Dara Gantly

Dara Gantly looks at how IT is finally being utilised to deliver much-needed reforms in the health service.

The message from the Minister for Health was clear at the recent briefing on the work of the Special Delivery Unit (SDU): “Reform does work and delivers for patients”.

After an in-depth analysis, brimming to capacity with numbers on trolleys and waiting lists, the Minister hinted at what was really behind this ‘big news story’. “Analysis and information is how you make change. And it has empowered the system. I think this has been huge… hospitals are now regaining the sense that they do actually have control over this.”

So how exactly have the health authorities achieved a reduction by 27 per cent in the numbers waiting on trolleys, given that the budget had been cut and will be again? One vital element seems to have been a realisation that IT can help improve the information available to hospitals, which in turn can improve patient flow.

Fundamentally, the task of improving waiting lists and waiting times comes down to capacity management: Has the system got the senior decision makers on the floor to discharge patients home, to residential care facilities, or back into the community with the support of home care packages? But even before that, the system has to know what capacity is available and what surges are ahead. And that’s where IT — such as the email system that can examine what the trolley rate pressure is like three times a day, introduced by the SDU in December — comes into its own.

Indeed, it has been an exciting start to 2012 for health IT nerds. The National Cancer Control Programme (NCCP) has set a target of doubling the number of GPs referring patients online to the eight designated cancer centres this year. A collaboration between the NCCP, ICGP, GPIT Group and the HSE ICT Directorate, the new referral system for breast, lung and prostate cancer aims to eliminate the use of GP letters and faxes, increase efficiency and provide more rapid access for urgent cases that need to be seen within two weeks of referral. It should ensure that — regardless of where a patient lives — the referral pathway they follow is of the same quality and standard, and should eliminate a repeat of the Tallaght referrals debacle.

And in this week’s issue of IMT, we hear that five more hospitals in the North East will shortly become part of the National Integrated Medical Imaging System (NIMIS), joining Sligo General, Waterford Regional, the Mater and Beaumont Hospitals. Beaumont’s turnaround-time for reports has decreased to less than 18 hours, and consultants in the regional hospitals are now able to quickly receive a second opinion from a Beaumont consultant, which becomes part of the patient’s record within minutes.

'It seems that behind many of the emerging success stories from our embattled health service are innovative IT systems that allow doctors, nurses and administrators to work better, faster and smarter'

And last Friday we had the official launch of the Caredoc Community Intervention Team (CIT) service, which has already carried out approximately 700 patient care interventions since it was established in the Carlow/Kilkenny region in mid-September.

Behind this service is also a highly intelligent IT system, where the clinical records of the CIT patients are managed via an electronic patient record system provided through a database linked to the Caredoc out-of-hours IT platform.  The CIT nurses can also record their treatments on an electronic hand-held device, which automatically updates the patient record and forwards this information through electronic messaging to the patient’s own GP’s software package.

It seems that behind many of the emerging success stories from our embattled health service are innovative IT systems that allow doctors, nurses and administrators to work better, faster and smarter. ‘Better, faster, smarter’… I must listen out for that one from the Minister next time around. What is it they say — ‘The geeks shall inherit the earth’?

Dr Garrett FitzGerald

With a little help from NASA, Dr Garrett FitzGerald discovered he was able, on reflection, to improve on one of Flann O’Brien’s greatest experiments.

The tablets are great. The dreams come thick and fast, mainly the former. They cover most areas of the human experience and much of the extraterrestrial. Frequently, they inspire great thoughts and insights. I have been in contact with a mind-seer in Vienna, sharp as a pencil in his 209th year, who interprets them for me monthly.

Other than his failures to understand and analyse the endlessly recurring episodes where I am presented yet again with the McCarthy Cup ar son na Tiobraidí, he is remarkably insightful; it was none other than himself who pointed to the ‘extreme likelihood’ that, in my most recent episode of existential parallelism, I was a jeep battery for General George S Patton throughout the Sicilian campaign.

No need of Herr Doktor Wien to sort out the most recent reverie, which is filed under the heading ‘scientific breakthrough’. This latter folder, now in the realm of the terabyte, has been recently expanding at a terrifying pace, suggesting that a cure must surely be nigh.

The dream concerned Flann O’Brien and his amazing reflections in the realm of mesuration. Eruditides amongst my readers will recall De Selby’s landmark work with mirrors, based on the hypothesis that when one looks into a mirror, one is looking at one’s past, for there is “an appreciable and calculable interval of time between the throwing by a man of a glance at his own face in a mirror and the registration of the reflected image in his eye”.

This image we’ll think of as ‘the first reflection’. Flann then recounts, in the Materials and Methods section of his communication, the experiment carried out by De Selby: “Ever loath to leave well enough alone, [De S] insists on reflecting the first reflection in a further mirror and professing to detect minute changes in this second image. Ultimately, he constructed the familiar arrangement of parallel mirrors, each reflecting diminishing images of an interposed object indefinitely. The interposed object in this case was de Selby’s own face and this he claims to have studied backwards through an infinity of reflections by means of ‘a powerful glass’.”

