Mónica Lalanda

Mónica Lalanda is an urgentologist at Hospital General de Segovia, Spain

Spanish doctors bear the brunt of funding crisis

By Mónica Lalanda - 13th December 2011 11:39 pm

I wish we could talk about something else but if you live in Spain, the intense economic crisis takes over any other issues. Things are not looking good over here. Our National Health Service which has traditionally been considered quite decent is struggling to stay above water. Widespread cuts are becoming a fact.

There is a general feeling of gloom; cuts in health kill people. It is incredibly frustrating that politicians don’t seem to see further than their own desks and comfy chairs. Closing down entire wards, cutting theatre lists down, growing debts with the pharma industry, closing Accident and Emergency facilities, and cutting down in clinics might be starting to pay off but not in the expected way. Only a few weeks down the line and there are already victims, human losses and great suffering.

This is scary stuff – not just for patients but also for the staff. Out of all the possible ways to decrease expense cutting doctors’ salaries and wages has taken priority. Cataluña is taking the lead on this ugly business and their junior doctors are the main victims. It is now said that many Residents are facing the next Christmas with half the salary they had a few months ago, this could mean little more than 1000€/month.

The starting point isn’t the best since Spain was already running a good health service on the cheap, mostly by paying peanuts to its staff; it is well recognised that Spanish doctors are amongst the worst paid in the old Europe. GPs are even worse off earning a salary that’s about a third of their British colleagues.

Even worse than low salaries is the lack of good working conditions and job security. A large proportion of doctors have short term contracts.

It has been incredibly frustrating to hear all the politicians gaining kudos for what they like to call “one of the best health systems in the world” during our recent election campaign. Apparently our system is good value for money but they all miss the point of why it’s such a great deal - our medical pockets.

The government might pay doctors peanuts, but let me assure they don’t get monkeys in return. I’ve worked in Spain for three years now and the health system might have some serious problems but the doctors are every bit as good as their British counterparts. I guess one of the beauties of being doctor is that money is not the only payment you get, patient recognition and the sense of doing something good is rewarding. There is no other way to explain certain successes of our national medicine; for example only this week 94 organ transplants were carried out in just 72 hours, an amazing record and well ahead most European countries.

The crisis might be coming down on doctors but sadly there is little reaction, minimal response; doctors in this country have been disrespected for decades and they just soak it up. When you feel mistreated and overworked, you have little energy left for anything else and of course since the mortgage needs paying, and you want to be chosen for the next available locum, you don’t want to be seen as a trouble maker.

Unless we regain some pride in what we do and stand up together for our rights and the rights of our patients, we’ll continue to have our toes stepped on. So here is an addition for your vocabulary if you are learning Spanish: medico cabreado.

We look forward to the new government, only time will tell if they are capable of turning around this mess. Fingers crossed.

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E coli: toxic cucumbers and other lies

By Mónica Lalanda - 10th June 2011 11:37 am

It seems that, yet again, we are all going to die.

This time it is a killer form of the bacteria E coli that is causing the international health scare. We haven’t had a single case in Spain (except for two people who have recently returned from Germany) but still the clinical guidelines on the management of intoxication by E coli have already been circulated to most A&E departments, and the media is talking about it non-stop.

It is almost a good thing that, after swine flu, people do not believe in health scares anymore, otherwise they would rush to hospital at the first loose stool, like they did with the first sneeze back in 2009.

One of the distinctive facts about this bacteria is its collateral damage. It has indeed killed a few people and has made a large group ill but you wouldn’t believe that a tiny bug can cause so much damage to the economy of a country, which is not even the one where the blooming bacteria is.

The utterly odd health events that we have witnessed in the last few years are a reflection of the modern era: the globalization, the open markets, the speed of information and the use of information to protect your own country or attack a different one.

And of course, let’s talk about cucumbers, now. Spanish cucumbers were initially blamed by the German government as the cause of the outbreak of E coli and as expected, the economic loses have been dramatic. It is unbelievable how fast Germany blamed Spain without having solid scientific proof. It is apparently extremely difficult to trace the culprit in this sort of situation and even now they are still searching.

