Peter Stringfellow, Yesterday.A pneumothorax and several fractured ribs is a fairly unpleasant injury. Normally, it would follow trauma such as a car-crash or a severe kicking. When you are married to a premiership footballer, it can, of course, be caused by a bit of rough sex. Certainly, a level of pain relief is required, usually in the form of oral analgesia, or sometime an injection. Very rarely, stronger painkillers are required. And even more uncommonly, epidural anaesthesia is required to treat the pain.
Epidurals come with complications. One such complication is an epidural abscess - an infection around the epidural site, caused by the presence of pus-forming bacteria.
Sometimes abscesses can be caused by the 'killer bug' Methicillin Resistant Staphylococcus aureus, known to newspaper journalists as MRSA. Contrary to public belief, MRSA rarely kills people, and it is not an insect with sucking mouth-parts and overlapping wings. Rather, it is an ordinary bacteria that has acquired resistance to certain antibiotics. Bad news if you are intensive care, not too bad if you are one of the one in thirty members of the population who have it living harmlessly up your nose.
A certain actress, who for some reason required an epidural after sex with her husband, has just been awarded £5 million, for contracting the 'killer bug' MSSA from the Chelsea and Westminster hospital, according to every newspaper and news site tonight.
Hang on...MSSA?
Dr Rant asks - What the fucking fuckety fuck is MSSA? It turns out that 'MSSA' in fact stands for 'Methicillin Sensitive Staphylococcus aureus'. Or bog-standard Staphylococcus aureus ( Dr Rant will refer to bog-standard Staph aureus as BSSA for the rest of this piece). This bacterium has been causing boils and pimples for as long as mankind has suffered from boils and pimples. Over one in three of us has this bacterium living on our skin, doing not-a-lot. Occasionally, it causes a zit. And if a doctor sticks an epidural catheter through your skin, it can find its way into the epidural space and cause problems. Such as an abscess.
A few questions spring to Dr Rant's mind on reading about this remarkably tragic case.
First of all, which fuckwit put an epidural into a patient for a rib injury? Was it someone who wanted to impress a rather minor celebrity with overkill analgesia, or was it someone gullible enough to be persuaded into giving one when painkillers failed to provide absolute pain relief?
Where did the BSSA come from? Was it a skin commensual? Did it come from a friend or relative? Or was it shown, scientifically, beyond reasonable doubt, to come from a member of staff of the Chelsea and Westminster hospital?
How the fuck did someone manage to break two ribs and to puncture a lung during sex? Dr Rant is sure that even the most dedicated sadomasochist would not end up with an injury like this. In fact, having the shit kicked out of you by your husband is most likely to give you these injuries. However, as a doctor, you live and learn - not every woman with a serious injury is an apologist for an abusive, violent husband.
What happens when someone injects boiled-up cow into your lips against your will, especially when you're not really one 'to mess with nature' and such like.The £5 million was for 'loss of earnings'. This money would have paid for roughly 500 hip replacements. Dr Rant would like to remind people that disastrous plastic surgery can also fuck up your already mediocre career, and send it into a spiral. He would like to know where the £5 million was going to come from.
Why invent a new name for a bacteria that causes pimples? Might it have something to do with flogging of a shitty autobiography? Or something to print in the papers? Or flogging off your own brand of 'infection fighting' soap?
And finally, how shit are the lawyers working for the Chelsea and Westminster Hospital? A crap, has-been actress with a face like an elderly trout allegedly gets seven bells of shit kicked out of her by her husband, demands a procedure than is not indicated, and when she gets a complication, probably arising from her own skin, makes your client's hospital out to be filthier than Satan's fuming arsehole? How hard would it have been to demonstrate that the infection had come from the hospital, rather than an alternative source? Did trout-face have a recent set of BSSA -ve swabs taken from every orifice in her body? Probably not.
