48 Hours...

... is the maximum number of hours per week that I am legally allowed to work here in the UK. The European Union have produced a European Working Time Directive (EWTD) to which all employees have to adhere, or sign an opt-out. In its infinite wisdom, the NHS has decided that although doctors-in-training were initially exempt from this rule, as of August last year, we’ve all had to comply both with average hours worked per week and with various rest requirements.

It’s a far cry from working in the un-restricted world of Kiwoko Hospital in Africa, although I actually believe I had a better work-life balance there and was generally less tired. I guess a lot of that depends on how busy the night-time workload is. Two years ago in Uganda, we generally worked 7.30am-5.30pm Monday to Friday. Then one week in three I covered surgical emergency operating outside of those hours Mon-Sun. I got a night off on Thursday, but had to work until 5pm on Saturday and covered the whole hospital overnight Sunday rather than just the surgery. The next two weeks were standard Mon-Fri only, with one extra Thursday night on call for the whole hospital.

That sounds a lot, but in general I wasn’t often called out overnight – there were occasionally emergencies before midnight, and a couple of 6.30 calls to theatre to help with a difficult Caesarean Section being performed by one of the other doctors who was struggling a bit, but in the main these weeks involved a decent amount of sleep except for the Sunday night which could end up being 4-5hrs only.

Now I’m back in the UK, the amalgamation of hospitals into larger centres, the transformation of out-of-hours healthcare to nurses answering telephones and seeing patients rather than the old model of General Practitioner doctor consultations, the reduction in training hours and therefore less experienced junior staff, as well as an aging population more prone to ill-health and with much greater 24hr expectations, has resulted in a much heavier overnight workload than was the case when I started work as a doctor over twelve years ago. The lack of expectation of sleep overnight combined with the EWTD means that I’m on shift work, and I hate it!!!! Unfortunately I’m one of those people who find it very hard to sleep during the day between night shifts, and so I get progressively more tired as my night-shifts go on.

Over the last three weeks I have worked: Friday, Saturday, Sunday nights; Monday to Friday daytime on a course 8.30-5.00; Saturday & Sunday off; Monday to Sunday Emergency Surgery shifts 8.00am-9.00pm; Monday off; Tuesday-Thursday nights. Admittedly my week’s course in the middle should have been a fourth night and then the rest of that week off, but it’s still a fairly punishing schedule. Fortunately before nights come round again I get five weeks of normal 8am-6pm Monday-Friday working. On paper it does eventually average out at 48hrs over the course of the rota, but of course in practice events require you to start earlier and finish later regularly. Life was definitely better with the old on-call one night a week and one weekend a month...

The best thing about this year is that in theory I finish my training at the end of October 2010 getting my Certificate of Completion of Specialist Training, and enabling me to register as a Specialist Surgeon and get a Consultant job. There’s the small matter of passing exams in a couple of weeks time, and then the need to find that new job. There are potentially a couple of jobs coming up in some of the medium-sized hospitals in Scotland – As a generalist with a laparoscopic surgery interest, I’m not specialised enough to go for jobs in the big city hospitals, which does limit the type of jobs available. I guess I’ll have to see what comes up, pray hard, and trust that I’ll end up somewhere I can be useful. Various things in life are suggesting to me that staying in this country initially would be better than heading immediately back out to Uganda... which is possibly what I would actually really like to do... but I’ll wait and see where God is guiding me.

One thing I am able to do much more easily from Scotland is head to the Alps to go skiing which is my next break at the end of February and hopefully a reward for getting through the exams. Anyone for Gluhwein?

Steve

P.S. The snow in Edinburgh (pictured above from Arthur’s Seat) has now all gone again. I hope spring comes soon!

