Is it worth setting up a new service?

Created - 15.07.2009

Nothing prepares one adequately to becoming a Consultant. Overnight one becomes independent and has to take complete responsibility not only for one’s action but also for one’s team. It is both exhilarating and scary at the same time. 

A lot of responsibility is thrust upon you by stealth even when you rigorously try to implement the mantra you had learnt on the management course for new consultants – “How to say No”. It seems I still haven’t learnt or I would not be writing this article on a glorious sunny afternoon, a rarity in March, instead of biking with my daughter.

As a registrar, I performed a lot of challenging interventional work. One of the simplest types of interventional work I performed was drainage of malignant ascites in patients with advanced ovarian carcinoma. However this was difficult for me, as I encountered a large number of patients who were nearing the end of their life, but had to come into hospital on a fortnightly basis to have their ascites drained for palliation. They had to stay in the hospital for 24 to 72 hours and so would reluctantly attend the hospital only when their abdomen was so distended that it caused difficulty in breathing. 

Four years ago, a medical representative showed me a Pleurex drain which was used to achieve long term drainage in patients with recurrent pleural effusions. This seemed the ideal solution for patients with recurrent malignant ascites and after discussion with the oncologist, decided to perform this on a patient with recurrent ascites who was having repeated drainages every two to three weeks. I soon found out that I could not arrange this without adequate funding for this “new procedure”. I now realized that I had received no training in this aspect of consultant work and this would soon form a significant part of my job. I had to research the management of malignant ascites and had to write to the Primary Care Trust to obtain funding. After a brief period of time, the powers that be in the PCT realized that in addition to improving patient care, this procedure saved money by preventing repeated hospitalization and agreed to fund the procedure.

I performed the first procedure in the ultrasound department under local anesthesia. However after entering the abdominal cavity using a large trocar and a peel away sheath, I was unable to introduce the blind catheter through the sheath. This meant that the ascetic fluid was pouring out like a fountain and even though the patient had confidence in me, I was nervous and so abandoned the procedure and converted it to a standard drain. 

Two weeks later, I persuaded my surgical colleague and his anesthetist, to allow me to use his theatre slot, to perform this procedure under general anesthesia. The general anesthesia certainly calmed my nerves as I felt more under control and the procedure went smoothly. I subsequently performed two more procedures in the theatre, before regaining my confidence and now perform this procedure in ultrasound department under local anesthesia.

I soon realized that performing the procedure was the easy bit. I had to make sure that the patient or the carer understood the procedure and was able to look after the catheter at home. I had to involve the district nurses and train them as well and I was starting to wonder if it was worth it. This is when I learnt the art of delegation and I am thankful for the radiology sister who subsequently has performed such a brilliant job, that nowadays I merely perform the procedure. And before I knew it, I had set up a service !!!

Although my team won a Service Improvement Award and a Health and Social Care Award for this service in 2008, I cherish the card from my patient which said “Thank you for helping me to get on with the precious time I had left in life with my family and friends without spending it in pain or in hospital”.

Abdul Razack, Consultant Radiologist, Hull and East Yorkshire NHS Trust