Winter Pressures..................... a test for every emergency physician

It is coming up to that time of the year when I start to question why I choose emergency medicine as a career. Yes, winter is here and along with it a crisis in most emergency departments around the country. Patients left for long hours in the corridors of an emergency department waiting for a bed. It is possibly the single most inhuman thing we do to our patients in NHS. Somehow we forget the basic decency any human deserves, privacy and dignity. Somehow it seems acceptable to leave a sick human being in the corridor of an emergency department. After all these years in NHS and emergency medicine, this is the one thing I fail to get my head around.

Overcrowding of emergency department does a lot of collateral damage. It leads to poorer care for patients in emergency department because the same number of nurses and doctors are now expected to look after sometimes twice or thrice the capacity of a department. It leads to delay in getting a patient seen by a clinician in a timely manner. Then there is the effect of all this on the morale of the doctors and nurses in emergency medicine. Every winter this issue is raised by everyone in emergency medicine. A sticky plaster is provided to temporarily silence the issue. Roll on another winter and the fundamental issues have still not been dealt with. In addition there is the year on year increment in number of patients with more or less no increase in workforce.

Is it possible to fix this issue or do we just moan about it and then shut up? ED overcrowding is a complex issue with a variety of factors which influence it. Below are some of the main issues.

1-Inadequate primary care access leading to patients not able to see their GP in time to sort out minor ailments and they end up coming to the emergency department. In particular elderly patients in a  nursing home who could have their problem sorted in the community by a GP ends up using a lot of resources to make the journey to the emergency department in an ambulance.

2-Annual increase in number of patients visiting the emergency departments with very little increase in number of health care professionals to deal with it.

3-Inadequate provision of minor injury/ailment centres in most areas. This leads to every patient attending the sole emergency department in each area.

4-Lack of adequate number of acute care beds and nursing home/residential home places. This is probably the single biggest factor leading to what is traditionally called exit block.

Even to a casual observer there are immediate solutions available and it does not need a rocket scientist to work it out. However the NHS management is riddled with short term thinking and a reluctance to invest money in the right place to fix this issue. Politicians would play their usual games of appearing to support the NHS, media would intermittently show some interest in the issue, the management of NHS meanwhile will appear to tackle the issues with predominantly short term plans and we will go through all this another year in ever worsening numbers. Meanwhile it is left to the individual doctor and nurse to somehow maintain their sanity in the madness of an overcrowded emergency department whilst trying our best to provide the best care possible.

There is absolutely nothing new in the above the blog which has not already been written about and discussed in various channels. Apologies for that. Somehow just putting it in writing here is cathartic for me and I might just have that little extra energy to go through another winter knowing that nothing will ever change in an overcrowded emergency department.

- a very tired disheartened emergency physician hoping that we put our foot down and say 'A BIG NO TO ANY PATIENT BEING LEFT ON A ED CORRIDOR'. Can we?

EMEC 2019

I booked for this course a few months back purely out of curiosity. I have often wondered how we achieve the balance between teaching and service provision in a busy emergency department. I was glad that I attended this conference where it was inspiring to hear from colleagues who described ideas on promoting teaching and making our own jobs more enriching in spite of the busy nature of our work. It is all about getting the balance right. I thought I will reflect on some of things I learnt and maybe inspire a few others who did not have the opportunity to attend this excellent meeting.

First of all kudos to the organising team for choosing such an inspiring venue, The Studio, in Birmingham city centre. The studio is one of the many new age meeting centres which have come up in our city centres which challenge and break rules with regards to meeting places. The place was conveniently located in the city centre with good rooms and an excellent dinner area. The choice of the after meeting catch up drinks, The Botanist, was excellent too.

The morning started with a stimulating talk about sex or should I say CEX by Simon McCormick. Although I found the frequent sexual innuendos tiresome, I was in the minority and the vast majority enjoyed such an unconventional speech. I completely liked the core message of the talk to embrace WPBA and to make it more useful and meaningful. If there is one thing I would take back to work it would be this because I have always found such form filling a bit tiresome and never really bought into it.

Next it was time for Rob Rogers from USA and Medutopia who talked eloquently about the importance of creating your own legacy but more importantly that education saves lives. Like me, if you have not come across Medutopia before I would strongly urge you to have a look at the website. Personally I found it quite inspiring because I do think we need to think of innovative ways to provide medical education for the future clinicians. The days of sitting and reading big textbooks is gone.

www.blog.mymedutopia.com

My favorite speaker of the day was Liz Herrieven. I loved the way the talk was delivered with not a single word to read on the slides, just pictures from 'Game of Thrones'. There were so many ideas I thought every emergency department could copy from her but my favourite was the educational resource box. Just a cupboard in the department with useful props to deliver short burst of teaching in emergency department.

