The harrowing hospital night shift nothing could have prepared me for

The most important part of every night shift is matching your scrub top to your bottoms. Odd shades, bad luck. Match for the best chance of success.

I’m full of superstition because fate doesn’t follow conventional rules. I sit, cross-legged comparing until I’m satisfied with my choice. I pull my clothes off and my blue scrubs on. Stethoscope, badge and water bottle. Downstairs, grab phone and rush to handover, hoping I’ve remembered my pen.

Back of house, but this is no theatre production. A list of jobs to mop up from the day. Twelve wards, the nurse practitioner and me, “Let’s hope they all behave tonight”.

First up, fluids. Ward 50 needs a cannula, or two, or three – while I’m there. A couple of bags of normal saline go up and it’s time for me to go down to ward 20 where a lovely woman has slipped off the commode. She’s ever so embarrassed. A check from head to toe, some reassuring words and an offer of a gingernut. Then back to the desk to scribble down the story.

The phone rings, again and again, sore foot, chest pain – blood pressures through the floor and in the clouds. A woman sobers up and wants to leave – listening, persuading, assessing and eventually letting her sign the papers to walk out the door, no doubt next week we’ll meet again for the same dance.

A warm hand on my shoulder and cup of tea beside my hand. “Do you want some cake doc?” – I want nothing more. The 3am slump is here and sugar is my drug of choice. I sit, and chat – and melt into the ward for a few minutes.

An unfamiliar sound from round my neck – I answer, crash call. I drop everything and run. Down two flights of stairs, along the corridor. Turn right. I see a set of anaesthetic greens in front of me. “Bay four, bed six” a voice shouts, we pile in.

A man lies on the floor, breathing hard. Oxygen on. Pulse felt. No response to voice, grumbling to pain. Eyes deviating to the left. I grab the notes and start piecing together the history. Mild upper body weakness, query stroke, a head scan showed nothing much. Back to airway, gurgling noises from his throat. A tube down the nose to help get air into the lungs. We take an arm each, one for arterial blood and one for venous. My hands don’t shake.

Stabilised, we need imaging and fast. I ring the radiologist, ready to plead my case. “Send him down” she says. The ease of the phonecall doesn’t fill me with hope. My senior house officer grabs the emergency drugs from the crash trolley and a fresh faced nurse clutches the oxygen ready to transport. They follow him down. The ward becomes quiet.

I flick through a thin set of notes to try and build a picture. Lives with a loving wife. Walks his dog every day. Gave up smoking years ago – drinks a couple of pints on a Friday. Not too bad for a man in his 70s. Children and grandchildren.

A bed slides through the doors and he returns, the report is back. Large bleed. Blood pushing the brain against the skull. Neurosurgical opinion advised. My registrar arrives, talking fast to someone. I hear “grave”, I hear “imminent”. The bleed is too big and his brain is crushed. There is nothing we can do. Keep him conscious, keep him comfortable, next of kin.

The newly qualified nurse goes white. The notes are in my hand. “I’ll call,” the words leave my mouth before my lips move. A 4am phonecall to a telephone number. A quiet voice answers. She only left at 11pm, the nurses say. “I’m calling from the ward, about your husband, things have changed and I think you need to be here”. She’ll be here as soon as she can. Panic seeps through the phone and into my hand. “Will I make it?” her voice cracks. “Will I see him before he dies?”.

“Call me as soon as she arrives” my registrar says. I nod. She leaves. I stay, breathe in, walk around the corner, shut myself in the clean utility and put two hands up to my wet face. These aren’t my tears to cry but they still come. I push them all back in. Professional.

Years of training do not prepare you for this. Nothing prepares you for your role in someone else’s tragedy. I will leave the hospital in four hours and his wife will still be clinging to his hand. I will come back in 16 hours and they will both be gone. A new name earmarked for his bed. Another story that might end a different way.

The phone rings, and someone needs something. A temperature, a catheter and some laxatives. I glance down at my trousers. They were a perfect match.

Some details have been changed to protect patient confidentiality.

If you would like to contribute to our Blood, sweat and tears series about memorable moments in a healthcare career, read our guidelines and get in touch by emailing sarah.johnson@theguardian.com.

Join the Healthcare Professionals Network to read more pieces like this. And follow us on Twitter (@GdnHealthcare) to keep up with the latest healthcare news and views.

The harrowing hospital night shift nothing could have prepared me for

Standing Rock Represents a Shift in American Consciousness

Water is sacred. Water is life. Water is freedom. Water heals.

What the world has witnessed at Standing Rock is an unprecedented coming together of Tribal peoples and representatives of indigenous cultures from around the world who understand the urgency of protecting the sacredness of the water and the land.
Standing Rock marked a turning point in our nation’s history as American Veterans came to stand between international corporate mercenaries and the First Americans. Veterans came to stand with their Tribal brothers and sisters in defense of the land, the water and constitutionally guaranteed rights. As they acknowledged the atrocities that separated these great peoples, they also sought forgiveness for the horrors of the past. Standing together to protect that which is sacred, a great healing began. This represents a monumental shift in the consciousness of the people of the United States.
The Spirit of God is in the water, the land, the trees and all of nature. All of nature is sacred and so are we. We are not mere stewards of this planet. We are her children. We are sovereign. The onslaught of violence against our Mother Earth has also been an onslaught against us as her children and against our sovereignty.

False Paradigm

The control or confiscation of land and water, the assault on the health and well-being of life, all for the sake of controlling the resources of this planet is the centuries old model for the false paradigm. The Agenda 21 and 2030 models of environmentalism that separates us from our mother and supplants our relationship with layers of bureaucratic jurisdiction is just as false as the model of corporate confiscation that is exemplified by the Black Snake of the DAPL. Both remove the people from the land and give all authority to a few controlling globalists. Both serve to violate the sacred relationship between the Mother and Child. The symbolism in this violence is not lost on us.
The Long Nights Moon of December holds vigil over Standing Rock. The December moon brings a time of introspection and self-examination. Symbolically, it is a time of death and rebirth. It’s a time for casting off that which has proven untrue or deceitful; a time for reshaping the direction of our path. So too is it a time for our country to cast aside the false paradigm of dependence, lack, confiscation and control. We must restore our relationship with the sacred.
The coming together of Water Protectors and the Veterans represents a cognitive shift in perspective. Our ancestral participation in the Manifest Destiny was but a prelude to WWI and WWII, Korea, and the Middle East. The prospect of war with Russia so zealously propagandized by candidate Clinton is still spuriously promoted by President Obama. American troops are being positioned to again serve the will of a false paradigm.
Global corporatists and social technocrats are aligned in their rush to control the resources of the entire planet. Technocracy has no need of the sacred or sovereign. Instead, that which is devoid of life would supplant the sacredness of all life and consciousness with the sacrilege of an artificially intelligent post human technocracy.

