Just a humble emergency department SMO in Queensland getting screwed by the government. It can’t be right! #qldpol #smoqld #keepourdoctors
Like many professionals, I find myself in my mid forties, settled, with a partner and two young children. I’m an older parent than most. My partner and I postponed having our children until I had completed my training since my pay, short term employment contracts and working long hours as a junior doctor in the public health system meant that it was financially not viable for us to start a family earlier. Qualifying as a doctor is just the beginning of a long, long journey. I completed nine years of postgraduate training and moved eleven times, including twice internationally, before I passed my final fellowship and became a consultant Emergency Physician.
That was ten years ago this year. Since then I have worked as a full time Staff Specialist in Emergency Medicine in the public hospital system of Queensland. I vividly remember the Bundaberg and Caboolture hospital scandals, and have no wish to return to the days of skeleton staffing and unacceptable standards of care. I deliver hands on, 24 hour a day emergency care to the people of Queensland in some of the most difficult moments of their lives. Sometimes I am with them as they are born, frequently I help them as they confront a serious illness in themselves or a loved one. Sometimes I am with them when they die. This is the challenge and the privilege of Emergency Medicine.
I am starting a ten hour clinical shift in a metropolitan emergency department. Most days we will see around two hundred to two hundred and fifty patients per 24 hours. Every single one of these Queenslanders brings their own unique medical problem in their own personal context. My job is to see that each one of them receives the care that they need in a caring, compassionate and timely fashion. I have a team of young doctors with me, and together we aim to achieve this goal. Today, at the 8am handover, I learn that two of our junior doctors are sick. Since we have a total of 6 juniors on the day shift, we have lost a third of our medical staff before the shift has even begun. The Emergency Department is already understaffed so there are no replacements. We will simply have to “suck it up” as it is known in the trade. The night doctors are tired. It has been a busy night, and the on call Consultant was called in for a critically ill patient at 5am, having only finished the evening shift at 1am. The call, however necessary, and her departure will also have woken her partner, and probably her two children. We are on call after an evening shift at least once a week, and the nights on call don’t just affect us, but our families too. She is finishing her clinical notes having just transported the patient to the intensive care unit. The patient, a 47 year old man with a young family, arrived with chest pain before promptly having a cardiac arrest in the emergency department. My colleague led the team who administered drugs and an electric shock to restart the patients heart, placed a tube in his airway to allow him to breathe and called in and coordinated the arrival of a Cardiologist and cardiology team to take the patient for an emergency angioplasty in the “Cath Lab”. As the senior emergency doctor, she personally escorted the patient with their life support machine to the lab. She remained with them for the duration of the one hour procedure, whilst administering anaesthetic drugs to keep the patient asleep, before escorting the still unconscious patient to the ICU. She should be back on duty in 5 hours, but has only had 3 hours sleep. Another Consultant, probably on their day off, will come in to cover the first half of her shift. The late notice phone calls to come in to work are just accepted as part of the job, but are disruptive to family life. Our children quickly learn that Mummy or Daddy’s promises to be at their sports day or school music concert actually come with a silent “unless the department needs me” on the end!
The Emergency Physicians and some of the Intensive Care doctors are the only senior doctors who work shifts. We know that a patient who is seen by a senior emergency doctor on arrival is more likely to survive, and we are committed to this concept. If you are sick, we will be there for you – 24 hours a day, 7 days a week, 365 days a year. That is the commitment that we make to you.
The day has begun badly, but it often does. We just have to deal with it. Public Emergency departments don’t close just because they are full or because there are no beds in the hospital or because of staff sickness, so we work on…
I see a 98 year old lady with a broken hip after a fall. She tells me that she is looking forward to getting her telegrams from the Queen and Governor-General. I prescribe morphine for her pain and order x-rays, a heart tracing and blood tests. I can’t just assume that she has tripped. If I miss the fact that actually she has had a heart attack, seizure, sudden disturbance in heart rhythm or any one of a dozen other conditions that could have led to her fall, then those telegrams may never become a reality. I reassure her that all will be well, and that our doctors will refer her to an Orthopaedic Surgeon for surgery.
I see a 27 year old girl who is 8 weeks pregnant and has started to bleed. This is probably a miscarriage, but I can’t assume anything. I need to be sure that this is not something more sinister like an ectopic pregnancy, where the fertilised egg develops outside the womb causing pain and catastrophic bleeding. I ask a female junior doctor to perform an examination on the young lady, and order an ultrasound and blood tests, whilst making sure that a transfusion sample is taken just in case. She also receives painkillers. The possibility of miscarriage is a devastating psychological blow for this patient, and a nurse and myself spend time trying to reassure her and put her more at ease before her partner arrives. I offer to break the news to him when he arrives.
I see a 19 year old heroin user who came in overnight having been found unconscious. The night team saved his life by giving oxygen and medication when he stopped breathing. Since then he has been sleeping peacefully, but now he is awake and angry. I want to x-ray his chest to make sure that he did not inhale any mouth secretions whilst he was lying unconscious in the park. He throws his breakfast pack at a nurse and delivers a stream of obscenities. I intervene and attempt to reason with him whilst security are called. He spits at me, but the presence of three burly security guards deters him from further violence and he relents. The x-ray is performed before he is discharged in search of more heroin.
