Saturday 21 June 2008

Flogging a dead horse

Heart failure. For the laymen amongst you, when the heart gets weak (usually after a heart attack, or just old age). Too weak to pump adequate blood to vital organs, like the brain and kidneys. Initially you can try medications to off load the heart of strain. Things like diuretics and sometimes beta blockers to help slow the heart down. But the heart is just like any muscle. My muscles ache after I run up to the 10th floor for a cardiac arrest. So too does the heart get tired after many years of strain.

Eventually, no matter how many medications they try you are past the point of no return.

So it is with our man on one of the wards. We could call the ward "Sunrise". Many wards have silly names designed to lift the spirits slightly and help diminish the overwhelming stench of urine as you approach. Most nurses are well meaning and would clean up said urine, were it not for their constant need to fill out "care bundles" and other meaningless forms that serve not to care, but to audit.

Our man is past the point of no return. The 8 different medicines are serving only to perpetuate his renal failure. He is drowsy. His wife, herself in her late eighties, asks for him "to be kept comfortable". She doesn't want him to suffer. I agree.

But his team of highly trained professionals are still pushing him full of diuretics, carefully timed iv fluids and performing daily blood tests.

They should let him go in peace. It's what his wife wants.


Tuesday 17 June 2008

The great unwashed

Dr. Genesis, before each patient contact.

Dr Genesis is back at work, after a week off. He was feeling human again. Now he feels distinctly inhuman. The same patients are on the ward, barely having improved despite intensive medical input. Most of them have got worse, probably because of intensive medical input. The other doctors flit around, mainly chasing their own tails, finding more problems each day, most of them iatrogenic. What most patients need, in Dr Genesis's humble opinion, is good food, regular exercise and a bit of a hug and cuddle.

Of course a few of them, particularly the younger ones, need high input medical attention and good treatment plans.

But the majority of our patients are elderly, with fairly non-specific complaints. They are the victims of modern medicine. They have lived far in excess of their life expectancy, had they been born, say, last century. Mainly they are just feeling the effects of old age. But writing "old age" as a diagnosis is not acceptable. It probably isn't "codable". So we search and search with blood tests and scans, desperately hoping something will turn up positive.

Have you had a blood test ever, dear reader? Dr Genesis has. It hurts. These poor people have blood tests almost every day.

No wonder they feel ill.


Thursday 5 June 2008

Fatigue in extremis

John Cleese with diminshed proprioception

Dr Genesis is now so tired he has developed an ataxic gait.

Although he can still touch type remarkably quickly, Dr Genesis now talks to himself with disturbing frequency.


Sunday 1 June 2008

Dangerous driver

A pictorial representation of Dr Genesis's cerebral function right now
Dr Genesis is now too tired to think straight. Despite this, he has just cannulated two patients. And now he is going to clerk in someone in A&E. Hopefully they won't have too much wrong this them.
Sleep beckons. Must sleep. But must also drive home.
Dr Genesis shouldn't be behind the wheel of a car. But he has no choice. He must go home.
If you see Dr Genesis driving toward you, swerve to avoid him.

Terminating one's contract with the NHS

No need to check his blood pressure.

Dr Genesis has just certified someone. He still remembers his first time. It was three days into house jobs. Dr Genesis was pedantic: he checked the carotid pulse, listened for respiratory effort, gently rubbed the supraorbital nerve above the eyebrow and checked the pupillary response.

Nowdays, it is fairly obvious when someone has died. Dr Genesis has certified many patients. He usually mutters under his breath, "I'm fairly sure he's dead", while checking the pupils. It lightens the mood. Of course, he would not do this if the family were present.

In the elderly, or those with advanced dementia, why fight against death? It is surely a natural end to life. Better to let them go with as little suffering as possible. Of course, if the patient is young, or is not expected to die so suddenly, Dr Genesis would do everything he could.

Dr Genesis has a plan. Pay heavily to a hospice by the coast. Make regular, generous contributions throughout the years. Then, when the deadly diagnosis is made, be driven down there to pass away overlooking the sea. That would be nice.

But he wouldn't want blood tests, cannulas, scans and needless medicines. Only to be certified by someone he's never met, a junior doctor with an open-necked shirt just ticking him off the list of jobs to do before having a break.