On mature reflection I cannot improve on the ‘Results’ section of the paper:
“[De Selby] claims to have noticed a growing youthfulness in the reflections of his face according as they receded, the most distant of them — too tiny to be visible to the naked eye — being the face of a beardless boy of 12, and, to use his own words, ‘a countenance of singular beauty and nobility’. He did not succeed in pursuing the matter back to the cradle ‘owing to the curvature of the earth and the limitations of the telescope’.”

Impressive work indeed from the low-tech era. No fancy words like ‘pre-stressed concrete’ and ‘marmalade’ in those dim, drear days beyond recall.
In the dreamscape, NASA came to the rescue. Dearest reader, you will be able to treat yourself lavishly to the details in a forthcoming issue of Science, but for the moment, I ask you to feed scantily on a summarised account.

My American colleagues had no problem virtually straightening out the earth’s curvature by mathematical jiggery-pokery beyond my ken. Then they augmented this with telescopic advances that even our descendents may yet marvel at. De Selby would turn in envy in his watery grave off Dalkey. All I had to do was gaze into the eye-pad of the scope while science did the rest.

Flann O’Brien’s De Selby believed that when you looked into a mirror, you were looking at your own past

Beardless boy
I saw again a beardless boy of 12 summers, this lad casting a serene radiance across miniaturised time zones, morphing quickly into a bambino of stunning appearance and demeanour, whose all-encompassing celestial warmth effected a highly spiritual elevation in my person, characterised by a long period of ecstatic levitation during which I briefly glimpsed in-turn; a strapping lad of proud and joyous mien taking pikes from the thatch to drive out the Gaill, chomping away on putrescent lashings of sweet black-puddings; a boy-ancestor of the Tuatha-de-Danann akimbo on the Lia Fail, reciting verse of unspeakable beauty and wisdom, discoursing all the while with elders in anapaestic pre-erse; a glorious choir of one angel; the Ark of the Covenant; the mason’s apron; a  hairy quarehawk etching her impressions of hadrons and fermions on a cave wall; the devil in the detail; a giant gnat with fluorescent chromosomes; the Ming Flanagan; a land-and-sea creature comprised solely of a solitary rheumy but sightless green eye; and — finally — a floating invisible box of infinitesimal size, which I couldn’t make out clearly.

At this last my anti-gravitational disposition ceased abruptly, and was soon replaced by a slow wave of confusion pouring forwards from the back of the head. It brought me down to earth.

Higgs boson
Yet the final message from Houston was in itself a stunning revelation; the head spacer there was of the very firm opinion that the invisible box contained the Higgs boson and there was a sporting chance that there could be a breeding pair. Levitation had just recommenced for an aerial acceptance of the Nobel Prize when our golden retriever’s cold nose made contact with my sacrum.

I woke in a lather of sweat and joy. Great tablets — way better than any amount of squeezes from the Bould Thady Quill.

Nothing much to report from the Sunny SE.

Dr Ruairi Hanley

Dr Ruairi Hanley is passionately opposed to any potential moves to pardon the Irish army deserters who went to fight for the British in World War II.

Over the past few months, a campaign has been launched to grant a pardon to those Irish army personnel who deserted our Defence Forces during World War II and subsequently joined the British Army. It appears to have gained support from the usual suspects in The Irish Times, Trinity College and the Fine Gael party.

My view on the matter is simple. I am passionately, vehemently opposed to this campaign. I believe the Government should immediately reject any suggestion of a blanket pardon for these deserters.

This may sound harsh. However, I think the facts need to be spelled out. These men did not have to join the Irish Army. Should they have wished to fight for the British Empire, there was nothing to stop them leaving the State to do so. Indeed, tens of thousands of Irish men did exactly that. Those soldiers acted honourably and their actions are to be respected and admired.

However, those deserters who are the focus of this campaign decided instead to sign up for the Defence Forces of our country. In doing so, they placed their hand on a Bible and swore allegiance to this nation and to the chain of command. Anyone who has ever worn the uniform of this State will be familiar with that simple and powerful ceremony. It is not an oath to be taken lightly.

We must also look at the context in which these men made the fateful decision to desert.

In 1939, Éamon de Valera decided to pursue a policy of military neutrality. Given that our fledging State had only 20 years earlier been at war with the British Empire, this position was logical. Furthermore, neutrality enjoyed overwhelming public support at a time when Europe was slowly drowning in a sea of fire and blood.

The ‘Emergency’
De Valera walked a tightrope throughout the ‘Emergency’, as it became known. His actions ensured our survival as a sovereign State and, even among political opponents, his behaviour throughout this time is grudgingly admired.

During the war, the threat of invasion did indeed hang over our country. The Germans contemplated such an act, code-named ‘Operation Green’.

Winston Churchill also seriously considered invading in order to seize key port facilities on our coastline.

Throughout these dark days, our impoverished, small nation did its utmost to protect itself. Thousands of young men joined the Army with the sole aim of defending the very existence of our newborn State. The vast majority of them retained their honour by serving their country throughout this period. A small number chose not to do so.

At the end of the conflict, those men who had broken their oath, betrayed their comrades and joined the army of a foreign power were duly found guilty of desertion. Unlike in other nations, where such crimes resulted in imprisonment, in Ireland they were merely convicted and excluded from holding public service positions.