My first work shop was the simulation lab. The team from Leicester, which by the way is the busiest emergency department in the whole of the country, were excellent. It made me wonder if such a busy department could commit itself to teaching then the other less busy departments have no excuse at all. Enjoyed making the model for lateral canthotomy. Most impressed by the #EM3 resus drills. These are essentially 15 minute drills which is broken into a 5 minute simulation scenario, a 5 minute reflection and a final 5 minute repetition of the scenario with the hindsight of the reflection and learning.

www.em3.org.uk

Ross Fischer's masterclass on how to do a presentation was excellent. The message was so basic sometimes it amazes me how most of us get it so wrong. I liked the idea of breaking it down into the the three fundamentals of Message, Media and Delivery.  He calls it the p cubed presentation style. It made me think about the innumerable times my presentations have fallen flat because I have messed up on one of the three fundamentals.

www.ffolliet.com or #htdap

Louis Daniels a counter terrorism officer was our mystery speaker. I liked the way he equated our ambulance pre alert to a phone call his cell would receive about a potential threat. Although the comparission was a little flattering I could see what he means by it. The key messages were to have a clear operational strategy, be familiar with your team, constantly reassess situation based on new information and finally remember to have hot and cold debriefs. If there is only onething I would take back it would be about the importance of debrief after every critical patient in resus like a poly trauma or a cardiac arrest.

John carter a very interesting and enterprising emergency physician from Edinburgh gave an inspirational talk about more or less his life story and how he approaches teaching in his own style. I could not help wonder how his creative talent could have easily been snuffed out by traditionalists. His way was to make pictures and art for teaching. He has one of the most creative brains and they maybe be difficult for us lesser mortals to replicate. However it was inspiring and I can only imagine how entertaining and stimulating his teaching sessions will be for the Edinburgh trainees.

www.prezi.com
www.pechakucha.com
www.mentimeter.com

Anu Mitra and Kamran Zafer from Charing cross hospital shared their experience of how they made the mundane departmental induction into a useful, entertaining and engaging experience for the new doctors. I think each and every department could learn something from them because we are letting down the young doctors through a rather forgetful day called 'Induction day'.

Finally it was time for the rather entertaining eduwars. This was a completely new thing for me and made me realize why can't other educational conferences be this entertaining and useful. Overall I was very impressed with the team behind EMEC and would like to thank them for one of the most entertaining and useful conferences I have ever attended. Special mention must be made of Nikki Abela who had the arduous task of making multiple short presentations on the theory of teaching.

Thank you for reading this. Have a great day and enjoy whatever you do because as per the chaos theory everything is connected. So go on and make a little change in the world around you so that you create a tsunami of enjoyable medical education for the future doctors.

RCEM Belfast 2019 Day 2 post Lunch session

Roof of Revolucion de Cuba restaurant in Belfast. excellent food and brilliant atmosphere.

Stella Smith(Manchester) started the afternoon session with a recount of experiences during the Manchester bomb an year back. It was quite personal for me having been at work on that night at Salford Royal Hospital. I still remember the first patient we took to the CT scanner and the radiographer asking us to check if there is some metal object behind the patient's neck after the initial scanogram. Soon we realised the metal object was a bolt lodged in the cervical spinal cord of this lady. I still get an uncomfortable feeling deep in the heart when I think about that day. The key learning points from the talk were the need for dedicated trauma surgical training for surgeons, improving communication at all levels and the need for dedicated training at all levels. Unfortunately we live in a dangerous time as reminded by the bombs last week in Sri Lanka.

Peter Hulme(Manchester) gave an account of his personal experiences dealing with injured children after the Manchester bomb. It was a well balanced beautiful account of the various simple yet practical difficulties a paediatric emergency physician encounters when an incident of this sort happens. 

Paul Russel(Salisbury) gave an excellent talk summarising various CBRN events around the world including the Novichok in Salisbury. I learnt that a Ram gene meter is used to monitor radiation. There was a brief mention of Bhopal gas tragedy which even today stands as the worst CBRN incident ever. The company responsible for the disaster conveniently avoided penalties by quietly closing down operations and selling the company to another company. He then went through the other incidents world wide from Sarin gas in Tokyo to Polonium in London. As emergency physicians we always are at risk of being the first to encounter a CBRN event. He rightly pointed out that the most dangerous agent will be the innocuous one with delayed onset of symptoms. I do not think there is enough regular training or education on this important aspect of emergency medicine.

Phil 'O' Connor(Belfast) gave a talk on his top 5 critical care papers. Use of high flow oxygen was the first paper and soon we should be seeing this used more in adult emergency medicine. Preoxygentation was the next topic followed by comparison of stylet and bougie for intubation. Then it was about generation of oxygen free radicals due to therapeutic use of oxygen. I do not think there is should be any department/hospital which should use oxygen without a clear prescription from the clinician as to its use.

Rob McSweeney(Belfast) continued where his colleague left off. This was a rapid fire round of critical care updates and he went through a trial every 30 seconds and it was difficult to keep up with the pace at which he was going. He went through the following- POLAR trial for prehospital cooling in traumatic brain injury, RESCUEicp for decompressive craniectomy followed by 20 other trials. I was lost after the first three and was glad that the day was over because my mind was already thinking about which pub and what drink to have that evening.

That was the end of day 2. Going to a conference is a bit like sitting in a classroom all day. I have not done that for a while and struggled to sit down for such prolonged periods of time. Anyhow soon it was drink'o'clock.


