Monday 27 November 2023

Acute Care Vehicles 2- Second Generation


I consider the second generation of acute care vehicles a golden age of engineering; this was from the late 1990's to the mid 2000's. The hero of this boom was undoubtedly Egerton, a company based in Poland. There were three general bed designs that made up the backbone of the JRH fleet. I can't remember their official names, but we nicknamed them the "blue" and "grey" because of their colours. The blue Egerton was a pleasure to handle. It was by far the most manoeuvrable bed I have ever used. It had a folding handle at the foot for the sit-up mechanism and a separate squeeze handle for the pitch. Level was raised and lowered by a pair of smooth pedals at the side which needed very little pressure to operate. The top level was about five feet which added to the vehicle's portability. The grey Egerton came in three models. There was one with a lift-and-pull headboard that was mostly used to replace the original fleet maternity beds. The second design was more like the blue, but had slightly different controls. The pitch was altered by two black squeeze handles at the foot. It was also slightly heavier. The third variant was basically the grey with electric posture controls. I have always considered electric power an extravagance and a typical example of over-engineering for its own sake. Early electric vehicles had to be plugged in whenever they were in use and had backup manual handles and pedals. They can also actuate by accident when, for example, somebody leans against the control paddle. They grey had no manual backup. It had a battery which very quickly ran flat because staff usually didn't bother to plug it in, sometimes because the ward bed-spaces didn't have enough electric sockets. Another problem was that very few staff used the proper storage hook for the flex and plug. Some developed a bad habit of wrapping it around the rear corner fenders. This not only made it easy for it to fall off, but when the bed was raised it sometimes ripped the flex out of its fitting. (One theatre porter in particular was very irritating because he would do this on purpose when I told him about the wrong method just to wind me up; because that's the kind of person he was.) The second generation was not all a bed of roses though, if you'll excuse the pun. I'm thinking of the Hill Rom. Only a handful of these awful contraptions ever made it into the John Radcliffe fleet, but I used to groan whenever I had to use one. They had a feeble plastic footboard that usually broke and without it, as I said in the background link below, it was like a car without a steering wheel. We often kept a secret store of spare footboards in the lodge and a Hill Rom one was like gold dust. It also had a nasty static sting problem, sometimes producing an audible crack and visible spark... Good job anaesthetics no longer use ether! There was one bed that was a real bummer; it lost one of its footboard mountings meaning it could only be used without a footboard. Whenever I saw it unoccupied I used to wheel it to the "cage", a store in the industrial block for vehicles needing repair. I stuck a note on it explaining that it was not safe to use, but the maintenance team always returned it to service without replacing the mounting. I was tempted to sabotage that bed quietly in secret so they had to take it off the wards.All the second generation beds have a centralized footbrake; the blue Egertons' were the best; they were easy to apply, like the level pedals, and the lever was unobtrusive.
The second generation also provided one of the best wheelchairs ever, the Bristol Maid. This was a nifty rear wheel steered chair with an excellent sliding footplate and retractable telescopic arms. Its small size made it ideal for cramped passages in corridors, wards and departments. It had a unique storage compartment at the back for patient notes folders, but I learned quickly not to use it because it was too easy to lose the notes, something that would get you into terrible trouble. If you get one of these chairs I recommend asking the patients if they can hold them, if they are able, or put them behind their back.
The second generation was the first to deliver what I regard as specially designed bariatric beds. Bariatric is a politically correct way of saying "very big and fat". These were sometimes based on standard designs but were bigger and stronger. There were some other models specialized for bariatric cases from the wheels up. Along with bariatric beds we were given equivalent wheelchairs, operating tables and even mortuary slabs. Together with these innovations were far better intensive care beds with inflatable soft mattresses to reduce pressure sores for patients who were stuck in them a long time. The largest and heaviest of these we called "the Beast" and it needed at least three porters to move it. I wondered where technology would take us in the future, to better or worse machines. The answer was both.