As the days pass the situation becomes more confusing: how come 17 different cases were coming from the same restaurant and it has remained open and only recently been investigated? Why have they taken so long to look into their own meats, their sausages, when this is the usual source of E coli? Do people in Northern Europe never wash their fruit and vegetables? We are talking about Germany here, not just any other country.

There is one more question that springs to mind, how much longer is Germany going to take to apologise to Spain.

There is another issue that is worth commenting on. On the morning of 31 May, the German health minister announced that the Spanish vegetables were not to be blamed. To my surprise, on 2 June, I received the table of contents of the BMJ with the news: “Outbreak of E coli is linked to cucumbers from Spain”. Apparently this table of contents simply reflects the paper issue which was already in print so it simply doesn’t get double-checked or updated even if it is sent three days after its edition. They way I see it; it is unacceptable to send mistaken information to thousands of international readers when the implications can be as sensitive as they have proved to be.

Furthermore, in the current digital era it makes little sense to include news in publications that are only edited weekly. Scientific papers should take extreme care to avoid behaving like the general media, spreading alarming news without checking on the evidence.

We’ll see how it all ends but in the meantime I suggest you all treat yourselves to a healthy and refreshing gazpacho and stay well away from German products, especially the bean sprouts; after all we don’t quite know where the E coli might be hiding!

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Sauerkraut and bratwurst for Spanish doctors

By Monica Lalanda - 13th February 2011 7:16 pm

Global politics are well beyond my understanding. Two facts are clear however - Spain continues to suffer from a major economic crisis and our government is useless.

What I find harder to understand are the offers of help that Europe is providing us with. A few days ago, Mrs Merkel offered jobs for up to half a million highly qualified Spanish workers. How kind! Germany is hoping to get an extra large bunch of medical specialists, nurses and engineers.

She will not, however, be offering any of our several hundred thousand illegal immigrants or construction workers or cleaners a job. Mrs Merkel is after our ‘best people’, the highly trained, the ones that have been expensive to produce. It would be laughable if it wasn’t tragic.

The funny thing is that there aren’t many jobless docs these days, the times back in the 1980s and 1990s when you kicked over a stone to find ten doctors underneath are long gone. However, our working conditions are not good. I’m not particularly talking about salaries - while the income is at the bottom end of old European countries it’s still fairly decent. Doctors’ working conditions, in terms of secure contracts, are a disaster; people in their late forties have to pass bureaucratic exams in order to secure their positions and avoid having to move towns. It’s pathetic.

Our health system is used to an excess of doctors and as a professional group we are treated with contempt. There is little pride after years of being simply grateful for having a job.

The numbers of doctors moving out of Spain are difficult to calculate. People leave quietly, independently; they don’t leave a trace or enter any database. However, our Organización Medica Colegial gathers that almost 1,200 doctors moved out in 2010, 56% more than the previous year.

beer-and-sausages1

Back in the 1960’s and even 1970’s many thousands of unskilled Spanish workers moved to Germany to make a living, mostly waiters and hotel keepers, the benefits were equal for both countries. The situation is hardly the same in 2011, the way I see it Spain is struggling to take off from a deep recession and Germany is taking advantage of it. Despicable.

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Why oh why have we got new ALS guidelines?

By Monica Lalanda - 18th November 2010 4:02 pm

A few days ago I saw the first victim of the new 2010 resuscitation guidelines. A very keen staff member at a nursing home must have read the contents of the first little box: “Unresponsive? Not breathing normally? Start CPR” and started chest compressions. Apart from several fracture ribs, this poor old thing in her late 80’s seemed pretty alive when she arrived to A&E. Since no drugs or electricity were used in such a heroic attempt to revive her, I have to assume that she was never in cardiac arrest but just fainted.

It doesn’t sound very smart to me to start jumping on anyone who is unresponsive and not breathing normally. The previous “no signs of life” seems somehow more sensible.

Still, one wonders why anyone would try to resuscitate an elderly woman, depriving her of her right to a dignified, natural death. We all seem to blindly accept that life is a right and death is a failure of medicine. New guidelines, same problems. We are still talking about out-of-hospital cardiopulmonary resuscitation rather than introducing a new term ‘cardiopulmonary resurrection’.