It was great to catch up with my brother at the conference.

RCEM spring CPD day 1 post lunch session

Above picture taken inside Fibber Magee, next to the crown opposite Europa.

Lunch was brilliant with a choice of Irish stew, salmon and tortelloni. I went for Irish stew and probably had one too many potatoes. This was the reason I had to excuse myself from one of the afternoon lectures. Apologies to one of my bosses Dan Horner. However to be fair I have read and referred to his excellent trust guideline on the hospital website many times over the last couple of years. It has always been a pleasure to learn from his in depth knowledge on every aspect of VTE.

Emma Greenwood from Belfast spoke about  her top five medical papers in 2018. LOMAGHI study has conclusively proven the benefit of IV magnesium in atrial fibrillation and I would change my practise on this topic. In pregnant patients with suspected VTE I learnt that d-dimer is relevant and pregnancy adapted YEARS algorithm is a useful decision making tool. I also learnt that there is current evidence which shows no correlation between IV contrast and AKI and the next time there is a delay in imaging due to 'waiting for results', I will be able to counter it with current evidence. OVIVA study has shown the lack of superiority of intravenous antibiotics over oral in orthopaedic infections. However I am not sure I will change current management before this is accepted by orthopaedic colleagues who will be most affected by this change in practise and the medico legal pitfalls are too high to make this change.

Ian Beardshell from Belfast gave an entertaining and energetic presentation on how we are practising emergency medicine the wrong way around. I would not change departmental practise of waiting for investigations until the clinician has seen the patient. However I will try and practise the habit of not looking at the results even before seeing the patient. I think the right order would be ambulance notes, triage notes, history from patient, examine patient, provisional diagnosis including differentials and then look at the results. It was good to have a gentle revision on snouts, spins and likelihood ratio. I am sure I will remember it for another 24-48 hours.

James Shawbrook from Belfast talked about Chest Radiology in ED patients. Key messages were difficult chest drains in loculated pneumo thoraxes(luckily we can leave that headache for the interventional radiologists, however identifying one is our headache), looking at the aortic calcific plaques in relation to the arch of the aorta, use of ECG gated CT to improve imaging(ECG gated CT is a nifty way to scan during the diastolic phase of the heart) and a message as simple as clotted blood is more dense than liquid blood.

Madeline Sampson(Belfast) gave a talk on radiology in blunt trauma. She focused primarily on CXR with useful tips on apical pleural cap, mediastinal shift, mediastinal widening, aortopulmonary window etc. It was a bit of a throw back to pre whole body CT for trauma times. Working in a MTC we often have a low threshold for CT and therefore sometimes often overlook the usefulness of a CXR. Since coming back from the conference I have had at least 2 patients with blunt thoracic trauma who had significant findings on CT which could have been missed on CXR. I do have my sympathies for colleagues in non MTC units where it can be rather difficult to get the radiologist to agree on a CT.

Tajek Hassan(President RCEM) gave a fantastic lecture on various issues he faces as President. He is like a movie star and I enjoyed his candid comments on how difficult the job of the President can be. Political correctness and risk of being misreported by the media is a potential hazard. I think he has done a remarkable job during his tenure and I am certain the president elect Katherine Henderson would continue to build on the work and success of her predecessors. I was disappointed to learn that the Indian foreign office refused to give Dr.Hassan a visa because of his Pakistani ancestry. I am ashamed of this silly stupid behaviour and I hope in future such stupidity does not happen and citizens of both countries can live in peace and visit each other's countries.

That brought us to the end of day 1. The drinks reception was excellent with informal conversations and wine flowing well. The canapes were excellent. Personally it was only marred for me by the unfortunate experience of having a unpleasant conversation with one of the vice presidents of RCEM, who took objection to my comments on twitter about the RCEM presidential elections. I think such behaviour should not happen in a meeting of fellow professionals and it was more like a silly confrontation at 11 pm in a local bar with a drunken man. The vice President of RCEM is a respected position and in a forum of colleagues he should have behaved in a more civil manner irrespective of his feelings about my twitter comments. On my side I can only apologise for my twitter comments and in future will avoid any personal comments on social media.

That's all for now.

More about day  2 and 3 in subsequent blogs.

Ps. Irish whiskey and live traditional music in Irish bars are a delight and I had an excellent evening at the Crown and Fibber Magee.


Picture below taken in Salford Quays. Maybe it will tempt somebody to come work for the excellent team at Salford Royal ED.

Dr.Kumar at RCEM spring CPD 2019

Picture taken inside Fibber Magee and excellent venue for drinks and live Irish music.

I thought I will blog about my first day at RCEM spring CPD for my own benefit and also give a little overview of what happened for the benefit of colleagues who have not been able to to attend.

First of all what a brilliant city Belfast is and I regret not visiting this fantastic city more often which is only an hour away by flight from Manchester. Usual morning registration and coffee with one too many 'light bites' setting me up. Forgot all about the apple on the table. Ian Crawford(Belfast) gave a warm welcome to all in his inaugural speech and then it was soon the first session.

