Kates Journal

So, a while back, the ConDem government said they’d be getting rid of lots of health service targets. There are, of course, multiple ways to look at this. As someone pointed out to me, when they instigate one target, they don’t really know what effects it’s going to have on any other part of the system, nor the subtle ramifications of the target itself. They skew treatment priorities – for example, the four hour ’standard’ in the ED has meant that patients with more serious conditions sometimes end up waiting longer to be seen because we have to clear a backlog of minor injuries. And to ensure that gets done within the four hours, we’ll steal doctors from the ‘majors’ team.

Patient experience can be compromised as we push and push teams to accept patients they’ve not reviewed onto wards – with the intention that they’ll be reviewed there – because we need them out of our department within four hours. We do, or at least I do, only push for ’stable’ patients to have this done, and we do ensure they have analgesia – and often other medications written up. But still, it’s an effect that was probably not forseen when they were implemented.

We have a ’sepsis’ protocol which means that patients who meet the sepsis criteria should have antibiotics given within one hour of attendance, which sounds like plenty of time, but for patients who come through triage it’s a struggle. If you wait 15 minutes for triage, and 25 minutes to get an initial assessment done* another 10 to get antibiotics prescribed & mix them (and some of these are not the easiest to mix); get them checked and administered. For that hour you’ll often find you’ve got two nurses tied up ensuring that all that is done, and other patients just have to wait.

Staffing levels haven’t changed to take account of how much more we’re doing as an ED, and for nurses, how many more tasks we’ve taken on that used to be the doctor’s jobs.

So anyhow, wandered off from my point there. The main point I’m getting at is, as an ED nurse I’ve often argued that the four hour target is not always a great thing. Indeed, I’ve condemned it for skewing care, for making me feel pressured, for making me move patients who I’m not really 100% happy to move, etc. But the concept of losing the target completely worries me deeply.

Before the target came in, I spent an enjoyable 12 hours in the ED in Bristol waiting to be seen for my ‘back pain’ (this is before I was a nurse) which turned out to be a pyelonephritis. I was in loads of pain for those 12 hours, and quietly getting sicker and sicker in the waiting room. I’m one of those disconcerting people who goes quiet when their in pain. Really, really quiet. Which is not necessarily a good thing. I know nurses who vividly recall full EDs with patients not moving because the hospital was full. Patients from the previous shift were still there the next day, and ED nurses became pseudo ward nurses, complete with drug-rounds for patients who’d been there so long they’d otherwise miss their medication.

The four hour target forces the entire hospital to work hard at admitting and discharging patients. It means we’ve developed better methods of caring for people at home, and access to rapid input for social care. Not just that, it’s good to be able to say to a patient roughly how long they’re likely to be in the ED – and how long before they get a ‘proper bed’ – because ED trolleys are not comfortable.

It does, however, instill a level of patient entitlement which really winds me up. Yesterday I triaged someone at 20 minutes after arrival – who stropped about waiting so long for triage, then ranted about the concept of waiting 2 hours to see the doctor (for his day-old hand injury). Indeed, he ranted so much that I gave up on triaging him, because he kept stalking off when I tried to explain and so I never did assess his hand; just documented that he was aggressive, and that he had a non-specific hand injury that he wouldn’t let me assess. Another family (triaged at 10 minutes and advised that their child had broken their wrist (even I could see that on the X-ray they’d had in another department), and advised it’d be around an hour ’til they saw the doctor (offered analgesia for their child in the mean time), did the whole “How long?!”. This from people who’ve seen me triaging five-at-a-time (we have a minimal triage scheme for minor injuries which is, with the patient’s permission, performed in the waiting room**) to try and get through vast number booking in (seriously, I did five patients, came back, and found four more had booked in). As a side point, I asked if they’d had someone talk to them about the Xray – they said ‘no’ so I brought them in, I’m not giving out confidential medical information in the waiting room, just so as you know.

And while I can wax lyrical about how this culture of entitlement is (a) really annoying, and (b) inappropriate, and (c) really annoying. And I can go on at length about the patients who I’ve had to move at inappropriate times, or who’ve had their care interrupted, or the worst possible experience thanks to the four hour target, I think as a *target* it’s a good thing.

The problem is that this whole 98% standard forces staff, from us lowly RNs up to the senior management to behave erratically to try and meet something which isn’t necessarily appropriate for the individual patients. But remaining in place as some sort of moderated target? I think that’s appropriate and ‘a good thing’.