The scan result on a 23 year old girl in our short stay unit has come back saying that she has a blood clot on her lung. Left untreated, this is life threatening. I prescribe medication to thin her blood, having calculated the correct dose, and explain the implications of her diagnosis and that she will have to be admitted to the hospital for further treatment and investigation. I refer her to a Respiratory Physician.
An alarm sounds, and our team rushes to the resuscitation area, where a middle aged lady arrives on an ambulance trolley looking sick. Very sick. This lady is now my absolute priority. Everyone else will have to wait. She has an abnormal heart trace, but also has back pain and low blood pressure. The resuscitation team, of which I am the leader, quickly apply oxygen, place intravenous drips and administer medications, but she rapidly deteriorates and her heart stops. I coordinate the resuscitation attempt, standing by the patient and managing the team’s interventions, whilst simultaneously alerting the rest of the hospital to events in the ED. I call ICU and a Cardiologist in order to mobilise the resources which this lady may need if she survives. She rallies for a period of time, but sadly dies without regaining consciousness. I ensure that she spends her last moments with her husband, and take time to express my condolences and to offer support. Putting my hand on his shoulder as he cries, I ask our social worker to speak with him, and offer him a telephone if he wishes to call anyone. Even in his moment of grief, he thanks me for caring for his wife.
The day continues. At 3pm I realise how hungry I am and that I really, really need to go to the bathroom. Time pressure has meant that food and bathrooms have not been an option until now. I have limited time, so the bathroom wins. Lunch will have to wait. There is always one more patient to see.
The last time I checked, if I chose to work in a private ED then I could earn two to three times what I do now. It’s not that I can’t work in the private system. The two fellowships I have completed during my training mean that my qualifications are as good as, if not better than many of my private colleagues. It’s simply that I don’t WANT to work in the private hospital system. I see my job as delivering high quality, compassionate and timely emergency care to the WHOLE population of Queensland, not just those lucky enough to be able to afford private insurance. I also value my role in helping to teach the next generation of Emergency Physicians, a responsibility taken on almost solely by the public hospital system.
Work pressures in Emergency Departments are increasing, as are emergency attendances, while at the same time budgets are being cut. We are constantly being told to do more with less. What is expected of the staff in this high stakes environment continues to increase. I work at least one evening shift and night on call a week and every third or fourth weekend. This has a significant impact on my home life, my partner and my children. I have accepted all of this without complaint. Emergency Medicine is not glamorous and rarely makes the headlines. I accept this. I just want to be able to do a good job and take good care of my patients.
My employer is now asking me to sign an individual contract with them, which removes all of the rights and protections which I currently enjoy under the award. My right of appeal to the QIRC has been removed. If I sign this contract, my ability to protect YOU from bad decisions by bureaucrats is massively compromised. I can be fired for speaking out over important issues, or for “refusing a reasonable direction” from a manager. This could include being ordered to not prescribe a particular drug or to open the Cardiac Cath Lab out of hours on the grounds of expense. At the moment I have the right to fight them, to fight for you, but I have a wife and two children to feed and clothe. I can’t afford to lose my job.
They have also removed the existing fatigue provisions from the new contract. Tired doctors make bad decisions, and these clauses protect us from being forced to work excessive hours by an organisation who’s own report into fatigue in doctors, produced at significant taxpayers expense, concluded that we should just drink coffee! The contract now states that fatigue will now be managed “locally”. I think we all know what that means.
The worst thing about the contract is that any aspect of it can be unilaterally and retrospectively changed by my employer without my consent. Half of the doctors leave? No problem, we’ll just flog the rest harder, they can cover the extra shifts. No need to employ any expensive new ones. After all, they can just drink coffee, our own report says so, and the patients will never notice. If the doctors complain, we’ll change their contract and put them on the minimum wage, or just terminate their employment. Try to open an operating theatre for a sick patient in the middle of the night? The bureaucrats might think it’s too expensive. Argue with them? You are terminated with immediate effect. That will make you think twice!
One leading employment lawyer described the contract as the most one sided contract they had ever seen. Like many emergency doctors, I have a mortgage to pay and a partner and two children who depend on me as their main bread winner. It will be a cruel irony indeed if my employer, the Queensland Government, forces me into the private hospital system by its insistence that I sign a contract which fundamentally shifts the balance of power in the health system away from those who actually care for patients, and towards accountants and bureaucrats, who only see the financial bottom line.
I work for the organisation which employed Jayent Patel, and then flew him out of the country when it all went wrong. It closed Caboolture Emergency Department by letting the working conditions become so hazardous and unbearable that all the senior staff left. It left us unpaid for weeks at a time by its incompetent management of the new payroll system, but now I am being asked to trust it, and put my employment rights and YOUR health in its hands.
The public health system is sleep walking into a disaster for patient care.
Queensland, I need your help!
I have always been there when you need me.
Will you be there for me?