Qld Health Under Stress?

[Julia]

For the last few years we in Queensland have been seeing newspaper headlines about the health system being under severe stress.
Many personnal anecdotes have testified to this: people spending days on a trolley in the corridor, waiting 12 hours or more in Casualty before receiving attention. People dying on waiting lists. Ambulances on bypass for all the hospitals because there are no beds.

So I was surprised to hear today from a relative who early last week tripped over a mat, fell, and cracked two ribs. Her husband was there, but rather than drive her either to her GP to get an X-Ray, or drive her to the hospital for same, he called an ambulance. For a couple of cracked ribs!

The ambulance came within half an hour, took her to the Royal Brisbane Hospital. She was seen immediately by the triage nurse, then waited just 40 minutes to be seen by a junior doctor, in the meantime having the X-Ray.

Now, you'd think at this stage the junior doctor would say "OK, you've got a couple of cracked ribs, they'll take about six weeks to heal and there's no treatment. Go home and take paracetomol as necessary for the pain."

Oh no. She was actually admitted and remained in hospital for four days, on a morphine drip!. She was visited daily by a physiotherapist and two doctors.
When finally discharged she went home with two prescriptions for two different forms of oral morphine.

I asked if she had had any symptoms of pneumonia which could possibly account for keeping her under observation. No. Not at all.

So what has occurred has been a considerable misuse of resources.

And now here's the crunch: On leaving she was given a questionnaire to fill out, asking for her opinions about the treatment she had received.

So is our fine Minister of Health giving instructions to hospital staff to massively overtreat patients for the period of some survey so he can quote to the suspicious population an amazing level of patient satisfaction?

 

[xoa]

I've worked in 4 different QHealth hospitals, all in regional or remote areas. Patients definitely weren't over-treated.

RBH is supposedly the best resourced, and might treat patients more comprehensively, but I don't think they would admit somebody unless it was justified. Your relative might have been admitted because of her age, or the site/alignment of the fracture.

QHealth management wouldn't (I hope) use RBH to compensate for suboptimal conditions in other hospitals. Clinical staff would tell Robertson to get stuffed anyway.

 

[white_crane]

Qld Health under stress? No way! lmao :microwave


As to Julia's post, their appears to be quite an imbalance (in a negative way) between people who don't ring an ambulance and should have, and people who do ring an ambulance and shouldn't have.

 

[Doris]

Julia

Has your aunt recovered?

I decided to send a copy of your post to my son to seek his opinion.
- he's a doctor at Cairns Base hospital.

This was his reply:

Mum,

Ummm.. cracked ribs ain't cracked ribs. They're painful as hell... and you can get complications such as a pneumothorax- air between the lung and chest wall... and that can become inflated with pressure and kill you - this is called a tension pneumothorax. so... XR is not just to Dx # ribs, but to exclude a pneumothorax. And if it's too painful to breathe then people favour parts of their lungs/chest and the painful parts collapse (lungs are like a sponge) and this can allow a pneumonia to develop and that can kill you too or have sequelae down the track. # ribs can be serious in older people.

 

[Julia]

Doris, I made the remarks I did on the basis of having had several fractured ribs myself. Yes, of course it's very painful. But once you've done it a couple of times you know what you've done and using resources such as ambulance transport seemed unnecessary to me.

There is no treatment - just a healing time of about six weeks.

The last time I did it I just phoned my GP, he agreed X-Ray was waste of time and resources, and I took some analgesics for the first week.
I would never have considered an admission to hospital necessary unless there was some complication which there wasn't in my cousin's case.
She's a very fit and healthy 50 year old, and was herself astonished at being admitted. Had an email from her today to say she's feeling good, is out and about and just avoiding lifting heavy objects.

Yes, it hurts all the time, more in some positions than others.
Yes, it can disrupt sleep if you lie on that side.
Yes, some of your activities will be restricted.

But it's a lot less of a problem than, say, a broken ankle or arm, requiring a cast.

Everything is relative of course, but I wouldn't rate cracked ribs as anything more than a painful inconvenience.

 

[Dink]

Generally it is difficult to pass judgement unless all the facts are known. We will never know and quite often the elderly patients do not know why they are in hospital. I would be surprised if she were kept for longer than she needed to be. Arguably more often that not people are pushed out the door too soon.