Brendan McGrath(Manchester) spoke about the various presentations and complications we can expect in ED from patients who have a tracheostomies. Main take home message for me was oxygen, secretions, differentiating tracheostomy patient from laryngectomy patients, remembering that they are complex medical patients and there might been an alternative reason for the breathlessness and importance of checking that your department has the right equipment and training for staff. Please check out www.tracheostomy.org.uk, www.globaltrach.org and NTSP app for more information.

Chetan Trivedi(Brighton) spoke about his endeavour to develop a decision rule for when to image in facial injuries. Particularly liked his own personal approach to rule out imaging with safety netting. Take home messages for me where children are different and should rarely be imaged, think of radiation exposure and review existing referrals to maxillo-facial team at local ED. I think we can soon expect a gold standard guideline from him.

Filipe Dhawahir- Scala(Manchester) gave an entertaining talk on when to wake up an opthalmologist. Loved his flamboyant style of presentation. Take home messages don't use cotton bud for removing corneal foreign bodies, ulcers from contact lens use can go badly wrong very soon, importance of identifying papilloedema, identifying the dangerous red eye(Acute Glaucoma), CT in suspected metal projectiles in eye ball(do not waste time doing an X-ray), simplicity of doing a lateral canthotomy and infections in post op patients.  Please have a look at BEECS(British emergency eye care society) and if possible attend one of their annual meetings.

Peter Johns(Ottawa) gave a head spinning talk on vertigo. I managed to stay with him until Dix-Hallpike test, Epley Manouvre, HINTS plus but lost it when he went to Horizontal canal BPPV(apparently 30% of BPPV). Take home message for me was keep revisiting these tests and manouvres, however in practise this is a specialist area and cannot be done in an busy UK emeregency department and there is possible a case for dedicated vertigo clinics in every region. More importantly identifying the patient with a central pathology using HINTS plus and being aware of vestibular migraine as a diagnosis.

Diana Hulbert (Southhampton) gave possibly the most important talk of the day on tried and tested methods for looking after the team in ED. Main take home message was the engage with other members of your team and taking time to know them. I think every senior emergency clinician has a moral responsibility to look after junior colleagues. If we cannot have compassion for our own team then we cannot deliver compassionate treatment for our patients. Learnt about Schwartz rounds for the first time but was even more surprised when a few persons in the audience raised their hands to tell they do it in their departments. I think the college needs to highlight this often neglected part of working in emergency medicine. Personally I have occasionally felt more lonely in a crowded ED than in the middle of a woods.

Chris Moulton spoke about GIRFT(get it right first time) and why it is soon coming to a hospital near you. I think the data gathered from this project will go a long way in having fact based discussions with the management and other specialities. It is still early days but I am sure all emergency departments and physicians will soon be talking about the data gathered from this project. My own person feeling was I wish there was a qualitative element to these quantitative measures because nothing can be more misleading than pure numbers without the qualitative element which can only be provided by qualitative research and assessments.

Soon it was time for lunch. For me it is time to take a shower and head to the conference venue. I will try to keep this going till the end of the conference if I can. If I have not then it is probably because of the excellent Irish Whiskies and hospitality. Have a great day.

Picture taken inside the apartment I am staying in with my brother(he is an emergency physician too).

Random memories of Dr. Kumar... the accidental emergency physician

Photo above taken of a brilliant poster prepared by an equally brilliant trainee advanced practitioner in the emergency department where Dr. Kumar currently works.

Autumn 2002

Dr. Kumar was now working in Trauma and orthopaedics in a DGH in the North east of England. He was not interested in a career in Orthopaedics but had to do this six months to satisfy criteria to write the finals of MRCS before he can embark on cardiothoracic training. He had taken time out from cardiothoracic surgery after a forgetful few months in a Manchester cardiothoracic centre. It was his second winter in UK and he went through severe low moods not realising that this was just SAD(seasonal affective disorder). Dr. Kumar grew up in the tropics where sunshine was guaranteed every day apart from the peak monsoon weeks. He did not know then that Manchester was the wettest and gloomiest city in England. He also did not know that he was going to end up becoming a Mancunian or Salfordian in a few years time.

Spring 2003

Dr. Kumar was working as a clinical fellow in Emergency Medicine in a University teaching hospital in east London. Towards the end of his orthopaedic job Kumar went for two interviews in London. One was a clinical fellow in cardiothoracic surgery and the other was in Emergency Medicine. He did not get the job in cardiothoracic surgery and little did he know then that he was going through one of the biggest cross roads in his life. He still thought he was only flirting with Emergency Medicine whilst still in love with cardiothoracic surgery. This is where he met some individuals who will go on to change his whole view of medicine in general and emergency medicine in particular. First there was the big daddy Alistair Wilson, a remarkable emergency physician who enjoyed the whole range of emergency medicine from leading the trauma team to pulling out fish bones from the throat. He was a walking encyclopedia of actual clinical emergency medicine. Then there was Tim Coates, a great academic who taught many emergency physicians how traumatic cardiac arrests are a completely different beast to medical cardiac arrest and why it was important to keep the acute physicians away from them. Then there was Helen Cugnoni, a mother like person who actually took time to speak to her juniors to find out how they were doing. There were many other persons and it would take a separate blog just to mention each and everyone of them including our own president elect Katherine Henderson.