Dr Rant has some advice for the actress concerned. First of all, if you are being beaten up by your husband, get in touch with the police and social services, and stop apologising for him. Secondly, if your injuries are caused by sex, then you are doing things very wrongly indeed. Thirdly, you have diverted £5 million from the healthcare of the people of west London to make up for your 'lost earnings'. Do not be surprised if there is a large backlash against you, especially when the full details of your case become public. And finally, stick with your lawyers - they have won you far more money than you will ever deserve.
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31 comments:
"First of all, which fuckwit put an epidural into a patient for a rib injury? "
Actually, this is a well recognised treatment of rib fractures, especially if multiple and the patient is at risk of respiratory failure.
ITU-doc
Point taken. Thanks.
In which case, which fuckwit allowed a judge to get the impression that the proceedure was unwarranted in this case?
*applauds*
DK
ITU-doc Ms Ash fractured x2 ribs - I can find no mention of a drain to deal with the pneumothorax, so I assume it was less than 15% of the lung field ?
According to Sirmali et al (2003) such an injury (i.e. x2 broken ribs) would not even mandate hospital admission let alone exposure to the risks associated with epidural.
http://ejcts.ctsnetjournals.org/cgi/content/abstract/24/1/133
A&E usually recommends 4hrs observation and a repeat CXR before discharging small pneumo (then follow up in the chest clinic in 1/52).
We send them away with an NSAID, if no contraindications, plus tramadol or similar.
The evidence for epidural vs opiod analgesia suggests that spinals are better for certain blunt thoracic injuries....but for x2 broken ribs, that seems a bit over the top to me (x10 years A&E experience)
http://bestbets.org/cgi-bin/bets.pl?record=00484
It is my belief that not all patients are honest about mechanism-of-injury but this should have no bearing on care standards (unless it means protecting a victim from their abusive footballer, sorry, partner).
Dr Rant highlights some important issues not least the diversion of scarce NHS resources away from those in dire need - I darseay, one or two of anaesthetists at the Chelsea & Westminster might now have to think long and hard before sticking another cannula into someones spine.
the a&e charge nurse said...
The evidence for epidural vs opiod analgesia suggests that spinals are better for certain blunt thoracic injuries....
~~~
The evidence for A vs B suggests that C is better?
Well one of my points 'anonymous' was that I cannot recall a young(ish) person ever requiring an epidural for a couple of broken ribs - I mentioned the bestbets link more as a point of general interest, really.
although tramadol is an opiod, of course
http://www.medsafe.govt.nz/profs/PUarticles/tramadol.htm
So the injury arose from a treatment which was not indicated and has drained NHS funds.
If I may throw my tuppence into the ring, while I am prepared to accept that epidural anaesthesia is well recognised as treatment for (multiple) rib fractures, it's not something that I have ever seen / done / heard of being done /know anyone who's done it. Most places I've worked raised their eyebrows at the idea of intercostal blocks... (this includes a stint at the Chelsea/Wesso, and more than my fair share of time in EM?Anaesthetics/ITU in case you were thinking my experience was solely that of e.g a dermatologist in Fiji...)
It does smack a little of overkill, surely?
http://www.thisislondon.co.uk/showbiz/article-23432505-details/Leslie+Ash+wins+record+%C2%A35million+-+not+%C2%A3500,000+-+payout+over+hospital's+MRSA+blunder/article.do
She can no longer play the 'attractive young blonde' characters for which she is known and her health is too frail to endure the demands of TV and film sets.
Wouldnt ever have described a 47 year old trout as attractive but horses for courses
Oh well done. Much better than my snarky offering on the subject.
1. So someone who can fund decent legal advice has got one over on the shit nhs, good
2. This doesnt scratch the surface of thousands of ordinary folk who cannot afford decent legal advice who get shafted by the nhs every fucking day
3. 1 - 2 still leaves the nhs significantly in cedit
4. The cunts running the dirty nhs places should be fucking shot, you dont need to be a medic to realise that the fucking filth commonplace in the nhs must be hurting folk, they may not all be able to prove it in court, but its certainly happening as even the fukcing nutters in the govt admit
5. re "It does smack a little of overkill, surely?" yet another treatment that would be routine no doubt in other caring western nations, which the nhs thinks is optional cos the docs r too busy or couldnt give a fuck, really its about time a scientific audit was carried out of uk nhs practises versus rest of developed world - get to the heart of the differences
the nhs is shit stop defending it
no one
Oh read the fucking piece won't you?
