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.

Random memories of an Indian doctor in UK

Picture above shows Chennai Central Railway Station opposite to Madras Medical College


Feb2000

I was starting my first job in the NHS. I had qualified as a doctor in 1995 in Chennai and completed a three year master's degree in General surgery by 1998. I then worked for a 6 month period in Plastic surgery and wanted to pursue this as my career. This is when the UK bug caught me and brought me to this wonderful country in Autumn 1999. After three months of trying to break into a job in surgery, I managed to get a senior house officer job in Emergency medicine in a leafy suburb of Birmingham. The department was run by 2 consultants from south Asia - one Indian and one Pakistani. It also had a middle grade tier which was made up of an Indian, a Pakistani and a Nigerian doctor. The senior house officer tier had a mixture of British graduates and overseas graduates. It felt like we were the  commonwealth ED department. This was before I realised most of NHS was run by the citizens of the commonwealth. A commonwealth of subtle and unspoken inequalities. All the British graduates were on a standard training pathway(as part of surgical or general practise training) and the overseas doctors were on a stand alone job desperate to break into a rotation of some sort somewhere.

We lived in a  hospital provided 2 bedroom flat within the hospital campus. I had a wonderful 6 months there with my wife. The most expensive thing we bought with my first salary was a panasonic music system which is still with us and working well, mostly. We were so happy, soon my wife became pregnant and the next thing we remember is a scan showing us the bundle of joy. Amidst the mood swings and hyperemesis of my wife, I was busy working the ridiculous shifts in a busy emergency department and applying for a job from August. The evil Home office would only give a short 6 month visa which barely covered my stay in UK till the end of the current job. I found my dealings with the Home office and visa the most stressful. You were somehow made to feel like an unwanted criminal even though you were adding so much value to one of the spines of this beautiful country, the National Health Service.

 The first thing I had to learn in UK was to understand what a surname and christian name meant. Coming from Tamilnadu, where we had done away with surnames two generations back it was a little confusing and there were many occasions where I would mix up the names like " Hello Mr. Smith James" and the patient would correct me that it is "Mr. James Smith". Even today my passport says I am Ganesan Arunkumar, whilst I go around calling myself Arunkumar Ganesan! The second thing I learnt was that the British have a passion for breaking their 5th metacarpal(a bone in the hand). I learnt that no matter what reason they give "I slipped and fell" "I accidentally knocked it on the wall", they are almost always due to a punch. Later in the day we probably will see another man with a facial injury who will also claim he slipped or that he accidentally knocked on the wall. I learnt that this is not an in frequent British past time on a Friday or Saturday night.

My most impressive colleague was a really cool medical senior house officer who had many years experience and could literally manage anything medical that came into the resuscitation room. Coming from a surgical background I probably learnt most of my medicine from this wonderful doctor. Unfortunately NHS hospital medicine had killed his spirit and I was told he was moving onto the world of Primary care to work as a General Practitioner. I could never understand this craze for becoming a General practitioner in UK. Coming from India in the 90's I always thought doctors practised General Practise mainly because they could not get into a 'proper specialty'. I was ignorant then and did not realise the amazing work done in Primary care in UK. I think it still remains one of the under recognised 'proper specialty' all over the world.

My most memorable nurse was one of the shift co-rdinators in ED. She was a fat( or should I say high BMI) middle aged nurse with the most amazing multi tasking ability. Sat on a chair at the nursing station she knew what was happening with every single patient in the department just by looking at a big paper chart in front of her. This was before the era of computerisation and I am yet to see a slicker co-ordinator and in some ways computers have probably slowed down the flow of decision making in emergency departments over the years. These computers have also reduced the time people actually look at the face of the person they are working with because most of the time we are like zombies looking at one screen or the other. I will not be surprised if psychologists come up with research to prove that these screens have increased human stress levels many times and has made us less human and humane.

My most memorable patient was a cardiac arrest. We were alerted about a young man who was in cardiac arrest as a result of injuries sustained because of an alleged assault by a group of drunken youth. He came in asystole (no electrical activity in the heart)and did not survive. Post mortem revealed traumatic brain injury, bilateral lung contusions, the liver lacerated into two pieces and ruptured bowel. A few months later I had to attend a court to give medical evidence in a case where the group of young men were facing murder charges. I still remember the shock I felt when the defence lawyer asked me if the liver and lung injuries could have happened due to the CPR(chest compressions) done by paramedics and emergency medical staff. I later came to know that the group of young misguided youth were convicted of the murder. I hope they went on to regret the day they thought it was ok to jump on a poor homeless guy on the street. I hope they came out reformed and better individuals.

