“You are having a heart attack but we will fix it”. If only everything was so simple.

I’m working my second stretch of nights in a week (due to a missing EU doctor, ironically) on the heart attack service. At 3am my bleep rattles next to me and then shouts “Primary Angioplasty. Inferior MI. 10 minutes”.

This means someone is flying towards us in the dead of night with a major heart attack. Inside, a vessel supplying the heart muscle is completely blocked, the muscle beyond literally dying by the second. Needless to say these patients are very unwell.

The patient arrives and her ECG confirms all our fears: a major heart attack. My 3am brain tries to simultaneously take her history, listen to the ambulance handover, scan her heart muscle and consent her for the procedure all at once. She’s looking very unwell and I’m very conscious of how short time we have. “Time is muscle” in cardiology land, and her heart and possibly life is slipping away by the minute. 

I end up simply saying “You are having a heart attack, but we will fix it”. We rush her into the lab and fifteen minutes later we have indeed fixed it. She’s looking much better and is very thankful. I love cardiology.

Simple eh? From the patient’s perspective she’s had some chest pain, called an ambulance, been told she’s having a major heart attack, and then told it’s been fixed. What could be easier?

Well, pretty much everything. The procedure actually takes at least five people to perform properly, all highly skilled and trained and working together seamlessly. Every bit of equipment we use has been developed over decades, rigorously tested in trials involving 100,000s patients, each part carefully evaluated, checked, stored and audited. The techniques we use, even the pathway itself, has been researched and tried and rejected and trialled again. When this technique was first pioneered many thought it ludicrous. Now it saves thousands of lives every year. Even the basic physiology is incredibly complex.

Which is not to say nothing ever goes wrong- far from it. We routinely have patients who we can’t make better, or don’t get there in time, or need even more advanced therapies: pumps inside the heart, artificial lung and heart machines, emergency bypass surgery, even transplants. There is an entire world behind the curtain that very few members of the public will ever glimpse. And even those who do so directly as our patient do so with only the limited and reassuring perspective of a problem that has been “fixed”. With only a tiny cut 1mm long in their wrist, who can blame them?

Which, by a rather roundabout way, leads me to Brexit. Obviously. This week the NHS and Brexit have been in the news on multiple fronts, mostly raising concerns about the implications of No Deal on the NHS and then some unbelievable absurdity about shortening doctors training times after Brexit to “plug staff shortages”.

The issue we seem to have is one of perspective. There’s too little scrutiny, too much wilful acceptance of “I can fix it”, and not enough people asking “how?”. And especially not enough detail for those of us behind the curtain that can see the vast monstrosity of interlocking gears and cogs that makes up the NHS machine. For those of us that worry Brexit, especially No Deal, will be a sledgehammer to a system already straining under pressure.

Take for example the No Deal scenario. Overnight we will leave the Customs Union and European Medicines Agency, meaning importing medication will require new licenses and tariffs, infrastructure we don’t currently have. Insulin has been the much lauded example– used by nearly half a million patients in the U.K., only one small factory in the U.K. makes any at all, enough for 1500-2000 patients a year. The rest (99.9%) is imported from France, Denmark and Germany. On day 1, with No Deal, there would need to be additional customs infrastructure to even EXPORT to us. In places like Germany where there wasn’t before. The new Health Secretary, Matt Hancock, has assured us they are stockpiling for contingency planning for this event. But insulin needs to be refrigerated, and we are talking about half a millions patients a year. I want to see the detail, I want to see the benefits of this plan, I want to see the mechanics of the machine before I accept this is even possible. So far I have yet to be convinced.

Similarly, Steve Barclay, Tory Health Minister, made headlines on Friday claiming that Brexit will be good for the NHS, claiming the EU forces U.K. doctors to qualify in five years minimum and we could shorten this to “plug staff shortages”. But behind the curtain we know nearly all U.K. medical courses are five years already, some graduate entry courses are four years (although some have switched to five now) and count the first year of work as qualification to meet the EU technical requirement. We know we can’t shorten medical school beyond four years due to the sheer breadth and intensity of work, and the reason most U.K. medical schools opted for five years in the first place. This suggestion will have no practical impact on doctor numbers, but might make undergraduate medicine overly pressured or dumbed down, and will only affect <25% of graduates regardless. And no mention of the 10% of U.K. doctors from the EU who already risk losing their right to work, to healthcare and to pensions here in the event of No Deal. It’s this nonchalant and worse, unchallenged, Brexit commentary that doesn’t inspire confidence amongst medical professionals. We doubt that our government understands the dangerous and complex machine they are tinkering with. 

Similarly Theresa May proposed a welcomed £20bn injection of funds into the NHS, but then predicated that on a “Brexit Dividend”, a dividend nearly every single economist agrees doesn’t exist, a dividend for which no legitimate cases has been made. It’s hard to trust a government that seems to speak to us without any substance. No wonder a majority of U.K. doctors support a referendum on the final terms. 

In the healthcare profession we have a pathological abhorrence to unsubstantiated claims. To b******t. Colleagues that say they will do something and then do not are unreliable, and unreliability is dangerous. Bald-faced lying is even worse, and the GMC hold us to a standard far higher than any politician. A lack of basic probity will get you suspended or struck off, such is the bedrock of trust that the practice of medicine requires. Trust between ourselves and our patients, and trust with each other. And the highest sin of misinformation? Wasting the most precious resource we have; time. Time is muscle. Time is life. Time I waste with you I could infuse into someone else, time that could make all the difference. And for Brexit time is running out. 

Despite occasional appearances suggesting otherwise, medicine teaches you a universal truth: nothing is simple. Absolutely nothing worth doing is easy. The Brexiteers waving away the potential healthcare disasters ahead think they are riding a tricycle down a garden path, that they can flick a wrist and change direction on a whim, when really they are aboard a runaway freight train, heading for a cliff.

We need to start hearing some practicality, we need to start seeing some understanding of the complexity of the machine, of the extraordinary stakes ahead. We need less of the perception “everything is simple”, and more of the reality: this is complicated, this really matters, lives are literally in the balance.

Please fix it.
Juniordoctorblog.com

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