Podcast Episode 5 - NHS staff strikes, ebola, space, infected chickens.

In our fifth podcast, Dave and I discuss infected chickens, NHS strikes, homeopathy and space. Enjoy! Share! Feed back!

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Strike.

There was further NHS strike action this week. You may or may not have noticed. This is because health workers set out to make a point, withdraw their labour but not to cause harm to patients.

I think most of us would agree that we would rather see our health workers working and not picketing the front of our local hospital. The thing is, is that most of them would rather be doing their jobs than stood out front in the cold. Some of them have had to take difficult decisions to forgo a day's wage to support the strike action. Can we assume, therefore, that they have done it for a good reason?

The global financial cliché has put ever increasing pressure on our publicly funded services. This has translated into a pay freeze for many NHS workers over the past four years, though the government deny it.

Most jobs within the NHS follow the Agenda For Change payscale. A given job will have a payband and within that there will be several incremental pay points. For example, a newly qualified nurse might be a band 5. If they meet their targets at appraisal, after a year they will move up to the next pay point within that band. If they are promoted to a deputy ward manager role, they will move up to the next band, where they will start again at the first pay point within that band.

The government has accepted a 1% pay rise, but only for those who are not entitled to an incremental rise (moving up to the next pay point after a year).

So a nurse/physiotherapist/occupational therapist/radiographer etc may have to work for several years and move up to the top of their pay scale before they are entitled to this 1% rise. Yes, they would get their annual increment, but because of inflation, each pay point is worth less and less every year.

This means that as a group, healthcare workers are earning less than their predecessors did 5 years ago. 

I think that pay needs to at least match inflation and that is before incremental increases that recognise the value of another year's experience and training.

If pay falls in real terms (as it has) then morale follows it.

You cannot separate health from wealth and many of our lower paid colleagues are really struggling to cope. There are some who feel they cannot support strike action because they cannot afford to lose 1 day's pay. Making a less-wealthy group of society even less wealthy will cause more social and health problems in the future. It will also affect recruitment.

How many radiographers, physios and OTs will be advising their kids to follow them into their professions when it's clear that the government doesn't value them?

In places where there is a reasonable amount of private sector activity, you will lose valuable staff to other companies. In places where there is not, such as many northern towns and cities, then people rely heavily on public sector employment as their only chance of a decent career. I also think it's naïve to blame managers for everything (as the UKIP representative did on Question Time when I asked about this) as healthcare is incredibly complex and someone needs to steer the ship.

Pay is not the only thing getting worse. Look at page 5 of this document for a comparison of pension schemes and you will see that it is moving towards career average (rather than final salary), with later retirement ages and reduced lump-sum benefits. Many workers, such as doctors, will have to make higher pension contributions. This led to the BMA taking strike action in 2012 for the first time since 1975.

Financially speaking, people don't have much sympathy with doctors and I can understand this. We are a relatively well remunerated profession. Junior doctors, however, end up worse-off year on year. Doctors' pay is calculated on a different pay scale. The pay has been frozen in a similar way to that of other healthcare workers. The only 'pay rise' they have received is when they move up from one year to the next having gained extra skills and taking on extra responsibility. If you want to see how the Daily Mail reported this please read here. Please also read the comments below to see some angry doctors' responses. The pay increases are, in effect, for a promotion from one grade to the next. When you get there, you get paid the same as what you would have received 4 years ago. With inflation, this amounts to a pay cut.

This is not the only financial hit junior doctors have taken in recent years. Tuition fee increases mean student debt for the 5 or 6 years of medical school has exploded. Up to 2007, hospitals had a duty to provide accommodation for first-year doctors. Now they don't. The loss of this benefit-in-kind amounts to a pay cut. The European Working Time Directive has reduced hours, but also reduced pay-banding for junior doctors. The NHS pension scheme is worse with each iteration, as discussed above.

Hunt will say that if we pay staff, we will have to cut jobs. This is a fallacy. The fact is, is that the NHS needs more money putting in. I think this needs to come from HMRC getting all the tax it's owed from the wealthy and from big businesses. I also think we need a more progressive tax system, with a tax on wealth, so that those who have the most, contribute more to our society and the country from which they benefit.

We spend less on healthcare than most comparable countries. We have an increasing inequality within our society. Pay cuts to healthcare workers affect many of the poorest in our society and will create problems for the future. I think we have to find the money to pay staff what they deserve.

Dog News

Cheers Alan and Emily for this one. Is he actually listening or is it on paws?

No-one knows why dog news is so popular. I always thought it was people listening to it, apparently it isn't.

If you (or your dog) listens to the podcast, please rate it and even post a review. It will help us climb the rankings and others find the show.

Search for 'MediCave' on iTunes

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Thanks for listening!

Podcast Episode 4 - Drugs, boozy calories, BBC Question Time

In our fourth podcast, Dave and I discuss appearing on Question Time, calorie labelling on alcohol, drug treatment vs punishment and some nonsense about beef. Enjoy! Share! Feed back!

www.medicave.co.uk
@mdmedicave

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Podcast Episode 3 - TTIP, lung cancer and dementia screening, killer spiders...

In our third podcast, Dave and I discuss appearing on Question Time, TTIP, lung cancer screening, dementia and killer spiders.  Enjoy! Share! Feed back!

www.medicave.co.uk
@mdmedicave

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BBC Question Time

A previous Liverpool episode

A quick note to say that I'm going to be in the audience for BBC Question Time on Thursday 23/10/2014 at 22.35 on BBC 1 from Liverpool.