Saturday 4 November 2023

Being Human

Being Human is a TV series by the BBC and it's one of the few by the Beeb in recent years I would say is any good. It is described as a "supernatural comedy drama"; but, although it has its droll moments, it's not very funny. Actually it's pretty grim. It follows the lives of three young urbanites who superficially appear to be ordinary people, but they are not. They're not even human, they're only trying to be like humans; hence the title. One is called Mitchell and he is a vampire, the second is called George who is a werewolf and the third is Annie, the ghost of a woman who was murdered. All three of them face different challenges. Mitchell is trying to get by eating normal food and giving up his lust for human blood. George is trying to manage his condition by hiding himself away every full moon; and Annie is haunting the man who killed her, her ex-boyfriend. Despite being completely different denizens of the undead, George and Mitchell share a very important common destiny; they are both HP's. My two brother porters, if I can call a werewolf and a vampire my brothers... Of course I can, they're HP's for goodness sake!... Anyway, George and Mitchell serve in the same hospital and appear to be in the same section, but they deal with the challenges of the profession differently. George maintains a light-hearted attitude and he has a part-time job teaching English as a foreign language. However, Mitchell is bitter and exhibits a lot of self-pity. In one scene where his partner is mourning the death of her goldfish, he says to her: "I wade through blood and shit from dawn till dusk for the minimum wage, so don't whinge to me about some bloody goldfish!" As I've explained before, that might be true, but the victimhood mentality is not helpful. It breeds an inner darkness and cynicism that becomes a goal in itself; almost an addiction. HP's can easily fall into that trap and we must avoid it at all costs. George manages to find a girlfriend of his own at one point. Of course this means he has to make up some excuse to explain why he goes away on his own once a lunar month. At one point he tells her: "I have to go off on a training course." She replies: "Training? You're only a hospital porter, George!" I'd dump her on the spot if she said that to me! There are some pretty horrific scenes and storylines in the series, making it more of a horror than a comedy. At one point, the protagonists are kidnapped by a religious cult who do sadistic experiments on them. Despite this, and its sometimes patronizing anti-HP-ism, it is very well done in terms of writing, acting and plot; so it's worth watching. Since the original BBC seasons it has been picked up by an American network that have produced their own version, as Americans tend to. See here for the trailer:

Tuesday 24 October 2023

Stop Expecting Better

I keep hearing complaints like this from my fellow HP's.
"Why do civilians talk down to me all the time?"
"Why does the head porter never take my side in a dispute?"
"Why do people have a go at me when I've done nothing wrong to them?"
"Why do senior staff lie about me or twist things?"
You might have noticed that I have made similar complaints about my own career, legitimately. The invention of the Dignity Statement is for the purpose of undoing and eliminating this situation, for example: It can't make the head take your side in a dispute, but it will work in all the other examples I gave. The first step to overcoming this bleak state of affairs is actually not learning the Dignity Statements, it is expecting these things to happen. I used to be like that too. Whenever one of the above scenarios unfolded I would storm around the lodge lamenting "That was so unfair!"... "Why did she do that!?"... "I can't believe he just told such a blatant and shameless lie about me!" I was not alone; nearly all my brothers and sisters did the very same, in fact hardly a shift passed without it. I only found a way to integrate these very unpleasant experiences when I realized that I should stop expecting better. We're part of a massive, heartless, mindless, gutless government bureaucracy. The NHS is the world's third biggest employer (after the People's Liberation Army of China and India Railways). It is a purebred mutant baby of the state. 1.27 million servicemen have to be organized into an effective healthcare provision unit with no natural incentives at all for justice, diligence, conscience and duty. More than that, these sentiments are actually discouraged, to say the least, by management. The unspoken truth very quickly sinks in that there are no rewards for honest hardworking service, quite the opposite in fact. Corruption waxes, discipline wanes. Is it any wonder people within it are so spiteful and backbiting? Battery hens peck at each other not the farmer. This realization is actually an incredible liberation. When you stop expecting better from your colleagues, including your brother porters sometimes, you can face the world for what it is rather than what it should be. That is when the Dignity Statements come in. That is the first step to creating a world that is as it should be.