This has got nothing to do with 'dirty hospitals' becasue she brought that bug in with her!
on the contrary youre side of the argument had your day in court and lost
suggest you think again
just like all the little people who get their genuine court cases thrown out cos the nhs throws more expensive lawyers at it
you lost as you increasingly will
She was in hospital for five days, a & e charge nurse, so I suppose her injuries were fairly severe. She was discharged without a check by a doctor (that's part of her case).
The hospital argues that she'd be in her current condition -- mainly -- anyway, i.e., even if they'd spotted the infection earlier (I assume they mean, because of the injuries that led her to that hospital stay).
One obscene thing about this case is the level of damages awarded given that they're for assumed loss of future earnings. The obscene thing about that is that earnings/'earnings' differ so greatly in our society.
But, you know what? Even 'troutfaces' have legal rights. And if the NHS doesn't want to lose the money for 50 hip replacements it should be more careful....
2. This doesnt scratch the surface of thousands of ordinary folk who cannot afford decent legal advice who get shafted by the nhs every fucking day
that's another obscenity, yes.
I presume Lesley Ash got the compensation as the infection was not accepted as "a well recognised acceptable complication" of her epidural. No doubt learned medical experts will have testified this to establish the negligence. (Negligence isn't all bad for doctors as it creates a lot work writing reports and giving opinions all of which can pay quite well)
Once that defence of "acceptable risk/side-effect" collapses the case goes to quantifiable damages and I presume Lesley Ash had some demonstrable good contracts/ audited accounts lined up. Hence the large sum in damages.
In this particular case MRSA/dirty hospitals is an irrelevance. As far as I can tell it's about the acceptable and unacceptable risks and consequences of a procedure.
What saddens me is the large sum she gets, when soldiers injured in warfare get far, far less.
There's something wrong where civil and libel damages are huge whereas military and criminal injuries compensation is tiny.
But as far as I can tell under current law Miss Ash is fully entitled to her compensation for negligence.
And I suspect she'd far rather be healthy and out acting again.
What saddens me is the large sum she gets, when soldiers injured in warfare get far, far less.
What saddens me is that when an ordinary person of limited funds needs to fight the nhs, after the complaints procedures becomes an obvious sham, and employees Y solicitors and baristers that the nhs will always fight back with Y x 3 in their legal team, the nhs legal team will then spend at least double the number of hours of the ordinary persons team, and when the sheer overwhelming use of resource wins the day in court the nhs will then always fight for costs, meaning that the ordinary person gets shafted by the nhs and its over the top legal approach, often leaving the ordinary person needing to sell their home or worse
If the nhs complaints process actually involved meeting someone in the real command chain, if it admitted its fuckups instead of repeatedly fighting them, if they used reasonable resources in court, and if they didnt ruin ordinary folk who they have already shafted by demanding costs, if they in general acted like an normal decent consumer facing organisation, then you know maybe people would feel sympathy for the nhs in this case
as it is the public think fucking good luck to her, and fuck the nhs and all the evil cunts running it
what i want to see in the papers is the thousands of small people who fail in their cases all the time against the nhs, and the sheer injustice in the system that allows this to happen, when so obviously decent upstanding folk wouldnt go to all that trouble if there wasnt big problems with the nhs
no one - on the one hand you characterise epidurals for minor chest injuries as routine in "other caring western nations" (no giggling at the back).
But presumably you want this (and all other)procedure(s) to be risk free and the 'evil cunts' to pay when things go wrong.
Well let me tell you my litigatious friend all catheters pose an infection risk.
Let me say that again EVERY SINGLE CATHETER POSES A RISK - now think of all the central lines, urethral or suprapubic catheters, PEG feeds, peripheral lines, arterial lines, etc, etc.