On the panel are Scotland's first minister Alex Salmond MSP, Labour's shadow energy secretary Caroline Flint MP, Conservative minister for disabled people Mark Harper MP, UKIP's Louise Bours MEP and the leader of the Unite trade union Len McCluskey.

We all have to submit one question by email today. Max thirty words.

I wanted to give people the opportunity to criticize the government's funding of the NHS and the pay-freeze imposed on its staff. I didn't just want to rant leftily, as I doubted that that would make the cut.

It also has to be based on current news events.

I went for:

How do we save our NHS from the ‘perfect storm’ of austerity, increasingly expensive treatments and an ageing population, whilst paying staff the wages they deserve?

This was based on the idea of the 'perfect storm' discussed by Monitor's Dr David Bennett.

It would also give the opportunity to discuss staff pay and the recent strike action.

I need to submit a second question on the day when I arrive at the venue.

What would you ask?

I hope I get to ask it. Keep an eye out for me.

What does UKIP really stand for? And what the hell is TTIP?

UKIP

UKIP have an MP. The Conservatives, Labour, Liberal Democrats, Greens, Respect, a couple of independents and several parties representing Welsh, Scottish and Northern Ireland parties already did. Are they on the news as much? Doesn't seem that way. Many agree - that's why thousands of people have signed this petition to get the Greens on to the televised pre-election debates if UKIP are.

UKIP are big news though, because they speak for us, for ordinary people and will make Britain fairer for all, right? They're different to the 'Westminster Elite'. Nigel Farage drinks beer! He's like me!

Farage went from private education to a job in the City as a banker. He was a member of the Conservative Party before helping form UKIP. From that, he sounds more like others in politics than like me, but you can't help your background. Better to look at what UKIP stand for.

If you're thinking of voting UKIP to get a fairer society and get away from the current rule by a wealthy elite, first read some of their policies:

– We will introduce a 35p income tax rate between £42,285 and £55,000, whereupon the 40p rate becomes payable. (Cutting taxes for those earning over £42k)

– Inheritance tax will be abolished. (Inheritance tax only kicks in on estates over £325k or £650k for couples - most estates aren't affected. Abolishing inheritance tax would only increase the accumulation of wealth by already wealthy families)

– UKIP opposes ‘plain paper packaging’ for tobacco products and minimum pricing of alcohol. (Measures backed by doctors and evidence that would make people healthier, but might affect some company profits)

– UKIP will withdraw from the jurisdiction of the European Court of Human Rights. (As a human, I'd like some rights)

– UKIP will require foreign vehicles to purchase a Britdisc, before entry to the UK, in order to contribute to the upkeep of UK roads and any lost fuel duty. (Yeah! Foreigners should pay for our roads if they drive on them. That would stop them coming over here, staying in our hotels, eating in our restaurants and spending their foreign money. And I assume they should charge us for using their roads as well?)

– UKIP will abolish green taxes and charges in order to reduce fuel bills.

– UKIP supports a diverse energy market including coal, nuclear, shale gas, geo-thermal, tidal, solar, conventional gas and oil.

– UKIP will repeal the Climate Change Act 2008 which costs the economy £18bn a year.

– UKIP will abolish the Department of Energy and Climate Change and scrap green subsidies.

(Yes, energy is too pricey but the energy companies still manage to make excessive profits. Global warming is coming and will be very, very expensive.)

– UKIP will abolish the Department for Culture Media and Sport. (Well, we've already had the Olympics, I suppose.)

– UKIP will cut the foreign aid budget by £9bn pa, prioritising disaster relief and schemes which provide water and inoculation against preventable diseases. (Foreign aid is good. It makes us slightly less unpopular abroad. With ebola, we've seen what happens if poor countries are kept poor and unable to manage crises such as deadly epidemics. Maybe it's just a nice thing for us to do.

The truth is that UKIP are misleading the electorate and are happy to allow people to think that voting for them will help them get a better life. A UKIP vote is one for the wealthy, not for ordinary people.

If you like, you can look at the Green Party's ideas. If you want to protest against the government or the Westminster Elite, there are choices other than UKIP. Yes, they like the environment, but they tie this in with the well-being of all people, not just the wealthy few. It's a far more positive message than that of UKIP. I wouldn't tell you who to vote for, but please check what the party you choose actually stands for before you make up your mind.

UKIP has been hit by scandal after scandal, but most of these stories seem to be quickly forgotten. Many members have some very backwards views on race and gender. They certainly care a lot about immigration. Immigration certainly bothers people, but it does have benefits. One of these is to low-pay employers, who can exploit them to make cheap goods. If they had to pay a living wage and treat workers fairly, they could no longer bring in cheap foreign labour to live in poor conditions. UK workers would be competitive and migrant workers wouldn't be 'stealing our jobs'.

Also remember that if we send all immigrants home, they might send all ours back.

UKIP want us to leave Europe and be free of all their pesky regulations. Regulations that affect our beloved corporations.

Only sometimes regulations are good. Corporations are robots. They are built to make money. They might be briefly not evil if that will result in them making money. If customers will only buy their stuff if they are good then they will respond to that. However, most of the time, people aren’t aware of the bad stuff they do, or there isn’t a choice, or they can’t afford to make the choice, so corporations will do whatever bad stuff they can get away with so long as it makes them money.