As for wastage of resources in QH mostly occurs within administration. While undoubtedly there are excess resources used in treating some patients I think it is very difficult to argue that these are where cuts should be made. It is much better we over utilize resources (and possibly waste some) treating patients and ensure adequate diagnosis and management rather than under utilize them and misdiagnose and under-treat.

 

[Julia]

Generally it is difficult to pass judgement unless all the facts are known. We will never know and quite often the elderly patients do not know why they are in hospital. I would be surprised if she were kept for longer than she needed to be. Arguably more often that not people are pushed out the door too soon.

Dink, I appreciate your point of course, though would not describe my cousin as 'elderly'. Neither is she silly and she was unable to find anyone able to tell her why she was admitted.



If we were not constantly hearing about people dying because of not being admitted, lying on trolleys for days, etc I would have just thought "Oh, isn't that nice that they are being so caring."

Wouldn't an alternative have been (to save congestion in the hospital) for her husband to drive her to the GP, GP to order X-Ray and then decide if any further action was required?

 

[Dink]

Dink, I appreciate your point of course, though would not describe my cousin as 'elderly'. Neither is she silly and she was unable to find anyone able to tell her why she was admitted.



If we were not constantly hearing about people dying because of not being admitted, lying on trolleys for days, etc I would have just thought "Oh, isn't that nice that they are being so caring."

Wouldn't an alternative have been (to save congestion in the hospital) for her husband to drive her to the GP, GP to order X-Ray and then decide if any further action was required?

Firstly - I apologise for suggesting that your cousin was elderly. There are a lot of people who do not have a clue why they in hospital. And to preempt your retort I do not think your cousin is clueless.

Secondly - the decision to go to the hospital and call the ambulance was the patient's. I have heard of people calling ambulances for much less. Hospitals are not in the habit and picking and choosing who they will see and who they will not and turning people away at the door is not an option in our society. To see a GP is often not an option especially with the difficulties people have accessing a GP these days.

Thirdly - I know better than to criticise another doctor for how they treated a patient. I do not know the circumstances and will never know the circumstances for why this patient was in hospital. If she was sent home on the first day had a complication and died there goes that junior doctors career. A death gets a lot more press for a lot longer than any life saved. If the patient was sent home and the doctor lost a nights sleep worrying something might go wrong it is not worth it.

Fourth - when we start altering our treatment of patients based on bed-numbers our health system is in dire straits. The answer to the this problem is more beds not poorer care.

 

[Gspot]

WAhealth, NSWhealth QLdhealth, Vichealth, Tashealth, SAhealth, ACThealth, NThealth and Federalhealth, all with their own department, own names, own logo, own ceo and beauracrats and administration costing the taxpayer hundreds of $millions. Trying to find extra money, after they suck up their share, to look after the hospitals in Australia.

Australia wastes over $30 billion a year on duplication.

Wake up Australia, and govern for the 21st Century, not the 19th, which we have today.

 

[Doris]

Thirdly - I know better than to criticise another doctor for how they treated a patient. I do not know the circumstances and will never know the circumstances for why this patient was in hospital. If she was sent home on the first day had a complication and died there goes that junior doctors career. A death gets a lot more press for a lot longer than any life saved. If the patient was sent home and the doctor lost a nights sleep worrying something might go wrong it is not worth it.

Fourth - when we start altering our treatment of patients based on bed-numbers our health system is in dire straits. The answer to the this problem is more beds not poorer care.

Yes - there are cracked ribs and there are cracked ribs. Each situation would be different.
In my son's case, his registrar insists he calls him for consultation only when it's an urgent unknown diagnosis/prognosis... potentially inferring he's incompetent if he seeks a consult.
The weight is on the junior doctor and let's hope we get one like the one your cousin had.

My son works 12 hour shifts (day or night) and it would be easy for these overworked doctors to assume diagnosis and ignore their training in possible related complications.

A colleague of his told me that, three times this year, she has taken a colleague into pharmacy, given them a script and told them she didn't want to see them for two weeks! There is no system for reviewing staff stress in the health system as there is in England where once a month they have to chat to a psych.