Spring 2004

Dr. Kumar was working in a DGH which liked to think of itself as a University Hospital in east London. This was an impoverished borough which was home to the most cosmopolitan community. My son attended a preschool here where there were kids from at least 30 different countries. It was a complete eye opener. The best thing about living and working in this part of London was not missing Chennai. All he had to do was walk down the high street in East Ham to buy the latest Anantha Vikatan, Kumutham ( both popular Tamil weeklies)and the latest movie releases. In fact East Ham felt so much like Chennai that occasionally I would see a native English person and wonder what that foreigner was doing there! Then there was the Mahalakshmi temple, Murugan temple and even Indian music in one of the bars. He still remembers fondly the old Hindi songs a beautiful singer sang in one of the bars. Anyhow soon the year was coming to and end and it was time to think about settling down somewhere where he can afford a home and good schooling for his son. And that is what brought him back to Manchester for the second time. This time a beautiful town in Greater Manchester famous for its markets and surrounding hills. Dr. Kumar never realised he is never going to leave Manchester this time around. Or will he.................

Dr. Kumar did not choose emergency medicine as career. He likes to think emergency medicine choose him. He realised very early that this was thankless job. There was always plenty to do and nobody ever is happy to see or hear from you because you bring more work for them. However this is one specialty when you get the balance between work and life right you could actually enjoy it for a long time. Dr. Kumar sees a lot of disgruntled and disillusioned emergency physicians. They are present in all cadres from the junior most trainee to the senior most consultants. He thinks this is one of the less talked about problems in emergency medicine. He has worked with senior emergency physicians who have authored books and held prestigious college positions who go around discouraging young doctors from emergency medicine. This is a problem very few emergency physicians will openly acknowledge. I think it is about time more emergency physicians talk more openly about times when they feel disillusioned with work and what they have done to cope with it and find the mojo back. I hope the president elect of our college takes this up as one of her key projects during her tenure.

Photo below shows one of Dr. Kumar's favourite buskers in front of one of the iconic bars in Manchester.

A tale of two cities by Dr. Kumar

If you have stumbled across this page wanting to read about the Charles Dickens classic my apologies. However I think the Tale of two city ED's by Dr. Kumar is an equally intriguing tale of bullying at work place and how different organisations deal with them. Dr. Kumar is currently off work due to a stress related illness which manifested with very real somatic symptoms. He has had an opportunity to reflect on his experiences because that is what the General Medical council expects of him. So here is the tale and since I know Dr. Kumar personally I can guarantee that this tale is based on real events. Dr. Kumar is happy for other persons mentioned in this tale to give their own versions of events described. After all every event is remembered according to the individual prisms and perspectives we wear in front of our eyes and brains. So this is a tale through Dr. Kumar's perspective/prism.

March 2019

Dr. Kumar is looking forward to restart his regular job after being off work for than 8 weeks. On 5th Dec 2018 He was admitted whilst working in the emergency department for suspected STEMI. He had a repeat ED admission for similar complaints on 25th Dec 2018. He has since had a 24hr ECG and Echo which were normal. He was reviewed by the cardiologist who advised CT coronary angiogram and sleep studies to rule out sleep apnea. Dr. Kumar got fed up of the waiting times in NHS and went to India to have these two studies. His  CT coronary angiogram was normal but the sleep studies showed he had some sleep apnea which needs to be managed either by a CPAP machine or by a surgery. He also realised that a significant proportion of his symptoms were psyhosomatic as a result of some sort of weird post traumatic stress disorder.

Feb 2019

Dr. Kumar came to know that his former mentor at RBH CM was going for the presidentship of RCEM. CM is a senior emergency physician who is the father of EM at RBH. Dr. Kumar worked in this department between Feb2005 and Aug 2013. Dr. Kumar had mixed feelings about this news. On the one hand he was pleased that CM was finally getting some recognition for his years of service to EM. On the other hand Dr. Kumar did not want CM with his archaic views on women in medicine and the person who failed to support fellow EM doctors, to lead RCEM which desperately needs a positive energy leader. Kumar is currently compiling a folder to be sent to the chief executive of RCEM GM to highlight why CM is not a suitable candidate to lead RCEM and that if he is elected it would be a Donald Trump moment for RCEM.

Feb2005

Dr. Kumar starts his Clinical fellow job in emergency medicine at RBH. He was recruited by a brilliant EM physician called RP. Unfortunately RP will go on to completely stop practicing EM. She will be one of many senior EM doctors to either partially or completely leave EM after working at RBH. This is the main reason why Dr. Kumar feels that the father of EM at RBH is not the right person to lead the EM doctors of the whole country. For all his good intentions he has been unable to look after the welfare of his fellow colleagues in his own department. RBH was a poorly run trust and the HR department was exceptionally bad even for NHS standards. Dr. Kumar did not know all this in Feb 2005 when he joined after promises of rotations to other specialities like acute medicine and intensive care and support with developing his career.