I’ll miss it when it’s gone, but I expect it’ll nicely cover the falling investment in the NHS. Because without the targets, and the figures**** that go along with it, the quiet disintegration of the NHS will be neatly undocumented.

* Observations, note that they meet the criteria, find a free ‘majors’ bay, changed into a gown, enough history to decide a most probable cause of infection, blood taken and cannulated (from multiple sites for individuals with existing access devices), perform a venous gas (same as an arterial gas but with venous blood. Lord help you if they’ve got ‘difficult’ veins and no existing access devices. I’ve got much better at cannulating people who’ve had chemotherapy (which often screws up your veins), but they’re still enough people that I struggle with.
** Yes, seriously. I am aware of the confidentiality issue here, but it’s policy, and for minor injuries – which is what it’s for, if the patient happily gives consent*** (even a brief hesitation leads to the ‘would you rather we talk inside’ offer) I’m reasonably happy to do it.
*** In general the questions I ask are “What’s brought you in today?”, and “Would you like any pain killers”. Sometimes it requires “Can I just see both wrists/ankles/hands”. And in some cases that leads to “let’s just get you inside for an X-ray”.
**** Lies, damn lies and statistics.

Well, in terms of updating I thought it was about time I did some. The house remains a hole, we’ve been working hard on getting it looking right for sale – and finally we overcame our fear and put up the wall paper. And I have to say, much to my amazement, it’s pretty damn good.

Not professional standard, and there’s a couple of spots which I wish were better, but all in all, it’s neat and it makes the wall – and by extension the room – look much better. Much more of a finished article. We’re now preparing to clean up, final few spots of paint, carpet, curtains and then dress the room. The most frustrating thing is we attempted to get away with just touching up the wardrobe doors (‘cos they were planed by the carpenter) and that’s not worked at all. The colour just doesn’t match quite right, which is incredibly frustrating. So we’ll have to put *another* coat of paint on them. I’ll be doing that in a bit, I suppose. I’m hoping there’s enough paint for that.

Other than that, though, it’s coming along pretty well. I spent a bit of time scrubbing at the floor like some mad cleaning lady, and got the excess tile grout off, and cleaned up the base of the shower where it’s been waiting for me to remove the excess tile grout for, uh, years. There’s just the wall-tile-grouting and cleaning to do, and ideally if I can locate the down-pipe’s chrome’d doojit, I’ll pop that on (rubber protector thing), and a bit of touching up on the walls, and that room is done. Then there’s just the back bedroom, the stairs, and some painting of skirting. And the door. I’d nearly forgotten the pain-of-the-doors. One of them is stripped, primed, filled and needs a bit of a sand and then should be good to paint. The other is mid strip and it’s taking ‘longer’ than is desirable.

In other news, we took the CRT to the storage unit yesterday (aren’t they so light and portable), and apart from freeing up a mountain of dust (well, that’s the problem with things you don’t move, eh) it’s improved the appearance of the lounge an awful lot.

It’s all getting there, but it’s painful. As are jobs.

I have not heard anything, which is not entirely surprising because applications to NHS positions tend to be quite slow to respond. But nor has Kathryn as yet. This is particularly difficult at this point – because we could really do with both of us employed, gainfully, before we shove off to Bristol. I could also do with my inheritance arriving right about now, because things are quietly niggling in the background about money. Sometimes they’re niggling quite loudly.

All of this notwithstanding, we went away for the weekend, up to Lauren and Chrissy’s, which was fabulous. We actually went to collect a prop, a 42″ dead plasma TV (specifically a Vision 4241), unfortunately, it’s lacking its stand, which is a bit of a pain, but we’ll have to see if we can come up with something – or more accurately, we’ll come up with something. It also came from a smoker’s house, which is a bit of a shame too. It’s currently sat in the back bedroom with the window open and hte door to the house shut – in hopes of it’ loosing that stale smoke smell fairly quickly. The CRT came from a smoker’s house and it took a little while, but became inoffensive quite quickly. And the breadmaker, similarly, stank when we got it and is now fine.