The mother of a friend was hospitalized with pneumonia. She died from complications from bed sores!
Give me someone who does their job thoroughly!

 

[Prospector]

Give me someone who does their job thoroughly!

Absolutely, but what is the difference between doing a thorough job, versus overservicing?

I guess if the pain was bad enough then the husband may have thought she was having breathing issues, and that may have panicked him enough to call an ambulance. It is probably a toss of a coin as to whether this was too reactive.

It seems over the top that she should stay in hospital, for 4 days, on a morphine drip. Given issues with people becoming addicted to pain medication, it has been my experience that Doctors try to wean off such medications as soon as possible. I agree that in older people then complications can ensue, and even your son Doris made the point that ribs can be serious in older people. But she was only 50, so not relevant.

Adequate treatment if this had been me would have been an xray just to make sure there weren't any significant complications; some oral pain medication, some advice about what to look for if there were complications, and information about how to breathe. And go home.

I dont think we can actually afford to treat people in Hospitals based on what the media says about treatment. Surely there is a middle ground where a Doctor can take all the tests, review them scrupulously, make an informed decision and decide what to do, rather than assume that the worst will happen and so overtreat? We can't afford the latter!

 

[Happy]

I agree that in older people then complications can ensue, and even your son Doris made the point that ribs can be serious in older people. But she was only 50, so not relevant.

I enquired about criteria and I was told that: very young, old, obese and skinny people would be assessed on by case basis with inclination rather to keep for observation, where type of trauma that caused broken ribs would also be considered if likely to cause any immediate complications.

As pointed out already there is no clear cut on many conditions.

Also imagine if mentioned doctor was earlier reprimanded or lost patient discharged >prematurely<, would be inclined to over rather than under service.

 

[Julia]

Secondly - the decision to go to the hospital and call the ambulance was the patient's. I have heard of people calling ambulances for much less. Hospitals are not in the habit and picking and choosing who they will see and who they will not and turning people away at the door is not an option in our society.

Exactly. And knowing this is why I suggested the GP should be the first port of call. I've been married to a GP and have worked in general practice for many years. Never would a patient phoning with suspected fracture of any kind not have been fitted in.

Thirdly - I know better than to criticise another doctor for how they treated a patient. I do not know the circumstances and will never know the circumstances for why this patient was in hospital. If she was sent home on the first day had a complication and died there goes that junior doctors career. A death gets a lot more press for a lot longer than any life saved. If the patient was sent home and the doctor lost a nights sleep worrying something might go wrong it is not worth it.

OK. And given that there have been several well publicised cases where a junior doctor has made the wrong decision, of course I can understand this effort at self preservation. But shouldn't we be looking at the general culture of the health system if this is the case? From your comment above it seems that what it's about is more political than genuinely necessary patient care.

Fourth - when we start altering our treatment of patients based on bed-numbers our health system is in dire straits. The answer to the this problem is more beds not poorer care.

Well of course. But, given my original point which you've not acknowledged, where we are constantly being told about the stresses on the health system, and people being unable to access beds when acutely ill, can't you at least acknowledge that we may have been looking at overtreatment and therefore imbalance in this case?
In other words, how can you justify an uncomplicated fractured rib being given a four day admission compared with an infarction being left on a trolley?
And, Dink, if you feel morphine is appropriate for fractured rib, what would you use for, say multiple limb fracture? And after four days, would you send the patient home on two different types of oral morphine???

Yes - there are cracked ribs and there are cracked ribs. Each situation would be different.
In my son's case, his registrar insists he calls him for consultation only when it's an urgent unknown diagnosis/prognosis... potentially inferring he's incompetent if he seeks a consult.

Or perhaps the registrar is attempting to encourage a belief in the junior doctor that at some stage he is going to have to make his own decisions.
He has, from what you say, left the door open for consultation in difficult diagnoses. Sounds to me like a pretty sensible registrar.

My son works 12 hour shifts (day or night) and it would be easy for these overworked doctors to assume diagnosis and ignore their training in possible related complications.

Young doctors have done this for decades. That doesn't make it right.
It's yet another reason for the funding to be appropriately applied as I initially suggested.

Wouldn't you rather your son worked eight hour shifts, if this were to occur by reducing patient over-servicing.

