To say I am having some difficulties being respected or my medical skills & expertise acknowledged by the hospital staff would be a gross understatement. It's not enough to calmly discuss with staff evidence based practice or use logic & reason. Like with a stroppy, hormonal teenager rationality doesn't appear to work here.
There have been only two occasions in the last year where I have momentarily silenced the torrent of defensive abuse & excuses from the staff & seen the look of recognition of a sound logical argument & almost heard the penny drop. This of course is short lived and is followed by rebound excuses and hostility.
The first occasion was just a few weeks ago when I presented a CPG (clinical practice guideline - the existing MoH guidelines are dated from 1999 so are currently being updated) on organophosphate poisoning (OP), a common overdose & method of suicide here. In the CPG it describes the cholinergic syndrome that occurs with OP - another great mnemonic opportunity SLUDGE (salivation, lacrimation, urination, defeacation, GI upset, Emesis). The CPG clearly states that Atropine - the antidote - should only be given if a patient has signs of a cholinergic syndrome AND NOT just pupil constriction.
This revelation started Dr L on a pompous rant about how ridiculous this protocol was because at least 90% of the patients they see with OP in ICU never develop signs or symptoms of cholinergic syndrome yet they will all still receive Atropine.
The current situation is that any patient who claims to have ingested organophosphates receives large doses of Atropine, the side effects of which include agitation & hallucinations. The end result is the patients being physically restrained for at least 5 days.
Calmly I proposed to him that perhaps another way of looking at this would be that the 90% of patients with OP that don't develop symptoms & signs of cholinergic syndrome DON'T need Atropine therapy.
There was a full beat of silence, then a full moment of quiet contemplation by the whole room. Finally Dr L countered - but what harm is there in giving every patient (regardless of indication) Atropine for 5-7 days?
My response - Atropine has very unpleasant side effects & results in hospital staff tying patients to their beds in direct violation of their human rights - that one got a laugh. Nothing funnier than a direct violation of human rights.
The second occasion was this week when I was in negotiation with HS regarding a 33 year old woman who was dying a slow, painful & undignified death on his surgical ward. I was gently trying to explore issues around palliative care - this woman had no analgesia or sedation prescribed, she was unable to eat or drink & had poor mouth care. Invariably however one tries to discuss patient care - mitigating for a saving face culture & fragile egos - there is always a defensive response.
Again calmly (this is a great strain for me with my usual highly excitable state) I asked him not to get angry and we were just discussing the best care for a dying patient. After hostility usually follows a hopelessness/helplessness response - "I can't do anything, its beyond my capacity, we don't have the resources....etc.etc."
An idea is commonly floated by the hospital doctors that I should just write in the notes & stop talking to them. It has been pointed out that as I would be writing in english none of the nurses & few of the doctors would be able to understand what I had written. Of course there are more fundamental reasons why I object to this suggestion which I carefully & calmly explained to HS.
If I write in english in the notes - nobody reads, nobody understands, everyone ignores. If I see patients WITH a clinician & then have a conversation where ideas are explored & challenged then perhaps I will change their attitude, better still maybe when faced with a similar clinical situation in the future they will change their behaviour.
HS looked at me long & hard as he processed what I had just said, then with a look of resignation - blinded by logic - he took the patents notes from me and prescribed analgesia, sedation, IV fluids & basic nursing care.
The woman died later that same day.
There have been only two occasions in the last year where I have momentarily silenced the torrent of defensive abuse & excuses from the staff & seen the look of recognition of a sound logical argument & almost heard the penny drop. This of course is short lived and is followed by rebound excuses and hostility.
The first occasion was just a few weeks ago when I presented a CPG (clinical practice guideline - the existing MoH guidelines are dated from 1999 so are currently being updated) on organophosphate poisoning (OP), a common overdose & method of suicide here. In the CPG it describes the cholinergic syndrome that occurs with OP - another great mnemonic opportunity SLUDGE (salivation, lacrimation, urination, defeacation, GI upset, Emesis). The CPG clearly states that Atropine - the antidote - should only be given if a patient has signs of a cholinergic syndrome AND NOT just pupil constriction.
This revelation started Dr L on a pompous rant about how ridiculous this protocol was because at least 90% of the patients they see with OP in ICU never develop signs or symptoms of cholinergic syndrome yet they will all still receive Atropine.
The current situation is that any patient who claims to have ingested organophosphates receives large doses of Atropine, the side effects of which include agitation & hallucinations. The end result is the patients being physically restrained for at least 5 days.
Calmly I proposed to him that perhaps another way of looking at this would be that the 90% of patients with OP that don't develop symptoms & signs of cholinergic syndrome DON'T need Atropine therapy.
There was a full beat of silence, then a full moment of quiet contemplation by the whole room. Finally Dr L countered - but what harm is there in giving every patient (regardless of indication) Atropine for 5-7 days?
My response - Atropine has very unpleasant side effects & results in hospital staff tying patients to their beds in direct violation of their human rights - that one got a laugh. Nothing funnier than a direct violation of human rights.
The second occasion was this week when I was in negotiation with HS regarding a 33 year old woman who was dying a slow, painful & undignified death on his surgical ward. I was gently trying to explore issues around palliative care - this woman had no analgesia or sedation prescribed, she was unable to eat or drink & had poor mouth care. Invariably however one tries to discuss patient care - mitigating for a saving face culture & fragile egos - there is always a defensive response.
Again calmly (this is a great strain for me with my usual highly excitable state) I asked him not to get angry and we were just discussing the best care for a dying patient. After hostility usually follows a hopelessness/helplessness response - "I can't do anything, its beyond my capacity, we don't have the resources....etc.etc."
An idea is commonly floated by the hospital doctors that I should just write in the notes & stop talking to them. It has been pointed out that as I would be writing in english none of the nurses & few of the doctors would be able to understand what I had written. Of course there are more fundamental reasons why I object to this suggestion which I carefully & calmly explained to HS.
If I write in english in the notes - nobody reads, nobody understands, everyone ignores. If I see patients WITH a clinician & then have a conversation where ideas are explored & challenged then perhaps I will change their attitude, better still maybe when faced with a similar clinical situation in the future they will change their behaviour.
HS looked at me long & hard as he processed what I had just said, then with a look of resignation - blinded by logic - he took the patents notes from me and prescribed analgesia, sedation, IV fluids & basic nursing care.
The woman died later that same day.
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