Tuesday 17 October 2023

Gaza Hospital Attacked

See here for essential background:
The news is reporting that the Al Ahli Hospital in Gaza City has suffered a gigantic explosion. It is reported that "hundreds" have been killed. The IDF says that this hospital was not one of its targets, but to me it is incredibly unlikely that this was not the result of Israeli offensive action. (EDIT: This is now seriously been called into question.) They have claimed that Hamas terrorists have established makeshift bases in Gaza hospitals. It is not the purpose of the HPWA blog to discuss the rights and wrongs of what's going on politically in Israel and Gaza now; we're going to focus on the HP's and their duties. The background link below has a wider scope. A spokesman for the Palestinian National Authority has stated that the Gaza hospital infrastructure has now totally collapsed. Water and fuel for emergency generators has run out. A surgeon, Professor Ghassan Abu Sittah, said: "Parts of the hospital are on fire. I don't know whether that is the emergency department. But it's certainly the operating suite, part of the roof has fallen. There is broken glass everywhere." Source: From what I've seen, at this point the situation at the damaged hospital is one for the fire brigade, and indeed I have seen videos of firemen entering the premises. Some casualties have been moved to waiting ambulances, but right now the ambulances are the only places they can be treated. There is nothing more we HP's can do at this point. With the breakdown of the infrastructure and the attack on the campuses, probably personnel discipline will also weaken. The surviving staff have their own families and loved ones who need them. I'm afraid I don't fancy the chances much of any patient still left in the hospital. If they were too sick to be evacuated a few days ago, they are unlikely to survive now. The focus must shift to those who have a fighting chance. An Egyptian spokesman claims that the border at Rafah is not closed, but this makes no sense because the bottlenecks of refugees on one side and aid lorries on the other are not moving in either direction. My heart goes out to all those affected by this, in Gaza and Israel.
See here for more information:

Saturday 14 October 2023

Gaza Hospital Evacuation

There is an ongoing evacuation operation underway in hospitals all over the Gaza Strip. This Palestinian enclave has a population of over half a million in an area of 141 square miles, about the size of the Isle of Wight. The enclave is therefore highly urbanized. The hospitals there are already overcapacity because of retaliatory strikes against Hamas by Israel (as are Israeli hospitals because of initial Hamas attacks). As a former hospital porter I can understand exactly how dire a situation these hospitals are in. Yesterday, the Israeli government warned Gaza hospitals that they had two hours to evacuate all their patients because the buildings risked being targeted by strike missiles and aerial bombardment. The reason is that Israel suspects Hamas has set up headquarters in some hospitals. At my hospital, the John Radcliffe in Oxford, we often did evacuation drills, but this was moving patients quickly from one part of the hospital to the other in case one area was struck by fire, flood or explosion etc. At no time did we think of a contingency involving the evacuation of the entire hospital. The noble welfare group Médecins Sans Frontières, French for "doctors without borders", protested saying that two hours is not nearly long enough to evacuate all the patients. Israel relented and increased the grace period to eight hours. Source: However, is this long enough? The difficulty in evacuating a patient is primarily dependent on how serious their condition is. The walking wounded can move themselves; somebody with a minor fracture, burns or lacerations can be transported by trolley or wheelchair, but what about somebody in intensive care? How about somebody undergoing major surgery? What's more, where do they go afterwards? When evacuating seriously ill patients there is really nowhere you can evacuate them to except another hospital. If all the hospitals in Gaza have to be emptied, where do the staff take the patients? It is obvious Israel is preparing for a full-scale invasion of Gaza which will probably happen in the next couple of days. The only way out is through the border with Egypt which is currently tightly controlled. There are large hospitals on the far side of the border that will be able to help, such as the Rafah Central Hospital. Obviously Egypt does not want Hamas terrorists in its midst anymore than anybody else does, but if they don't help then there will be carnage in Gaza and 99% of the people killed will be innocent. I salute my Extremely Proud and Dignified Brother and Sister Porters in both Gaza and Israel; as well as the brave civilian healthcare providers. May this crisis end soon and without further atrocity.