The 6 months flew by very quickly and soon it was time to say good bye to the wonderful team I was working with in Birmingham. Somehow I managed to get a job in Cardio thoracic surgery from August. It was not my first choice specialty and I would have much preferred Plastic surgery but given the difficult job situation for overseas doctors in NHS I felt I cannot be too fussy. More importantly I could not believe I was getting to work in one of the Premier University cities of UK in a equally prestigious cardio thoracic department. Unfortunately my wife could no longer cope with our life in UK because of her homesickness aggravated by some serious hyperemesis. So she went away to India to provide the right atmosphere for herself whilst she grew our bundle of joy. I was off to Oxford for the next stage of my life in UK.

Pause.

Picture below taken through the window of a Boeing flying over the skies of Arabian sea

Around the M60 in Eight-E Departments!

One of my all time favourite stories is 'Around the world in eighty days'. I was envious of my hero Michael Palin when he choose to do it for real with the support of BBC. I hope to do my own around the world in 80days one day. For the moment due to time, financial and family constraints I am unable to do it. However I thought I shall write about my own little journey around my own world of emergency medicine and the circular motorway around Manchester.

There are 3 university hospitals and 10 district general hospitals in the greater Manchester area. Currently there is a review of all health care provisions in the greater Manchester under healthier together. A very ironic name which probably is going to threaten the very foundations of health care delivery in Manchester region and is probably going to be lethal to a quite a few hospitals and their future health.

Out of the 10 District Hospitals already 2 have been downgraded and only have an Urgent care centre. In the near future another 2 possibly 3 will go down the same path. Over the last 4 months I had the opportunity to work in the emergency departments of 6 of them apart from another 2 in the university hospitals. This is my own un-official review of the 8 'E' Departments.

1-MRI
University Hospital based in the centre of the city. Extremely busy, chaotic and urgently needs an expansion to increase the footprint so that staff can deliver the high quality care they provide in more suitable work environment. Academically and educationally brilliant place to work. They have opted to deal with the work force crisis at registrar level by creating their own internal rotation which has been successfully run over the last 6-7 years.

http://www.cmft.nhs.uk/royal-infirmary

2-Salford
University Hospital based in west of the city. Dubbed one of the best emergency departments in the country and recently named as the trust of the year in the whole of the NHS. Probably the best emergency department I have worked in and certainly the best in terms of work culture. Senior clinicians in all specialities and emergency medicine in particular are actually delivering clinical care and doing so in a healthy atmosphere. It is a University hospital with the friendly atmosphere of a DGH. Excellent place to work.

http://www.srft.nhs.uk/

3-Wigan
District General hospital in the western fringe of greater Manchester. Reasonable department with some positives. Probably one of the better run district general hospitals and certainly one of the cleanest. One of the emergency departments likely to survive the review of services because of their success in obtaining trauma receiving unit status. Currently discussions going on to work collaboratively with a neighbouring DGH. In future likely to take over the neighbour because of the dire financial and organisational status there.

http://www.wwl.nhs.uk/

4-Bolton
District General Hospital in the north western fringe of Greater Manchester. In spite of having the busiest emergency department and a good team of doctors and nurses likely to suffer adversely in the imminent cull of services. This is purely down to a poor work culture and dire financial and administrative situation over the last few years. Likely to be taken over by its relatively more successful neighbour.

http://www.boltonft.nhs.uk/

5-North Manchester
District General Hospital North-central part of the city. One of the emergency departments which are under threat in the review of services. Part of the problem is that it is one of four district general hospitals run by the same trust which is probably too big with a complex organisational problem and conflicting priorities. This department is currently plagued by a serious shortage of senior emergency clinicians and is too reliant on temporary staff.

