Ever feel out of your depth?

GPs deal with "undifferentiated disease". That's medical speak for "anything can walk through the door". Dr Genesis lends his mind to so many different areas of medicine, I sometimes wonder if I actually know anything substantial about anything. Can my job be done by a nurse, or even just someone with a bit of common sense?

I saw a woman in her 60s who'd had a hip replacement recently. The operation was a success but she's been left with some emotional issues about adjustment to her new (mobile) life, feeling dependent on people post-operatively, and apprehensive about going back to work (having been off for months with the arthritis). She came with her husband.

I'm not sure why, but the image of them in bed came to mind. How easy is it to have sex with severe arthritis of the hip? Have they tried to have sex since the operation? Is she worried about the metal hip coming out of joint? I tentatively suggested a holiday with some "romance". The husband nodded. She nodded. Then she promptly changed the subject.

A young doctor asking a couple in their late 60s about their sex life.

Am I cut out for this?

How can I help, when I can't help myself?

To impart guidance, one must be a master

Dr Genesis is having trouble sleeping.

He is not enjoying his job. The patients are too demanding, the staff too sparse, the practice manager out of his depth, and the partner too inexperienced. Dr Genesis is just a locum, but has a notice period of several months. He feels underpaid, overworked and exploited. But this is nothing new. During the years of hospital training, I often felt overworked and underpaid. But this is different.

There is no one to look up to. At least in hospital, I may think: goodness, the consultant's skill is really exceptional, I don't mind working like a dog because I have respect for my senior. But in this GP practice, the "partner" to whom Dr Genesis reports, is only slightly older but does not engender professional respect. Dr Genesis does not agree with his medical decisions and is not impressed with his clinical acumen.

And thus Dr Genesis found himself awake at 4am, two nights running, worrying about work.

Later that day, the familiar patients with their familiar concerns. "I'm having trouble sleeping, doctor". So am I, I think. What can I do for you, if I cannot help myself?

Travel expenses reimbursed

That's what I call a house visit

Every morning after surgery we meet for coffee and dole out the house visits. Despite people saying "doctors don't come out to your house for love nor money these days" we do about half a dozen visits a day. Usually the GP who knows the patient best will go out, but if it's someone who is only known vaguely it will just be random. Often if it's far away there will be a subtle umming, erring and mumurings about having a lot of paperwork in an attempt to avoid having to drive out a distance.

So the furthest visit away, practically in a different town, was apportioned to poor old Dr Genesis, the registrar. Remember, an old colleague in hospital once said, sh*t travels downstream.

But I'm glad I went.

A poor man had innocently remarked to his doctor that he felt a bit more tired than usual. Hardly surprising for a 79 year old. But something must have ringed the bells of the partner because he was sent for blood tests. The tests showed an obstructive liver picture and an ultrasound confirmed...metastatic cancer. Within three weeks the culprit had been found: a tumour in the lower bowel. I say tumour, but really ought to say cancer. It just sounds more manageable when you say tumour.

Although he had seen the surgeon, the oncologist and countless junior doctors he was none the wiser as to the extent of the disease, where the primary was (a lot of people do not understand what is meant by "bowel") or what the future held.

Dr Genesis explained it all, in language he and his wife could understand, and took his time doing it. "Thank you, Dr Genesis", he said. "You've told us more in the last ten mintues than we've been given the whole two weeks in hospital".

I love this stuff. I think talking to patients and explaining things, particularly palliative care, is more rewarding than most other areas of medicine.

I wonder how much longer he'll be around with a liver packed full of metastases.

I wanna make a difference

Has he made a difference?

What difference do doctors really make? There is a school of thought that if we take the last 100 years and balance out the iatrogenic harm and the benefit, it comes out at neutral. Most benefits to health have come through public health measures, like better sanitation and diet. If we took the Quality and Outcomes Framework to Africa, it would make scant difference to their health. They need food and water. As a colleague wrly pointed out recently, "you can't get IBS if you don't have three square meals a day".

My last patient was a lovely old lady with a sore shoulder. Examining her, I found only tight muscles and I smoothed out the knots in her trapezius with some gentle movements. "Don't worry...it's nothing serious. You've just pulled some muscles". Her relief was obvious. If I were 90 and had a persistently sore shoulder, I would think I had shoulder cancer...with brain mets.

I helped her put her cardigan on before she left. Was that the most helpful thing I would do today?

Learning to deal with failure

Life can't always be full of success

Most doctors were high fliers at school. Although they may look like hapless, mal-coordinated little mites on a ward round at medical school, don't forget they probably got straight As at A-level to get there. Then they passed vigorous exams at med school to qualify. I think nurses/HCAs/physios/managers etc forget that. They don't realise just how intelligent most doctors are. On an academic level. Some don't have much common sense. But anyway, they are used to succeeding.