Anyhow, Lauren and Chrissy’s – so we saw their new house which has the potential to be excellent – it’s got really great bones and is in a lovely spot, complete with pretty views and a gorgeous old apple tree (which is incredibly productive) – and a eucalyptus tree which is a delightfully quirky addition :)

The whole place is being rapidly renovated by Chrissy and Lauren – putting our 3 year restoration to shame! We also spent Saturday basically chilling out (maxing, and relaxing all cool too, I suspect. We didn’t shoot any b-ball though) – a couple of hours wandering on the beach at Hunstanton was exactly what the doctor would have ordered, at least if we’d seen one. It was, to be honest, lovely to see old friends (and Jay-the-cat) and not really have to do anything (beyond collecting the TV).

On the TV front, if anyone wants to help me source parts for it, that’d be helpful. Online reports suggest the fault ties in with a dead ‘FMSD102A’ – which shorts and kills four resistors (surface mount, obviously, so that’ll be easy to fix – Kate calling John! We may need your microscope…) on the PC42V-PYS40-01 Y-Sus board. I’ve poked around the internizzle and not yet found any cheap sources of either the complete board or the FMSD102A, which is a shame, because yer man who we got it from reckoned that a place called maxsource could do them for $25 – which would be worth a shot. It is, incidentally (for anyone who feels like helping) a Vision PTS-4241, also sold under the brand name Conwa, and apparently the boards are made by Orion. None of this has so far lead me to success. When the house is done I’ll pop the boards out (it rattles, also, suggesting that previous owner may have attempted to fix it, and dropped a screw inside).

Searching for the board has lead me to a selection of people saying ‘it’s b0rked’, which isn’t helpful. I think I found a spares place a while back when I was thinking about getting it, but I can’t find it now – and they wanted £70 – which is a lot of money to spend on something where I’ve not actually looked for the fault. One doesn’t like to trust others judgements of what might be faulty when spending that much :)

Anyhow, I think at this point it’s time for me to shower and make some grout.

Incredibly, I woke up at a sensible time this morning and despite feeling a bit like death microwaved hauled myself out of the bed just in time to say bye to my beloved as she headed off for work. Unsurprisingly despite a series of promises to myself to watch an episode of Caprica and start work on the house, I didn’t quite manage that. I watched an episode of Caprica, dinked on the internet for 20 minutes, watched Top Gear (which I never watch, but wanted to know what had wound Nikki up so much) and *then* set to work.

Still, that has not negated my feeling of positive achievement, because I have:
- Retrieved the desk fan from the attic, which is enabling me to stay a sensible temperature.
- Sanded the filler in the skirting board, and put a new layer of filler on the bits that weren’t that great – next job, incidentally, is to sand the new filler…
- Removed the old tile adhesive from where I had to take the floor up (ready for the new floor)
- Hung and filled the lounge door. Let’s just hope no-one closes it when viewing the house, not because it doesn’t close, but because it’s a good 6 mil smaller than the frame :(
- Washed and hung up some laundry
- Uncovered the plants in the garden that live sheltered lives (slug protection, y’see)
[Made and eaten lunch!]
- Measured the wood for the replacement section of boxing in the bathroom
- Measured the fillet strip beside the door (where the plaster’s knackered from having the new front door fitted (before I arrived).
- Walked to B&Q and purchased a selection of stuff, including wood
- Cut the bit of the fillet strip that I couldn’t get cut at B&Q
- Attached most of the fillet strip, except the bit where the plaster wasn’t merely rough / cracked but as actually no longer attached.
- Made tea (because it was frackin’ hot on that walk to B&Q).

Which brings me to the moment I’m currently enjoying in which the fan is wafting air at me and my tea is slowly cooling to drinking point.

What are you all up to today? That’s the question…

As usual, it’s the day after nights and I’m struggling through the beyond an entire day awake in the hopes of forcibly readjusting my sleep pattern. Not least because there’s huge, vast, enormous quantities of stuff to do on the house to get it ready for valuation and then sale.

So after my 77+ hour week I’ve stayed up, as I do, for 25.5 hours so far (about another 3 to go). I’ve watched the film of ‘The Girl with the Dragon Tattoo’ – which is, it turns out, an excellent film. The subtitles came off the internet and weren’t exactly perfect, but having just read the book it wasn’t really a problem – and it was really interesting to compare / contrast the two.

Normally when I do a book/film comparison it’s because I’ve watched the film and then read the book because I liked the film. This time it’s the other way around – and it’s very interesting, because I’m used to more being added to the story – more depth, layers, characterisation. But this time, it’s the opposite – it’s paring down the book to the point where it’ll fit in a film – and I think to a greater extent they’ve done it well. The character of Lisbeth does loose something from not having more of her background hinted at – and her recent history too. The other thing that was either lost in translation or lost to my British sensibilities (it is, after all, a Swedish film) was the humour in the (translation of the) book. There’s some very darkly funny moments in the book and they seemed to be gone entirely which was sad – I was particularly fond of a scene (no spoilers) which takes place is Lisbeth’s kitchen. And it’s hinted at a little in the film, but it’s a brief moment of humour.