Frankly, in my opinion, this is nothing more than these men deserved. How can those who broke an oath of allegiance to our country in one of its darkest hours honestly have expected to subsequently be given permanent employment by the State?

I acknowledge that some of these deserters did indeed fight bravely for the British Empire against Nazi Germany. Nonetheless, this does not excuse the fact that they fundamentally betrayed Ireland.

'It is a little-known fact that serving members of the Permanent Defence Forces are forbidden from engaging in public commentary in national newspapers. That is why you will not read any correspondence in the press from Army Officers, who might vehemently oppose this campaign'

In my opinion, to grant these men a blanket pardon is to belittle the integrity and honour of those who did not. Such an act of retrospective clemency is also an insult to every man and woman who has ever served in our Permanent Defence Forces.

UN peacekeepers
It also undermines all those brave and loyal citizens who subsequently wore our uniform on United Nations service in war-torn lands.

Indeed, as I write this article, I am conscious of the fact that hundreds of Irish soldiers are currently serving in the Lebanon. Naturally, their bravery and patriotism rarely features on the letters page of The Irish Times, while those who abandoned our army decades ago are treated as plucky folk heroes.

Of course, many people may be wondering why this campaign has suddenly gained momentum after all this time. I believe the answer is obvious — Fine Gael is in power.

I believe there has always been a small, unrepresentative neo-Unionist element lurking within the ranks of Ireland’s largest political party. For these people, insulting our Defence Forces would not cost them a moment’s thought.

Dev’s shadow
I also suspect that, pathetically, in the eyes of some fanatical Blueshirts, this issue may even satisfy some deep unspoken desire to get ‘even’ with De Valera — the one politician they could never fully defeat.

For all of Fianna Fáil’s many failings, somehow I seriously doubt they would have agreed to a blanket pardon.

Finally, it is a little known fact that serving members of the Permanent Defence Forces are forbidden from engaging in public commentary in national newspapers. That is why you will not read any correspondence in the press from Army Officers, who might vehemently oppose this campaign.

I believe the issues raised in this debate are far greater than the actions of a few thousand men 60 years ago. This is now about defending our national pride, our national dignity and the very honour of our sovereign nation. This pardon must not be granted.

Dear Editor,

My name is Dr Bassim Dhaif FRCSI, FRCS (Orth), Consultant Orthopaedic Surgeon, Salmaniya Medical Complex, Bahrain, Associate Professor, College Of Medicine, Arabian Gulf University, Past Chairman, Department Of Orthopaedics, Past President, Bahrain Orthopaedic Association, Past President, Bahrain Sports Medicine Association. I am married. I have four children; the eldest is 19, the youngest is 10.

I was arrested on March 19, 2011, two days after the main crisis in Bahrain. My arrest was at home and in front of my whole family. It was violent and aggressive. I was beaten by several persons, approximately 12. They entered all the rooms in my house and destroyed some items. They asked me to open the safe box and stole cash worth us$20,000 that was never returned. They have taken all ownership documents of five properties that I own. In addition, they took two of my cars, which were only returned after three months.

I was back-handcuffed, then pulled down the stairs and taken to an unknown place. There I was subjected to violent physical torture of various kinds. I was kept in solitary confinement for seven days. I was kept standing for the whole day for nearly 12 days. As a result, I developed massive swelling of both legs and feet that resulted now in a loss of sensation of both feet and permanent congestion and swelling.

I was subjected to verbal abuses of all kinds. I was deprived of sleep for nearly 26 days. I experienced aggressive verbal attacks on my religious beliefs.

This seems to be a standard practice against all doctors who are from the Shiate sector.

The physical torture continued for 26 days. During that period I was subjected to lengthy interrogation that lasted eight hours. This was violent and aggressive. No specific charges were read to me. At the end I was forced to sign 20 pages without reading them. During those 26 days, I was blindfolded continuously and back-handcuffed. I came to know subsequently that I was in the CID, Criminal Investigation Directorate.

On the 23rd day, I was taken to a detention centre and the torture continued and was even more violent. This continued for three days, following which, the blindfolding and handcuffing were stopped. In those three days, I experienced the most terrifying moments of my life. This was the torture and the witnessing of the death of two jailed persons.

The circumstances in the detention were very difficult and painful. This lasted nearly four months before things started to ease down. During that period, I was taken again to the CID with many doctors. We were forced to give confessions and stories that had never occurred in real life. For me, I was forced and threatened to say that I had performed fake surgeries to patients that had no injuries and reported that to international media, so as to distort the image of Bahrain.

I was forced to confess that one of my colleagues had weapons. I was forced to say that one of the surgeons opened the chest of a patient, not to take out a bullet, but to make his injury worse. This was a painful experience for all of us. However, the amount of torture and threat I was subjected to forced me to say anything just to save my life.

It’s important to mention that I was sexually harassed during those 26 days. In the detention centre and while I was taken to a medical clinic blindfolded and handcuffed, I was punched on my face and kicked on my legs many times.

Going to the medical clinic was a terrifying experience the first two months in the detention centre. We were not allowed to see the doctor since we were blindfolded. After three months, the visit to the clinic was not with the blindfold. To my surprise, the doctor was one of my former medical students.

