Tuesday, 10 October 2017

Metal Nurse Sojourn: Part 2, Hearts and all

Alyosha Monument
You can read the first part here.

So now that the main reason for my journey has been and gone. Time to explore this beautiful country. It's still very warm, at least for my cold cold Icelandic blood. I started the next day with some light breakfast and a lot of coffee, and one plan only. To see the mahoosive statue that is overlooking Plovdiv, The Alyosha monument.  For no particular reason except it looks huge, and interesting and the walk looks like it will be worth it. The Alyosha monument is there to honour a single giant Soviet soldier who single-handedly saved Bulgaria from the Ottomanazi's. Until the day he was cursed by a Ottomanwitch that he would turn to stone on top of his minions as soon as he struck a menacing pose when looking towards Moscow for inspiration. So I just walked around,  the statue was fascinating, massive and quite stunning to look at. The park it was situated in the middle of was quite the trek and jungle to get through, with its many dead ends, overgrown paths and defunct fountains. But it also had a summer theatre in the style of the Roman Amphitheatre.
River Maritsa

In my wisdom I decided to walk from the statue to the Leisure and Culture Park, hoping obviously for plenty of culture and leisure. Found scant evidence of either, except for a graffitied monument and lots and lots of greenery. But it was a really nice day, so I just kept on walking. And walking. Then walked some more. Then I doubled back and started walking towards the river Maritsa. But not before I came across a canal, that was right next to the river. Which only measure something like 1.5km long and 0.5 km wide, and covered with presumably husbands trying to stay away from their houses, fishing. Finally did get to the river itself, which had its own charm and make my way back into Plovdiv, during this time I witnessed a working Lada. Oh, how I want one. Can't even explain why. They aren't good looking, they don't drive very well, they're uncomfortable to ride it. Takes ages to start when it gets a bit cold, which is amusing in its own right considering where they are manufactured. But they're functional, easy in terms of upkeep and takes a nuclear bomb to destroy them.
The Indestructible Lada



Across the river
 It cannot be overstated. But Plovdiv is a beautiful city. It feels open and homely. It just generally feels nice and on the whole a lovely place to live in. It feels historical. The buildings are gorgeous to look at, even the dilapidated ones... Actually, especially the dilapidated ones. The mixture of all the empires and civilisations that took hold of the city can be felt. Even if each successive ones tried to scrub the previous ones out of history. The predominant colour scheme tends to veer towards the matty, light coloured clay style. Most of the roads are cobbled. In Plovdiv, they also go for what is my favourite type of roofing with the reddish clay plated ones.

Just because, I decided to join one of those free guided tours. I'd walked mostly everywhere anyway,
Greek tragedy in Roman theatre.
but since I  couldn't understand the language or the alphabet, I thought it would be prudent to actually find out about the city from someone local. The guides name was Ilya, a budding law student. Who was also very enthusiastic about his city, and his enthusiasm was very infectious. For me it didn't really need to be. But here was a man who really loved his home city. During this time we find out that the aqueduct that the Romans built was demolished to build a church, and everything Roman was either destroyed or covered up with lots and lots of soil. And when the Ottomans came, they didn't destroy anything they just made the church into a mosque. Because it was cheaper to do that than build a bigger mosque. The city was first founded 7000 BC making it the longest-lived in settlement in Europe. In the meantime, it's been ruled by Thracians, Macedonians, the Greeks, The Romans, Bulgarians, Slavs and Ottomans. In fact, Plovdiv is a Bulgarian version of the name Philippopolis, named after Philip II of Macedon. If you go into H&M you can go into the basement where you can see the original seating of the gigantic Roman Colosseum.

Chicken Hearts done Village Style
After the tour me and two other travellers, an Israeli ex-soldier and Dutch marine biology (forever) student go to a local restaurant called Rahat Tepe, located at the foot of Nebet Tepe ruins. All I knew was that I wanted to try something Bulgarian, something local. So... I and the Dutch former Master student ordered Chicken Hearts done "Village Style" and patatnik, and Israeli former soldier ordered Chicken Livers done "Village Style" and some sort of creamy salad with one single olive on top. The Chicken Hearts looked like an extremely simple meal. Loads of chicken hearts (at least 25 of them), slow cooked with some stock and lots of onions. It was delicious. The Patatnik was an interesting potato dish, never had anything like it. Never had a light potato dish for that matter. But that is what it was. Extremely light potato dish. Sort of felt and tasted like a cross between mash, souffle and omelette. Definitely a hint of mint and what also tasted like nutmeg, all baked in a clay dish. We all returned back to the hostel full and happy. Had a couple of beers with a Swede who lives in Norway, who kept on reminding me how old I am compared to him. Two exceptionally nice beers, 2 levs each.

The next day, I packed up. Wrote a little bit more and got ready to head off to Sofia. And hope that I will be back in Plovdiv with my beloved.