Sunday 8 October 2023

Platelet Hand Agitation

What is it about HP's that when we do our job we might have to do it well, but not too well? I have been challenged several times in the course of my career, not because I wasn't being a good enough porter, but because I was too good a porter. One of these examples involves platelets. Platelets are blood cells whose function is to cause coagulation when a blood vessel is breached. They clump together at the rupture site and form a gelatinous blockage which eventually hardens into a scab. This is essential for stopping bleeding; without it we could not live. Platelets are extracted when blood components are separated in the transfusion laboratory before being given to patients. They look like opaque yellow fluid and are stored in a plastic bag, illustrated above. Unlike red corpuscles and plasma which have to be chilled, platelets have to be stored at a warm room temperature, twenty to twenty-four degrees. They also have to be continuously "agitated", this means kept in constant motion otherwise coagulation initiates and they set into a solid lump of jelly; making them useless. In the storage cabinet they are put on a machine that constantly lurches and rotates. Now, when I was being trained in the late '80's the porters who trained me told me that when I'm carrying the platelet units to where they are needed I have to do something called "hand agitation". This means simply imitating the action of the storage machine with our hands. I did this for my entire career when delivering platelets. Newer porters didn't do this because that part of our training was discontinued, like so much else in our traditional skill-set. Welcome to a result of the casualization that I have described elsewhere, for example:
One day I was delivering platelets and was accompanied by a "boy wonder", a young and well-connected individual with "one foot in the lodge", as we used to say. Basically they all had ambitions to be trust directors and were doing their standard six months in portering for three words on their CV. I can't recall why this boy wonder was with me, but we were standing in a lift together while I did the hand agitation and he frowned and said "Why are you doing that?" I explained why and he immediately replied: "Don't do it please." I asked: "Why?" He said: "It looks unprofessional." I asked him to explain and he made a chopping motion with his hands and said: "I'm not going to have this conversation with you here and now; I am a senior member of staff and I am just asking you not to do that with the platelets." I refused and continued, calmly and politely, to demand some clarity and he said: "Very well, Ben; if you're refusing to obey my order I will have to report you to the office." He looked almost as agitated as the platelets I was holding. I shrugged and said: "Go ahead." He never did. Actually I was never really worried that he would. Despite this, I was dismayed and baffled at his actions, and his insistence that I do not do the hand agitation. What difference does it make? Where's the harm? It is almost as if he had been given instructions to pull the porters up if they did their jobs too well. Are the original skills of hospital portering not merely being accidentally forgotten, they are being deliberately outlawed? Is the enforcement of mediocrity a policy? Is porters' Pride and Dignity a threat? Is expertise and commitment in the Hospital Portering Service a detriment to today's NHS? If so, why is that? I can think of other examples and I will describe them in future articles. Something to think about, isn't it?