There is enough evidence to suggest that anybody that drops dead out of hospital who is older than 80, and has no ongoing good CPR, should be certified dead rather than subjected to an attempt at resurrection. Still, no guidelines will dare to put that in writing and the ones in 2010, with all that so-called international expertise, have failed the basic principles yet again. Who wants to be accused of ageism?! And of course, let’s not forget that these new guidelines have once more got the lowest grade of evidence possible in medicine.

I have other issues with the guidelines. I found the change in the depth of the chest compressions from “4-5 cm” to “at least 5 cm” almost hilarious. Honestly, can this have any practical use? It would make a funny article for the Christmas BMJ issue - get a bunch of doctors and nurses and a cushion and see if they can differentiate between compressions of 4-5 cm and compressions of more than 5cm.

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Then of course is the issue of the intra-osseous needle rather than ET-tube to administer drugs when iv access is not successful. Is there really strong evidence for this? You need to have an IO needle, you need time to stick it and of course you need the skills. I have been an EM doctor for well over a decade and only used a handful of these in paediatric resuscitation. An IO needle in an adult is easier said than done and was already considered a possibility before these new guidelines arrived anyway. It is not a practical change but at least it is going to make the IO needle producers quite happy.

One of the mighty beauties of the ALS guidelines since they started is the fact that they are simple, international and easy to remember. Getting rid of the beloved ABC will surely create chaos for months to come. Why the fuss of new guidelines when the old ones are only five-years-old and they are written by consensus rather than evidence?

Maybe insisting on the importance of good chest compressions in all ALS courses around the world might have been enough. I look forward to more exciting changes in future guidelines, who knows, it might be CBA and 5.6 cm chest compressions next time.

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A summer of sun stroke and bull’s horn wounds

By Mónica Lalanda - 29th September 2010 9:16 am

It has taken me ages to write a new blog - I simply couldn’t find the time. One of the main reasons is that being an emergency medicine doc in Spain over the summer is awfully busy. I remember summers at my hospital in Leeds as fairly quiet, now I understand why: the potential patients were all in Spain.

My adopted town, Segovia, gets thousands of visitors a day. Despite this it’s fairly quiet and most come for the cultural sightseeing, with very little of the usual madness on the coast. We have no beach even if we do have the sun and excellent food and wine. Still, when there are people there are accidents, strokes, heart attacks, indigestion, billiary colics, all sorts.

It is also common in this country that the elderly population, who live during the hard winter in town, move back to their childhood villages for the summer; they then decide to become really ill, all their chronic complaints become acute and they end up in A&E. Since they come from outside the area they have no medical records, no lists of medication, just the usual and very international: “Yes, I take a little yellow one for my blood pressure.” It is amazing how much more complicated a chronic patient is without the records and in the middle of the night.

And then of course there’s the shifts. A&E staff follow the same pattern of other specialties and that means that we do on calls. In fact the hospitals are run at night by the ‘adjuntos’, the equivalent of the consultants, with the help of their residents (juniors). It is such a long time since I’ve worked on the shop floor at night that I am finding it quite hard. Since I am pretty sure it is safer for the patients, I think working non stop for 24 hours should be forbidden by law after one reaches 35 years of age. It is hard!

There are things that one needs to learn to work in Spain during the summer. Wounds have to be dealt with differently than in cloudy Britain. As part of the management of any skin injury you have to prescribe some form of complete sun block cover to make sure the scar doesn’t get over pigmented and therefore more obvious. Then there’s sun stroke, we get quite a bit of that. In places like Segovia, the temperatures roar up to over 40º C at the worst and in winter it can easily be as cold as -10ºC, so you have to be as good at managing hypothermia or frostbites as heat related illnesses. In my own department, with several skiing stations within 30 minutes reach, you can be treating sun burns in July and then skiing injuries a few months later. It is truly a country of contrasts and the work of emergency departments are good proof of it.