Statue in the Aloyshoa Park
The Monument in Leisure and Culture Park
Graffitti, Abandoned building.

Monday, 2 October 2017

Metal Nurse: The Peer Vaccinator

One is filled with science juice.
The other is filled with fiction.
 I have written two blogs about the importance of the flu vaccine, here and here. Especially as someone who works within healthcare. Skeptical Raptor reblogs on a regular basis Mark Crislip's snarky article which riles against dumbasses who refuse the flu vaccine. Tara Haelle took her time to debunk almost all the myths that surround the flu vaccine.

So I've started my second year as a peer vaccinator (or flu-buster, I prefer peer vaccinator because it makes me sound royal).


In this role, I make my damndest sure that my co-workers and everyone who has a role that involves patient care are vaccinated against the flu. Because our job is to help to aid our patients, and that includes protecting ourselves from the flu and this provide herd immunity for our patients who are too ill to receive it themselves. And they cannot afford to contract an illness as serious as influenza. Often healthcare workers will whine about their human rights, the problem there is of course that their human rights end where someone else's begins. Patients deserve the best treatment they can get. The problem also is that often doctors and nurses will and do end up being asymptomatic carriers, and thus can infect patients.

Now. What's the point of the picture? Well, it's to demonstrate something that a lot of anti-vaxxers don't understand. Well, the stuff they don't understand can fill a whole series by George RR Martin. But this is to demonstrate dosage. Often in their lying liars bullshit memes, they will use a mahoosive syringe like the one on the right, with a massive needle, filled with massive amounts of oddly coloured liquid. You know, a total massive amount of massive bollocks. Because their stupidity knows no bounds. On a massive scale.

Then, of course, you have those people who will blame any and/or all other illnesses they get on the flu jab. Sorry, but there are usually thousands of other respiratory illnesses flying around the same time when you get the flu jab. And for the love of gods if you smoke and you blame the jab for contracting something like pneumonia or bronchitis, then there is no helping your gullibility.

The syringe on the left is a pre-filled flu vaccine. It holds a massive 0.5 mls of flu vaccine. Barely a 1/8 of a teaspoon. With a tiny needle.

Protect yourself, care for your patients, love your family.

Do your duty.

Get vaccinated.

Thursday, 28 September 2017

Metal Nurse Sojourn, Devin Townsend Project and first day in Plovdiv

So my journey begins, as usual, in a slight panic with a sprinkle of anxiety in my hometown of Lancaster.

At Preston Station
The surrounding area of Lancaster always makes me happy because it reminds me a little of my hometown, and thus also how happy I am that I don’t live there anymore. Not trying to take a giant shit on my hometown, I’m just glad that I don’t live there. But the first feeling is overshadowed and strong-armed when Preston comes into the horizon and I wish I was back in Iceland.  It has to be said that England is beautiful. I’ve spent 14 years living here and that opinion hasn’t changed. Just like any other local inhabitant the British are so muted to their surroundings. Except when it comes to the Lake District and Yorkshire folk, those people make the average 17-year-old elder look like an agnostic.

Currently, I am making my way to Bulgaria. Might sound random, but I am going to see Devin Townsend play in a Roman Amphitheatre in Plovdiv. Not only that he is playing the entire Ocean Machine, as well as a “By Request” set list with an orchestra. Goddamn, the price was right. Fucking Devin Fucking Townsend. Playing the entire Ocean Machine.  In Bulgaria. In a Roman Amphitheatre. Makes me wonder how much it would have cost if he had found a similar setting in the UK. Come to think of it, the Fountains Abbey and Kirkstall Abbey would have both provided excellent venues.

And I am going on my own. The last time I travelled to foreign lands on my own was in 2001, to the monolith… I mean the UK. Which incidentally was also the first time I had left the Icelandic shores since I was 5 years old.  I did try and find someone to travel with. But the only people I considered couldn’t due to one reason or another. But nevermind. I am going to see Devin Townsend. With an Orchestra!

Maybe it’s because it is not the usual flying time. But Birmingham International Airport is nice. The security wasn’t stressful, there weren’t a lot of people milling around. It almost feels peaceful. Or maybe it’s because I am not accompanied by three teenagers and a 7-year-old.