Dealing with success is one thing. Dealing with failure is another. Dr Genesis has been fairly fortunate in his career so far. He hasn't been out of work for even a day. He has never had to locum. He has only failed one exam (the MRCS clinical in case you're wondering), but he passed it on the next attempt.

So Dr Genesis' ego took an understandable battering when he was rejected after a job interview. Who on earth could they have preferred? Surely the good-looks, quick wit, steady deep sage-like responses and sharp dress sense would have been enough to wow them? Apparently not.

Greeting patients, dealing with their problems, was difficult when Dr Genesis had just found out about the job. But then two things happened which made him feel better. The first was a young lady with "period problems". She was having on-going bleeding "like a period" for the last three weeks. She was a little shy talking about this at first. It was probably from messing up her pill taking on holiday. I prescribed her some medicine and suggested she come back next week if the bleeding was still there for "an internal" and a smear. Of course, Dr Genesis, added, you could see a female doctor if you prefer. "No", she replied, "I'd rather see you".

The second was a lady with her daughter. I recognised her because she had brought her son in a few weeks ago with costochondritis. He was in tears as he told me about his chest pain, which was stopping him playing football in the playground. Dr Genesis figured out what it was and showed him a picture off the internet. On his way out, Dr Genesis learned, he had turned to mum and said "I feel so much better already". She asked how long I was at this practice. Only till August, I'm just a registrar completing my GP training. The look in her eyes was rewarding to say the least. She couldn't believe I was still in training. "Well you've certainly impressed my family".

That made up for not getting the job. Almost.

What defines an alcoholic?

Cabernet Sauvignon. Dr Genesis prefer Shiraz.

Two amazing things happened during this morning's surgery. I saved two people's lives I think.

The first was a pretty healthy 82 year old man. His blood pressure's fine, he hasn't had any cancers and, more importantly, he's happily married to his sweetheart of over 50 years. They live together, they're both fairly mobile and they've got all their marbles.

How did Dr Genesis save his life? By doing nothing. The man asked for a "prostate cancer" test. His daughter had been thinking about it and she thought "it was about time I got tested". Well, dear reader, I am sure you can hazard a guess at Dr Genesis' response. What if the test were high for the cancer marker, I postulated. You would then need a painful biopsy from the prostate up the "backpassage". Don't get me started on the treatment. Finding out may be worse than not knowing.

He understood. In fact, he seemed relieved.

The second was a nice lady from Slovenia with a tiny baby. They were both healthy. The problem was the husband. A successful banker, he lived by the rush. "You only eat what you kill", I could hear him say in the boardroom. The problem is, as Dr Genesis knows only too well, the lunchtime meetings are usually lubricated along by a couple of bottles of wine. Then the stress of the job takes its toll when you get home in the evening: enter stage left, another fine bottle of Cab Sav.

It was destroying their short marriage. She was too scared to leave him alone with the baby. They were arguing.

He will see Dr Genesis next week to discuss it. He knows if he carries on drinking, it will be the end of his life.

Medical students are often high achievers. If they have no doctors in the family (like Dr Genesis) their parents are overjoyed when they get in to med school. The chances are they were pretty high up in their secondary school. They probably got straight As at A-level. If they dropped a subject to a B they were likely devastated. They they start at med school and realise everyone else is quite bright too.

If you go to Oxford or Cambridge university, the pressure is amplified. Mummy and Daddy expect their angel to be top of the class. The workload can be intolerable. Although medical students are strong academically, they can be quite weak emotionally.

10% of our year dropped out in the first term. Dr Genesis didnt' know if it was just him, but he secretly thought of them as weaklings. They couldn't cope with the pressure.

One of Dr Genesis' medical housemates knocked on his door once, came in, sat down on his bed and burst into tears. She was overwhelmed with her dissertation. The pressure to succeed from her parents was immense.

And so it was that Dr Genesis was called to a home visit to see a young man who had been studying biochemistry at Oxford (of course I have changed the details to fox you). Everything had been going fine until exam time. He had locked himself in his room for a few days, barely eaten and barely seen anyone. All his friends were working. He retreated back home to stay with his parents. But even then he took refuge in his bedroom, under the pretence of studying.

But then he said he wanted to end it all. There was no point living. What would happen when he went back to college without revising properly? Failure was not an option, yet it was likely to happen. He just wanted to die. He took a bread knife up to his room. That's when his parents called the doctor.

Dr Genesis hopes his children don't feel that kind of pressure. He doesn't want them to do medicine. He certainly hopes they don't apply to Oxbridge.

As one enters, another leaves

Not Dr Genesis' baby

The NHS gets a pretty bad press. Journalists seem to take delight in twisting the knife into our healthcare system. Then the same journalists make an appointment to see their GP about their "snuffly cold I've had for a few days".

It's true that there are some pretty awful doctors out there. Some of what Dr Genesis did in hospital was subtly prevent certain doctors from seeing his patients, while gently coercing others to offer their opinion. Surgeons are not all the same calibre for example. It is important to see the right surgeon.