On June 6, at 4am, I was taken to an unknown place. I discovered at 9am and for the first time that I was in a military court. Between 4am and 9am, and on the way to that place, I was also back-handcuffed, blindfolded and subjected to physical attacks and verbal abuses by the security personnel.

In the court, and to my surprise, I saw my family for the first time. All throughout my arrest and detention I was denied any access to my lawyer and my family for more than three months. Even during the court sessions, I was allowed only 10 minutes to see my lawyer. I had only one formal meeting with my lawyer and that was in detention and it was at the end of July 2011 — more than four months after my arrest.

Only in mid-June 2011 did I become aware of the charges against me. These included:
1. Occupying a government hospital by the use of force;
2. Attempting to overthrow the ruling Royal Family;
3. Performing fake or sham surgeries and broadcasting false information to international media so as to attempt to overthrow the government;
4. Hiding information about the use of weapons by some of the doctors;
5. Many other charges.

I absolutely denied all these charges. All my confessions actually were never said by myself and, not only that, I was forced to sign papers that apparently contained those confessions. This was obtained under torture and threat and without the presence of my lawyer. I was forced to record these in front of a TV camera, the tape of which to this date has not been broadcasted. The usual trend in this country is to publish or broadcast them on a national TV without a permit.

We brought more than 40 witnesses in the trial. Many of them are senior consultant doctors, paramedics, nurses and others. All of those witnesses had testified that the hospital was never under occupation at any moment of the crisis in Bahrain from the period February 17 to March 16.

We showed an official interview with HE the Minister of Health on Bahrain TV on March 9, 2011, stating clearly and strongly that the hospital service was running quite normally and patients were accessing the hospital without any difficulties.

We showed an official statement by the Assistant Undersecretary for Hospital Services at the Ministry of Health, Dr Amin Al-Saati, saying that all the services at the hospital were being carried out normally, except for a scattered five days where there were injured protestors brought to the Accident and Emergency Department.

I myself, a practising surgeon at the hospital, used to run my clinic and do my surgery up until March 13, 2011. Yes, on a few occasions when there was a flood of injured protestors, the hospital administration themselves would stop elective admissions. This occurred only occasionally. Obviously, the number of cases attending the hospital had dropped and the reasons for that was that the country was in crisis and there were days when more than 300,000 protestors gathered in Pearl Square.

I had never interfered with the work at the hospital. I was doing my clinic and my surgeries both at Salmaniya and in a private hospital. I have worked at Salmaniya Hospital since 1987. I am a senior consultant. I am involved in teaching medical students and have been training doctors since 1997.

I treat all sectors of Bahrain equally, Sunni and Shiate. I don’t need to prove that, as the whole country knows who Dr Bassim Dhaif is. I have performed thousands of operations during my career. I operated on many players from various national teams — football, basketball, volleyball and many others.

I was involved in the treatment of many injured protestors who sustained serious injuries as a result of the use of bullets and live ammunition. I reported that to the BBC on February 18, 2011. Obviously such comments disturbed the government. On February 17, the ambulance was not allowed to bring injured protestors from Pearl Square between 6am and 11.30am. The order for this action came from the security forces.

We submitted the voice recording of such orders to the ambulance services to the court, but this was never considered.

In fact, between February 17 and March 16, several doctors, nurses and paramedics were attacked by the security and military personnel. Some of those sustained serious injuries, including head injuries and fractures. All this is documented by videos.

As a result of this, the health professionals were furious. This act is not acceptable and risks the provision of best medical care. The health professional have protested against that. I myself have protested twice.

As regards the aggregation of hundreds of protestors in front of the car park of the accident and emergency department, I have absolutely nothing to do with such acts. I was never involved. On the contrary, I objected to such action. I personally spoke with the chief of medical staff about this issue. Not only this, in a meeting with H.E. The Minister of Health, I opposed such events taking place: never in that time of the crisis that a protest should actually have taken place in the vicinity of the hospital.

Regarding our trials, first it’s a military court and I am obviously a civilian. I was denied any of my basic and simply rights, such as a lawyer and access to my family, access to evidence etc. The torture that I sustained was documented by the Bahrain Independent Commission of Inquiry. This Commission was established by His Majesty the King of Bahrain. The interrogation, confessions were all under threat and torture and in the absence of my lawyer.

Therefore, this trial is illegal and has no basis. I demand the dropping of all charges.

If such a retrial should take place, I urge the international community to monitor and follow these trials. I urge the King of Bahrain to intervene and stop such trials that have distorted the image of Bahrain and have clearly shown to the entire world the extent of human rights violation taking place.

Dr Bassim Dhaif, Frcsi, Frcs (Orth),
Consultant Orthopaedic Surgeon,
Salmaniya Medical Complex,
Bahrain.

The official report of the BICI, which was tasked with investigating and reporting on the events in Bahrain from February 2011 and on allegations of human rights violations, was published in November and can be accessed online at www.bici.org.bh.

Dear Editor,

As I sit in my office on a quiet morning in general practice, I can hear strains of Mr Tambourine Man gently wafting in from the radio speakers in the waiting room next door. This is followed by Pat Kenny talking about something utterly predictable, elucidating an array of opinions on the usual subjects; all of which are presumably in keeping with those of the listening public.