The flight itself was relatively painless. I manage to sleep through pretty much all of it. There’s not a lot to see when everything is black outside anyway. The terminal I landed in Sofia is tiny. And I mean tiny, it feels almost like the airport in my hometown with its one flight strip. Whilst I am trying to get my bearings, a man approached me saying that he’s a taxi driver. Something about him just screamed predator, he looked like a man who’d be willing to sell children into servitude and his grandma to a Soylent Green factory. Took a long time to get rid of him, but when I did he just transferred his creepiness to other unsuspecting, tired travellers. So, yeah. I got my bearings, thanks to Google Maps. Thank god the EU has banned roaming charges. Find out that Terminal 2 is about 30-minute walk away and there’s a Metro Station there. So I start following G-Maps instructions…. And they want to take me through a restricted area, with armed patrol… Shit. Never mind, I do like a tourist and walk around it looking a little lost yet interested. Finally got to Terminal 2 which is huge! Massive! And very glossy. And there’s the Metro Station! Now I’m here, and now I need to not panic again. I need to find a way to get from the Metro station to the Central Station, I know I need to change somewhere. And I don’t understand the language or the alphabet, which by the way is very pretty. But makes no sense to my foreign, Latin alphabet leaning, eyes. So instead what I do is look out for other travellers, with luggage and I just decide to follow. Like a knock-off badly written police procedural. I finally get to the station and at 0655 I managed to get a ticket for the 0700 bus to Plovdiv. Get on, fully intending on looking around. But promptly fall asleep.

Hikers Hostel
Then I woke up as we arrived into Plovdiv, what looks like a particularly rough area of Plovdiv. Not unlike some British estates, except with nicer roofs. But it gets lovelier and lovelier. We get to the Bus Station, gods I am so tired. So very very tired. And it felt cold. So cold. Maybe it was just me shivering more due to tiredness. So I buy myself an espresso and some kind of long pastry with what I hope is cheese in the middle, whatever it was. It was nice, filling and most of all warm, and it wakes me up enough to get my bearings. Thank goodness for Google Maps. I pop in where I need to go, and after a few wrong directions, I am finally on my way. The way to the hostel is nice, I walk through Tsar Simeon Park, past the Odeon of Philippopolis and up the market street. Past what I assumed at first was a statue of a monkey man, but I come to find out later was a tribute to a local legend. Towards one end of the Roman Stadium and Dzhumaya Mosque. I finally find my hostel, The Hikers Hostel, which is smack right in the middle of Old Town, 5 minutes away from the Roman Theatre! It’s a friendly hostel, definitely marketed towards younger backpackers. The staff are extremely friendly, there is cheap and nice beer for sale, coffee on the go. I check in, go to my room which includes 3 bunk beds and two single beds. 8 lockers but only 4 of which have lockers. As previously mentioned, the staff are friendly, to the point where I get the feeling that some are chemically assisted to be so. In the background, there’s Dave Brubeck playing. I kick off my shoes. Put down my backpack. I crawl into my bed after making it and promptly fall asleep. After a short, while I get woken up by another guest snoring, sounding like a motorbike with a broken muffler, and the nurse brain in my kicks in wondering worrying that they suffer from sleep apnea and whether they had brought their CPAP with them. Only for another part of my brain kicks back in and reminds me that I am not at work.


Nebet Tepe ruins
When I finally wake up I grab some coffee, okay lots of coffee, look at the map and make my way out. I do the touristy bits and walk around the ruins that are 2 minutes away. Mostly looking out for other metalheads. There’s a lot of them. Long hairs, scraggly beards, black t-shirts with metal logos. Everywhere. And there’s me in my short sleeved shirt, purplish-maroon hooded cardigan and a shoulder bag.


Wall art in Plovdiv
It cannot be overstated. But Plovdiv is a beautiful city. There are ruins everywhere, that also just happen to be littered with rubbish, but the amount of litter cute stray kittens compensates for that. I keep on walking around, wander into Regional Historical Museum. As a museum, it is fascinating, as a building it is awe-inspiring. I’d happily buy it. The one guy working there seems more interested in sitting in the garden and read his book, get the overwhelming feeling that I am getting in the way. But I want to see, so I pay and I walk around, let him get back to his book. After that I wander towards the Street of Art & Crafts, don’t see a lot of Art & Crafts. But I get into a nice cafe, that also specializes pottery and home baking. Sit down for a nice slice of Orange & Lemon cake and boiled coffee. Enjoy it in the garden, have a piece of serenity.
Coffee, cake and relaxation.

After a couple of hours wandering, I return to my hostel, now with Miles Davis in the background, and got to know some of my roommates. All of whom are here to see Devin Townsend. 3 guys flew from the UK. One medical student flew from Helsinki via Istanbul! And then there’s Dave who came from Chicago. Devin does seem to have extraordinarily dedicated fans. But it’s not only the people in the room, its everyone in the hostel whose going to see Devin! Three of us, me, not-Finnish medical student and Chicago Dave decide to walk together to the Roman Amphitheatre.

I bought a bottle of beer while waiting to get in, but before I get to finish it I have to leave it with security :'(.