I am sure most people are familiar with images of a herd of bulls running along the streets of Pamplona amongst hundreds of youngsters dressed in white and red. Most years someone gets killed and a lot of people seriously injured. But what most people don’t know is that smaller versions of these ‘encierros’ take part in many Spanish villages during their fiestas which of course happen to be in summer too. The management of bull’s horn wounds was well buried in the dungeons of my memory from med school where this was part of the general surgery program. They really are different sort of wounds from anything I have seen before, unlike RTAs, shot gun or sport injuries - you need different skills.

Your patients might also be the audience of a ‘corrida’ where the bull has been known to jump over the fence and create chaos with its 600Kg bulk and huge head swords.

Spain is a great place to have fun, with lots to do, lots to see and it seems that the same applies to Spanish EDs, lots to do, lots to see but in a rather different way. I’m just glad the summer is over, everything is just too intense.

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Abortion: why can’t I be a conscientious objector?

By Monica Lalanda - 2nd August 2010 10:59 am

We have a brand new abortion law in Spain, it is called something like Law on Sexual Health and Voluntary Interruption of Pregnancy and it replaces the previous one, which was already 25 years old. Some people describe it as one of the most liberal of its kind in Europe even when the rest of the world still think of Spain as a very traditional and catholic country.

With this new piece of legislation, Spanish women will be able to request a free abortion up to week 14/40 without needing any excuses and up to week 22 if there is any risk for their health or their lives, and beyond then if there is serious fetal malformation.

In 2008, there were 115,000 abortions according to the Ministry of Health but since the morning after pill became available without prescription on January 2010, there has been a decrease of 9% in the abortion rate.

This law has been approved after a lot of controversy and against the will of the Spanish Conservative Party (Partido Popular) but there is currently a great campaign against it by doctors themselves and led by the Organización Médica Colegial (which is like a mixture of the BMA and GMC).

The reasons for this fight are twofold. First, the new law makes allowances for doctors and other health workers with issues of conscience to be allowed to refuse taking direct part in an abortion but is leaving all those doctors who might need to be involved in an indirect way without any legal cover. For example, a GP who is approached by a patient requesting an abortion will not have the chance from a legal point of view to object getting involved. The second issue that is creating uneasiness is the situation is with 16 and 17 year old girls who want to abort. These young women do not need parental consent but they have to show that at least one parent or legal tutor is informed and they have to attend the abortion clinic with them. However if the girl can prove that informing her parents could cause her a serious conflict it is the doctor who takes the responsibility.

So, now that I have told you where we are at, I’ll get on with my blogging. My personal opinion about abortion and whether it is right or wrong is somehow unclear, I find myself unable to stand up and say either that I am in favour or I am against it in a blank way and for all cases; I guess I can probably understand some of the women that go for it and I can be very judgemental with others. I don’t think I would ever choose to have an abortion myself but I don’t know how I would react if my daughter ever wants to have one. No black or white there.

However when it comes to my medical opinion, I am very certain of what I think. I want to stick to the most basic principles of medicine, the kind of medical ethics that will allow me to look at myself in the mirror every morning and be comfortable with it. I refuse to be involved in abortions on the principle of primum non nocere, I simply don’t want to cause any harm to any human beings born or unborn. It is upsetting to know that if a woman asks me to refer her for an abortion, I’ll have no choice as the law does not to allow me to be a conscientious objector. I do respect the doctors who agree to it, or the women that go for it, but I never want to take any part on it.

It will be interesting to watch what happens from now on, it is unlikely that any other changes will be introduced so it will be outrageous to watch a doctor being penalised for practising the sort of medicine he or she strongly believes on.

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High time we gave our footballers some stick

By Monica Lalanda - 18th June 2010 3:32 pm

I was at work in my Spanish A&E department on Wednesday during a World Cup football match. The department was empty for several hours and the waiting area totally deserted.

On any other day, having a quiet department is a blessing and it doesn’t happen very often at all, but on Wednesday it bothered me. It is an international thing that A&E departments all over the world become quiet during important sport events and particularly with football. This can only have a reading to it; for many patients A&E is a place of convenience and not a place for real emergencies.