Feb2006

Dr. Kumar is enjoying working in RBH which has one of the friendliest nursing teams. A couple of months later UK decides to embrace a new training system for junior doctors MTAS and in the process cancels permit free training for International doctors. These were turbulent times and in the midst of all the turbulence Dr. Kumar realizes that the trust has forgotten to renew his work permit in spite of his repeated reminders and that he is being paid on the senior house officer tier even though he has been working on the registrar tier. He also realised that another colleague RJ was being paid a supplementary pay band 3 whilst he was paid a band 1A. This was the first of many other incidents where Dr.Kumar felt that his British white colleagues were treated more favourably. It will take RBH nearly a year to sort out the pay in a equitable manner. However he lost a whole month's play because of HR forgetting to renew the work permit in a timely manner.

Feb2007

Dr. Kumar has been at RBH for 2 years without a formal appraisal. When he requested for one he was told by his mentor that he did not believe in things like appraisals. It would take another 5years before eventually CM agrees to do his appraisal. Meanwhile the effect of shunting out all the International doctors was becoming evident with difficulties in recruiting and covering the Rota at Registrar levels. This lead to the line manager for Registrar cover(consultant RicP)to engage in ad hoc contracts based on personal whims and fancies. This lead to a lot of disgruntlement amongst the registrar tier. It was around this time another doctor from India AEj was getting some 'special' treatment by RicP. RicP was a good man who will support you as long as you submit to his whims and fancies. Kumar genuinely believe that he has good intentions. However there is a darker side to RicP,when he is challenged, he takes out his wrath on the individual. So after pushing AEj to extreme stress  and when he inadvertently does a small mistake, the department starts a witch hunt and chucks this doctor out of RBH. Fortunately he joins a better department at MRI with a supportive clinical fellow programme and goes on to become a consultant in a few years time.

Feb 2008

Dr. Kumar is continuing his work at RBH. He has a passion for playing cricket and badminton therefore he is happy being a Registrar for now whilst he is young and able to play his sports. Towards the end of that year He realises being on a short term clinical fellow contract with annual extensions is not correct and is not recommended by BMA. He therefore starts to research how he can be regraded into a contract based on BMA guidelines. By now he has had a total experience of 14 years as a doctor which included 4 years as a general surgical resident in India with successful completion of masters at an institution ranked in the top5 in India. He also had nearly 2 years experience as senior house officer in cardiothoracic surgery in UK, 5 years experience in Emergency medicine at registrar level out of which two years were in east London teaching institutions reputed for Trauma care. He felt that the right grade he should be entered into would be the Associate specialist grade.

Feb 2009

Dr. Kumar started communicating with RicP and GS(clinical lead at RBH) with regards to the regrading as associate specialist. He was aware and informed both of them to act fast because the grade was closing up in about 6 months time. Dr. Kumar sent a letter requesting the associate specialist re grading to the associate medical director HB(one of the RBH endocrine consultants) and copied it to GS and HR. HR at RBH and ED at RBH kept dragging their feet and eventually no action was taken regarding the associate specialist process. Dr. Kumar was told he would only be regraded as Specialty doctor for a 10PA contract. Dr. Kumar was still on a work permit and was essentially a bonded labourer at RBH. He had no choice but to accept this position. He had no intention to uproot family and his life. One of the main reasons he moved out of cardiothoracic surgery was to give some stability to his young family.

Feb2010

Dr. Kumar continues his work in RBH but the terms and conditions of the specialty doctor were much better than the previous Clinical fellow contract. He seemed have a little bit more breathing time to recover from the constant treadmill of providing clinical cover in a busy emergency department. He still was waiting for his annual appraisals. His current mentor OMc told him he did not believe in appraisals. OMc was one of the newer consultants. He had an abrasive personality but Kumar liked him because there was no ambiguity about what he felt and said to him. It was like dealing with an Indian or Italian, emotional and expressive but at least you knew exactly what he felt and he would be up front with you about it.

Feb2011

Another year goes by without any appraisals. A lot of changes happen at RBH around this time. First they recruit using an agency two doctors. One from Spain and another an Indian from middle east. RicP did not like the HR department going ahead with this recruitment. He felt he was no longer in charge and controlling who enters RBH registrar team. He gave his usual 'special' treatment to the Indian doctor. He is usually assisted in these activities by DB who shared his office space. DB was Kumar's hero. One day Kumar felt he should be a consultant like DB. Stable family, calm and composed and leading an active life outside of work. He was also in charge of RBH ED trauma related work. So RicP and DB successfully give the Indian doctor such a hard time that he left RBH in frustration. Kumar could see what was happening but unfortunately did not have the balls to intervene. Kumar did wonder if some of RicP's actions were because of some unholy connection with one of the locum agencies. However Kumar had no proof to support this suspicion.