Indeed, the typical nature of my day, with its rather typical opening and somewhat predictable conclusion, causes me to seriously question the pace or the existence of social, cultural or intellectual evolution — at least in an Irish context.

Mr Tambourine Man was written and recorded by Bob Dylan in 1965. It was famously re-released by The Byrds sometime later and is included in Rolling Stone magazine’s list of the 500 best songs ever.

It is often described as an ode to the use of drugs such as LSD, which was certainly part of the social experiment that was the hippy 60s. My point here is that whilst Dylan’s muse is of some historical relevance and was clearly of significance in the 60s, why does it remain part of the frozen musical repertoire of RTÉ today?

Fortunately, with the internet and YouTube we have access to a world outside of the ‘Groundhog-day’ that is our national broadcaster, and to my delight and sadness my 14-year-old son almost every night introduces me to a world of music that evolves on a different planet to RTÉ.  Bands like Beirut, Joanna Newsom, Anthony and the Johnsons, Life in Film, Devendra Banhart, M Ward, and many more, all of whom will hardly see the light of day if they are to struggle through the fixed concrete that RTÉ has poured upon the landscape of Irish media.

The interesting thing here is that the artists I have mentioned are not only almost entirely unknown to the Irish mainstream but are, however, known throughout the world. If the numbers of hits on their YouTube videos are anything to go by, they are part of an evolving world of music that is passing Ireland by.

Yet there is also a sinister twist to the artistic stagnation that defines our national media. It is possible that this national ossification is more by design rather than accident. One is not suggesting a conspiracy theory. However, there is at present a massive global evolution occurring on an intellectual as well as an entertainment and artistic front — an evolution of which we in Ireland remain almost entirely ignorant.

Old dogs are being buried around the world; new thinking and new art is awakening. Popular philosophers like Slavoj Zizek are re-inventing democracy, capitalism and socialism, and would be very quick to point towards the brutal irony that Joe Duffy is as much a media millionaire as he is a ‘man of the people’; that he walks in the material footsteps of the developers and bankers of yesteryear, as much as the footsteps of a self-styled James Connolly.

The actual social distance between presenters like Duffy, Kenny, Finucane, or the late Gerry Ryan and the ‘real’ people of Ireland could be measured in light years, and yet theirs is the petrified view that spans the airways and silences all dissent and almost all hope of newness. Not only is RTÉ incapable of evolution and intent upon containing it beneath a thick layer of stone, but it is happy to resurrect the retired in the form of Gay Byrne who, not arguably but definitely, retired years, if not decades ago!  He is now back, presenting a number of shows on radio and television. RTÉ has at least evolved the notion of the job for life into a job for life and beyond retirement!

The newness of thinkers, of artists and of ideals seems to remain an anathema to RTÉ, perhaps because newness is an anathema to the Irish people. That we ourselves continue to ‘play the lotto’ and suffer from the same GPI (General Paralysis of the Insane) which Joyce accused us of in Dubliners and again in Ulysses.

Is this the same GPI that caused Joyce to flee to Trieste, and caused Beckett to flee to Paris? Perhaps it is this same paralysis which causes 1,000 young people to flee Ireland every week. Perhaps the usual palaver about our young having to leave Ireland because of the recession is as untrue as it is true.

We will never know because only the media tells us so.

Perhaps many of the emigrants themselves believe that the sole reason they depart Ireland is economic? And yet despite the media embrace of the recession, there may be more to this. It may be that we Irish have no sense of ownership of our land, no sense of belonging to Ireland.  No real sense of pride in who we are and where we have come from. Is that why we find it easier not only to leave but to litter, to decimate our bogs, despoil our heritage, ignore our language and carve up our countryside with motorways and ghost estates?

I consider myself a middle-class socialist; it is, to my mind, the path of least destruction amongst the by-ways of political philosophy.  I suspect that most in Ireland are of a similar political leaning.

The socialist TD Clare Daly has embarked upon a campaign to ignore the new residential tax. The Left, as usual in Ireland, have missed the banana boat. Their tactics remain unchanged since the water charges and the bin tax a decade ago. Don’t pay — go to jail and hopefully raise the profile of the socialist agenda. Yippee, and here we go again!

But the Government is ahead of Clare Daly and Joe Higgins; the Government has passed legislation to ensure that the socialists will be denied their day in jail, as no-one is to be jailed for non-payment, and the non-payers are to have the residential tax taken at source from their wages. Checkmate to socialism.

The real charge that Daly and Higgins and the entire Leopold Blooming nation of ours should be rejecting with heartfelt enthusiasm is our TV licence, as it is this money that pays for the concrete that is being poured upon the intellectual and artistic landscape of Ireland every single day. And yet it is hard for us to see the trees or the forest, or even the wolves and the sheep, when all is concrete and we must contend with our GPI.

Dr Marcus de Brun,
Rush,
Co Dublin.

