seniority. And she died in front of our eyes.

A paediatrician contacted me about a child who died recently from sepsis, within half an hour of watching her favourite Peppa Pig video and eating a yoghurt, in full view of the ward staff and having been seen and reviewed by all the consultants. She had some signs of lactic acidosis (not as severe as Jack Adcock’s) but the staff were given false reassurance by how well she appeared. Children who are critically ill can shut down their vital organs but may selectively perfuse their brain for survival. And they will use that brain perfusion to do what they enjoy. Which is why it is vital to pay attention to the blood results even if a child appears well, and particularly if sepsis is suspected.  Jack Adcock too died from undiagnosed sepsis but had the extra error of being given his heart drug, enalapril, on the advice of another junior doctor who asked how he was over the phone – ‘He’s much better, sitting up, drinking from a beaker and watching Toy Story’ – and presumed he was well enough to have it. But his blood results suggested it could lead to a catastrophic lowering of his blood pressure.

Stephenson and Massey have no excuse for not getting better legal advice. Any one of Ian Burnett, Terence Etherton and Anne Rafferty would have got the law right first time and prevented a huge amount of expense, harm and broken trust. Stephenson has left the GMC with a knighthood. Massey is clearly out of his depth, as MD pointed out on his appointment (Eye … ). Massey was Jeremy Hunt’s little helper at the Department of Health who came across as disastrously ill-prepared when trying to explain the funding and staffing requirements of the government’s magical ‘seven day NHS’ to the  Public Accounts Committee (PAC). He was shunted sideways to the GMC and must now leave.





September 9, 2018

Medicine Balls, Private Eye Issue 1477, 24 August 2018
Filed under: Private Eye — Dr. Phil @ 10:00 am

A convenient scapegoat

Was the General Medical Council merely grossly incompetent in pursuing Dr Hadiza Bawa-Garba through the courts to strike her off following the death of six-year-old Jack Adcock on 18 February 2011? Or is it complicit in a wider cover-up of where accountability should lie? An internal investigation by Leicester Royal Infirmary admitted “79 domains of systemic failure” in Jack’s death, and made 23 recommendations, including that the consultant on call for emergencies should review all the new admissions in person (something that was already happening in units providing a decent standard of consultant-led care).

Dr Bawa-Garba made a serious error, which she openly admitted, in not recognising the significance of Jack’s very abnormal admission blood test results, which made a diagnosis of sepsis more likely. However, her consultant Stephen O’Riordan made an even more serious error – given his seniority, experience and responsibility – in failing to spot that same risk of sepsis. He was told the abnormal pH of 7.084 and the fact that the blood lactate concentration was high, and wrote them down in his notebook. At that moment, the overriding duty of care for Jack was passed from junior doctor to consultant, and O’Riordan became responsible for acting on these very abnormal results. And yet he chose not even to review Jack. Sepsis is particularly hard to spot if you’re nowhere near the patient.

The GMC even tried to defend Dr O’Riordan by making a ridiculous assertion about consultants. Its counsel, Ivan Hare QC, claimed that “a consultant is only there to deal with matters drawn to their attention”, prompting the appeal judge to reply: “[You] conjure up a picture of a consultant sitting in a chair, waiting for them [junior staff] to come and get them.”

MD disagrees with the GMC’s argument. It is surely the consultant’s duty to use his or her wisdom and experience to know the significance of test results. The GMC seems to have rejected the concept of consultant-led care in its desire to have Dr Bawa-Garba erased.

All doctors make mistakes – it’s what happens next that matters. After Jack’s death, Dr O’Riordan and Dr Bawa-Garba should have visited the parents together, expressed their deepest sympathy and promised an independent, open investigation to ascertain the full facts. Instead, Dr O’Riordan insisted on seeing Jack’s parents without her. Given the parents’ sudden change in attitude to Dr Bawa-Garba from thankful to extremely hostile, it seems likely that blame for Jack’s death was apportioned to her. And O’Riordan even forbade her from talking to the parents because she was “under investigation”.

This fuelled a vicious cycle of blame that has seen her go from a highly regarded paediatrician with an unblemished career to being found guilty of gross negligence manslaughter, fined £25,000 and only escaping imprisonment for two years as she has a disabled son and her spouse was working abroad. Summing up at her trial, Mr Justice Nicol told her that “your career as a doctor will be over”. The deanery removed her training number, she had to sell her house to pay her fine, her passport was held back by police, her criminal record made it impossible for her to get insurance for anything, and she had to move house because of racial abuse, threats and trolling sparked by aggressive media reports.

Meanwhile, Dr O’Riordan quietly removed his name from the GMC register, moved to Ireland and re-registered with the Irish Medical Council, which has allowed him to carry on consulting and thus far has not investigated him. The GMC erased or suspended 119 doctors from the medical register in 2014, 50 percent of whom are known to be black and minority ethnic (BME). This could be because the GMC is racist, or somehow softer on white doctors, but in MD’s experience BME doctors are very likely to be completely open and honest – almost to a level of naivety – when serious errors are made, particularly if they have a strong religious faith. This makes them sitting ducks for blame.