Often, the only thing stopping them doing this is regulation from national and supra-national bodies. The EU isn’t just about straightening bananas, it does all sorts of stuff for us including cheap flights, cheaper international phone calls, consumer protection, food safety and human rights. Yes, the European Convention on Human Rights is a good thing. Unless you like being a slave, discriminated against, or killed, or being told what to believe or being tortured etc. It just has some unintended consequences, as all regulations do.

It’s bodies like the EU that will be instrumental if we want people and companies to pay the tax they owe without stashing their cash in tax havens.

But one thing going on in Europe now might be about to make things a whole lot worse. Apparently that thing is called TTIP.

TTIP

A sticker on a bus

I’d love to say I know what TTIP is, but, to be honest, I don’t. So what's the concern? Boris Johnson says I'm a 'numskull' for worrying about it. Thanks Boris. I'm not the only worrying, though. Here are some angry protesters.

When I say I don’t ‘know’ what TTIP is, I mean that I only know these brief details that have been leaked. The negotiations are actually happening in secret.

It’s supposed to be a free-trade agreement between the EU and the US.

The pitch:

To remove restrictions between the two areas to make it easier to invest.

To decrease bureaucracy and duplication of regulations, so companies only have to meet one set of rules when creating products and services.

To increase growth and create bazillions of jobs.

Brilliant.

So what’s everyone’s beef? Well, beef for one. If we harmonize food production rules, we might find Europe’s current safety standards lowered to those of America. Have you seen the state of an American chicken farm? Sardines in a can don’t know how lucky they are. The example often cited is the use of growth hormones to make cows bigger. Europe doesn’t allow this, America does. What’s wrong with grass and grain?

Ok, what else? Companies investing sounds good, right? Not necessarily if they are investing in our healthcare system. TTIP will make it easier for US companies to take over NHS contracts. Worse than that, they could sue governments if they are prevented from doing so. The corporations tout fair competition but they want to remove the NHS’s protection from predatory PLCs. Cameron has been asked to keep the NHS out of these discussions.

If you need reasons to be concerned about TTIP, try:

These ten

and

These (similar) six.

And if you agree that it sounds bad in it's current form, that we should be told more about it and that we should make sure that our safety standards and public services are corrected, then look at these petitions:

https://secure.38degrees.org.uk/page/s/vince-cable-fix-ttip#petition

http://www.change.org/p/to-the-eu-and-uk-governments-do-not-sign-up-to-ttip

So, in summary...

Is it a contradiction to criticise UKIP's anti-Europe stance and the TTIP negotiations going on in Europe in the same post? Maybe. But maybe it's just that the world's a bit more complicated than 'Europe is bad for Britain' or 'immigration is too high'. It's the nuances of these debates that are more important than the headlines.

Think long and hard before you vote UKIP. It is unlikely that all your problems are because of immigration, it's just a simple and visible thing to make you scared about. If you care about the rest of UKIP's policies, then please read them and decide if they would benefit you and really make Britain the kind of country you want it to be.

The world has changed and Britain isn't in charge any more. Our own well-being is tied up with that of the rest of the world. Maybe there's more to life than being the most powerful country and reducing inequality within our own country would make us all happier. If we do want a say on the world stage, then it's hard to do it alone and being part of Europe has many more benefits than drawbacks.

We need to engage with Europe and hold it to account. Sometimes it is too expensive. When things are going wrong, such as with TTIP, we need to know about it and do something about it. The alternative could be disastrous.

Podcast Episode 2 - Anaesthetic awareness, sporting head injuries, ebola.

In our second podcast, Dave and I answer the question 'Will I wake up during my operation?' and discuss sporting head injuries, ebola, green cola and dogs.  Enjoy! Share! Feed back!

www.medicave.co.uk
@mdmedicave

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Ban Boxing (and every other sport)!

Image: Andrzej Krauze - taken from New Scientist article

I have to say that I don't like professional boxing. Not to say I've never watched it, but it does make me uncomfortable. I've watched amateur boxing at the Olympics. They wear headgear and it seems more of a sport to me. It may be no safer than the pro side but at least it has the sheen of a points-based contest. As argued in this New Scientist article, head injuries are the aim of pro-boxing. I don't see how we can still justify it as entertainment. I'd get rid of it if I was in charge. You may be glad I'm not.

That leads to the question: What level of risk is acceptable in a sport, either to the competitor or others? I don't have the answer to that, but all sports should be trying to get the balance right between preserving the game and protecting those playing. No, 'they make loads of money' isn't justification for putting them at unnecessary risk.

Dave and I talked about this on the pod, but we came across some interesting articles and stories that you might want to read.

I'm obsessed with NFL (American Football) at the moment and we mentioned in Podcast 1 that we wanted to talk more about it so we got to it in Podcast 2. Head injuries have been big news in the NFL for some time. Over 3000 former NFL players sued the league in 2012 and a settlement was agreed in 2013 for $765m to provide medical care for those affected.

NFL involves HUGE guys tackling each other. All players must wear a helmet, but this can only help so much. There is now an initiative starting in schools called Heads Up Football that aims to teach kids proper tackling technique and reduce head and spinal injuries. When concussions do occur, the NFL has guidelines in place for the assessment of players and when to let them play again. This involves pre-season baseline testing and the presence of neurologists at every game. When players sustain a concussion, they should not play until they have fully recovered as the risk from second injuries is great.

The lawsuit above covered a few different types of head injury, but it seems that the main issue was CTE or chronic traumatic encephalopathy - a degenerative disorder related to repeated concussions. It's linked with movement disorders, personality changes, substance misuse and suicide. Clearly, even minor head injuries need to be taken seriously. As a vast money-making machine, the NFL is finally starting to take responsibility for reducing these injuries and protecting its employees.