Anyhow, definately worth watching.

In other news, I’m quietly distressed about the Lib-Dem/Con coalition’s actions. I find myself in a painful place where I felt I could not in good conscience vote for Labour – their disregard for civil liberties and disgraceful behaviour surrounding the DEB meant that they had lost that chance. So I stuck my vote for the Lib Dems. I’ve always liked lib-dem policy proposals. They seemed to walk a fine line between left and right, not much privatisation, less privacy invading crap, fairer taxes, electoral reform, blah-dy-blah-dy-blah. And yes, I had a bit more faith in them, mostly because I imagined that politicians who’d decided to stand in a party that had as much hope of winning an outright election were smaller than a gnat’s toothpick probably had some kind of morals.

I have lost that hope now. I find myself increasingly distressed by the things that they, as members of the coalition, are allowing through. The recent budget while it shouldn’t hit me terribly hard (although fuck people who think the public sector should pay for the private sector screwing the economy – the thing these people forget is that we* get shite pay – which has continuously lagged far behind private sector pay and then when things go wrong our pay gets held at whatever shite level it was at for years, before finally starting to creep upwards until the private sector fuck it all up again, at which point we’re even further behind private sector pay**) does hit those on low incomes (lower than ours) *really* hard.

And I notice the ‘all-in-it-together’ ConservoDems or whatever they want to be thought of as managed to barely touch top-rate tax payers, the increase in tax their paying is all down to already existing stuff brought in by Labour.

The few good things the lib-dems have manged to add in are so vastly overshadowed by the crap that they’ve supported that they can add themselves to my ‘no, not voting for you again’ list. Have some fucking morals, people.

Can you tell I’m tired (and a bit cranky). In other news, well, there isn’t a great deal of other news. The garden continues to look lovely; the house schedule has, depressingly, slipped. I’d neglected this week of nights, but it does give me a week of solid house-work. Unfortunately, it looks like it’s going to be ridiculously hot all week, which will slow me down…

In other, other news – I’ve listened to Nikki’s appearance on Geekcast (excellent, very impressive Ms GB), and watched more of Caprica. Caprica hasn’t grabbed me like BSG, but it niggles at my brain summoning me back to see the world develop – so I’m reckoning it’s going to be quite interesting :)

And that’s it.

*By we, I’m referring to the we of which I have some experience – i.e. health and education sector workers.
** Seriously, I have no idea how Paramedics and even more so Techs and ECA’s survive. They are paid *pathetic* amounts of money to be sworn at, spat on, kicked and have less protection from their employers than any of them deserve.

Sometimes I want to write about work. Often, actually, as I’m coming home and before I end up unburdening myself on my poor beloved I contemplate entries. Entries about pain and suffering, about joy and success, about when the team comes together, or when the team fails to work.

I want to rant frustratedly about the lack of equipment, or the celebrate when the NHS rocks and everything happens quickly and effectively.

Sometimes I want to talk about the complaints, about the feelings of entitlement from members of the public, for whom 4 hours is far too much of their life to consider as an acceptable wait to see a Doctor, for whom the statement “I’m sorry for the long wait, but our doctors are very busy in resuscitation – we’ve got a lot of very sick patients at the moment” yields the reply “But I’ve hurt my toe”.

Sometimes I want to wax lyrical about the wonderful and patient people who suffer delays, who wait calmly and politely ask for us to meet their needs. Who understand as one nurse rushes around trying to meet the needs of 4, 6, 12 people who are all potentially sick. I want to thank them kindly when they send in their letters of thanks for the care we’ve delivered – because it lets me know I’m doing something right.

But it all disappears.

The dead people don’t often march through my brain, the ones we couldn’t save, or the ones for whom we only prolong the torment. The vulnerable adults and children I refer on to social services don’t often stick with me, at least not for a long time. But sometimes they pop by – usually making themselves known as I’m thinking about something positive.

My brain’s kind to me like that. It lets the nasty stuff go fairly easily – although Kathryn will attest that sometimes it takes a while.

Which is why I don’t often post about work.