Reclaim the Sacred

As the long nights of introspection give way to the re-birthing of life, we must find both the will and the wisdom to reclaim the sacred in ourselves, in our land, in the water, and in our future.

The Water Protectors remain encamped in the snow and blizzard conditions to safeguard their land from the Dakota Access Pipeline. The whole world is watching. In solidarity, we are all standing watchful and determined. The path forward must be a sacred path. We each claim the sovereign responsibility to heal ourselves, our water and our land.

Let the coming together of the Water Protectors and the Veterans set an example for the reuniting of our beleaguered and election weary Country. Let the courage of forgiveness and true healing lead us forward. May our next President rise to the responsibility of leadership that healing this sacred nation requires.

Standing Rock Represents a Shift in American Consciousness

My Christmas shift showed me the human connection behind medicine

My first medical on-call shift was on the evening of Christmas Day. Wary of what to expect, I joined my family for an early dinner with a cloud of trepidation hanging over it. The post-food cosy daze that everyone has after their traditional meal turned into the pre-work tetchy panic that every doctor has before a night shift.

I arrived at the hospital at 9pm to find remnants of Christmas cheer lingering on every ward. Boxes of half-eaten chocolates, needles starting to drop from Christmas trees, tinsel becoming unstuck and dangling from the walls, and families trickling away from the hospital after spending the day with their loved ones – it’s like you’ve arrived late at a party after everyone has left.

For the first few hours I was strangely enjoying my first medical on-call shift. It was a refreshing break from the daily grind of writing in patients’ notes what my consultant says on ward rounds and typing discharge summaries. I was reviewing and managing unwell patients, which is what I had been trained to do.

Fuelled by adrenaline, excitement, and those half-finished boxes of chocolates on the ward, I was in full flow. Please review this patient who is not producing enough urine: “urine problems – I remember the causes and treatment in a kidney lecture”. Please review this patient who’s got a temperature: “review patient, check the nursing observations, take some bloods, do I need to start some treatment straight away?”. Please review the ECG of this patient who’s developed chest pain: “reading ECGs – let’s decipher these squiggly lines step by step”.

I had just managed to clear the backlog of jobs when my bleeper barked into life: “Cardiac arrest, ward x. Cardiac arrest, ward x”. I immediately got off at the next floor and ran to the arrest call. By the time I got there, CPR had already started and my medical registrar arrived 20 seconds after I did. It was my first arrest call.

I took over doing compressions. Crack, one rib broken. Crack, another rib broken. At least I was doing good compressions. The consultant asked: “Can you get a blood gas from the patient?” Stab, the needle goes into the groin, nothing. Someone else has got it already. He continued: “Can you get the results please?” pH 6.9, lactate 11 – not good. I ran back to find the patient’s heart had successfully restarted.

At this point, a medical TV drama would cut to another scene. In reality, the patient’s heart was restarted but they were intubated and unconscious. The family later arrived and decided it would be in the patient’s best interests not to continue further care. I later certified death, feeling particularly poignant as it was Christmas, a time of celebration for a birth and new life. As I wrote the last entry in the medical notes, I saw the patient’s distraught family walk away from the ward, feeling their sadness as I signed my name and wrote the letters RIP.

With those swirling thoughts, I was no longer a doctor, but a ​person​ mourning the loss of another

Unyielding and relentless, I was bleeped again. My steps towards the next job got slower and slower as my brain swirled with thoughts of that arrest, that patient, and that family. The arrest call itself is a paradox – laid bare it is the most human act done in the most inhumane way. The act of trying to save someone’s life, of you pumping your fellow human’s heart, touches on the very essence of humanity’s common bond. The process, however, is as savage and barbaric as it is life-saving.

As part of the arrest call team, I was focused on my job of restarting the patient’s heart. That focus strips away the humanity of the patient, reducing life to lines on a screen and numbers on a chart. With each passing cycle, the focus intensifies until it changes into a mix of desperation and willpower – willing the tube to go in the lungs, the blood to flash back into the syringe, the pulse to return. And when it’s suddenly over, the humanity returns.

With those swirling thoughts, I was no longer a doctor, but a person mourning the loss of another. I stopped, turned around, sat in a quiet room and had a chat with one of the nurses who was also at the arrest call. We talked about anecdotes from the patient’s stay in hospital and our own lives. It felt refreshing to talk about the life that was lived in the face of the sadness of a life that was just lost.

Mentally and physically exhausted, I was glad to hand over the on-call bleeper at the end of my shift to the next bearer of that cross. As I walked out of the hospital, I reflected on every job I’d had during the night, still wondering how the family of the patient who died was coping and what the diagnosis would be of one patient I asked my registrar to review.

Nights are said to be one of the best learning experiences. At the end of my set of nights, I was comforted not only by the wealth of skills and knowledge I could take into the new year, but by the care I had given to my patients to make their Christmases that little bit better.

Everyone takes something different away from their medical on-call experience. I will always remember that behind every patient and medical diagnosis there lies a human connection that binds us all together.

Join the Healthcare Professionals Network to read more about issues like this. And follow us on Twitter (@GdnHealthcare) to keep up with the latest healthcare news and views.

My Christmas shift showed me the human connection behind medicine

The night shift in A&E: a hellish blur where my best is never enough

It’s the start of my night shift in the district general hospital as the medical registrar. I’m on my own and I know it.

