Preparations for the storm
How do doctors manage when there are more patients and fewer resources?
I’m not fond of the heat. I’ve toyed with the idea of moving overseas my entire life. Greenland was my country of choice as a kid. Then Alaska, Iceland, Hobart. For the past decade it was London. Grey skies and incessant drizzle, or so I’d heard. So when I flew there recently, I packed an umbrella, gloves and a jacket – and arrived during a freak heatwave.
London herself was ill-prepared. Taxi drivers imploded, the hotel’s aircon failed what may have been its first test. People on the streets were a wilting pink mass. At train stations, a kind female electronic voice repeatedly warned us to carry bottled water and urged us to hold off hitting the emergency stop button in the event of distress, explaining that it would be impossible to provide assistance were we trapped in a tunnel a mile beneath London. Even if I wanted to obey her, which I was inclined to, given her politeness and her clear rationales, the platform vending machines stood in belligerent emptiness. Unprepared, all of us. I wondered if kids of the future would sing global-warming nursery rhymes that contained comforting if useless health tips equivalent to the pocket full of posies before we all fall down. I wondered how the already struggling NHS hospitals would accommodate the inevitable deluge of the desiccated and the collapsed.
Most jobs entail periodic work avalanches. I worked for years as a TAB cashier, and the avalanche came a few seconds before the jump. At Myer men’s collections it was Christmas Eve and then Boxing Day. Waitressing, it was every night, the roomful all thirsty, hungry and needing more bread at exactly the same time. The day before press, the minutes prior to boarding, the sound of the bell at the theatre. Workers sweat to accommodate our last-minute dashes. In hospitals the crush is weather-dependent: heatwaves, and the three months of winter.
I was on the wards for most of this year’s winter, an ultra-marathon of pneumonia, gastro, ODs and flu. And, as in any winter hospital, there was never enough of anything to go round. Not enough beds, not enough staff. It was week after week of Boxing Days. Department stores quadruple their staff to prepare for the Christmas rush, but it’s difficult to flex up a diverse group of highly trained multidisciplinary staff, let alone provide an extra 30 beds in institutions that are funding-strapped and already fit to burst. Management do their best. They fantasise ways to increase efficiency, decrease waste, maximise flow. They devise protocols, “stretch targets” and KPIs. Nothing turns them on quite like a winter squeeze.
Every clinician in a winter-crowded ward is under constant pressure to make room for more patients. They juggle the needs of the individual patient they’ve started to treat with those of the institution and those of the soon-to-be patients mobbing the emergency department corridors. Deciding that a patient is well enough to go home is a negotiation between them and their doctor. There are those who want to take to their own beds as soon as the drip’s out. Those who want to stay till they can run around the block. Doctors vary in their ability to tolerate risk. In the US, they send patients home when they cannot pay. Is it any different to send someone home earlier than you’d like because the hospital needs the bed, or because LOS (length of stay) is a KPI (key performance indicator) and you’re being watched?
A hospital bed is much like a table in a restaurant. If you can seat and feed and boot out three sets of diners on each table each night, you’ll triple the number of people you serve and generate more income. But there won’t be any chitchat from the waiter. Take away a doctor’s time for chitchat, and you may as well hire technicians to do the job. Like radiologists, we could make the diagnoses from home, based on the data the techs collect. Hey, electronic voices could even deliver pre-recorded treatment advice to the patient. (“Play her the pneumonia package, Siri.”)
There are sensible and humane ways to decrease a patient’s LOS: don’t harm your charges, review them regularly, visit them at their home the days after an early discharge, find them somewhere to live. But surely, I still think, there must come a point where you’re doing as much as you can with what you’ve been given. Saying this is not only a waste of breath, it’s considered a whine. We’re asked to pitch in, to find new ways to pare, to – as one manager put it – “prepare for the storm”. He didn’t mean next winter. He meant for a future where there are even more patients and even less funds.
A few weeks ago I found myself in a vast and festive room with a crowd that included the three party leaders: blue, red and green. In my brief and separate conversations with all three, each raised the obesity epidemic. Sugar tax? two wondered. Cash incentives? mused the other. I was a disappointment. I didn’t have a pithy and easily digestible solution to offer regarding this bio-psycho-social-consumer catastrophe. But I imagined being them. These guys don’t prepare for storms; these guys change the weather. As my brother would say, How cool is that?
To change the weather, to prevent the storm – and everybody working in health knows it – would require a gigantic system overhaul: the integration of community and hospital care, robust bio-psycho-social community services, serious and disruptive disease prevention strategies. And, just like halting actual climate change, this is increasingly unimaginable, given our shrinking, split and gutless governments, and the aggressively defended interests of industry. Keep your eye on the forecast. Pack your own water and tarp. In the event of emergency, join the queue.