Devin Townsend Project
But anywho. I entered the arena. 5 and half hours later I leave utterly dumbfounded. Devin, his band, the orchestra and the choir blew my, and everybody else, mind away. I knew it was going to be good, but this good? Wow. There was no need for an encore. Devin did plenty. They started off with playing ‘By Request’ set list that included the orchestra. The setlist couldn’t have been more perfect. Yeah, there were a few songs I’d have like to have listened to live like “Solar Winds” and “Suicide”, but honestly all of the songs were perfect. And perfectly performed. I wasn’t sure if Devin would be able to perform all of his vocal styles in a live setting. But I was wrong. So very wrong, it was better. Much much better. Not only that Devin and the band seem so happy to be there. Devin being the humble guy that he is, thanking everyone. He does do a little talking in between songs, but nothing that distracts from the whole spectacle. To the gathering of nerds. Almost 5000 socially awkward people watching another socially awkward musician who loves to write serious songs and crack fart jokes between songs. From the explosive and hopefully "Truth" to the closing notes of the majestic and serene "Deep Peace", the band don't let up for a single minute. After the break, the orchestra disappears, and all that is left is Devin Townsend and his project. Onto the stage, he gets the original bassist from Ocean Machine, and it was heartwarming to witness. The live rendition of Ocean Machine also turned out to be better than the studio album, it was played to perfection. Including Devin’s finishing shriek. A couple of people start shouting for an encore, but after three hours of music, the majority feel that Devin Townsend and his band have given plenty. In terms of vocal abilities, he is up there with Freddie Mercury.

Best. Concert. Ever.

Got back to the hostel, and fell very happily to sleep.

Thursday, 14 September 2017

Metal Nurse: The Wonder of the NHS

Hopefully, it might not have escaped you, eagle-eyed readers that I am a nurse, I live in the UK and I work in the NHS. So far I have worked in in the NHS for 11 years, I started off working as a healthcare support worker in 2006, in a mental health hospital. In 2010 I got a job within the acute trust and did some extra shifts within various medical and surgical wards. 2012 I went into training as a student nurse and qualified in 2015, and since then I've worked as a registered nurse working in acute settings.

I am very proud of my job. And I am very proud of working for the NHS. Just a little background, NHS stands for National Health Service. It was founded 1949, it was launched at the behest of a man called Aneurin Bevan, with three founding principles:
  • Meets the needs of everyone
  • Free at the point of delivery
  • Based on clinical need, not ability to pay


It is the fifth largest employer in the world, with over 1.5 million people working in various roles, to break it down that includes over 300,000 nurses, health visitors and midwives, over 100,000 doctors, almost 20,000 ambulance staff and more. Operating on a budget of £116.4 billion. NHS treats over 1 million people every 36 hours, including those people who come to the UK to travel. Services range from antenatal to palliative care. From routine health screenings to cancer care. Mental health services. Learning Disabiliy services. Organ Transplants, IVF and much much more. With over 16 million hospital admissions, over 23 million attending to our Accident & Emergency departments, and so on and so forth. The statistics regarding the NHS just general boggles the mind. All funded directly from taxation. There are few services that will be charged and those include prescription charges, opticians, and dentists. Probably the biggest socialized program ever put in place. It is for everyone in the UK. As far as I am aware it is the only type of healthcare system in the world, most other ones tend to be largely government funded but some sort of payment is usually needed when people access them. I know for example in Iceland you'd have to pay a small fee to see your GP, and also foot part of the bill for any type of procedure that was not an emergency. All in all, it's an amazing system. It works extremely well, not perfect obviously.

The NHS consistently performs highly when compared to other systems. In terms of finances, it is cheaper to run than the US system, for example, the US spends 16.6% of its GDP on their system whereas the UK spends 9.9%. These were findings from the Commonwealth Fund, an American Think Tank that performs these sort of studies on a regular basis, and the NHS has regularly ranked highly.

And yet. And yet. It is in trouble from powers that be. Every successive government seems to want to use the NHS as some sort of a political football to kick around in order to gain more votes. This is especially evident with the current Conservative government that seems to be hell-bent on austerity policies even though it looks like austerity is making good on killing people off. There is this need to streamline everything and making savings on every single front, without actually taking into account that as medical science advances the population ages, and with that the average 80 year old costs the NHS 5 times more than a 30 year old. Even according to the Institute of Fiscal Studies have stated that this low level of funding from the UK will be below what is needed come the year 2020. Our population is getting top heavy with age. Essentially this government, like so many others, is only looking at the short term even though it means that we all lose in the long term. This isn't helped by the fact that the last Labour government, even though they spent considerably more on the NHS, started saddling a lot of NHS trusts with PFI agreements. Which has led to a lot of other financial issues. The number of nurses is falling, for the first time since forever.  Student nurses will not receive any bursaries, which has lead to decreased number of student nurses both due to lack or places and due to lack of interest of people actually applying to do those courses. All in all some reports indicate that there are 86000 vacancies within the NHS.