A colleague of his told me that, three times this year, she has taken a colleague into pharmacy, given them a script and told them she didn't want to see them for two weeks! There is no system for reviewing staff stress in the health system as there is in England where once a month they have to chat to a psych.

I don't see why this is any different from a person in any other occupation experiencing stress. It happens everywhere. A young doctor, as with any other employee, can access psychological care for free via Medicare. It's part of learning to look after yourself as preparation for a career in any stressful occupation.

The mother of a friend was hospitalized with pneumonia. She died from complications from bed sores!
Give me someone who does their job thoroughly!

Oh God! Then couldn't you equally deduce that she should have been encouraged to be active earlier if possible. And I don't see how this advances the argument in either direction. Bed sores are a feature of inadequate nursing care and have nothing to do with my original question.

=Prospector;346960]Absolutely, but what is the difference between doing a thorough job, versus overservicing?

I guess if the pain was bad enough then the husband may have thought she was having breathing issues, and that may have panicked him enough to call an ambulance. It is probably a toss of a coin as to whether this was too reactive.

Prospector, thank you for providing some balance here.
As it happens, my cousin had never had any sort of injury before. She wasn't having any breathing issues whatsoever. She fell on carpet.

Her husband is, umm, very obedient and would hate to put himself in a position where she could later accuse him of failing her. Hence the ambulance.
Covering all bases, as it were.

It seems over the top that she should stay in hospital, for 4 days, on a morphine drip. Given issues with people becoming addicted to pain medication, it has been my experience that Doctors try to wean off such medications as soon as possible. I agree that in older people then complications can ensue, and even your son Doris made the point that ribs can be serious in older people. But she was only 50, so not relevant.

Adequate treatment if this had been me would have been an xray just to make sure there weren't any significant complications; some oral pain medication, some advice about what to look for if there were complications, and information about how to breathe. And go home.

Quite so.

I dont think we can actually afford to treat people in Hospitals based on what the media says about treatment. Surely there is a middle ground where a Doctor can take all the tests, review them scrupulously, make an informed decision and decide what to do, rather than assume that the worst will happen and so overtreat? We can't afford the latter!

Yes, this was my point exactly. Fine to hospitalise everyone with a sore throat if we have billions to spend on the health system, but we don't.

 

[white_crane]

And then someone comes along and sues the doc because he/she made a mistake...

 

[Prospector]

And then someone comes along and sues the doc because he/she made a mistake...

And then someone comes along and sues the Hospital because there are no beds!

Doctors can never be successfully sued if they have taken the correct examinations, reviewed them appropriately and have documented that they have informed the patient to return immediately if any symptoms worsen.

 

[Dink]

And, Dink, if you feel morphine is appropriate for fractured rib, what would you use for, say multiple limb fracture? And after four days, would you send the patient home on two different types of oral morphine???

Morphine is appropriate for treating severe pain regardless of the cause. Pain is a subjective thing and if someone has pain and says it is severe we treat it as such. People have different perceptions to pain and as a result require different treatment. As for what I would use for a multiple limb fracture is enough morphine (with other analgesics) to keep the patient comfortable.

As I keep saying I can not say whether I would have used it in this situation as I do not know the circumstances. If she was on a morphine "drip" then I imagine it would have been administered via a pump that is controlled by the patient (known in hospitals as patient controlled analgesia). This is continued for as long as the patient requires it. If your cousin was using minimal morphine it would be stopped and oral medication started. Sending an opioid naive patient home on two forms of oral morphine does seem excessive but once again I do not know the circumstances and I would question whether they where both oral forms of morphine. If you could tell me which medications you are referring to I may be able to comment.

I have seen the extremes of pain with fractured ribs. I have played rugby with team mates who have played on despite having fractured ribs. And I have seen grown men needing epidurals to achieve adequate analgesia.

Trust me I could tell you plenty of examples of over-servicing but it is not where the problem is in Queensland Health. There are some much bigger problems that need attention.

 

[noirua]

Remain in good health. Do not become a fat old thing and flop dead much younger than you should. It's surprising how very clever people with high IQs cannot see that. If you are fat and unfit you are more likely to get many diseases and keel over at a quite young age, well, relatively young anyway.