Like every night shift, I have no idea how I’m going to function effectively and people’s lives are in my hands. These thoughts are not new – I expect them – but each time they feel painfully new and unwelcome. I push down feelings of panic and remind myself that I have experience and training. I have done this, I can do this.

There is a long line of people waiting in A&E. They must experience only one thing: reassurance. It isn’t a convenient time to feel the anxiety that threatens to overwhelm me, so I ignore it. These people are sick and worried, and they deserve the best.

After putting on scrubs, I sit down with the team of doctors and nurses who’ve been on the day shift and listen to their handover. Half them haven’t eaten that day. It’s been a busy one. Things started to go wrong after 5pm so at least 10 people have not yet seen a doctor and two of them are so ill they are being monitored in resuscitation. Someone jokes: “It’s OK though, A&E is closed now”. If only.

I need to prioritise but there are distractions. A family member is kicking off on the acute medical ward about their mother not getting appropriate feeding time that evening. Important but not life threatening, they will have to wait.

The surgical team wants the medical team to take over a patient who, they’ve found, “doesn’t have appendicitis”. This patient, too, is de-prioritised – I have two adults about to die in the resuscitation bay. It’s 10pm and we have already spent far too long talking about the patients from the day – I need to crack on.

I’m told there are no critical care beds available, so if one of my patients needs intensive care, we’ll need to send a patient in an ambulance to another hospital to create space. This is not a new scenario. I tell the bed managers this is “exactly what I want to hear”. Another joke. Without this attitude, we wouldn’t be able to get through the night.

A lot of people will be unhappy with how long they’ve spent waiting by the time I get to see them. Although I won’t rest, it will never be enough. I thank the stars for the nurses. They are masters of everything and seem to be everywhere in the hospital at night, roaming the wards, expertly identifying sick patients. They can put in cannulas blindfolded, and support you with tea and banter.

All six beds in resuscitation are full. Two patients require machines to breathe: one is alert, the other is already anaesthetised. Anyone who can’t talk, as a general rule, needs to be seen immediately. However, these sick people cannot be moved from their temporary beds in A&E – there are no beds free in the hospital.

It’s going to be a long night. I see the exasperated paramedics in a queue; they can’t drop patients off. My juniors, just two of them for 150 patients, get to work, but it is hard. There is nowhere private to see people. They are reduced to clerking patients on trolleys and chairs – it’s not dignified. The unsung heroes of A&E – the technicians – efficiently take blood and perform basic but critical investigations such as urine dipstick and electrical heart traces.

In a moment of clarity, at 1am after I have barely stopped to breathe and an elderly lady has died in my arms, I ask myself: “Is this not supposed to be a developed country? Do we not care for our people? Do we really accept that this is the way it needs to be? Doesn’t anyone out there care that there are no beds?”

The night starts to blur. At 4am I anticipate a huge drop in my performance as my mind sleeps while my eyes remain open. I attempt and fail to get 20 minutes’ sleep – the bleeper doesn’t stop. But before I know it the porters, domestics and secretaries start turning up in the corridors, usually the earliest to start, and I know that this hellish night shift is almost done.

I hand over my patients to the day team and the consultants. I get changed. I leave. For a moment it feels like I am a kid again, carefree, outside, letting a warm downpour wash over me, soaking my clothes, removing the things that happened overnight. Relief.

I have a brief, pointless cry in the driver’s seat. And then it’s forgotten. It has to be, because in in a few hours, I’ll do it all over again.

If you would like to contribute to our Blood, sweat and tears series which is about memorable moments in a healthcare career, please read our guidelines and get in touch by emailing sarah.johnson@theguardian.com.

Join the Healthcare Professionals Network to read more pieces like this. And follow us on Twitter (@GdnHealthcare) to keep up with the latest healthcare news and views.

The night shift in A&E: a hellish blur where my best is never enough

Emily’s List aims to shift US Congress to the left – state by state

In the midst of a political season in which all eyes are on the US presidential election, one of America’s largest women’s rights political advocacy groups is turning its attention to a new mission: state legislative races.

Emily’s List, a group that traditionally focuses on electing individual pro-choice women to office, announced a new plan to target seven vulnerable states where they believe they can flip the some of legislatures from red to blue – and then, perhaps more permanently, the US Congress.

The idea is that if the group can help elect enough Democratic women in state legislatures by the 2021 congressional redistricting cycle, they’ll be able to swing both many state houses and the House of Representatives in favor of Democrats, and make it more likely to pass legislation in favor of reproductive rights and women’s equality.

“Currently, Republicans control 68 of 98 legislative chambers in the United States,” said Emily’s List president Schriock. “That’s a result of the 2010 elections, when the Democrats lost so many state legislatures.”

Once there, she said, “Republicans gerrymandered a huge number of Congressional seats,” a reference to the constitutionally-protected redistricting process, leading to the Republican takeover in the US House. They also pushed what she termed “an extreme anti-choice legislative movement” on the state and federal level, while blocking any progress on equal pay legislation, child care assistance, paid sick time or family leave.

The women of Emily’s List want that to stop. To that end, on Tuesday the organization launched Focus 2020, vowing to help elect enough pro-choice Democratic women in 2016, 2018, 2020 and beyond that they will be able to build Democratic legislative majorities in 14 states in time to affect the partisan make-up of the US Congress.

“We’ve got to end this process of gerrymandering by Republicans,” Schriock added. “We have to make sure that we have fair districts in this country, so that we can fight over ideas, not process.”

First up in 2016, Emily’s List is pushing candidates in Michigan, Maine, New Hampshire, Nevada, Minnesota, New Mexico and Colorado – all states that have passed or nearly passed anti-abortion legislation over the last few years.

In Colorado, widely seen at the original home of the so-called “personhood” movement – which attempts to define fetuses as people under the law and thereby classify abortion and even some methods of birth control as murder – the senate went from blue to red in 2014, after a razor-slim Democratic majority created by the recall of two pro-gun-control Senators in 2013 failed to hold.

To change that, Emily’s List has endorsed three pro-choice women in state senate races there, though Democrats need to only pick up two seats. Rachel Zenzinger, who is challenging a Republican incumbent, Laura Woods, to retake the seat she she lost to Woods by 663 votes in 2014 is one of them.