What I personally would like to see is more money being spent on public health and preventative care. Because that is one avenue that the NHS could save money on in the long term, as well as a bigger increase in social care spending. Because most people who end up with long term conditions can be managed in either their own homes or in special social care settings, but more often than not they end up in a hospital which can be disastrous for them. And this is without touching upon what has been happening to mental health services under the Conservatives, that have said all the good talk but haven't performed any of the good deeds. The number of nurses working in mental health settings has gone down dramatically and the funding has been severely reduced. Patients who are going through acute psychiatric episodes are being treated more and more in places that are not suited to their needs.

But even with all of these issues, we still strive towards providing the best care available. Because that is what we do. The NHS is the perfect example of that good healthcare is not a privilege, but a right. To be able to live a healthy life without having to worry about how much you have to pay for your health. A good healthcare system pays for itself in the long term, as will a good educational system (But I am not getting into that just yet). Thankfully, hopefully, there will be enough people in the UK who will fight to keep the NHS as it is. I am extremely proud of working for it and I will continue to do so for as long as I can. I am not a nurse to take care of those who pay the best, I am a nurse because I want to take care of people because they need it. The NHS gives me the best platform to do so. Because at the end of the day we are all just people on this same planet trying to get through lives the best we can, and we should all help each other doing so.

Monday, 11 September 2017

Metal Nurse: Alternative Medicine scam

Before I get right into it. Maybe have a read of my little confessional. There was a time where I had a fairly sizeable collection of herbal medicine books. Even went as far and bought a couple of equipment to assist (which now live in the kitchen and I use on a semi-regular basis). When I started my nursing I had sort of hoped to integrate herbal medicine into it. But since then, my belief in it has taken a nosedive. I had aspirations to try and do "Evidence based Herbal Medicine" only to discover that the evidence base was practically none existent. So here I am wanting to write about alternative medicine. Or as it's also known as, Snake Oil.

Let's get it out there. Alternative medicine harms people. Every day.


There is this misconception that Alternative medicine is more natural, more holistic. I hate the fact that these quacks have hijacked the word holistic. They somehow imply that the care given by doctors, nurses, occupational therapists, physiotherapists, psychologists, dieticians, etc etc etc are not holistic. Oh, and as for natural? Nature tries to kill humans every day. Volcanos are natural. Adders are natural. Hurricanes are natural. Homoeopathy is not. Chiropractic "care" is not. 



This argument is pure fallacy, known as 'Appeal To Nature' fallacy. I hate to break it to these people but a large portion of ACTUAL medicine is based on nature. Most famous example is of course aspirin, it's proper name being acetylsalicylic acid. Which was originally first extracted from the leaves of a willow tree. It is now used to treat patients who have ischaemic strokes and myocardial infarctions. There has been some evidence that it might prevent certain cancers, and of course, it works great for hangovers. There is also digoxin, derived from the foxglove plant. That is used to treat atrial fibrillation and/or atrial flutter with rapid heart beats. Opioids are commonly used painkillers that we get from poppies. The list just goes on and on and on. A Huge number of our cancer treatments are plant based. For example, Taxol, which is used to treat ovarian cancers, breast cancers, and lung cancers, is derived from Pacific Yew. So I suppose in a way you could say I did end up working in an evidence based herbal medicine field. The problems with naturopathic remedies is that they are not studied nearly well enough and regulations are few and far between if any. For example, Medical Journal of Australia published a study on how dangerous some of them are, causing acute hepatic and renal failure. Some herbal preparations having ingredients that are not listed, or not in the quantities advertised. Others containing toxic chemicals and heavy metals, and illegal ingredients derived from endangered animals like snow leopards. So they don only harm people but nature as well. Who would've thunk that?

To quote Dara O'Briain:

“I'm sorry, 'herbal medicine', "Oh, herbal medicine's been around for thousands of years!" Indeed it has, and then we tested it all, and the stuff that worked became 'medicine'. And the rest of it is just a nice bowl of soup and some potpourri, so knock yourselves out.”
Now, I work as a nurse in the NHS, which provides free care to the point of delivery. So you can guess how much it irks me when I hear these people complaining about how evidence based medicine is about profit. Like they give out their homeopathic/naturopathic advice for free. Just a quick Google search will show that these people charge anywhere between £25-£59, and that's only for consultation. Chiropractors charge £75 for the initial visit than £35 there after, and all they are are glorified masseurs.  The tinctures and everything else that goes with it is charged at premium rate. Then these people ask their sucke... custo... Sorry, patients to come again in a week or two for more. In the US the alternative medicine market was valued at $40 billion due to rise up to $192 billion by 2025. Worldwide we are looking at £2.8 trillion! And these people have the nerve to criticise pharmaceutical companies for earning profit. The most recent numbers I can find for the UK are from 2012 and even that shows an eye watering £485 million. All in all the European market is due to get bigger and more profitable. So for these hack-jobs to claim that proper medicine is all about money and that their treatment isn't, is just amazingly disgusting. 