Dear Editor,

I would like to thank Dr Ruairi Hanley very much for the support he and people like Prof Damian McCormack and others in Ireland are expressing locally and internationally on Bahrain (Irish Medical Times, January 27, 2012, http://bit.ly/A2qbzd). I am very pleased with Dr Hanley’s enthusiasm, which unfortunately some of our colleagues in Bahrain are standing against.

I am one of the medics who was sentenced to 15 years’ imprisonment, for nothing but doing my job in helping my fellow Bahrainis who where injured by the Bahraini and Saudi troops attacking peaceful protestors who were asking for reforms.

I was in Ireland in the summer and autumn of 1983 in University College Dublin, worked in Our Lady’s Hospital for Sick Children in Crumlin, and obtained my Diploma in Child Health from UCD. I am a consultant neonatologist.

I was one of the medics who was arrested and tortured by the Bahraini and Saudi security forces, both physically and psychologically, and sexually harassed for nothing except for doing my job.

The sad side of the story is that the government is accusing us of occupying a hospital in which all of my colleagues have worked throughout our entire lives, for treating the injured there as well as in the Pearl Roundabout medical tent, offering our services for the people there during the crisis in February-March 2011.

The RCSI-Bahrain also played an unfortunate role during the crisis, suspending some students as well as a Bahraini lecturer.

Dr Nader Dawani MBChB (honors), DCH, MRCP (UK), MRCPCH (UK),
Consultant Paediatrician and Neonatologist,
Salmaniya Medical Complex,
Former Assistant Professor — Paediatrics,
Medical School, the Arabian Gulf University, Bahrain.

I didn’t suspect I had a dickie ticker,
If  I did, I may have gone to A&E quicker,
The pain came on slowly, not all of a sudden,
So, thankfully, I’d time to finish the black and white puddin’.

But, despite my profound wish, the chest pain persisted,
When it radiated to the neck, I knew I’d have to be shifted,
Straight to A&E, without a GP letter —
A rare occasion, when to do so is better.

In WRH, just up the road, and very efficiently indeed,
I was examined, troponind and multi-ECGd,
The staff, working flat-out, were most helpful and kind,
But the medical Reg was the hero to my fretful mind.

After 10 hours wired up in Cubicle 3,
Observing the wonderful crew in my A&E,
He put his head round the curtain: “Blood tests and ECGs show
nothing amiss”,
I asked, a little bashfully, could I give him a kiss?

He politely declined and professionally advised,
An ECHO and stress test would of course be required,
Three days later, in MAU, when the treadmill I mounted,
The ticker, stout fellow, held up when it counted.

What was the diagnosis? Stress was suspected —
An overburdened GP, working too hard, I reflected,
Increased workload, decreased resources, cuts left, right and centre,
Medical card ‘Central’, patient and GP tormentor.

But, let it be said, the health service has a heart that’s still beating,
And great staff doing their job without bleating,
So, in these hard times, what is the master plan?
Pension-off the most experienced, as many as they can.

The moral of this tale, if one can be found,
Patients well cared for by staff on the ground,
Staff and the system all increasingly stressed,
Just about managing to give of their best.

Dear Dr Reilly, fellow GP and health service master,
Please now do your best to avert a disaster,
Support the front line; It’s what we’re all about,
So cop on, shape up and if your heart’s not in it… step out!

Dr Cyril Murray,

Waterford.

Dr Muiris Houston

Dr Muiris Houston looks at the implications of new research, which examined whether physician body weight is a barrier to care in overweight and obesity.

When it comes to giving lifestyle advice to our patients, does it really matter what sort of shape we are in? And are doctors role models for their patients?

These are interesting questions that are now being asked by medical researchers.

According to new research on the topic, a doctor’s BMI can in fact impact on how they treat their overweight and obese patients. Sara Bleich and her colleagues from the Johns Hopkins Bloomberg School of Public Health and Medical Institutions in Baltimore found that doctors with a normal BMI were more likely to initiate a discussion on weight loss with their overweight patients compared with doctors who were overweight or obese themselves.

The researched, published online in the journal Obesity, also found that these physicians with normal BMIs demonstrated more confidence in their ability to provide advice on diet and exercise compared with their overweight or obese colleagues.

Commenting on their study, the authors said: “Physician body weight may be a barrier to obesity care. Understanding how a doctor’s BMI influences his or her treatment decisions regarding weight management is critical, given the important roles practitioners play in helping their patients lose or gain weight.”

The study involved a cross-sectional survey of general practitioners and hospital physicians. Participants completed a questionnaire on how they recorded an obesity diagnosis, initiated weight-loss discussions, rated self-efficacy for providing counselling, and prescribed weight reduction medication. The researchers also looked at how participants differed in their outlooks on the value of modelling healthy behaviours and whether the doctors believed that a patient’s trust in medical advice might be influenced by the weight of the doctor giving it.

The results showed that doctors with a normal BMI were more likely to believe that doctors should model weight-related behaviours, such as maintaining a healthy weight and exercising regularly compared with their overweight or obese medical colleagues.

Those within normal BMI limits also said they believed that overweight or obese patients would be less likely to trust advice given by a physician who also was overweight or obese.

Interestingly, doctors were found to be more likely to record a diagnosis of obesity or start a weight-loss conversation if they perceived the patient’s body weight met or exceeded their own.