Perhaps the most serious error in Jack’s care had nothing to do with Dr Bawa-Garba. Jack’s mum quite reasonably asked a nurse if her son could have enalapril, a drug used to take the pressure off his heart after surgery to repair a heart defect had left it scarred and weakened. However, enalapril is a very risky medication to give to a child with Jack’s combination of lactic acidosis and altered kidney function, as it can cause a sudden lowering of blood pressure. Dr Bawa-Garba had correctly not put the drug on Jack’s drug chart, but another junior doctor sanctioned its use when called by the nurse. an hour after being given enalapril, Jack went quiet, blue and into cardio-respiratory arrest.

This terminal error has barely been mentioned as it wasn’t “one of hers”. As Sir Liam Donaldson, the former chief medical officer, once put it: “To err is human, to cover up is unforgivable, and to fail to learn is inexcusable.” To which MD would add, to shift the blame on to someone else is criminal.

 





Medicine Balls, Private Eye Issue 1476, 10 August 2018
Filed under: Private Eye — Dr. Phil @ 9:58 am

Tiredness and Overwork can be Lethal

MD’s first ever Eye Column (Eye 785 17/1/92) featuredjunior doctor Chris Johnstone ‘who won the right to sue Bloomsbury health authority for subjecting him to a particularly onerous obstetrics job.  Johnstone had taken his decision after falling asleep at the wheel: he used a portable EEG to measure his cerebral activity during a 48 hour shift and found that he was registering sleep waves while sewing women up after labour. Despite his high court victory, the job remained the same and the doctor who followed him spent time in intensive care after a paracetamol overdose.’

Like many junior doctors at the time, MD made catastrophic errors while overworked and sleep deprived, and drove his car off the road after an 81 hour shift. Several colleagues committed suicide during or after such long shifts, and it became clear that poor judgement, exhaustion and mood disturbance caused by sleep deprivation and work related stress was contributing to the deaths of doctors and their patients. 30 years ago, junior doctors were paid just a third of the standard rate for overtime, so it was much cheaper to make one work 120 hours a week than to hire three to work 40.

But the problem wasn’t just political resistance to funding and staffing the NHS safely. Many senior doctors embraced the macho culture of workaholism, and often the alcoholism and drug addiction that went with trying to keep your eyes open for 81 hours. Some would boast of being on call 24 hours a day, 7 days a week when they were juniors, in a secretive culture where cock-ups were buried. In the 1992 election, MD stood against Health Secretary William Waldegrave with the strapline ‘If junior doctors were prisoners of war, then under the Geneva Convention the sleep deprivation they suffer would be considered torture’.

There is now clear evidence for the danger of sleep deprivation for everyone. The less you sleep, the quicker you die from any combination of depression, anxiety, dementia, stroke, heart disease, obesity, cancer, diabetes, suicide and accidents, especially falling asleep at the wheel. Doctor specific research found that they are far more prone to diagnostic, treatment and surgical errors when they are sleep deprived and fatigued, particularly when having to make complex decisions under pressure. They are also more prone to needlestick and scalpel injuries, and crashing on the drive home. This helped convince the government to legally cap the hours doctors can work. They are not supposed to do more than a maximum 72 hours in any 7 days, with a maximum shift of 13 hours with rest breaks every 4 hours. They can still be on call for 24 hours, or 48 at weekends if it is somehow deemed to be ‘safe.’

The problem is that doctor numbers have not increased to compensate for the reduced hours and increased demand of very sick patients with multiple illnesses and the myriad high tech treatments that could help or harm them. And there are no legally mandated safe staffing levels to protect junior doctors (and nurses) from abuse. So they work very intensively and often longer than they are supposed to because their rotas are often not fully staffed and they are covering several jobs. The fatigue from this level of overwork is likely to be very dangerous, particularly when combined with alternating shift patterns that disrupt regular sleep routines and diminish recovery. Even worse, they are hung out to dry if they make an honest and inevitable error in such dangerous circumstances.

When Dr Hadiza Bawa-Garba returned to Leicester Royal Infirmary in 2011 from 13 months maternity leave she may already have been sleep deprived. She certainly needed induction training. Yet she was put straight on call for paediatric emergencies with no induction and an absent consultant and registrar. She had to cover 6 hospital wards across 4 floors, responsible for dozens of critically ill children during a 13 hour shift with no time for breaks. The IT system crashed.  An emergency prevented her from attending the vital morning handover. Amid largely great care she made serious errors in one case (Eye ). The Crown Court deemed this to be gross negligence manslaughter. The GMC then compounded this injustice by striking her off. Over £300,000 was donated to her appeal to overturn the GMC decision. The Appeal Court  verdict is awaited from the lord chief justice, Ian Burnett; master of the rolls, Terence Etherton; and the lady justice of appeal Anne Rafferty. Doctors are stuck between a rock and a hard place, legally and professionally obliged to admit errors but punished by the court and GMC if they do. And neither take into account the proven dangers of overwork, lack of rest and sleep deprivation. To destroy the career of a brilliant paediatrician with a previously unblemished career for honest mistakes in such an unsafe setting is simply unforgivable.





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