Football (our football) is much earlier in this journey. It's a non-contact sport though, right? Well that's fine until a keeper wants to get a ball with his hands or body and an attacker wants to score with his legs. Petr Čech (Chelsea) suffered a depressed skull fracture in 2006 and has been wearing protective headgear since. Last year, Tottenham were criticized for letting their keeper Hugo Lloris play on after being rendered unconscious in a similar collision.

Partially in response to this incident, the Premier League introduced new guidelines prior to the start of the 2014-2015 season. These included giving doctors (who are employed by the team...) the power to remove players from the game, rather than leaving the decision to the team or player. Surely the Premier League can afford an independent doctor at a game to assess these things - armed with a rule that says, "If a player is knocked out, they are getting subbed off. I don't care if you've used all your subs, it's great when a defender has to get his gloves on."

Last week, the inadequacy of the current set-up was displayed again when another Chelsea keeper was knocked out. He was assessed by the club doctor and allowed to carry on but was subbed later when he felt unwell, with blood coming out of his ear. FIFA have supported the decision to keep on playing (caution - Daily Mail link) but I can't see how unconscious players should be allowed to wake up and carry on. It's not bravery or commitment, it's reckless and stupid.

I don't watch much rugby, but the RFU puts out this info sheet, which looks pretty good. it talks about the 4 R's when concussion is suspected (such as when a player has been knocked out):

Recognise

Remove

Recover

Return

If any one knows whether this works in practice, I'd be keen to hear.

The conflict between safety and spectacle is rarely more apparent than in motorsport. Fans want speed (and many will freely admit, crashes) but no-one wants to see drivers hurt. As the pinnacle of motorsport, Formula 1 has improved greatly from earlier decades, where death was an accepted and inevitable part of the season. There's not been a driver death in F1 since I was ten. Circuit design, improvements in protective equipment, car safety and rule changes have all helped reduce the risk. The lessons learnt in F1 have filtered down to lower formulae and to our road cars.

But any thoughts that F1 was now "safe" were shattered last weekend, when Jules Bianchi crashed into a recovery vehicle that was by the side of the track to move another stricken car. I had read that he had undergone surgery for a subdural haematoma (bleed on the brain) but I can't actually find confirmation of this now so sorry if that isn't the case. What has been said is that he's suffered a diffuse axonal injury, where rapid acceleration and deceleration causes damage to nerve cells due to shearing. This is a common but devastating consequence of severe head injury.

We'll be thinking of him and his family.

At this point I'd like to say that motor sport, at all levels, can only run because of the dedication of a legion of unpaid marshalls, who stand out in all weather to keep the racers safe. They are backed up by knowledgeable and passionate officials and an enthusiastic community of doctors and paramedics who are constantly trying to improve medical provision at these events. Here's some concussion guidelines for F1 and for loads of information about Medicine in Motor Sport, read that.

A HANS device and helmet

Will any good come from this? This accident occurred following a previous incident and the organizers have come under fire for not putting out a safety car to slow everyone down in wet conditions whilst the first car was recovered. There is a debate about closed cockpits in F1 (like a fighter-jet canopy to protect drivers' heads) but worry that fans won't like the look of it. Some fans will moan about every change in F1 but ultimately get used to it. We'll have to wait to see what lessons can be learned.

Ultimately, organizers should take all reasonable steps to protect their athletes. We, as fans and consumers, should accept changes to improve the safety of the sports we love.

Mad Men

Mad Men is our show at the moment. We're only on series three but flying through it. It's early 1960s Manhattan and the Mad Men are the advertising executives of Madison Avenue. The word 'Men' refers to just that. In this industry, the males get the office, the big salary and the prestige. The women work as secretaries and try to pick up husbands. The one girl who breaks through struggles to be treated on equal terms.

It's not just a man's world but a white man's world. The African-Americans have to content themselves with operating the lift. The series touches on the struggles in the South, but this is just another unfairness you have to accept in the show.

Much of the show trades on the discomfort the viewer feels in the inequalities of the day and in the smugness in just how far we have come. There are many ways in which the world has improved and in which we can be proud. However, I think it pays to be reminded that we're only part way down the road with regards to many of the issues portrayed.

Gender inequality.

Yes, women can now get top jobs but it's still no level playing field. Australian women earn 18.2% less than their male counterparts. Less than a third of Northern Ireland's top jobs are held by women. This Guardian article shows some of the progress made but also the challenges remaining.

We should be increasing childcare provisions for working mums and eliminating pay gaps. Organisations should be working to improve access to top jobs. This has to start in parliament.

The darker side of male and female workplace inequality rears it's head in the show, with sexual harassment rife. There's also really disturbing scene of rape within a relationship. It would be great to say that thankfully this doesn't happen any more but I can't.

Smoking

There is a LOT of smoking in Mad Men. In the office, in the car, around the kids. I'm glad that we see less of it on TV now. This is a period piece, but I'm not convinced that that justifies it. Smoking rates have come down since the sixties and legislation such as banning smoking in enclosed public places and in cars carrying children should be celebrated. The Mad Men have a tobacco account and are struggling to cope with the negative publicity surrounding links with cancer and heart disease.

I remember tobacco advertising and sponsorship in the UK. Good riddance. The tobacco companies are fighting back though. They are challenging plain packaging laws and moaning about hiding cigs in supermarkets. They are buying up e-cigarette companies and marketing them to young people. My co-podcaster Dave doesn't mind this but I do not want people to remain addicted to nicotine, or to start smoking as young people. All the while the companies are promoting cigarettes in developing countries and there are now more than 300 million smokers in China.