This is something Dr Arabella Onslow, a GP in Cumbria, England, would probably agree with. Having successfully lost over 10 stone in 14 months, she is quoted as saying: “I can see in hindsight that my idea of what constituted normal weight was massively skewed… when I weighed 22st, if I saw a patient who weighed 18st I found myself thinking they weren’t that overweight — while, of course, they were.”

‘Not everyone agrees with the need for doctors to be role models’

Example to patients
Commenting on her reasons for losing weight in the Daily Mail, Dr Onslow commented: “At the back of my mind was the knowledge that I wasn’t providing the best example that I could to my patients. I really care about them and I wanted to be the best doctor I could for them.

“I knew that at the very least, I was giving tacit approval to someone who was overweight. If their own doctor, the person they went to for health advice, could be that fat, then surely it was okay for them to be fat too.”

In the same article, Dr Michael Wilks of the British Medical Association and Chairman of the Sick Doctors Trust is quoted as saying that “previously, people accepted what doctors said without question…now, however, people are more likely to look at their doctor with questioning eyes”.

And backing up Dr Wilks’s theory is a UK survey carried out by the Department of Health, which found that fewer than half of those questioned would readily accept health advice from a health professional who appeared to have an unhealthy lifestyle. A third would actively not accept that advice. But despite the research results, not everyone agrees with the need for doctors to be role models when it comes to weight and fitness.

Dr Daniel Sokol, a Medical Ethicist at Imperial College London, is of the opinion that: “Doctors must be trustworthy, competent and professional, but this does not mean they must lead healthy lifestyles or be thin or good-looking.”

Meanwhile, a spokesman for the Royal College of General Practitioners said that as long as the doctor acts professionally, there is no dilemma. “When the patient leaves the consulting room, they must feel that the doctor has listened to them, addressed their needs and was kind. This is the best way to ensure that the next time they visit their GP, they can trust them enough to talk about their eating, drinking or any other personal concerns,” they added.

But as Dr Onslow says: “I don’t think I am a better doctor because I am no longer obese. But I do think I am a better role model for my patients.”

Ed Madden, BL,

Fifty-six-year-old Raymond Francis Roche is a former member of An Garda Síochána and lives in Dundalk, Co Louth. On November 20, 1999, Mr Roche, who was on crutches following an arthroscopic procedure carried out on his right knee some four days previously, was assaulted by a member of the public.

He was kicked and struck repeatedly by his attacker and received at least one kick to the right knee.  He suffered physical and psychological injuries as a result of the assault and was out of work until September 2000.

Mr Roche ultimately developed septic arthritis in his right knee. This was formally diagnosed at the Mater Hospital, Dublin, in August, 2002. The condition was caused by the bacterial infection staphylococcus aureus (staph aureus).  Because the infection could not be brought under control in early course, it eventually caused the destruction of the right knee joint, with catastrophic consequences for Mr Roche.

In November 2006, Mr Roche had a total knee replacement.  However, he again developed significant septic arthritis in the knee joint and underwent further surgical procedures.  He will require chronic antibiotic treatment for the rest of his life and may need to have his right leg amputated above the knee.

Mr Roche claimed compensation from the Minister for Justice under the provisions of the Garda Compensation Acts 1941-1945 in respect of injuries sustained by him during the assault in November 1999. Part of his claim was that by reason of the assault, he had gone on to develop septic arthritis in his right knee — a condition he maintained would not have developed if it had not been for the assault.

At a hearing in the High Court in 2011, the issue for the Court was whether or not Mr Roche was entitled to compensation in respect of the pain and suffering caused by reason of the staph aureus. If he was to succeed, Mr Roche would have to establish that the assault “was the substantial cause of the injuries complained of”.

The Court was told that staph aureus is a bacterial organism, which is known to be responsible in many cases for the development of septic arthritis. The organism can enter the bloodstream or obtain access to the body in many different ways.  It can, for example, enter the body in the course of trauma, including any invasive medical procedure or surgery.

Expert evidence
When the proceedings were initially instituted it was Mr Roche’s contention, based on the evidence of a general practitioner, that he had contracted staph aureus in the course of the assault in November, 1999. In deciding the issue of causation, the Court had the benefit of expert evidence from Prof Muiris FitzGerald for Mr Roche, and Prof Samuel McConkey for the Minister for Finance.

Having advised the court as to the acute nature of the infection, Prof FitzGerald said that based upon Mr Roche’s evidence and the content of his medical records, it was likely that he developed staph aureus in late November, 2001. At that stage he had many of the hallmark symptoms of the infection, including significant pain and swelling of the knee.

In considering what role the assault might have played in the fact that the infection, once contracted, ultimately seeded to Mr Roche’s right knee, Prof FitzGerald said that, in his opinion, this probably occurred as a result of the combined effects of the surgical trauma to the knee occasioned in the course of the arthroscopic procedure of November 16, 1999, and the physical assault to the same knee some four days later. He said that these two events, when taken together, resulted in a damaged knee joint, which rendered it vulnerable to attack from any subsequent staph aureus infection.