What sort of emergencies are those that stop being such emergencies if there is a good match on? Anything that can wait for the final whistle of a sport involving some men in shorts kicking a ball around is most definitively not urgent. It might be time to redefine what is appropriate for an ED: “All those mental or physical pathologies of recent importance that cannot wait till the end of a football match, even if it is the World Cup”

I guess it is obvious that I am not fond of football but really it’s the footballers I dislike and even more nowadays. The economic crisis has hit Spain so hard that some professionals, like us doctors, are having our salaries decreased by a minimum of 5%. In the meantime, the ball-kickers are protected by a law which keeps them as low tax payers and, even worse, if they win the World Cup they get a massive bonus.

Isn’t winning the World Cup or even just being in the national team enough reward? Shouldn’t I get an extra payment every time I treat a fracture, reduce a dislocation or diagnose an acute abdomen? Should these guys being rewarded for doing their job well? Outrageous.

There is a lot of talk about getting the patients to pay part of their treatment in Spain at the moment. The government has denied it categorically which of course is always the best indicator that they are about to promote it (yes, I am a cynic). I am all for a free national health system but surely there should be some sort of penalty for those patients who make inappropriate use of key services like A&E.

And that gives me another idea just as I write: our international footballers should be financially penalised when they lose a match, too. The carrot is clearly not working for us so maybe the stick will.

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Swine flu: were we lucky or were we had?

By Mónica Lalanda - 5th June 2010 12:34 pm

Today, when you think about swine flu you either feel that you’ve been had or you’ve been lucky. The truth is that the flu pandemic had very few victims in terms of mortality but has killed public trust in the system.

The whole dynamic of what happened during 2009 - the intense fear that paralysed the first world, the globalisation, the interpretation of data, the minute-to-minute follow up or the part played by the media - were unique.

Looking back into it now seems almost surreal. For several weeks back in April and May we all felt at high risk of death or severe illness, we all praised how the WHO took charge and how health authorities all over the world worked together; at the time, vaccines, antiviral, prevention measures all seemed appropriate. We were all in the same boat.

By June things started to change, we already had data about what happened in the southern hemisphere and the numbers confirmed that the H1N1 was highly contagious but caused very little mortality.

During the summer, one boat turned into two boats. One boat carried the health authorities, the government and the media, and another boat took the growing number of sceptics. The internet played a revolutionary part during these months for some underground information.

I’ll tell you what happened in Spain, which was probably different to how it went in Britain, perhaps because the Spaniards are never good at following orders; here there was a strong and well organised group of medical bloggers called Gripe A, ante todo mucha calma (Swine flu, remain calm) and a few other medical blogs that started to look at the situation with more critical eyes and who were welcomed and religiously followed by medical and lay population alike.

As the weeks went by, and the mismatch in between what we were told might happen and what was really happening increased, the GPs in their surgeries became more and more despondent with the official information and unsurprisingly the vaccination campaign was a huge failure.

By December, the BMJ and Channel 4 unveiled a huge scandal: the studies used by the WHO to recommend the use of Tamiflu were scattered and paid by Roche itself. The investigation also questioned the effectiveness of the drug.

Strangely enough, in the last few months we have seen several simple studies on the immunity to the H1N1 published by Science and The Lancet. They show what we have already realised, that a large part of the population was already immunized since this virus was not new at all.

Why did the governments of the world prefer to use their resources to buy unproven vaccines rather than trigger studies to learn the real risk? Why did they carry on with a policy of fear after July?

I personally think we were had and I am terribly disappointed to see that we abandoned the current obsession with evidence based medicine and moved to a medicine based on clairvoyance. Resources were used as if they were unlimited and we allowed the media to manipulate us all through the irresponsible use of the power of words and images.

There are two clear victims of the flu pandemic, the trust of the population in national and international health authorities and the trust of the population in vaccination.

Both of them might be irreparably damaged, with dangerous consequences. We surely have a lot of lessons to learn, saying that we were just lucky is simply not enough.

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There’s a lot to be said for a uniform approach

By Mónica Lalanda - 18th April 2010 6:15 pm

During my last few weeks working as a British doctor, I made myself look like a warehouse man. This had more to do with personal principle than fashion.