And this is the bit that will amaze you infections occur even in "other caring western nations" - none of these procedures are risk free.
Here's a couple of research articles pertaining to complications of epidurals to be going on with;
http://www.rcoa.ac.uk/docs/nerve-spinal.pdf
http://bja.oxfordjournals.org/cgi/content/full/92/6/896
http://www.biomedcentral.com/1472-684X/6/3
Well
Re "no one - on the one hand you characterise epidurals for minor chest injuries as routine in "other caring western nations" (no giggling at the back)."
Not my intent, I meant to characterise widely different treatment regimes for many common issues between UK front line medics and their equivalents in other Western nations. I don't pretend to be a medic and know which is the best course of action, but I do notice widely different practises from docs in the UK to abroad for broadly similar regularly occurring issues. Take the simplest case of SEVERE ear ache (note the word severe please) then the total lack of any action at all by even the emptiest UK A & E can be compared with what happens with similar condition walking into other European hospitals. Again we've had this discussion before, I am not pretending to know the best course of action, I simply observe that the votes from multiple other European countries seem to indicate that the UK position is not regarded as best practise in the rest of the world. There are other examples. Don't you guys ever compare notes with your foreign colleagues?
Re "But presumably you want this (and all other)procedure(s) to be risk free"
All good professional endeavours to reduce risk as much as possible, you know washing hands, cleaning floors, stuff like that for a start
Re "and the 'evil cunts' to pay when things go wrong. " yep evil cunts should always pay wherever they are found
Re "Well let me tell you my litigatious friend all catheters pose an infection risk.
Let me say that again EVERY SINGLE CATHETER POSES A RISK - now think of all the central lines, urethral or suprapubic catheters, PEG feeds, peripheral lines, arterial lines, etc, etc."
Yes everything in life is a risk, but reasonableness and calculating the pros and cons come into it, catheters in a dirty ward presumably have a higher risk? So therefore shit on the walls that I can see with my own eyes is not reasonable, and that is the basics of it
Re "And this is the bit that will amaze you infections occur even in "other caring western nations" - none of these procedures are risk free." yes we agree on this, but I think you'll find many much cleaner hospitals in other parts of Europe, and no doubt this does the individual patients odds a whole lot of good
Re "Here's a couple of research articles pertaining to complications of epidurals to be going on with;
http://www.rcoa.ac.uk/docs/nerve-spinal.pdf
http://bja.oxfordjournals.org/cgi/content/full/92/6/896
http://www.biomedcentral.com/1472-684X/6/3"
Bit out of date some of this? What you need is some basic stats training, not medicine
Out of date !!!!
Infection rates associated with epidural indwelling catheters for seven days or longer: systematic review and meta-analysis [2007]
Nerve damage associated with a spinal or epidural injection - Information for Patients: the Royal College of Anaesthetics, articles cited published in 2004
There really is no pleasing you is there 'no one' ;o)
A&E Charge Nurse,
"No-one" is not going to be happy with any retort - I wouldn't bother. S/he is angry about something - I don't know what.
FYI, "No-one":
Dirty hospitals:
I agree. Hospital floors, walls and ceilings are filthy. You will find few people in the NHS who disagree. However, unless the epidural catheter was dropped on the floor or swiped across the wall before entering the patient's epidural space then that is largely irrelevant.
The main problem with the Government's current handling of the infection problem in hospitals is that it is guided towards public perceptions rather than evidence-based practice. A prime example is doctors wearing watches and long-sleeved shirts. There is no evidence at all that this will reduce infections, however there is lots of evidence that increasing nursing numbers does reduce infections. Which option do you think the Department of Health has opted for? And why do you think doctors who dress professionally and wear ties get frowned upon and bollocked by hospital managers?
Science and politics do not mix. The sooner the NHS is taken out of politicans' hands the better.