Alcohol

There's almost as much boozing as smoking. Every time someone walks into another office, they get a drink poured. After work drinks lead to accidents (and affairs) and drink driving is the norm. The show is also a vehicle for product placement. Them talking about how to advertise a particular product on the show IS advertising that product, obviously.

The costs of alcohol to the NHS alone run into the billions. Advertising definitely plays a part but price is likely to be a bigger factor in determining consumption. The government caved into pressure from the alcohol industry and backed down on minimum unit pricing.

We have not made the same leaps forward on alcohol that we have on smoking.

In The End

It's good to think that some things have got better. Mad Men is set before car seat-belts were compulsory. Now we wouldn't think of getting in a car without them. There are no actual tobacco adverts on British TV anymore. But there is still big money to be made in advertising, because it works. It might be cigarettes in China, e-cigarettes on our TV, junk food with kids toys, Coke pretending to care about health, the excitement of gambling or winning in an online casino or lager companies sponsoring major sporting events. We can look back at the sixties and be glad that things have moved on. In many ways, however, the adverts are just more clever and the Mad Men are still one step ahead.

Will I Wake Up During My Operation?

This is a major concern for many patients who have an impending date for surgery. It seems to be a primal fear, lying there, unable to speak, unable to move, in pain. But is it going to happen? A golden rule in medicine is that nothing ever ‘never’ happens, but it’s very unlikely. ‘Awareness’ is reported in 1 in 19000 anaesthetics. But the idea of it is terrifying, isn’t it?

There was even a film!

It’s made the news because of the NAP 5 audit. This is a ginormous study involving every public hospital in the UK, looking for incidences of AAGA – accidental awareness during general anaesthesia, undertaken by the Royal College of Anaesthetists (RCoA) with the Association of Anaesthetists of Great Britain and Ireland (AAGBI). It’s commendable that the speciality would examine itself in this open and honest way.

Awareness. It’s a broad term. It could be someone who remembered their breathing tube coming out at the end of an operation, it could be someone who remembered something happening whilst they were sedated (and not supposed to be completely unconscious). It could be someone who was not adequately sedated when being moved from the operating theatre to the intensive care. In the study, awareness was most likely to occur when just going to sleep (induction) or when being woken up at the end of the operation (emergence) rather than in the middle of operations.

To get your head round the results, it might help to know a bit about anaesthesia itself. Skip this bit if you’ve ever given one.

Anaesthesia is an oft-misunderstood medical speciality. I think we should remember the incredible contribution that advances in anaesthesia have made to the world. Surgery that was once either completely intolerable or technically impossible is now performed safely and regularly. However, when I started my training (I only did 18 months before changing specialty) I was asked if I was still a doctor!

It has been compared to being an airline pilot, where all the action’s in taking off and landing and you can just kick back for the middle bit. Like being a pilot, you need to be trained for the worst-case scenarios. Unlike it, emergencies arise frequently. During the operation, it might look like the anaesthetist is not doing much, but they are monitoring, adjusting gas flows, giving antibiotics, analgesia and planning the next phase of the procedure. They have to constantly modify their techniques depending on how the operation is going or the patient is doing. But what is ‘an anaesthetic’?

Anaesthesia can be local – you cut yourself and need stitches and the A&E doctor injects some local anaesthetic (LA) to numb the immediate area. Many minor operations in operating theatres happen under LA alone, without an anaesthetist present.

A surgeon or anaesthetist may administer regional anaesthesia by targeting one or a group of nerves to numb a larger area, for example in foot surgery. This can occur alone, or in combination with a general anaesthetic.

A neuraxial block may be used – an injection into the space around the spinal cord will numb everything from the waist down and is handy for knee surgery etc. An epidural works in a similar way. These are often used in combination with sedation, where consciousness is reduced with medication, but the patient is not fully anaesthetised.

A general anaesthetic (GA) is where a patient is given medications to render them unconscious. This usually starts in the anaesthetic room and involves several stages:

1)            Induction – Drugs are given, usually straight into a vein, to temporarily render them unconscious. Once this happens, the patient can no longer protect their airway and a device is inserted to keep it open and allow the delivery of oxygen and anaesthetic gases later. If a breathing tube is to be inserted, then the patient must be paralysed, to relax all the muscles in the mouth and throat and allow the tube to pass.

2)            Maintenance – The patient is transferred to the operating theatre and is kept asleep. This is usually with anaesthetic gases but can be with a continuous infusion of medicine into the vein. The patient may breathe for themselves, depending on the operation. For certain operations, such as abdominal procedures, continuous muscle relaxation is needed so the patient remains paralysed and the breathing is done by a ventilator.

3)            Emergence – Once the operation is finished, the anaesthetic gases are turned off and the patient starts to wake. If they have been paralysed, then a reversal agent is given first so their muscles can work again and they can breathe. Any artificial airway is removed and the patient can be taken for further monitoring in the recovery room.

There are many more ways to give an anaesthetic than to skin a cat, I would imagine. You have to consider the patient and the procedure. In some ways it’s a very scientific speciality, built as it is on the three P’s of physics, pharmacology and physiology but in others it’s an art. You can learn what the right anaesthetic is for a particular operation and the dose of a drug that the average patient of a particular size, sex, age and fitness will need, but it must be individualised and you must respond to all the information that is available. You might be watching the patient and two screens with many variables displayed whilst getting information from the surgeon and the rest of the team and administering five or even ten different drugs and vapours. Anaesthetists are very well trained but you can see how there are opportunities for error.