Zenzinger describes her race as “a swing district in a swing country in a swing state” where “you would think [Woods] would be trying to defend and protect women and women’s issues, but she’s done the exact opposite”.

Woods supported a variety of anti-abortion bills in the last session, including ones that Zensinger said “ranged from mandatory, invasive ultrasounds to defunding a local university because it used fetal tissue for research” in addition to one that would have defunded Planned Parenthood.

Given the anti-abortion movement’s history of unsuccessfully putting “personhood” legislation on the ballot, Zenzinger believes that many Republicans “will try to seek action legislatively, where they have the opportunity to control the agenda if they are able to maintain the Republican majority” in the state senate.

But beyond the immediate concerns for reproductive rights in the state, Zenzinger says that if her party fails to regain a majority presence in the state Senate by 2020, her constituents will see a “significant rolling back of the clock, just trying to go back and undo some of the good, progressive work that has been done over the past few years that really benefitted everybody in Colorado” – let alone anything that might be on a Democratic president’s agenda.

Last April, the Michigan state House of Representatives passed a budget defunding Planned Parenthood. It’s another state where Emily’s List is backing candidates under the Focus 2020 initiative in an attempt to bring that state’s House of Representatives back under a Democratic majority. One of these candidates is Collene Lamonte. Like Zensinger in Colorado, Lamonte also lost a seat she held during the 2014 midterm elections. She’s running to regain the seat she lost to a Republican opponent.

“A lot of issues in Michigan, things are not able to move forward because of a lack of women in our political system right now. Pay equity in our state is a huge issue – Michigan is lower than the national average when it comes to pay equity for women. And we haven’t been able to get that addressed with our current legislature,” Lamonte says. “And we continue to see bills that restrict women’s access to proper healthcare in the state. We need to ensure that women receive proper access to healthcare when they need it, without facing barriers.”

In 2018, Emily’s List plans to expand its focus to Ohio, Pennsylvania, Florida, Georgia, North Carolina, Virginia and Wisconsin – many of which have legislatures that are notoriously hostile to women’s reproductive rights, and some of which have voted for national Democrats even while their Congressional delegations skew Republican.

“We know that we have three full election cycles ahead of us,” said Schriock. But, if Republicans are able to gerrymander as many districts in 2021 as they did in 2011, “Women for generations are going to be left behind in this country.”

Emily’s List aims to shift US Congress to the left – state by state

"I crashed my car after a night shift and now have post-traumatic stress disorder"

Last month, the Guardian Healthcare Professionals Network published an article about the dangers of doctors driving home after working nights. Two in five UK doctors (41%) have fallen asleep at the wheel after a night shift, according to an online survey of 1,135 doctors from Doctors.net.uk.

Within hours of publication, the network was flooded with emails, tweets and comments below the line and on Facebook from various healthcare professionals who wanted to share their thoughts and experiences. Here are some of them:

I crashed my car after a night shift and now have post-traumatic stress disorder

Back in 2005, I was an FY2 doctor in orthopaedics. Like most junior doctors even today, we would do seven night shifts in a row. Sleeping during nights (even if you had a chance) was frowned upon. When I started foundation training, there was a doctors’ office which had a bed but it was removed by the management in front of us. They insisted that junior doctors should never sleep during their night shifts and if they did have a free moment they should be doing discharge summaries etc.

One Wednesday morning after I had worked five, 12-hour night shifts and had two more to go, I managed to get home and caught a few hours’ sleep. I woke up at around 12pm and decided to drive to the shops. Once on the main road, I quickly began to feel very tired and disorientated. I turned around to head home, but at a major roundabout suddenly crashed into a car. I am convinced that more than 60 hours of night work were behind the accident that day and still feel incredibly lucky that I did not kill anyone that day or get killed myself.

The NHS is destroying its staff, sometimes literally by the accidents from driving home so tired.

As a result, I have post-traumatic stress disorder related to driving. I am so terrified of driving post-nights that I only live within walking distance of hospitals and walk home after every shift. I dare not apply for jobs that involve a commute of any kind and hence I am stuck in non-training jobs.

I fully understand that night shifts and night work is an integral part of my job but it does not have to be so hard or so difficult to provide us with on-call rooms or a reduced number of shifts. I will be 37 soon and I am still doing blocks of three or four very intense nights shifts. My body, my spirit and my life are feeling the pain.

Dr Hunniya Waseem, senior clinical fellow, emergency medicine, Bury St Edmunds

Nurses are not allowed to sleep on their breaks – it is a sackable offence

I have fallen asleep at the wheel after working a night shift. I have been a nurse for 10 years and this has happened to me on quite a few occasions.

Nurses are not allowed to sleep on their breaks – it is a sackable offence if they are caught. I spent almost five years working in emergency medicine and the shifts are tough. We often go without food and drink for the entire shift.

I once worked a shift where I had three patients suffer a cardiac arrest in one night. The first was an elderly gentleman; I hadn’t even been told his name before he arrested. He survived. The second was a man in his late 70s who we expected to pass away. The third was the toughest; it was a man in his 30s who had alcoholic liver disease. He arrested at 6.55am, just before the day staff came on. I was working with an agency nurse because we were short staffed. We worked on him for 90 minutes. I left the hospital at 9am after starting at 7pm the evening before.

That morning there had been two major accidents on the roads. It took me two hours to do a 20-minute journey. The traffic was going at a snail’s pace and I fell asleep multiple times that morning in the car. It was midday by the time I got home, showered, reflected on my horrific shift in order to rest properly and crawled into bed. My alarm went off five hours later to do it all again.

Anonymous

Sometimes I wonder how I’m still alive – who looks after NHS employees?

I am a mental health nurse who has worked within the NHS since 2003. Sometimes I wonder how I’m still alive.

In the morning, at about 5am when I’m about to finish my shift, I find it very difficult to keep my eyes open or concentrate enough to even have a conversation with my colleagues.

My concern is when you finish at 5pm, and then get a call immediately from A&E. We cover a big area and I have to go out and assess the patient within four hours. Then you get another call from another A&E, and then another. Sometimes I’m almost home by midnight and get another call.