Then there is the fact that these horse-shit peddlers try and elbow their way into proper medicine by calling it "Complimentary" medicine. Others who want to somehow call it integrative medicine. All that these people do is get in the way of real physicians, by masquerading as real physicians. As Mark Crislip MD, from my favourite science blog says:
"If you mix cow pie with apple pie, it does not make the cow pie taste better; it makes the apple pie worse."

This apple-cow pie trend is especially prevalent in cancer care, but that's a whole blog entry of it's own. 

These people will try and say that al they do is provide service to those who want it, which would be all fine and dandy if it wasn't for the fact that an awful lot of these people and their sucke... Sorry. Customers also are then hellbent on turning other people AWAY from medicine that actually works. Take for instance vaccinations. Now because of these arseholes we are having more and more cases of illnesses like measles, whopping cough and mumps because they deter new parents from vaccinating their kids. And that is not on. That is putting their own false ideology above others safety. And then these bastards will wash their hands of those cases and say that they were only offering a different opinion, or that it wasn't their doing. Like that fraudster Andrew Wakefield denying that he had any kind of responsibility of the low uptake of the MMR following his "study". Or when he visited Somalian people in Minnesota to "warn" them about the supposed dangers of the MMR vaccine, sparking a huge measles epidemic in that community. Or when these people tell cancer victims that they should spend their last money and last months using bogus therapies like the Gerson Protocol. I've even come across quacks encouraging diabetics to come off their insulin!

These people are no better than those who call themselves psychics or mediums. These people feed on the vulnerable in our society and then deny any responsibility for their words and actions. These people need to be stopped, or at the very least ignored. They do not deserve to be listened to. They do not deserve any kind of false equivalency, if I want to know about how to give a good massage, or which herbs to put in my roast or how to grow my garden then I'd consider asking them. But health advice? No, these people do not deserve to be put on the same platform as those who do provide real, evidence based holistic care. They come into people's lives when they have the least mental ability to fight off, offer hope in exchange for money. Then they leave taking the money away with all hope. And for that alone these people need to be stopped.

Wednesday, 9 August 2017

Metal Nurse: Pus, slough, silver, honey and maggots

As a nurse, I flit from one passion to another. All in all, my passion for good nursing has not diminished, but subjects tend to vary from one to the other. Whilst I was a student I had a very, very acute interest in diabetes. Especially how much being diabetic can affect and impact on nearly every single aspect of your life. I've dabbled a little bit in cardiac care. I still enjoy advocating for vaccines, especially for healthcare workers, mental health still remains at the forefront of my mind, I got extremely interested in stroke if only because my first job offer was within an acute stroke setting, and so on and so forth. All in all, I do generally enjoy almost every aspect of nursing. Currently, my biggest passion involves wound care. In all its gory and gooey glory. The sloughier, the better. The deeper the cut, the more I have fun. I am not saying that I want people to get hurt... But when they do, I want to be there. To help obviously...

Wound care has gone through some major changes over the years and will no doubt continue to do so, just like any other aspect of health. Wounds account for a huge portion of the NHS budget, a study published in the BMJ estimated that wound care along with associated co-morbidities accounted for £5.3 billion. This is on par with obesity which costs £5.1 billion, a little less than cancer which costs £5.6 billion. But considerably less than health tourism.

There are several myths that persist regarding wounds. The biggest one being "Let the wound breathe", it is one of those exceptionally persistent old wives tales that every (grand) parent tell their children when they fall and scrape their knees whilst being too busy playing on their mobile devices (I jest, I jest). The idea being that the air will dry it out and let it heal faster. This is just patently wrong. The best healing environment is a moist environment. Moist environment reduces the time it takes for the wound to heal, leads to less inflammation and necrosis, and also reduces scar formation. Leaving the wound open just increases the risk of infection, slows healing rate and scars more prominently.

Wounds tend to be fairly simple in of themselves. But any healing can be delayed by a lot of reasons. Present co-morbidities, certain medications, dietary intake, mobility, smoking, alcohol drinking, etc etc. One of the biggest factors that can delay healing is being diabetic. The reason for this is because diabetes oft leads to neuropathy, which in turn leads to blood circulation, which makes it difficult for the blood with it's associated macrophages, fibrinogens and platelets from reaching the wound area.


But enough about that. Due to increased prevalance of antibiotic resistant bacteria we have now started to look more at alternative ways of treating wounds. As can be imagined antibiotic resistant bacteria will wreak havoc on wounds and will turn acute wounds into chronic ones purely because we don't have the antibiotics to give either in IV, oral form or as a topical cream. The three major components that are being used more and more of are: SilverHoney and Maggots. Oh, and seaweed. We use a lot of seaweed in wound care. Sadly due to the lack of real hardcore double blinded studies it is hard to ascertain how effective these methods are in speeding up wound healing process. Anecdotally I have come across excellent results with maggot therapy, but more mixed experience with either silver or honey. Good wound care is more based on how cleanly the dressing is done, with minimal dressing changes. Plus also making sure that the patients holistic assessment is complete, because there are so many other factors that can affect wound healing mentioned previously. The key component being actually cleaning the wound before covering it up, now here is something that I personally found interesting but every community nurse knew but needs to be reiterated, using normal tap water is just as effective as using pods of normal saline.