Why not just give more?

Fair question. Unfortunately, all the sleepy drugs have side effects. Probably most importantly effects on blood pressure. Also, the more you get, the worse you feel afterwards.

So what did the audit find? The headline figure is that AAGA is reported once for every 19000 anaesthetics. This means that you are more likely to be killed in a traffic accident in any single year than experience awareness during a single anaesthetic.

However, the chances very much depend on the type and technique used. When neuromuscular blockade is used (paralysis) then the incidence rises to 1:8000.

Why and when does awareness happen? Well, there are several reasons...

During the induction phase, the anaesthetist needs to secure the airway. This can be straightforward or take a little longer. The longer it takes, the more chance the patient has of becoming aware of what’s going on. They then need to be moved to the operating theatre and are not connected to the anaesthetic machine at this time.

During maintenance, there are a variety of ways that the anaesthetist determines whether enough anaesthetic is being delivered. Sometimes EEG brain monitoring is used. The anaesthetic machine may give a display of how much anaesthetic gas is being breathed out by the patient (a good approximation of how much is in the brain). Small rises in pulse rate might indicate that the patient is not ‘deep’ enough. Another is that a patient may cough on the airway device or move on the table. This is not to say that they are conscious, just that some primitive reflexes are being stimulated and the patient needs more anaesthetic. Neuromuscular blocking drugs prevent this movement and so take this valuable warning sign away.

As the patient wakes during the emergence phase after the op, if the neuromuscular blocking drug is not adequately reversed, it can be that the anaesthetic wares off before the paralysis. This could lead to awareness without being able to move. For emergency procedures, the patient must be more awake before the breathing tube is removed, to ensure that their airway is protected if they were to vomit. There is a chance that they could remember the tube coming out.

Particular operations are higher risk for AAGA as well – heart surgery and C-sections as different drug combinations are needed in these patients. Pregnancy poses many particular challenges to anaesthetists, due to altered body shape and physiology and the need to care for two patients.

The study makes particular mention of reducing drug errors and how institutions can change lists and practices to reduce avoidable errors.

I think the main thing to pick out is that awareness is rare but not absent. When it occurs it can cause significant psychological harm. Awareness includes many experiences that are not 'waking up in the middle of the operation'. But the report is positive in that in identifies many ways in that the risks can be reduced. So things will get better.

So will you wake up during your operation? It’s extremely unlikely and will become even less so.

Podcast Episode 1 - eCigarettes, Scottish Independence and the NFL!

In our first podcast, Dave and I talk eCigs and eCars, Scottish Independence, Ashya King, the NFL and dog ownership. Enjoy! Share! Feed back!

www.medicave.co.uk
@mdmedicave

If you want to download it to your computer, you can click this link directly.

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http://feeds.feedburner.com/PodcastMediCave

War On Drugs - Top Ten Films!

Have you seen End of Watch? My wife and I watched it this week and it made me (almost) cry. Not in the usual Hollywood way. And not in the Apollo 13 triumph over adversity way (the other film that always gets me). It’s a buddy movie about two cops in south-central LA who are doing their best to uphold the law and take down the bad guys. The crime in question is drug dealing and the violence that goes along with it.

It’s the way it’s shot as a realistic fly on the wall / found footage type thing (often a crap start to a film) that sucks you in and really makes you feel it at the end. No one wins. It made me think about the senseless loss of life on both sides of the law that have occurred in the War on Drugs.

So in true box-office style, here are my top-ten films that depict the tragedy of the War on Drugs.

10 - City of God

The birth of a Rio De Jeneiro cocaine empire and the violence that accompanies it.  Think of cocaine and cannabis and many will think of Central and South America. Be it the Columbian cartels, Mexican narco-terrorism or farmers surviving on growing 'Bolivian marching powder'. 

Several countries are making progressive strides though. One example is Uruguay, who are regulating production and sale of cannabis. This graphic from Drug Law Reform explains how it works. US states, such as Colorado are taking their own steps. As you can see, it's not designed to create a free-for-all, but to control who has access to cannabis. The aim is to take production and sale out of the hands of the criminals and place it within a regulatory framework.

9 - Scarface

The glamour of running a cocaine business in Miami! Until you end up hooked, friendless and full of bullet holes. This one is ridiculously over the top, but it shows where the money goes, to local gangsters, paying off officials and ultimately to huge and powerful cartels, leading to politcal instability and conflict in producing nations.

8 - Human traffic

The story of a night out involving alcohol, ecstasy, cannabis and, I think, cocaine.

This film is showing its age now. Ecstasy use is decreasing amongst young people, possibly being replaced by newer psychoactive substances - 'legal highs' and our drug laws are struggling to ban the substances quick enough. If they were all brought under the same regulation as alcohol, tobacco and other currently illegal drugs, then the onus would be on the manufacturer to prove contents and safety and scientists would stand a better chance of studying the substances to aid classification and control.

All drugs have adverse effects. I include alcohol and tobacco in that. There are, however, millions of people who take drugs and don’t end up as addicts or in hospital. They must enjoy themselves, or they wouldn’t take them. When people do come to harm, it is often a failure of education. When Leah Betts died in 1995 after taking ecstasy, there was a huge national campaign against the drug. It can be dangerous and there are deaths associated with it but in her case it was likely because she drank several litres of water in a short period of time (leading to low blood sodium levels and swelling of the brain) rather than the toxicity of the drug itself.

