e 3 a s h i g R E F L E C T I O N S

Classic Piece Of Hospital Politics

Every organization has its political problems that can sometimes get in the way of it delivering its purpose. Hospitals, like any other organization, are full of them. Occasionally, patients health is compromised because of that.

Ward managers are a special breed of people. They come from a nursing background and have ascended the nursing/management hierarchy to get to the “Matron” level (the term Matron is no longer used). They are the boss of everyone on the ward except doctors where the relationship gets a little blurry. Wards are environments that have evolved politically to a point where they are stable. Doctors never settle in one place long enough to be a stable part of this environment. They keep moving that they are somewhat taken out of the political equation. We come in, look after the medical decision making and before we know it, we move jobs (my own rotations last only for 4 months each). There is often some sort of tension between junior doctors and ward matrons as we have our own hierarchical system that we answer to. Its like two separate organizations trying to function in one place.

A woman was once part of a swap between one of the surgical wards and our side of the hospital. She needed a certain medical intervention that could not be provided by surgeons. Our ward sister has negotiated a deal with her counterpart in surgery to send this woman back straight after her intervention. We diagnosed type II respiratory failure secondary to cardiac failure which we started treating her for while awaiting her heart investigations to come through. In this job, once you do it for long enough, you sort of develop a creepy sixth sense for who is going to live and who is going to die. This woman looked like she belonged to the second group even though she pulled through the acute episode. Few days passed before the echo-cardiogram (heart ultrasound) happened and one afternoon I spotted the porters on the ward asking where this woman is because she was being moved to an other ward. I was clearly pissed off.

This patient was added to the list of people I am responsible for without anyone telling me. She just appeared one day in a bed on my ward and I had to take responsibility for her health. Now, without anyone checking with me again, she was being chucked back into a surgical ward. This is both inappropriate for the patient’s health and discourteous to me. I was being sidelined. Worse still, a patient was used for a political maneuver to show who is boss.

“Who organised the transfer of this patient? and how come I don’t know about it?” I asked the nurses and they were quick to point me into the ward sister’s direction.

“Why is this patient being moved from the ward?”

“She is going back to the surgeons. She is now better.”

“Who made that decision? Has the SpR seen her?” I asked, comforted by the fact that only him can override my assessment.

In the same monotonous speech, she answered: “Is anything about her different from this morning?”

This question is clearly intended to establish the boundaries. I now have to start justifying myself which is not the point. The point is, a patients was being transferred to surgeons without my knowledge or the knowledge of anyone on the medical team. What happens if she arrests in the way? that is on my conscious. Fair enough, if this sort of thing happened on my first year, I would have caved in but I can not do that now because this woman really was not ready to go back.

“No. But even this morning when I saw her she was not stable!”

“that was the original deal with the surgical ward”

“This woman has heart failure on her clinical picture. She is better from her lungs point of view, but we need to sort out her heart”

“I believe there are doctors on the surgical ward who are capable of doing that”

Do you hear yourself woman? They are surgeons. They don’t do heart! Its one of the rules of the universe that once you decide to become a surgeon, anything that doesn’t involve a knife is not your problem. I was not going to send my patient to a surgeon to look after her heart. Surgeons exist out of necessity in hospitals because pharmacology has not advanced enough for doctors to treat everything medically. As a result, everybody has something that needs chopping off at some point and that is when these highly paid plumbers with inflated egos come in to save the day.

“Yes there are. But there is still work for us to do.” I said to re-enforce the point and then I declared: “She is not stable!”

Sensing the tension in the air, I continued: “Look you are the ward manager and you could move her on managerial or bed-availability grounds. My medical assessment is that she is not yet well enough to leave.”

My boss was sat right behind her. Only two days before, I was complaining to him that at times I feel pressured into doing things I am not happy with; give people sleeping tablets because patients are giving nurses hard time, discharge patients because beds are needed, over investigate people because other professionals get it into patient’s head that they need something extra, etc etc.

Sure enough, over the next two days the patient deteriorated and then she arrested and died despite everything we did to her which was sad. The fact remains however, on a medical ward, she had a far better opportunity to live than she would’ve had in surgery.

PS: This post is dedicated to my late sister (1992-2003) who passed away in Mafraq Hospital.