Prof McConkey, for his part, agreed with Prof FitzGerald that the infection could not be attributed to the assault of November, 1999. However, he disagreed with his colleague as to the likely date of infection, saying that he believed that it was far more likely that it was contracted much later than November, 2001, and probably as late as August, 2002. In coming to that conclusion, he relied inter alia on the results of a number of investigative procedures carried out through the latter months of 2001 and the first six months of 2002.

In considering what role the assault might have played, Prof McConkey stressed that Mr Roche’s right knee was vulnerable to infection for a number of reasons entirely independent of the assault.  For example, he had gout in that joint for at least 10 years prior to contracting staph aureus. Apart from causing inflammation, gout causes crystals to develop, making it difficult for the immune system to eradicate infection in the event of an attack.

Giving her judgment in the case, Ms Justice Irvine said that, having carefully considered the evidence, she preferred the testimony of Prof McConkey as to the likely date upon which Mr Roche became infected with staph aureus. In this regard, his evidence was consistent with the nature of the infection as described to the Court, was supported by the test results and history contained in the medical records and was “further validated” by the medical literature produced to the Court.

The judge was not satisfied that Mr Roche had established that the substantial cause of the staph aureus infection was the assault perpetrated upon him on November 20, 1999.  Both experts were agreed that the infection had been contracted entirely independent of the assault. In addition, by reason of the existence of a significant number of alternative reasons as to why the infection might ultimately have developed in the right knee, including the existence of gout, it had not been established that the assault was the substantial reason for the infection.

Mr Roche’s claim for compensation for pain and suffering arising from the staph aureus infection was, therefore, rejected by the Court.

Reference: [2011] IEHC 482

Dara Gantly

Are the long-promised plans to move towards chronic disease management in primary care in a chronic condition, asks Dara Gantly.

In last week’s Editorial, we heard about how the HSE plans to minimise the impact on services of a €750 million reduction in its budget by fast-tracking new, innovative and more efficient ways of using reduced resources.

The Executive has suggested that by moving to new models of care which, as the Minister for Health Dr James Reilly has stressed, must treat patients at the ‘lowest level of complexity’ and provide quality services at the least possible cost, the health services can keep the inevitable and unavoidable cuts in services to a minimum. In many cases, and particularly with chronic diseases, this ‘lowest level of complexity’ means primary care.

A perfect example of such innovation would be to put in train long-hatched plans for the management of such chronic diseases as stroke, acute coronary syndrome, heart failure, COPD, asthma and diabetes in primary care. But what did the HSE give us? An uncosted pledge to develop an overall ‘chronic disease watch’ model of care, with initial focus in 2012 on the diabetes programme.

Readers will be familiar with Heartwatch — the first such programme in general practice, which saw 470 GPs involved, 11,000 patients treated, and 81 deaths prevented or postponed due to treatment in the first two years of the programme. The big problem with it was that it was only ever brought out to 20 per cent of GPs and never rolled out nationally. But the template worked, and can do so in other disease areas as long as it is GP-supervised but practice nurse-delivered.

Dr Barry White, HSE National Director for Clinical Strategy and Programmes, accepts that we have to improve chronic disease management in primary care. While it may not necessarily give us a decreased demand on hospital services in 2012, it is very important for the overall health of the population and will have longer-term benefits.

Speaking at the launch of the 2012 Service Plan, Dr White noted that the HSE had identified diabetes as the most important area within that context, where patients have the highest risk of cardiovascular complications. He said the Executive was “very keen to start the implementation of chronic disease management in diabetes in 2012”, albeit there was quite a lot of work to be done in terms of working through the funding stream and having discussions with GP representative bodies. The Service Plan has set the target of Q4 for commencement of the phased roll-out of the programme for diabetes, which means the danger of it being pushed into 2013 is all too real.

An immediate action the health authorities could take would be to prioritise legislation for a unique patient identifier and assist every GP in the country to create a register of their patients with the six major chronic diseases

Minister for Primary Care Róisín Shortall believes that implementing primary care programmes for chronic diseases are “overdue reforms” that will deliver significant health gains and savings on expensive hospital care. She has committed the Government to establishing the first phase of the diabetes chronic care programme in primary care this year, with the scheme extending in the years ahead and expanding into other disease areas. But do we really need more pilots?

Back in 2006, a three-year shared-care, IT interactive, collaborative heart-failure management pilot, involving St Vincent’s University Hospital and 50 GP practices, covering a patient population of approximately 200,000, commenced with funding from the HSE. Spearheaded by Prof Ken McDonald, this integrated programme decreased hospital admissions by 4,000 per year. In that small area in South Dublin, this is the equivalent of building a small-to-medium sized hospital, at a cost of €27 million!

An immediate action the health authorities could take would be to prioritise legislation for a unique patient identifier and assist every GP in the country to create a register of their patients with the six major chronic diseases. This will be an essential element of any programme and should be a ‘first step’.
We have heard a lot of ‘talk’ over the great pace of change around the whole area of chronic disease management since the new Government took office.

We got a junior Minister for Primary Care for the first time in the history of this State, and the Minister himself is a GP, fully aware of the potential role primary care can play in the reform process. But we have yet to see much of the ‘walk’.

Moves may well be afoot for reform of our chaotic healthcare model, but the strides we are taking remain stubbornly small.