Something really needs to be done about this. It’s dangerous for anyone to drive while tired, and I know some people would say, park and rest. At that time of the night/morning, where does one park and rest?

The NHS is destroying its staff, sometimes literally by the accidents from driving home so tired. Who looks after NHS employees, because the NHS certainly doesn’t?

Mental health nurse, West Yorkshire

Related: ‘Don’t be a smart arse’ – a junior doctor’s survival guide

I fell asleep at the wheel and was woken up by the car running out of petrol

I fell asleep at the wheel once as a student nurse coming home from a particularly difficult night shift at my placement hospital 30 miles from home. I was lucky as it could only have been for a minute before I got shaken awake by the car running out of petrol as I’d not been able to afford to fill it up on my way in. I sat on the hard shoulder and cried for a good hour until the police came along and knocked on my window. Luckily for me one of the kindest policemen I’ve ever met went and bought me a fiver’s worth of petrol and then followed me home to make sure I got there safely.

Anonymous nurse

It’s not fair for the doctors or their patients

Some hospitals still let you rest but some are militant against any sleeping (often the nurses get it worse than us). As a more experienced junior doctor now, I know my decisions around clinical care and my safety on the journey home require me to have some sleep. Even if that’s just 20 minutes, the difference is vital.

I have been a qualified doctor for three years. Last year my commute was 10 miles down winding country lanes and after a series of seven consecutive night shifts (totalling a 90-hour week) I crashed my car into a brick wall outside my house. Fortunately the damage was only material.

My hospital didn’t provide rest facilities after a night shift so when I finished my medical shifts at 10-11 am I would have to decide whether to risk driving home or sleep in our communal staff room where my day-time colleagues would be taking their breaks. There is no dignity in this. It is not safe and it is not fair to the doctors forced to make these decisions or to the patients they are treating half an hour earlier.

We are doctors, we are humans and our first priority is all too often our patients. Sometimes we need an advocate to protect our interests and safety and this is sadly lacking.

Jenny Worrall, doctor

Join the Healthcare Professionals Network to read more pieces like this. And follow us on Twitter (@GdnHealthcare) to keep up with the latest healthcare news and views.

"I crashed my car after a night shift and now have post-traumatic stress disorder"

White Home Strategies To Shift Medicare Away From Fee-For-Support 50% Of Payments Tied To Good quality By 2018

The Obama administration will push Medicare payment swiftly away from charge-for-services medicine within four years, outlining a program to have half of all Medicare bucks paid by to doctors and hospitals by means of “alternative” reimbursement models by the finish of 2018.

U.S. Secretary of Well being and Human Solutions Sylvia M. Burwell today said reforming Medicare payment is a priority now that millions far more Americans have overall health coverage beneath the Affordable Care Act and her company as a result will concentrate “energies” on making use of “incentives to inspire increased-value care.” A detailed seem is here.

“A vast majority of Medicare charge-for-service payments currently have a link to good quality or worth,” Burwell stated in a standpoint piece published in the Jan. 26 New England Journal of Medicine. “Our purpose is to have 85% of all Medicare charge-for-service payments tied to top quality or worth by 2016, and 90% by 2018. Probably even far more crucial, our target is to have 30% of Medicare payments tied to high quality or worth by way of alternative payment designs by the end of 2016, and 50% of payments by the finish of 2018.”

Currently, just twenty percent of payments from the Medicare well being insurance system for the elderly are paid through option payment versions like bundled payments, patient-centered health-related houses and accountable care organizations, a swiftly emerging care delivery program that rewards physicians and hospitals for operating collectively to improve top quality and rein in expenses. In these designs, medical doctors and hospitals get on more risk that they can streamline the care, improve quality and remove bureaucratic inefficiencies.

“Three many years in the past, Medicare produced virtually no payments by means of these alternative payment versions,” Burwell stated.

Just last week, UnitedHealth Group UnitedHealth Group (UNH) reiterated its commitment to enhance payments that are tied to value-based mostly arrangements to $ 65 billion by the finish of 2018.  Aetna Aetna (AET), Cigna Cigna (CI), Humana Humana (HUM) and other individuals are expected to supply updates on their worth-based mostly contracting for this yr inside the subsequent two weeks.

Asking yourself how the move away from charge-for-support medicine  will affect your overall health care? The Forbes eBook Within Obamacare: The Resolve For America’s Ailing Well being Care Technique answers that query and much more. Accessible nowat Amazon and Apple.

• Page one / 2
  


• Continue
  

White Home Strategies To Shift Medicare Away From Fee-For-Support 50% Of Payments Tied To Good quality By 2018

Guideline Critics Shift Attacks From Beta Blockers To Statins

With the release today of updated European and US guidelines the ongoing controversy regarding beta-blockers appears to be resolved. But that doesn’t necessarily mean there will be an outbreak of guideline peace and harmony. The critics who helped ignite the controversy over beta blockers now say new statin recommendations contained in the guidelines are based on deeply flawed evidence.

The previous incarnation of the European guideline on perioperative evaluation and treatment of people undergoing noncardiac surgery was the subject of intense criticism due to the scandal discrediting Don Poldermans, a Dutch researcher widely published in the field. To address the current uncertainty US and European medical societies earlier today released updated versions of these guidelines.

“Given the recent publication of several large-scale trials, including POISE-II, and new risk calculators, as well as the controversy regarding the use of beta blockers related to the DECREASE trials, the writing committee felt it was necessary to reevaluate all of the data on cardiovascular care for the patient undergoing noncardiac surgery,” said US Writing Committee Chair Lee Fleisher, in a press release.

Regarding beta-blockers the US and European guidelines now do not recommend routine use in patients who undergo non-cardiac surgery, though people who are already taking beta-blockers should continue taking them. (Previously the European guideline but not the US guideline did support routine use of beta-blockers.) Both guidelines state that beta blocker therapy may be initiated prior to surgery in carefully selected higher risk patients.