Tuesday 19 September 2023

Acute Care Vehicles 1- Original Fleet

A few years ago, while I was still serving, I wrote to all the manufacturers of hospital acute care vehicles offering my services as a consultant, free of charge. No false modesty here; I am one of the most highly qualified people in the world, having used these vehicles every day for over twenty-three years as a hospital porter. Throughout my long career I watched technology advance to improve these vehicles... mostly... and it is important for you, if you are a HP, that you learn about these tools of our trade and their history. When I started at the John Radcliffe, almost the entire fleet consisted of vehicles deployed to the hospital when it first opened in 1973 for the JRI Maternity unit and 1977 for JRII general side. The maternity beds were all equipped with "lift-and-pull" heads. There was a flat piece attached to the headboards which could be pulled out at an angle to allow the patient to sit up, with a few pillows behind her of course. This was considered sufficient for maternity patients long after these beds became obsolete. They were of fixed height, which was extremely awkward especially as Caesarean patients were put on them immediately post-op to recover, even if they'd had general anaesthetics. They had single wheel footbrakes on the front right and back left leg; again, not very user-friendly because to secure the bed the porter had to walk all the way round it. The footboard was a wooden one, but these were upgraded to metal handled ones in the 1990's. One golden rule for HP's, a footboard is absolutely essential. Without one your bed is like a car without a steering wheel. I've seen porters struggling to manoeuvre beds by clinging onto the corners of the mattress, sometimes grasping the woollen blankets with their fingernails. Also, without a footboard the mattress tends to slip off the stead as well. I've seen them half hanging off, threatening to dump the patient onto the floor. (A possible exception to this rule is the Blue Egerton, but I'll cover that in a future article.)
On general side these lift-and-pull beds were agreed on as being inadequate for general patients and so we had beds with a sit-up mechanism that raised the head section of the stead up at an angle. This was operated by a handle under the footpiece which could be folded away. There was also a hand-cranked system for raising and lowering the bed's level on the left-hand side of the stead, but the handle was detachable; big mistake! It was stowed on a pair of hooks beside the turning connector, and the designer naively assumed everybody who used it would always kindly return it to the hooks afterwards. No way! Anything in a hospital not tied down or nailed down grows legs and walks. (This incidentally is why the AWARE study was doomed to failure, see: Pitch was altered by a lever surrounding the level crank. It had three positions, foot-up, head-up or both together, which was the actual leveling. An awful piece of engineering. Another problem the original general fleet had was static shock. The motion of its wheels would build up static in the metal frame that would sting badly when it discharged to earth. This was an even bigger problem with other designs such as the original Hill-Roms, but I'll cover that in a future article. Happily the old rust buckets of the original general fleet have now been scrapped.
Hospital wheelchairs vary considerably in design, but they fall into two basic categories; front wheel steering and rear wheel steering. They all have four wheels, one at each corner with one pair fixed along the north-south axis. The other pair are casters. Different HP's have different preferences and, in my experience, there are advantages and disadvantages with both formats. The original fleet were all rear wheel steered. In the case of wheelchairs single wheel brakes are by far the best. In fact a later, supposedly more advanced, design had a single footbrake, but it was operated by a long pedal that stuck obtrusively out from the back right into the space where the porters' legs have to move while pushing. It meant that the only way to push the chair was to stand much further back and lean forward; which is actually a back care hazard. What anti-genius came up with that quantum leap? You see why it's a good idea to consult with HP's when designing these vehicles? I'll describe more modern wheelchair designs in future articles. You may wonder what the difference is between a hospital wheelchair and one made for use outside in the normal world. Wheelchairs for disabled people in everyday life and designed to traverse streets, pavements and other public places. They usually have pneumatic tyres and suspension, and sometimes a large rear wheel with handle-rims if the person is able to use their arms and hands to propel themselves. They often have to be used for many hours at a time so they are cushioned to be comfortable. Hospitals wheelchairs are designed only to be sat in for a few minutes to an hour or so at a time so they have a straight seat and back without any angling and minimal padding. Their wheels are solid and the hub is fixed to the axle without shock absorbers or suspension. The tyres are usually solid rubber.
I like the word "gurney" because it is uniquely descriptive, but it is only used in American English. We Brits still call the narrow waist-high vehicles for supine patients "trolleys", which of course means you have to add the word "hospital" in front of it if there is any ambiguity of context, otherwise you might end up putting your groceries on one in Sainsbury's. The original trolley fleet were used in A and E, X-ray and a few other places. They were only designed to be lain on for a few hours at the most; but, as is more and more often the case as waiting times increase, some patients end up lying on them for too long. Beds should always be used for stays of more than a few hours. The original fleet, amazingly were also all fixed height. Their side-rails only had two positions, up and down; and they were lowered or raised by rotating away from the frame. This meant you had to do this while the trolley was at least the height of the side-rail's distance from the receiving vehicle. We did lose a few patients down that gap. The only difference with the resuscitation trolleys was that they had an F-size oxygen tank holder underneath, and I once got into trouble for putting one in the general trolley pool by the major side entrance instead of in the resus room where it belongs. The mattress was foam coated by heavy-duty plastic and we had to take it off the vehicle to wash it. The stead and legs were bare steel and they used to rust after a while. This is the first part of a series of articles about acute care hospital vehicles and in the next one we will discuss the next generation of designs. This series is also intended to be just one part of a larger project, the formation of a hospital portering guild, see here for background: Oh... and one last thing; to clear up the eternal confusion once and for all, the rule for entering a lift with a vehicle is: bed and trolley feet first, wheelchair head first.