"No-one" is not going to be happy with any retort - I wouldn't bother. S/he is angry about something - I don't know what.
er crap service and repeated crap service, several times ive given up this little stand on this web site only to have the nhs fuck my family around again a few days later, so the crap nhs keeps me motivated
FYI, "No-one":
Dirty hospitals:
I agree. Hospital floors, walls and ceilings are filthy. You will find few people in the NHS who disagree.
agree
However, unless the epidural catheter was dropped on the floor or swiped across the wall before entering the patient's epidural space then that is largely irrelevant.
dont agree at all, the air quality, the clothes being worn, are all affected by dirt on the walls etc when it is such extreme dirt
The main problem with the Government's current handling of the infection problem in hospitals is that it is guided towards public perceptions rather than evidence-based practice. A prime example is doctors wearing watches and long-sleeved shirts. There is no evidence at all that this will reduce infections, however there is lots of evidence that increasing nursing numbers does reduce infections. Which option do you think the Department of Health has opted for? And why do you think doctors who dress professionally and wear ties get frowned upon and bollocked by hospital managers?
agree
Science and politics do not mix.
mainly agree, main problem is political system has largely broken down and ordinary folk know their views do not count
The sooner the NHS is taken out of politicans' hands the better.
agree, it should be disbanded and the taxes used to setup a state backed insurance company, people pay in what they contribute now, folk get cheques out for what they are entitled to now, but importantly all the medical providers are sold off to whoever wants them and the state stops trying to run hospitals and clinics as it is clearly crap at it
is it just me ... Or is no-one suffering brain damage?
the NHS IS you and I and all the fucking rants on this blog. Lesleys case has taken money away from all our future care. These payouts don't fall off the magical fairy money tree. I have a measure of sympathy for anyone harmed by NHS UK..and no-one has a vested interest in allowing hospitals to be dirty but if you want to destroy it utterly then a few more of this level of payouts will mean game over for good.
Insurance, private healthcare seen it - done it. Great for healthcare professionals not so much for joe public.
and just try suing them if it goes tits up... Seriously ... Do - its a new and interesting lesson in futility. Worry not however 'cause in 5 years that's exactly what we're gonna get. Not sure I want to be the one saying Dr Rant told me so..
This was the best article I've read in years, Dr. Rant! I laughed my ass off and yet I am oddly unsettled by the public's lack of knowledge and the media's exploitation of that lack of knowledge. Maybe microbiologists should begin a public education campaign, TV ads, leaflets etc. Surely this would reduce frivolous lawsuits and public and media pressure to pay out big every time someone gets an infection caused by a common and treatable bacterium. Fucking hell, if getting an easily treatable infection as a recognised complication of a procedure were as lucrative as this for all patients, the NHS would be bankrupt and obsolete in a matter of weeks and all medical care would needs be privatised as there would BE no NHS....wait...I think I'm onto something here.
I want to know more about the fact that she was discharged without seeing a doctor. As a nurse I have never let a patient go without seeing a doctor and reviewing the notes to make sure that the doctors had written the order for discharge. All the staff nurses I work with are the same.
I have however had patients demand that the doctor who is covering countless other patients drop what he/she is doing now and come and review for them for discharge home.
So I call the doctor repeatedly because the patient is threatening me with bottley harm if the doctor doesn't see him NOW.
Doctor is in an emergency on another ward and he is not happy I have called him when he already knows to come and see the patient as soon as he can. I explain the situation to the patient. A doctor cannot leave dying patients at the drop of a hat to come and review you for discharge because discharge is not a fucking emergency. Patient gets pissed off and walks out.
That's the only times patient get "discharged" without seeing a doctor.
For someone like Ms. Ash, who would have needed tto's in the form of pain medicine..how could she have just gone out without that as it requires a discharge letter from the doctor there and then?
If her infection was not symptomatic at the time of discharge would anyone have picked it up if they had seen her right before she left? Did she go home unwillingly? What signs would they have seen if they had looked at her right there and then the minute before she went home other than the usual signs of infection brewing?
I haven't looked after a lot of patients with epidural cathetars.
Actually since I have mostly done medical rather than surgical nursing I don't think I ever looked after a patient with an epidural.