A very un-African New Year

I still find myself thinking of Kiwoko Hospital in Uganda frequently, recalling the life that I lived there over two years ago with fondness. One obvious and major difference between Edinburgh and Uganda this New Year has been the weather – for once the UK has had a proper cold spell with winter weather that has now lasted over two weeks! I suspect my friends at the Equator have been suffering with the beginning of the dry season, temperatures of 28-30 degrees (Celcius), and a distinct lack of water. Here we’ve had more snow than I’ve seen in Edinburgh in over 15 years, repeated snow-falls, temperatures dropping to -14, and plenty of ice. It makes a nice change from the usual dark, wet, windy pseudo-winter that we usually suffer each year, and I’m all in favour of it, especially as it happened over Christmas.

New Year was spent in the middle of Edinburgh’s Hogmanay Street Party for the first time this century! We wrapped up well, took a hip flask of a rather nice Tobermory 10 year old, and joined the crowd for some live music, dance and banter. In fact midnight itself was seen in with a rather flamboyant Cuban band and some Latino music. And the fireworks were magnificent. It turned into a late night as we went on to another friend’s party, very handy at a flat overlooking Edinburgh Castle. I’ve had much quieter New Years in the recent past, so it’s good to remind myself that I can still enjoy myself even as I get older!!!

My friend Mark from Uganda wouldn’t have coped with the cold. I Kiwoko hospital again in October, and brought him back for a few weeks to the UK, which was a fantastic experience for both of us. It’s surprising how much you can squeeze into a short space of time. I had only ten days in Uganda on this occasion, but found myself working (Dr Peter tends to take some time off if he knows I’m visiting!), and it was good to find a couple of patients specifically attending to see me. One was a lady with intermittent jaundice due to gallstones and I was able to unblock her bile duct and remove her gallbladder – an operation the local surgeons wouldn’t have been comfortable doing. The other was a patient with swallowing difficulties. I was able to use the Endoscopy facilities that were still working well (see previous notes for details of setting up an Endoscopy Unit in 2007), and unfortunately found he had a large obstructing oesophageal tumour. Here in the UK we would have seen if the tumour had spread by means of a CT scan before deciding on surgical or oncological treatment. However, this man couldn’t afford the cost of a bus to Kampala, let alone the CT scan (albeit only costing £15), and I didn’t think that taking on such a major operation as an oesophagectomy without the back-up of an intensive care bed was very sensible. The best I could offer was a plastic stent to allow him to swallow food again – fortunately I had brought one of these out with me previously, and this was successfully put in place. It’s certainly not a cure, but hopefully he’ll at least have some quality of life over the next six months before the tumour spreads further.

Back in the UK with Mark, we found all sorts of things to amaze a person from Uganda who’s never travelled outside of his country before! I think the whole experience was a little overwhelming, but he went home with lots of photographs and a better understanding of our part of the world – people in Uganda get many visitors from the West, but have a number of inaccurate preconceptions of how life is here. Hopefully Mark will be able to address this. He was particularly impressed at our street-lighting and the orderly nature of the traffic on our roads, and amazed at the cost of living.

We managed a few days sightseeing in Edinburgh and nearby Scotland, a few days in London, a week at my UK hospital, and finally meeting up with several UK friends who managed to visit while he was here. Particular highlights included staying next-door to the Queen (a hotel near Buckingham Palace), taking in a show (Grease seemed to be fairly straightforward to follow), and of course tube and train travel. The main reason for his visit was to get some experience of Theatre Nursing in a UK hospital, and my colleagues at Edinburgh Royal Infirmary were very friendly and willing to show him how we do things here – hopefully he’ll have several thoughts that may be helpful back at Kiwoko. The main surgical difference he noticed – laparoscopic (or keyhole) surgery, which he found very exciting as its not seen in the hospitals he’s been in in Uganda.

But here I am at the beginning of 2010, with my final Surgical Exams in less than six weeks. After that I plan to get out and enjoy myself a bit more with skiing trips, mountaineering trips and social outings planned! I’ll need to focus then on what I do when my contract here ends in October – the options probably being to find a Consultant Surgeon job here in Scotland, or to head back out to work in Uganda again... not an easy decision – I’ll let you know how it works out!

Steve