Educating users on how to avoid harm is a more pragmatic approach than hoping they won’t take it at all. Other fatalities have come because of mixing drugs together or taking drugs with dangerous impurities. If they were sold in a pharmacy, with warning labels and advice, this would be much less likely to occur.

Professor David Nutt was fired from the government’s Advisory Council on the Misuse of Drugs for suggesting a more coherent approach to drug classification, presumably based on actual harm to users and society rather than political hysteria and the thoughts of the Daily Mail. At some point he pointed out that ecstasy was less dangerous than horse riding as well as tobacco and alcohol though I think this was after his dismissal. Scientists do not say that drugs are safe, just that they should be classified according to harm. Many now think that legalizing and regulating (and of course taxing) is the best way to reduce this harm.

7 - Trainspotting

Fairly obvious but it does depict the devastating effects of heroin addiction and how hard it is to get off. It shows the strength of the addiction and the lengths to which people will go to get their fix. What it also shows is that the threat of criminal punishment does nothing to alter this. Whether it’s a crime or not, addicts need their drugs. Not all drugs are equal. There is no doubt that heroin is harmful. It wouldn't take long walking around my local city to find someone who has lost one or both legs due to the drug. People die from overdoses. People catch life threatening diseases from using dirty needles. Addiction fuels crime.

People need treatment and this takes time, effort and money. People also need to know that there’s a viable alternative life to the one that they are trapped in. Prohibition is a public health disaster. If you want people to take less heroin, locking them up is not the answer. They need support and compassion. Clean, unadulterated drugs or substitutes, counselling, needle exchange programmes, detoxification facilities, accommodation and the prospect of a job and a future.

6 - 25th Hour

The drug dealer’s going to prison. There’ll be another one to take his place. He made a shed-load of money but lost. The temptation will be there for the next one. I put this one in because Philip Seymour Hoffman is fantastic in it and now he’s dead. That’s very sad. The fact that his drug taking was illegal didn’t stop him wanting to take it. The fact that drug dealing is illegal doesn’t make them hard to buy. Prohibition failed and a great actor died.

5 - Requiem for a Dream

A tale of a dream of a quick buck from selling heroin turns to a tale of addiction and illness. The protagonist ends up in prison and there’s devastating physical consequences of his drug use. The American legal system is bonkers. Mandatory minimum sentences for drug offences destroy communities. Whole generations are in prison or dead. This chap is also denied proper medical care because he’s in jail. It’s no better for his mum though, who gets hooked on prescription diet pills.

If drugs were legalized and regulated, then more dangerous substances like heroin would only be available through pharmacies or other licensed medical establishments. There wouldn’t be a market for dirty or adulterated street drugs and this guy would have looked for another way to make a living and would have stayed out of jail or received proper treatment for his illness. The money saved in law enforcement and gained in taxing less dangerous substances, could be used for education and treatment to keep people off more harmful drugs.

4 - Breaking Bad

You’ve all seen it, people love it and yes, it's not a film. Thankfully crystal methamphetamine has not made a huge impact in the UK. Interestingly, whereas crack cocaine hit black neighbourhoods in the USA, meth has had a bigger impact on poor white areas. Again, it’s a cheap, highly addictive drug, with huge profits to be made and law enforcement cannot stop it. Educate, inform, treat, regulate.

Another point is that Walter started all his drug empire shenanigans because he was faced with huge medical bills after getting lung cancer. Under the NHS, his treatment would have been free. Remember that. 

3 - A Scanner Darkly

A messed up dystopian future (as most of my favourite books and films tend to involve) is the setting for this kind of animated live action film where a cop goes undercover to expose the source of a new drug called Substance D that has swept America. He is overpowered by the drug but does make some amazing discoveries along the way. This is the War on Drugs lost.

2 - The House I Live In

If you want to know more about what America's drug policies have done to its people, please watch this. This great docco interviews people on both sides of the failed War on Drugs. Police, officials, criminals, users and prisoners. Watch it, you’ll learn a lot. And look at their site.

1 - The Wire

Not a film, but the five series of this Baltimore-set show do more than anything else I’ve seen on TV or film to portray the futility of the War on Drugs. There’s good and bad on both sides. There’s murder after murder, death, relapse into addiction. There’s an overstretched police department who are struggling to keep up with the drug-gang related murders. There’s people born into families where ‘the game’ is all people have ever known, with no hope of a better life. Schools are underfunded and kids have no role models other than older gang members. There’s a couple of big winners and a whole heap of losers. The worst thing is that at the end of it all, nothing’s changed. This is a stunning examination of the War on Drugs, urban decay, education, law-enforcement, city politics and the media. It makes me laugh, shout at the TV, frustrated and sad and I love it.

More...

I could give all the arguments for and against legalizing and regulating drugs, but helpfully it’s been put in this great information leaflet by The Transform Drug Policy Foundation. It would be hard and there would be unintended consequences. It would require a lot of political will and international co-operation. A step-wise move towards the goal is the most likely. What we need to do now is have an honest debate about the pros and cons. Look at the evidence from other nations, make the conversation follow science and reason and not right-wing hysteria. People will take drugs, whatever the rules are. It's our duty to help reduce harm.

What is the Matrix?

The Matrix is everywhere. It is all around us.
Even now, in this very room.
You can see it when you turn on your television.
You can feel it when you go to work… when you go to church… when you pay your taxes.
It is the world that has been pulled over your eyes to blind you from the truth.