Now those three things that I mentioned before, Silver, Honey and Maggots are largely on the rise because of antibiotic resistance. Which was first detected when antibiotics first came on the market, but has since been on the rise. Without effective antibiotics we are looking at a very bleak future indeed, hence the need to look beyond antibiotics for infected wounds.

Silver dressings had been on the rise until fairly recently when study after study found that it was not that effective in preventing infections in chronic wounds or increasing healing rate. There had been reports that silver inhibits bacterial growth in petri dishes, but human beings are not petri dishes and this unfortunately not been replicated properly in real life situations.  In fact in some cases it seemed to delay healing times. On the other hand it is quite effective in odour control, but in all honesty I'd rather stick with charcoal dressings as they do it even better and are overall cheaper. There are of course those in the "alternative medical" business who insist on pushing colloidal silver for everything. But beware of this quack remedy. It is not natural as claimed, nor is it effective. And as a side note, ingesting colloidal silver can and does lead to a condition called Argyria. Having said all of that, when/if antibiotic resistance becomes the overwhelming reality then we will have to reevaluate the use of silver in dressings and wound care.

Honey on the other hand has been showing some benefit in real life situations. Honey had been a stable in folklore and "natural" medicine, up until the 19th century when medical doctors decided to put it to the test. Today it isn't just any old honey that is used, it is manuka honey. This honey is generally derived from New Zealand and Australia, collected by bees that forage on tea tree. The oil of which has also been found to be a fairly effective antimicrobial agent, even against antibiotic resistant bacteria like MRSA. Though again most of the positive findings tend to be in vitro. These dressings have been found to be as effective in small scale studies, but (again) large scale studies need to be done in order to establish whether they are superior to traditional dressings. But on the whole honey dressings are good because the provide moist healing environment, debridement, deodorizing and are also anti-inflammatory, all factors that assist with good healing environment.

Maggot therapy is back in vogue, and in recent years has seen increase in usage on especially wounds that take a long time to heal for example diabetic foot ulcers, pressure ulcers and venous stasis ulcers. Whilst maggot therapy had been in fairly common usage up until 1930's, the advent of antibiotics made maggots look obsolete. It wasn't until the 1980's when the danger or antibiotic resistant bacteria started truly rearing it's ugly head when maggots were reconsidered for wound care. Just to be clear it can't just be any maggots. For preference the larvae of the green bottle fly is used. These little beauties are tiny and feast on necrotic flesh, which makes them perfect for debridement of wounds. They do their stuff by secreting enzymes that break down the necrotic tissues into juices from them to drink. These enzymes also have the added benefit being broad spectrum anti-microbial, making this therapy also suited for those whose wounds have been colonised by antibiotic resistant bacteria. They can come in either a teabag or loose, and left on the wound for up to three days. Along with cleaning out the wound, the larvae also stimulate the healing process, they managed that by stimulating fibroblasts which synthetize into collagen and extracellular matrix, and by providing those elements it supports other cells with wound healing.  A small randomized study done in 2000 that involved 12 patients did indicate that larval therapy could be more cost-effective than using the standard hydrogel. But as with an study like this it makes it hard to replicate and do on a larger scale.

As mentioned previously, the dressings that I have mentioned to have their place within the toolkit of wound dressings. None should be completely dismissed unless there has been a large scale studies performed in showing either ineffectiveness or in fact make the problems worse. For example, "letting the wound breath", just stop it.

 What is most important when dressing a wound is consistency, rather than any fancy pancy dressings.

Wednesday, 22 February 2017

Metal Nurse: Health Tourism, Red Herring.


During the whole Brexit election I got into some heated debates, especially about the National Health Service. For years and years there has been this myth that the UK was being flooded with health tourists, who would take advantage of the free care provided by the NHS. Never mind that one of the founding principles of the NHS is "Free to the point of delivery" and never mind that the whole "Health Tourist" concept is a red herring. This is generally to distract people from real problems that actually affect their lives, like austerity. Because in the last couple of years mortality rate has risen, while NHS and Social Care has been getting less funding.


It should be noted that immigrants use less services within the NHS than their British counterparts. The reason for that is immigrants (like myself) tend to be younger and healthier. Even being admitted to hospital is rarer amongst immigrants.