I admit to having been one of the last dinosaurs, so keen to wear a white coat that when my hospital instructed us to ditch them, I refused to take orders. I cut the sleeves of the item and dyed it in denim blue. It looked terrible and I looked awful but I made my point, my white coat was not white any more so it wasn’t really a forbidden garment. A few daring nurses approached me: “What on earth are you wearing?” The answer: a white coat in disguise.

The idea that doctors’ coats were making hospitals soar with infection is ludicrous particularly because doctors stopped wearing white coats in Britain ages ago. Funny enough, back in 1991, 72% of hospital docs wore white coats but, by 2004, only 11% did, just the inverse evolution of the MRSA infections. I guess high bed occupancy, dirty hospitals and excessive use of antibiotics are the biggest culprits.

Most doctors stopped wearing white coats long before they were officially banned. No matter the symbolism that they carry hope, tradition, scientific approach, cleanliness but also practicalities such as easy recognition, protection of own clothes and the almighty pockets; white coat detractors say that they are uncomfortable and that uniforms bring down the prestige of the profession.

My first day as a Spanish doctor was fantastic; during my personal induction I was taken to the sewing room, measured and then provided with a huge pile of white pyjamas, white coats and white trainers, everything marked with my name, the hospital logo and a big ‘DOCTOR’. I must admit I spent a while in front of the mirror, admiring my newly recovered ‘doctor look’ and remembered my pathetic last days as a warehouse man in England.

It certainly feels good. The Spanish hospitals provide the uniforms and of course take charge of cleaning them all too; there are no excuses abour wearing dirty white coats.

I mentioned it several times during my first days here, with some long sighs; it feels so good to have a white coat again. Why? What do British doctors wear? My colleagues thought I was kidding when I explained to them that doctors in Britain don’t wear any form of protective clothes and mostly just wear their own clothes. Their faces tend to go from incredulity to disgust. For Spanish doctors the concept of white-coatless doctors is almost as surreal as that of an astronaut in a bull-fighter’s suit.

So, for me, wearing a white coat again is the end of a personal battle against the system; it is just a shame that I had to move countries to win.

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“My language skills should have been tested”

By Mónica Lalanda - 29th March 2010 9:11 am

The GMC wants to get tough on all these doctors with funny accents (and fashionable clothing). It is calling for a change in the law to enable it to test the language skills and competency of European doctors.

I should feel hurt about it, after all I am a Spanish doctor who moved to Britain straight after medical school and worked in the UK for over 16 years. But, I tell you what, I don’t feel hurt at all. In fact, I have always been intrigued as to why my language skills were never tested. Even more intriguing is the fact that colleagues from India or Pakistan, who use English in medical school, do have to undergo these tests. Unlike us Europeans, their English skills have already been tested, ours haven’t.

Communication is the most basic principle to good medicine so if you don’t speak the local language perfectly, you can have the best medical degree ever but you will still be a terrible doctor. It is a shame that political correctness and European laws are failing to grasp such a simple fact.

When I started as a house officer, my English was reasonable, good for holidays, shopping, interviews and friendly chats but not good enough to understand what went on during a ward round, the abbreviations, medical terms, complicated expressions and accents. I was lucky at the time to have a brilliant team who saved me and my patients from huge mischief. Hopefully I didn’t kill anybody but I was given plenty of chances!

And, don’t remind me of telephone conversations. Losing the body language and the context of the issue was a total nightmare. I used to say: “Sorry, where are you calling me from in the hospital?” I’d then put the phone down and physically run to the spot. The price was losing seven kilos in weight in six months and never having enough time to even go to the loo. Passing concentrated pee should have been part of the job description for any European junior doctor at the time.

“Don’t worry, we will look after you,” said my very first consultant when I mentioned to him during the interview that I had never worked as a doctor and that I had never worked in English before. I was on call on my very first day (well looked after indeed).

The trouble is many English people haven’t realised that there is intelligent life outside planet Britain and they speak a different language. Surprise, surprise, a doctor who doesn’t speak English will struggle.

It is not just Britain which is being affected by all this European silliness. Here in Spain, we are importing lots of eastern European doctors whose Spanish is simply not there at all. It is becoming a common scenario to provide these doctors with translator to work alongside them.

You tell me, but I don’t think it can get any more stupid than that.

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