Anonymous said...
agree, it should be disbanded and the taxes used to setup a state backed insurance company, people pay in what they contribute now, folk get cheques out for what they are entitled to now, but importantly all the medical providers are sold off to whoever wants them and the state stops trying to run hospitals and clinics as it is clearly crap at it
....
Are you brain dead? Do you seriously think that patients would be better-off in a "sold-off-to-whoever-wants-them" health market? How the fuck do you think you're going to get better treatment from a company that diverts 20% of the cheque you give it to it's shareholders, rather than spend it on your medical care? And you think their hospitals will magically be cleaner? -Would that be because they'd be prepared to spend more on a superior cleaning service, or is it because you think their cleaners would do a better job because they're happier/better-treated/more fulfilled in their jobs? Wake up, twat! The reason some areas of the NHS (notably, cleaning) are as bad as they are now is because those are the areas where privatisation has, in effect, already occured - outsourcing to private contractors who pay their staff fuck-all, treat them like shit, have not the first clue about clinical hygiene (seriously, the lot at my place are "Rentokill" -no, they really are...) and are only interested in maximising profit for their shareholders and undercutting their competitors. Now, just imagine that "MacDonalds" business model applied to the A&E department that you'd like to get get your earache treated at....
20 % going to the shareholders is necessary to give them an adequate return on their capital given the risk profile of their investment, otherwise they would just put their money in the bank and take the interest
its a lot better deal the 40 % to useless administrators
shareholders tend to nudge management to be more efficient which would do clinics and hospitals good
there are no state owned monopolisitic industrys providing good service anywhere, no in the old soviet block, not in china, not in the old post war labour controlled paradises, and sure as not now in a brown government
it needs individual patients to be able negotiate the terms of the deal with their individual providers, its would quickly force change, cleaner places, easier access, and so much more
Anonymous said...
20 % going to the shareholders is necessary to give them an adequate return on their capital given the risk profile of their investment, otherwise they would just put their money in the bank and take the interest
...
That argument merely confirms the conditions necessary to persuade spectulators to invest their money in the healthcare company, it doesn't deny that the resultant healthcare provision is 20% less than you'd get from a not-for-profit system. So the result is: shareholders make a killing (no pun intended) while those of us who need healthcare get 20% less for our money. Although there is some wastefulness in the NHS due to unecessary bureaucracy, the actual service-provision is done extremely efficiently (it has to be, as we all face constant service improvement targets at the same time as budget cuts). I've worked in both private and NHS pathology labs, and the private ones were far more wasteful and inefficient than the NHS ones. It's about time someone corrected the media's constant insidious assertion the all branches of the NHS are woefully inefficient: that is simply not the case in reality, but they're convincing a whole generation of ill-informed public (like you, judging by you comments thus far) that the NHS is some dreadful, wasteful behemoth. It's almost as if the media are colluding with someone to discredit the NHS in order to turn public opinion towards privatisation....
you dont understand the basics of how a free market economy works, and why free market economies are ALWAYS more succesful than a command and control centralist state run monopoly style communist approach
take a little time, study rice production in china over the last 100 years, figure it out
people are complex things, the way they act, and the way the are motivated is the issue
I see your saying that a private system would work so much better.
Well the American private health system has the same problems as the NHS, they only circumvent these problems by chucking you out of your bed and withdrawing drugs when your insurance has run out. The problem with the american model is this you pay money to an insurance company, then said insurance company pays the hospital or doctor that is treating. Both of these entities are trying to making a profit, that in turn increases the amount you will have to pay and if your unfortunate to be in a low paid job your, well not to put to fine a point on it FUCKED. Private health care only benifits well paid professionals, as the majority of the populace in the UK if faced with a chronic condition would no doubt have to sell their house to finance the course of care over the duration of the condition.
As for Leslie Ash, well she was a has been 5 years ago and im pretty much disgusted by the whole procedure, I worry about the ramifications of such cases will it lead to a culture of protection first and treatment second. Will it lead to nonsense tables such as which surgeon is safest that doesnt take into account the procedures they will undertake.
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