Feb 2012

Kumar finally gets his annual appraisal by CM. He gets a glowing review and CM informs him that he should be upgraded to consultant level/associate specialist level. Kumar is really enthused and writes to RicP about his appraisal and what CM has advised him. This is when RicP the angel transforms into RicP the demon/destroyer of non british doctors careers. He keeps delaying Kumar's requests repeatedly. Eventually after six months Kumar loses his cool and leaves a shift 2 hours early because of an altercation with RicP. The very next week DB joins RicP and refers Kumar to occupational health for mental instability. RicP and DB keep this mental instability theme going in spite of repeated assurances from MS(occupational health consultant at RBH) that this was a departmental organisational matter which needs the involved parties to sit down and discuss. This never happens. Kumar raises his concerns of bullying by RicP and DM at the weekly departmental meeting. Kumar does not realise he has bitten off more than he can chew. He did not realise that the Klu Klux clan at RBH would now hound him out of the department. He was a naive fool who trusted people too easily.

Feb 2013

Kumar been working for the brilliant acute medicine team for a few months since the start of 'investigations under NCAS' for his unprofessional behaviour. No investigation was done regarding Kumar's concerns that RicP and DB were bullying him in RBH. They were ably assisted by OMc and CM. Yes CM, the same man who only 6 months back gave a glowing review in the appraisal and full support to Kumar, the same CM who gives bombastic twitter comments about his support for all grades of doctors in emergency medicine. Kumar could forgive all the other members of the team at RBH apart from CM and another really disruptive character who was recruited by RicP sometime in 2011. I will simply call him 'The Dick'. The Dick was a middle aged man who is from a GP background and worked for many years as a doctor at bike and car events. He had a special knack for financial dealings and making money. He will come across as a spoilt brat who probably suffered some childhood psychological trauma. He was a drama queen and always wanted to be centre of the attraction. The Dick would be the Judas in the story of Kumar.

Feb 2014
Since his resignation from RBH a few months back, Kumar has joined Frimley Park hospital in Surrey as an Associate specialist. He was enjoying his job is a progressive department which has been transformed through the legendary work of a SriLankan PC  and ably supported by a proactive chief executive. The only problem Kumar had now was his weekly commute up and down the M6. Kumar's wife and 12 year old son were very supportive and stepped up to take the additional responsibilities whilst Kumar was away. Kumar had to pause all his extra curricular activities and social life. He was cut away from all his former friends in the nursing, paramedic and administrative team at RBH. Kumar would never again allow himself to become emotionally attached to work place colleagues. He would continue this new cold exterior at his new job at Salford in a  years time.

Fast forward to Feb 2019

Kumar has now successfully re established his career at the new department. He had some really difficult teething problems. However this was a different type of department. Kumar has have been told the credit for that goes to an iconic leader PDriss who currently works as a lecturer in Lancaster/Scotland. Kumar would love to meet this man sometime in the near future. Essentially Kumar now works in a department and hospital known nationwide for being possibly the number one hospital in the country. However I would say do not believe everything you say or hear through the marketing team of Salford and the Health minister's office. However I would say both as an employee and recently as a patient Salford has proved to me why all the adulation is justified. Like all trusts up and down the country it is also overwhelmed with financial and administrative pressures. However the way Salford responds to this is different. The way it treats it's employees is different. The easiest way to describe would be 'firm but fair' with a focus on providing high quality care. I think this is the right approach to running an organisation.

I wish more people from other trusts are able to actually come and experience the benefits of working in Salford even if it is only for a short secondment. They would learn a lot of good practices which they could go back and implement at their own trusts.

My final point is that we owe it to our patients for us to learn the good practices from each other. At the moment a Salford patient gets five star treatment whilst a Bolton patient cannot be guaranteed even a three star. More importantly the archaic, discriminatory practices in trusts like RBH needs to be eradicated if we want to stride forward into the future in NHS. This is where real leadership comes into play. A leadership drive by actions rather than bombastic words. A leadership driven by values rather than narrow short term objectives. This is were RBH fell down spectacularly. In 2012 a senior ambitious Geriatrician took over the Chief executive role. She knew exactly what was happening to Kumar through Dr. Surendra Varman her colleague( currently working in Singapore). However Dr. JB(acting chief executive of RBH) choose to cover up the bullying rather than act on it. It is a sad story where an organisation through poor leadership gets away with dodgy employment practices. However the person who is affected the most because of the actions of such poor leaders is the end user. The Bolton patient. End.

PS
I understand this is a tale through the perspective of Dr. Kumar.
I invite the persons mentioned in this tale to come forward with their side of the story.
Because every story has one side, the other side and the real truth which only the Universal Force called by different names(Jesus, Allah, Shiva, Vishnu) would know.

Goodbye.
Have a great day, week, month, year and life.
Hakuna Matata.
All is well
Anbae Shiva.

Random memories of a Dr.Kumar in UK

Picture above shows Leicester square. Dr. Kumar enjoyed travelling to London for a quick break during his Oxford days.

Dr. Kumar was born in Kerala, grew up in Tamilnadu, graduated from Tamilnadu, post graduate from Karnataka and landed in UK shores in late 1999. He has just completed a six month job in Accident and Emergency. He was heading for a University town to start training in cardiothoracic surgery. The most difficult part of UK life as a junior doctor is the need to move from place to place. If you were a UK graduate or if you are a lucky International graduate or more importantly if you are an exceptional International graduate than your life in UK can be smooth because you will land a rotation in your preferred specialty and do not have to keep moving jobs and home every six months. Unfortunately Dr. Kumar was an international graduate who was neither outstanding nor lucky. So Dr. Kumar followed a trajectory that some of his lot follow in the career circus of NHS over many decades. We just have to satisfy ourselves with left overs.