http://www.pat.nhs.uk/Our-hospitals/Our-hospitals-North-Manchester.php

6-Oldham
District General Hospital in the north east of Greater Manchester. This department is currently being refurbished and expanded into a modern emergency department. Once completed it will not only be the flagship of this trust which runs four hospitals, but will probably become the model template for development in other hospitals in the region and possibly the country. It is a well run department with a healthy work atmosphere.

http://www.pat.nhs.uk/Our-hospitals/Our-hospitals-Royal-Oldham.php

7-Tameside
District General Hospital in the eastern edge of Greater Manchester. Unfortunately one of the hospitals which is frequently slated in the local and national press because it was one of 14 trusts which were reviewed by Keogh because of its high HSMR. I was pleasantly surprised by what I saw in this hospital. This is a trust which has listened and learnt from all the criticism it received. The emergency department is possibly one of the best I have worked in and has an excellent team of people working. All I can say is, this department and the trust will probably survive into the future simply because of this positive work culture.

http://www.tamesidehospital.nhs.uk/

8-Stockport
District General Hospital in the south of Greater Manchester. One of the busier emergency departments and possibly the most innovative and advanced in use of modern technology. This department and hospital probably has a secure future because of all the investments in the right direction.

http://www.stockport.nhs.uk/

That completes my journey around Eight-E Departments around the M60. Unfortunately I did not get a chance to work in one university hospital in the south of the city, two other DGH's and two Urgent care centres.



In summary there are good practises everywhere and some bad stuff in some places. Hospitals and emergency departments which are doing well appear to have a better 'work culture'. I wish senior decision makers take time to visit their neighbouring hospitals and departments to learn from each other. Our duty as an emergency physician is to deliver the best possible care to our patients and we will only achieve it if we are willing to take the extra effort to learn from each other. There will always be a lot of factors which are beyond our control which might determine the future of our departments. However to walk around moaning, whingeing and generally disillusioned with life as an emergency physician will get us nowhere. Good bye for now. Have a great 2014. I'll be back!

Keogh, Francis and Berwick reports and its impact on the future of urgent and emergency care

We are almost coming to the end of 2013. It has been an eventful year for NHS and in some ways for me too. After 8 years of working in a single emergency department, through certain unexpected circumstances I had a chance to work in a variety of emergency departments in the Greater Manchester area. Soon I shall be starting a new job in a different emergency department down south.

In the preparation for the new job I had another closer look at what these three gentlemen have been saying. I can clearly see that these three landmark reports are going to change the future of emergency medicine, acute care and the whole NHS over the next 10 years. This is irrespective of whether the NHS survives in its current form, which I very much doubt.

For those who have not yet looked into what these three reports are all about and just want an idiot's guide- Bruce Keogh's report is all about 14 individual hospital trusts and their unusually high mortality rates. Francis report is all about the mid Staffordshire debacle. Berwick is all about improving patient safety. The core message is the same in all three reports and most health care professionals with a few years experience and some common sense would have been able to give these answers even without a detailed investigation/review.

So what exactly is the core message

1-Put the patient first.
2-Do not get blinded by targets
3-Look after the health care professionals
4-Robust clinical governance and commitment to training and education
5-Have the right type of Leadership

There are going to direct and indirect implications for emergency departments in UK as a result of these reports and the current push for changes in the way urgent care is delivered and managed. There is an urgent need for emergency physicians to change the way they work currently. I can clearly see that the departments where senior emergency physicians(consultants and SAS doctors) work more flexibly and deliver actual clinical care will survive as emergency departments and the ones which are stuck in the old ways of crowding during office hours(mostly inside offices!) and disappearing afterwards will just slowly degenerate into glorified walk in centres.

There is also a need to work closely with our acute medicine colleagues to ensure that our patients get the highest quality treatment they deserve. The future hospital commission has tried to address the complex issue of delivery of acute care and has projected the need for clinicians who are trained to deliver acute care in a variety of settings. Any budding emergency physician( and current ones with more than a decade of working life left) will do well to read this report as well.

Further reading

http://www.nhs.uk/NHSEngland/bruce-keogh-review/Pages/published-reports.aspx

http://www.kingsfund.org.uk/projects/anticipating-francis-inquiry-report

http://www.kingsfund.org.uk/audio-video/don-berwick-improving-safety-patients-england-full-presentation

http://www.rcplondon.ac.uk/sites/default/files/future-hospital-commission-report.pdf