Statin Recommendation Comes Under Fire

Both the new European and US guidelines say that preoperative initiation of statin therapy may be considered in patients undergoing vascular surgery and that people already taking statins should continue taking them. Now some of the same critics who attacked the reliability of the beta blocker guideline say that this recommendation is not supported by the evidence.

The new recommendation is based on several observational studies and one randomized controlled trial. (Two other randomized trials were not considered because they were performed by Poldermans’ group and have been discredited.) The  critics, UK cardiologists and researchers Darrel Francis and Graham Cole, say that the one  trial by Durazzo et al has fatal flaws that make it completely unreliable. (Durazzo, it may be worth noting, had been a frequent co-author of Polderman’s and had been a co-author of several of the controversial or retracted studies.)

In an analysis published earlier this year, Cole, Francis, and co-authors wrote that the Durazzo study

…was a double-blind randomised trial of 100 patients undergoing vascular surgery, with a 45-day course of atorvastatin or placebo. It sought reduced perioperative events in the atorvastatin arm, which indeed was what was found: 8% versus 26% (p = 0.031) at 6 months [22].

This study has serious failings, which make it an unsound basis for recommending therapy. First, its sample size calculation is stated to have been based on a 22% event rate at 6 months in a previous paper [23]. In reality, the source article states that the rate was 12% at 6 months. Such a transcription error would cause a study to be approximately 4-fold undersized.

Second, the authors indicate that they designed their study to detect a relative risk reduction of 95%. This study design is not credible as no therapy has ever been so effective in preventing myocardial infarction. If the true effect size was, for example, half of this, this overestimate would have contributed a further ~ 4-fold undersizing of the study.

Third, the survival data published cannot be correct. The paper reports that of the 50 patients in each arm, none were lost to follow-up. Therefore, every patient surviving to each displayed time point should be exactly 2%. With this in mind, in the Kaplan–Meier graphs, almost all the numerical values in the survival follow-up figure contradict the graphical values shown.

Finally, for 50-patient groups with no loss to follow-up, event-free survival rates must again be multiples of 2%. They are quoted as 91.4% and 73.5%, values that are not possible.

Francis and Cole sent the following comment about the new guidelines:

We are very sad that over 100 world authorities were forced to sign the European guideline without all having had time to read the papers on which their recommendations were based, and without being able to openly voice dissent.

Their awful predicament is easiest to see for a therapeutic idea whose road has been very “bumpy” indeed: the perioperative course of statins. The outcome data of the key trial by Durazzo et al has for over 6 months been publically known to be impossible. This is buttressed by Don Poldermans’ now notorious DECREASE III and IV trials, whose own university’s investigation revealed extensive fictionalisation, and by meta-analyses whose events arose mostly or entirely amongst these extraordinary pieces of science.

There are important lessons to learn. First, guidelines must in future have the right to say that all the major trials have now been discredited, so there is no longer a recommendation. If we fail to recognise this, we have truly failed our patients.

Second, never again should we pretend that all the experts have agreed on recommendations. It was always unlikely, and in this case clearly ridiculous.

In an interview, Fleisher, the chair of the US guideline, defended the committee’s recommendation of statins. He said that the committee was aware of the limitations of the Durazzo study and that the recommendation was based on the totality of the evidence, including the observational studies. He agreed that there was a significant need for more high quality studies.

Guideline Critics Shift Attacks From Beta Blockers To Statins

Shift Perform Linked To Elevated Chance Of Kind two Diabetes

Kind 2 diabetes is much more frequent in people who perform shifts, according to final results of a new research.

Data from the study adds to the ongoing concern for those who function shifts, in which known dangers currently contain cancer, digestive diseases, and cardiovascular disease.

Findings of the review have been reported July 24 in the Journal, Occupational and Environmental Medicine.

“Physicians have long been mindful that rest is a critical component of our health,” explained Dr. Alan Manevitz, Clinical Psychiatrist at Lenox Hill Hospital in New York City.  “So a new study linking shift perform – in which ten million Americans take element – to type two diabetes is not ‘new news’.”

“Since diabetes itself is induced by a blend of genetic and way of life variables, like rest, the results make sense,” additional Manevitz.

It is believed that disruption of rest patterns top to lack of rest, triggers metabolic and hormonal adjustments foremost to boost in appetite, and subsequent excess weight achieve.

In truth, benefits of earlier sleep scientific studies in laboratory settings have already demonstrated that asking people sleep during daylight hrs can lead to the early phases of type two diabetes inside a couple of weeks.

The examine, a meta-evaluation, evaluating over 226,000 persons, offers an even more powerful association among altered sleep patterns and improvement of kind two diabetes.

Data from the study, from the Huazhong University of Science and Engineering in China showed that general, shift workers have been 9 % far more likely to have sort two diabetes. In guys, the threat rose to 35 % and in individuals who rotated in between day and night shifts, the danger was even higher—42 percent.

The authors publish, “Given the growing prevalence of shift function around the world, and the hefty economic burden of diabetes, the outcomes of out study supply useful and valuable clues for the prevention of diabetes.” With the addition that “male shift workers should shell out much more interest to the prevention of diabetes.”

The cause for boost chance for variety two diabetes is very likely connected to altered sleeping and consuming patterns as a result of shift operate. 1 explanation is that eating late at night makes one a lot more likely to store the calories as excess fat, major to an boost threat for growth of weight problems, and consequently variety two diabetes.

Another explanation is that the daytime amounts of the male hormone, testosterone are managed by the circadian rhythm, the body’s internal clock. Shift operate seems to influence the clock foremost to lower testosterone levels, which are in the end linked to insulin resistance and development of diabetes.

Nevertheless, other aspects beside testosterone might also be at function.

“Study authors implicate the disruption of the male hormone testosterone as a single likely trigger of insulin resistance and diabetes in examine participants,” Manevitz explains, “but a wide array of other physique chemical substances are also skewed when typical rest patterns are disrupted, which includes leptin and development hormone.”

Bu yet another critical syndrome predisposing one particular to diabetes also deserves special mention, in the setting of the discussion of diabetes.