Kumar however did not know that this is what will happen to him in Aug 2000. He believed he was good enough and luck had nothing to do with career progress. He was too excited about joining a premier cardiothoracic unit and an University teaching hospital in the oldest and certainly the most prestigious University in the world( apologies to Cambridge, Harward, Nalanda etc). He was joining in the lowest medical tier- Senior house officer in Cardiothoracic surgery. For people not used to the NHS training systems this is a job where you are the dogsbody of everybody in the department. You are essentially this automaton who answers only questions specifically targeted at you, you clerk all preoperative patients, you do your 24 hour on calls every few days, you will ensure the post operative patients are progressing in the right fashion and ready for discharge, you prepare their discharge summary on time and anything else that can make the life of your registrar and consultant smooth. In return for this you might occasionally get the privilege of entering the operating theatre to help with harvesting the vein and help close the sternotomy and thoracotomy.

Kumar was completely unprepared for this chastening experience. He was a qualified surgeon from India who has done the above shitty jobs as a first year resident in surgery in 1996 and had progressed  on to being a respected and valued member of the surgical team during his final year as a post graduate resident in surgery. But that does not count here because "United Kingdom" does not recognise any of your overseas experience, unless you are from a "white country". Kumar had nobody else to complain other than himself. He chose to come here in spite of knowing about the discriminatory nature of "United Kingdom". Anyhow the first three months was a difficult experience and Kumar found it difficult to adjust to the the new environment. His main supporters were a remarkable "you can do it"Naik from Kerala and  an ultra suave Srilankan "James bondesque" Ratnatunga. He could not have survived the job if not for the support of these two individuals. He was also well looked after by a Bengali Brain box Poirot like man, another brain box from Greece and finally a good friend in Nambiar who looked at Kumar as his own brother.

The department had five cardiothoracic thoracic surgeons those days. Each was an icon in his own way. There was one surgeon who was supposedly the youngest cardiothoracic surgeon in UK when he was appointed many decades back. He showed Kumar that it is not all about reaching a destination quickly. There was a swashbuckling all singing all dancing superstar in Westaby. He was not the most popular person amongst the team and it can be a bit difficult to get his attention because his enormous head and ego came in the way of any meaningful discussion. However Kumar thought he was a pure genius and his ability to think outside the box was legendary. He is a prime example of an extra ordinary genius being under utilised in the NHS. He can still remember Westaby's patient with the Jorvik mechanical heart device who was in the intensive care unit during his first night on call. He was clearly told that if there is anything to do with that patient he should NOT get involved and should instead immediately call the big boss himself.

Kumar's favourite surgeon was a Rajinikanth like Ravi, who was considered the best trainee ever under the great Mr. Yacoub. There were a lot of rumours flying around the department during this time about this fine gentleman and it made Kumar realise that as you rise higher you have to be more wary of un savoury individuals who will want to pull you down. Ravi rose through those difficult times like a phoenix. His surgical skill and decision making was unparalleled and even the great Westaby probably secretly prayed he could be like Ravi. The most quirky and misunderstood surgeon was a little Scottish man who even after a year kept calling Kumar 'Gupta'. It is possible that was the only Indian name this little genius had time for in his incredible brain. He had the right idea when it came to coronary re-vascularization, he had all the right data to support his decision making, his only handicap if any was he was not as supremely skilled as a Ravi or a Westaby. Finally to Kumar's own super hero Ratnatunga- not the illustrious Srilankan cricketer but the James bondesque Cardiothoraic surgeon. Ratnatunga would never make any extravagant claims to be the supreme surgeon or the greatest intellect but to me he was the overall package when it came to be a complete adult cardiothoracic surgeon and a well balanced human being. He was also the only person in the department with the right interpersonal and communication skills to lead what can be a very difficult bunch of supremely talented human beings.

Towards the middle of Kumar's first six months in the unit, he called for a meeting with the Ratnatunga. The senior house officer team came up with a variety of suggestions which would make the lower most tier part of the team and contribute more effectively to the team. The changes were sanctioned, a couple of Kumar's colleagues choose to stay on for a further six months. They were joined by four newer members in the SHO tier in Feb 2001. By the spring of 2001 the cardiothoracic anaesthetic team which worked closely with the surgeons made an open statement at a departmental meeting that they were the best ever team of senior house officers seen at the unit for a long time. Kumar felt the praise was justified because they were truly performing at the most optimum level. Soon it was time to leave Oxford because Kumar felt that he needed the experience at a different cardio-thoracic unit. Somewhere where transplantation programme was going on. This is what brought Kumar to Manchester on the first occasion and that is where Kumar fell out of love with cardio-thoracic surgery. More about that in the next blog.

Picture below shows a book published by the iconic Westaby.