What truth?

That you are a slave, err, (insert your name here, unless it is Neo, then keep that one).

I watched it for about the twentieth time the other day. 1999, that film came out. My friends and I saw it at the cinema when we were 15. We hadn't seen a film like this before and were blown away by the special effects, the sounds, the slide down Nokia phone! Bullet time! And of course, the concept.

Now I don't actually think that we live inside a computer generated virtual reality. I'm also aware that I'm unlikely to be the first to compare the 'real' world to the Matrix. It still has a lot to say though.

As my walk through Ellesmere Port emphasised we are surrounded and bombarded by a world that is often out to hurt us, or at the very least, keep us quiet whilst bad stuff goes on elsewhere. Not all of it, not everyone, of course. The world is incredibly complex and everyone has their own set of incentives. The girl in the red dress isn't a computer program but has her own priorities and motivations.

But there is a system. Maybe multiple systems. Battling against each other. And it's hard to tell who is who. Companies have to make money. They have to make more money each year so people will buy their shares. They can grow their market, but if they have cornered the market then they have to make more money off each person. People within companies might care about your health, but most companies do not. They just need to sell you stuff. Maybe stuff you need, maybe not. Maybe they are selling booze, fags, takeaways, sugary drinks, time on the sunbeds or maybe healthcare itself. Either way, they care about profits. They care about your health if it is in line with their profits.

Now obviously companies employ people, but many don't care about their employees either.

On the other side should be the government, working for us, not for profit. National institutions such as the NHS are working for us, but bits are being snipped off and sold at an alarming rate. More and more contracts are going to private providers. This is often the more profitable end of an operation, leaving the NHS underfunded and having to cope with increasing disease with decreasing funding.

So let's break it down…
"You can see it when you turn on the television" –
'Television is the opiate of the masses'. The original quote was about religion by Karl Marx, not sure who coined the TV version. There is a lot of nonsense on TV. Watch it on Saturday night and you will gain little insight into the issues facing our world today. I asked someone if they were going to vote in the local elections. They said 'I don't know anything about politics, but how many Kardashians can you name?'

One, the one who married Kanye West.

TV is there to entertain us, but surely there's some room in there to educate us about what's going on. 15 million votes were cast for the final of series 7 of the X-factor according to the Wikipedia page (do not waste your time following that link). Yet only a third of eligible voters turned out for the local and European parliament elections this year. Some might say this was an argument for compulsory voting. I would say it's an argument for improved publicity and engagement, with options for online ballot casting. And compulsory voting.

Worse is the content between the programmes. If you watched TV for a whole day, how many adverts for unhealthy or high sugar foods, high interest short-term loans, gambling websites or booze would you see? How many would your children see? Advertising works, or they wouldn't advertise. I'm concerned when I see sexy young people 'vaping' on TV adverts. I'm sure e-cigarettes are better for you than tobacco, but that doesn't mean they should be promoted to young people as something cool to do.

"when you go to work" – Pretty broad this. How many people are trapped in low income or minimal wage jobs? Is there good job progression? Is there hope? Is childcare available and can you take advantage of training opportunities? Can you live an acceptable life on the minimum wage or are you still relying on benefits or debt? Employers have a responsibility to pay a living wage. If they won't, then the government has a responsibility to raise the minimum wage. Working full time should enable you to live.

"when you go to church" – Maybe you go, maybe you don't, but religious institutions still have an effect on your life. I went to Church of England schools and had to pray and sing with everyone else. I wasn't offered a choice until much later and it was never put to me that many people don't believe in Christianity and live perfectly fulfilling lives. 26 Bishops sit in the House of Lords and help decide our laws. Members of religious organisations are asked for their opinion on every topic under the sun and given a load of air-time.

Thought For The Day on Radio 4! What is that?! Programmes on Radio 4 should be either informative or entertaining. That is neither. Ditto The Archers.

"when you pay your taxes" – I've just read Thomas Piketty's Capital in the Twenty-First Century and it describes thoroughly and brilliantly how our financial and fiscal system funnels money from the poor to the rich and functions to widen the gap. We should have a progressive tax system that prevents the increasing inequality and divergence of wealth that we see in this country and others. Our taxation system benefits those who have money and power and wish to increase it. And I bet that you don't have access to an expensive accountant and aggressive tax-avoidance schemes.

There is enough money in this country to fund the NHS. We have good outcomes and provide excellent value to the taxpayer. If everyone paid their fair share and the NHS was given the funding it needed, we could do even better (and it would still be cheaper than most private systems).

"That you are a slave, Neo." – Not literally, I hope. But you probably aren't getting a fair portion of the fruits of your labour. I do not wish to promote wealth envy, just fairness (and I'm definitely not a communist!). The world is set up in a way that it is easy to make unhealthy choices and give your money to people who already have plenty. It's not designed to improve our health and well-being.

Later, the Matrix talks about the prophecy of 'The One' – "a man born inside who had the ability to change whatever he wanted, to remake the Matrix as he saw fit." In some way we all have this ability. (Imagine quiet music) It's our voice and our vote. If politicians are doing something you don't like, vote for someone else. Make sure that they bring in regulation that is there for you, not for the businesses that lobby them. (Music starts to build) We can choose the products that are sold to us by buying something different. We can make small changes in our lives that will make us healthier and take responsibility for our own well-being (louder). Write to your MPs, register to vote, write to the papers, rant on the internet! (music climaxes in a thundering crescendo!) We are all The One!

Boom, big finish. I frickin' love that film.