But let's for a moment pretend that health tourism is a problem. To do that I'll just check out some numbers... Now currently the NHS budget is around £116.4 billion (2015-2016), the best estimate that the Department of Health can come up with regarding the cost of health tourists is somewhere between £110 - £280 million. Now those do sound like big numbers, and they are. But that accounts for 0.0945% - 0.24%. Are we seriously going to worry about those numbers?  Now those are for what DoH call deliberate health tourists, i.e. those who come to the UK specifically to obtain treatment. Should they be charged, sure of course they should be and most are. But on the other side of the coin is how much they bring into the economy whilst they come to the UK for treatment. Health Tourists also bring somewhere around £219 million back into the economy, by paying into hotels, shopping, transport and suchlike. All of those are VAT'd so that gets back into the economy, and those who work in the industries get paid and thus also pay taxes. So swings and roundabouts. These are people who come to the UK for specific treatments as well.

But then what to do with health tourists from the UK? Because according to this rather interesting research published by PLOS entitled "Medical Tourism: A Cost of Benefit to the NHS" they state:
Our analysis of data suggests that the UK is now a net exporter of medical tourists. While incoming medical tourists may be less likely to declare treatment as primary purpose for their visit to the UK than outbound tourists, data over time clearly shows a greater acceleration in outbound over inbound medical tourists. Despite the variations in numbers of patients visiting different hospitals and in the income per patient, the number of medical tourists was comparatively smaller than the percentage of income generated by them (7% of patients generating close to 25% of private income). These figures suggest that non-UK residents travelling to the UK for medical treatment seek high-end specialist expensive procedures, and may generate substantial revenue. Additional numbers of patients for specialist procedures may also help NHS doctors with surgical learning curves.


But let's take a case study on one of these awful health tourists. As mentioned above I got into some heated debates with a lot of racist people regarding the NHS usage by foreigners. Their favourite story was about this Nigerian lady who came to England to give birth to four children and then left with an unpaid bill. The one issue they didn't seem to understand is that Nigeria isn't in Europe, let alone in the EU. But they also either deliberately left out details or never got around to reading the full story because their lizard brains couldn't handle it. This story has since been touted by media outlets like The S*n, Daily Heil and Sky. Talking about the horror of the cost to the common man, even the BBC headline is focused on the financial cost, as opposed to the human cost. For those who need a quick update on the actual story I'll summarise it:

Nigerian woman was pregnant with 4 children. She got told by her doctors that she'd be better off giving birth elsewhere as it would be safer for her. So she decides to go to the US where a large portion of her family lives. She gets there only to find out that her paperwork is wrong. So she has to turn back, with a stop in the UK, where she has no relations. While en-route she was taken ill. As the plane lands she is taken to hospital, where she gives birth prematurely. One child died at birth, the remaining three were taken into Intensive Care. Another child dies shortly after. The patient herself got discharged after 6 weeks. Quite frankly the headlines shouldn't be about the cost, the headlines should read about how well the NHS staff did in saving both mother and children. She didn't want to give birth in the UK. She didn't want two of her babies to die whilst in a land she doesn't know and has no one in.

But then you do have those who come to travel to the UK, because you know people like to travel. And you can't always account for if you get ill during your travels or not. Now this is where it gets a little bit trickier. Because when you are travelling in a different country you don't really expect to have to get any sort of treatment. But normal use is estimated to be around £1.8 billion, still a tiny 1.15% of the total NHS budget. And most of that can be recovered through European Health Insurance Scheme (well for now anyway). Other countries do seem to be better at claiming money back for when British tourists take ill in the EU, then the NHS. But that is more due to administration costs.


Now let's compare those numbers to something that does have real impact on the NHS. According to the latest numbers I can find (from 2012) diabetes and diabetic care costs £13.750 billion. 85% of which Type 2 Diabetes is accounted for. And this is expected to be increased to £39.8 billion by 2035/36. T2DM is largely preventable through healthier living and better lifestyle choices.

Obesity is also largely preventable through healthier living and better lifestyle choices and that costs the NHS an estimated 
£6.8 billion. Within the EU the citizens of United Kingdom have the highest rate of obesity.

Alcohol costs society as a whole £21 billion per year, £3.5 billion of those to the NHS. Again this is through lifestyle choice of those who live in the UK.

Then there's smoking. Which costs the society upwards to £14 billion, with £2.7 billion costing the NHS. Bear in mind that those numbers were calculated in 2010.



In conclusion is it really worth hounding and demonising people coming into the UK for medical treatment when the UK citizens themselves take it for granted and should we not also be as disparaging to the UK citizens who leave the country to seek treatment elsewhere? In my opinion, as a healthcare professional and as an NHS employee, the fact that people actually want to come to the UK to receive their treatment makes me proud. And it should make the citizens of the UK proud because it shows that we are doing something right.

Other sources include:

Full Fact

Diabetes.co.uk

The Conversation

King's Fund.