Shift Perform Linked To Elevated Chance Of Kind two Diabetes

Coroner"s ruling witnessed as a "seismic shift" in how eating problems are addressed

A coroner’s ruling that a younger girl killed herself even though struggling from anorexia nervosa should be the jolt that leads to a “seismic shift” in the way eating problems are addressed by policy makers, the chief executive of Australia’s peak consuming disorder help group says.

Employees failed to observe 23-year-previous Alana Goldsmith when she walked out of the private hospital exactly where she was receiving remedy for the eating disorder she had suffered since she was 15. She was located dead a couple of hrs later.

The coroner handed down his findings at the inquest into her death, in July 2012, at the New South Wales coroner’s court in Sydney on Tuesday.

Coroner Mark Douglass found Goldsmith died as a consequence of committing suicide whilst struggling from anorexia nervosa, but explained the motives for his finding would not be launched right up until the following week.

The chief executive of the Butterfly Foundation, Christine Morgan, stated it was the 1st situation she was mindful of in which a death certificate would consist of a reference to suicide alongside anorexia nervosa.

“If you are struggling from an eating disorder, and anorexia nervosa in specific, your rate of suicide is 32 occasions higher than a person who is not struggling,” she said.

“It is a really, very critical psychological illness that needs to be recognised for what it is. It is not a life-style selection.

“By recognising suicide threat is heightened for an individual struggling from anorexia nervosa, this obtaining can jolt a seismic shift in the way governments resource communities to deal with eating disorders.”

The newest obtainable figures recommended 914,000 Australians suffered from an eating disorder in 2012, she stated, and much more than one,800 died prematurely from an consuming disorder in the exact same year.

Anorexia is the most lethal of all psychiatric ailments. However it has been exposed that in NSW, there are only two public adult inpatient eating disorder beds.

Morgan said supplying far more beds was essential, but there was also a dire need for far more funding for consuming disorder care in the local community from psychologists, psychiatrists and GPs.

“The most important issue is to keep somebody [struggling from an eating disorder] protected and the second most critical point is to preserve doing work with them,” Morgan said.

Douglass discussed whether or not to release Goldsmith’s identify, but the family’s attorney stated they wanted it created public. Douglass informed the court: “I think it is in the public curiosity these sorts of deaths are the topic of public scrutiny.

“The court offers its assistance to the loved ones of Alana and especially her mother, who has persevered on a day-to-day basis right after what occurred to her daughter.”

Following the coroner’s obtaining, Goldsmith’s younger sister, Simone, go through out on a statement on behalf of her household.

“We hope that the findings handed down today bring about meaningful discussions amongst our well being policy makers and lead to decisions that consequence in a lot more sources and greater care for this epidemic dealing with Australia,’’ she mentioned.

“Alana was a enjoyable-loving, vivacious and intelligent young girl until anorexia nervosa starved her brain and destroyed her hopes and dreams.

“For the final 3 years our hearts have been heavy without having Alana enriching our lives. The inquest has shone a light on the many issues impacting eating disorder sufferers, carers and practitioners.”

Butterfly Basis Supportline: 1800 33 4673

Lifeline: 13 11 14

Coroner"s ruling witnessed as a "seismic shift" in how eating problems are addressed

New skin cancer drug hailed "paradigm shift" in therapy

Advanced skin cancer, which has spread to other components of the entire body, has a bad prognosis and currently only 1 in 10 individuals dwell for a yr after diagnosis.

However some men and women have lived for two many years although getting the new therapy.

The new drug is being evaluated for use in 30 varieties of cancer.

The review, presented at the annual meeting of the American Society of Clinical Oncology (ASCO 2014), showed 3 quarters of sufferers responded to the drug.

The drug is an antibody that enables the body’s immune system to as soon as again ‘see’ the cancer as a foreign invader and so attack it.

Numerous businesses have begun producing similar medication and have been testing them in a selection of cancers.

A single known as ipilimumab (Yervoy) is presently on the market place for advanced malignant melanoma and can improve regular survival from six months to ten months when in contrast with common treatment.

The new drug was found to increase survival in those sufferers whose cancer had started out increasing once more following treatment with ipilimumab.

Gillian Nuttall, Founder of Melanoma Uk explained: “Advanced melanoma is a horrible disease with a bad prognosis.

“Pembrolizumab represents the most current advance in a whole raft of new treatments in superior melanoma which have come by way of above the past couple of many years.

“The pembrolizumab outcomes are really fascinating and could signify a turning point for sufferers affected by innovative melanoma giving them a greater likelihood of survival.”

The makers, MSD, are hoping to apply for a European licence by the end of the yr and it has been accepted for a rapidly-track licencing method in America.

Professor Peter Johnson, Cancer Study UK’s chief clinician, said: “It’s interesting to see the variety of new therapies that are emerging for individuals with innovative melanoma. These new therapies harness the body’s own immune system to fight this cancer that has previously been so difficult to treat properly.

“Melanoma can only grow by discovering a way to escape detection by the immune technique. One way it does this is by triggering a shut-off switch on immune cells when they get near to the tumour.

“This therapy blocks the cancer cells’ capacity to use this switch, permitting the immune technique to recognise and ruin the cancer. We are seeing a entire variety of these immune therapies coming into the clinic, primarily based upon the excellent progress we are making in our investigation into the immune program.”

New skin cancer drug hailed "paradigm shift" in therapy

Half of nurses function by means of breaks or beyond their shift

Half of nurses are working by way of breaks or past their shift, revealing a health services beneath “significant strain”, a new report has warned.

A survey of almost three,000 nurses by Unison showed that two thirds believed they did not spend enough time with individuals, which most stated impacted care.

The report, Operating on Empty, stated half of nurses had been not confident about raising any issues they had with their local managers.

Gail Adams, Unison’s head of nursing, explained: “1 of the most damaging findings of this survey is how tiny has transformed given that final year. Despite all the government rhetoric, in spite of the Francis, Keogh and Cavendish reports, the spectre of one more Mid Staffs still looms big over the NHS. Progress on safe staffing amounts has been glacial and that signifies poorer care and patients nevertheless at risk.

“It really is clear that in spite of nurses doing work through breaks and past their hours, they merely do not have ample time to give patients the care and attention they want. That is distressing for patients and for the personnel trying to care for them.

“The Government requirements to encounter up to the damage it is inflicting on patients and staff, by not introducing legally enforceable nurse to patient ratios, and take urgent action.”

The union claimed that the survey also exposed an “in excess of use” of agency staff in the NHS.

In one more review final week, Unison said the ambulance support was on the verge of breaking down due to the fact of anxiety levels between employees.

The concerns will be debated at Unison’s overall health conference in Brighton, which opens these days.

Half of nurses function by means of breaks or beyond their shift

Doctors paid up to £3,000 a shift, official figures show

All the sums incorporated costs paid to agencies, which typically consider around 15 per cent of the bill. Some medical doctors had been rewarded not just for the hours they worked, but for all the time they had been on phone, like when they have been sleeping.

The figures propose that the complete bill for these agency employees in 2013 was almost £250 million, a rise of one particular third in two many years. This would have been enough to pay out the yearly wages of 3,000 consultants or more than seven,000 junior doctors.

Experts stated the figures disclosed the full extent of a crisis in which casualty departments have turn into “entirely dependent” on short-term workers, amid desperate shortages of senior physicians and consultants.

Senior managers have previously insisted that rates of £1,000 per shift or far more are paid only in crisis situations where there is no alternative.

The investigation by The Telegraph shows that NHS trusts are routinely paying out such sums to meet workers shortages.

The evaluation located:

• Heart of England NHS Basis Believe in in Birmingham paid at least £1,000 per shift on 719 occasions final 12 months

• Kettering Common Hospital Foundation Believe in paid such charges 595 occasions in 2013, while Northern Devon Healthcare Trust did so for 255 shifts

• Barking, Redbridge and Havering University Hospitals Trust in Essex had the highest bill for A&ampE company personnel, spending £7.1 million last 12 months, like 217 shifts paid at prices of at least £1,000 each and every.

The hospital was recently put on special measures right after its casualty unit was discovered to have the worst shortages of senior medical professionals in the country, with 13 out of 21 posts vacant.

The University of Emergency Medication, which represents A&ampE medical professionals, says there is a shortage of virtually 400 consultants in Britain.

They say shortages have occurred since not sufficient physicians had been skilled, while hundreds much more have emigrated to countries where the workload is less onerous.

Authorities say the crisis is prompting consultants to take on added work at extremely lucrative costs, whilst others come here from abroad.

Dr Cliff Mann, president of the College of Emergency Medicine, mentioned: “The use of agency medical professionals has turn into endemic in the NHS. There are units which would implode if they weren’t relying on them, day in, day out.”

Dr Mann, the most senior A&ampE medical doctor in the United kingdom, extra: “The figures are surprising and ludicrous. The worst of it is that with the cash we are wasting on temporary personnel we could double the number of A&ampE consultants, if only a far more long-phrase technique was taken. It doesn’t make financial sense, nor does it make clinical sense — because this is not great for patients.”

In total, 64 hospital trusts, out of 144 with A&ampE departments, responded in some kind to freedom of info requests.

Of people, 36 trusts supplied particulars on how many occasions they had paid more than £1,000 to cover a shift in A&ampE in 2013. Among them, they invested such sums on 2,317 events last year — the equivalent of 9,268 shifts, when extrapolated to cover all 144 hospital trusts in England with a casualty unit.

The trusts presented information of the highest quantities paid to a single medical professional or nurse at any time because 2011. At Lancashire Teaching Hospitals Basis Believe in, a consultant was paid £2,400 in May possibly 2012 to operate 9 hours in the hospital, plus 15 hours on contact.

Hospitals also spent heavily plugging gaps for nurses. Royal Devon and Exeter Basis Believe in paid £1,620 for a twelve-hour nursing shift in January 2012, even though University Hospitals Bristol Basis Trust invested £1,235 on an eleven.five-hour shift last April. Close by North Bristol Trust spent £1,150 on a twelve-hour shift in Could final year.

Amid desperate shortages, even the most junior employees were paid at inflated prices. Walsall Healthcare Believe in paid £968 for a clinical support employee to function an 11.5-hour shift last Christmas. This kind of staff, who assist in clinics and laboratories, are normally paid in between £14,000 and £17,000 per yr.

The trusts also offered figures for the overall complete commit on temporary medics for each of the final 3 many years. These had been employed to determine an NHS-broad figure, which exhibits £242 million invested final year, compared with £181 million in 2011 — a rise of 33 per cent.

Many of the trusts explained they struggled to find workers simply because of the national shortage of consultants and that security of patients came initial. Many mentioned they have been doing work to reduce their investing on agency workers, but that payments were in line with normal fees paid for locum employees.

Heart of England NHS Basis Trust explained it was one of the largest trusts in the United kingdom, and that its priority was providing protected care, which often meant exceeding standard fees. It said it had just recruited 10 far more A&ampE medical professionals.

Kettering Common Hospital Foundation Believe in explained lowering spending on company employees was a priority, even though Northern Devon Healthcare Believe in said it suffered “abnormally high” workers sickness among A&ampE consultants last 12 months.

Wye Valley Trust said its difficulties have been compounded by its rural spot in Herefordshire.

Barking, Redbridge and Havering University Hospitals Believe in explained it was functioning “tirelessly” to recruit employees in spite of the nationwide shortage. Last winter, senior medics warned that A&ampE units had been like “war zones” as they struggled to cope with rising numbers of sufferers, several of whom had failed to safe help from out-of-hrs GPs.

On Friday, figures disclosed that casualty departments have had their worst week but, with a hundred of England’s 144 NHS trusts with A&ampE units missing targets to deal with patients inside 4 hrs.

A Division of Well being spokesman explained: “Holding on to doctors in A&ampE has been a dilemma for over a decade. There are a lot more than 20 per cent far more A&ampE consultants than there had been in 2010, but we know we need to have even a lot more and we have a program to make that happen.”

A spokesman for NHS England mentioned: “We recognise there are challenging troubles about senior healthcare staffing in the emergency medicine specialty, and this is compounding pressure on hospitals as A&ampE attendances improve 12 months-on-12 months.”

Doctors paid up to £3,000 a shift, official figures show