But then occasionally something will happen which restores Dr Genesis' faith in the NHS. Just the other day I saw a tiny baby with his new mummy. He was tiny. Really tiny. The mum explained. At just 24 weeks, her waters broke. She happened to be in central Sometown, fortunately near to a large hospital with a neonatal intensive care. She went into labour a week later. By good fortune, a miracle maybe (does Dr Genesis believe in miracles?) the wee nipper survived. After 2 months on intensive care, then another month in hospital he is at home with his mummy. Technically he is 38 weeks gestation. He shouldn't even be on this earth.

All of this care, without having to open their wallets. Try your luck going into labour at 25 weeks in America. Or in southern Europe. Or anywhere in the developing world.

On my drive back to the practice today after a home visit, I passed the flat of the lady who I certified dead from lung cancer a few months ago. I remembered how I broke the news to her daughter, who promptly burst into tears.

And you thought you were healthy

The people of Framingham, Massachusetts enjoying their breakfast

Deciding when to begin treatment for heart disease prevention is a big part of the GP curriculum. Once you start a drug for blood pressure the chances are you'll be on it for the rest of your life. Until you either get sufficiently demented to stop taking them, or just too bored to keep popping pills when you'd rather be down the bowling club chatting up the other octogenerians.

Your GP will almost certainly use the "Framingham risk calculator" to see if you need to take a statin, a blood pressure tablet and an aspirin a day. It is a useful tool. If it came about that you had a heart attack and weren't on a buffet of medicines beforehand, many GPs are afraid they will be sued. So they will tap in your details. If Dr Genesis were 70, didn't smoke (although he's thinking of starting up cigars when he hits 75), wasn't diabetic, had a blood pressure of 140/90 and a cholesterol of 6 he would be a happy man. He would consider himself one of the healthiest 70 year old men in the world.

Think again my friend. For Dr Genesis would be classed as "high risk" by the Framingham calculator. He would have a 20% chance of having a heart attack/stroke/angina/sudden cardiac death in the next 10 years. He would instantly be advised to take an aspirin, a statin, at least one if not two antihypertensives and do more exercise. No cigars for Dr Genesis.

Dr Genesis would have the good sense to gently decline his GP's best efforts. He is a little prone to gastritis so would refuse the aspirin. He enjoys tennis and wouldn't want to risk muscle ache from a statin. He is rather fond of his electrolyte balance and so would eschew a diuretic or ACE inhibitor. He would take his chances and do his best to avoid doctors.

But many do not have Dr Genesis's wily and fox-like cunning brain. They will swallow the medicine because it what they have been told to do. They will think of themselves as ill. What a shame.

Roll of the die

Ou est le needle?

Christmas period in GP land, deep in the heart of Worryshire. Almost all of Dr Genesis' surgery is dealing with people with coughs and colds. Runny nose, achy, sore throat, a cough that's "gone to my chest" and, of course, there's no way they could go to work.

Dr Genesis was ill a few weeks ago. Achy all over, shivering uncontrollably, no appetite (not even for expensive chocolates). He lay in bed all evening, drank lots of sweet tea and took the morning off. But he went in for his afternoon clinic.

But then Dr Genesis has a strongly internal locus of control. He believes he is responsible for his health. So when he gets ill, he blames himself. He thinks of himself as weak. So he must regain his strength quickly.

The problem with all these patients is one of risk assessment. Fever, sweating, poor appetite, glands up in the neck. Hang on, this sounds familiar. It sounds like the patients Dr Genesis saw when he worked in a haematology clinic. They had lymphoma.

So which one of these people with a cough or cold has lymphoma or leukaemia? Hopefully none of them. If any of them do, let's hope it's Hodgkins.

Death and taxes

Not a colleague of Dr Genesis

They don't tell you that much about death at medical school. I suppose it would bring down morale a touch. But it's everywhere. A junior house officer will encounter more death in that first year than they have ever seen before. In hospital it tends to be rather clinical. A bleep during a busy evening on-call: "can you just certify this one on ward Zeus? Then we can shift the body?". Some kind words to the family perhaps then onwards. Only once did Dr Genesis have to take some time out to rest his head on a window ledge and sigh after a patient's death. He made sure no one could see him. He didn't cry, but he came close. Other than that, there is very little emotion.

But out in general practice, it has proved to be a little different.

Dr Genesis had a house call a few weeks ago to an elderly man with cancer. Loose stools, said the house request. He died only a couple of minutes before Dr Genesis pulled up in his Mercedes. His body was warm as I listened to his heart. Certifying someone in their own home has a certain sadness. There were dozens of photos of his family everywhere. A legacy of three generations.

The children were sobbing. "Would you like me to stay for when your sister arrives?" I asked. Yes they would. I broke the news to her as she came in the house. She sobbed too.

Dr Genesis gave his baby, his future legacy, extra cuddles when he got home.

Thankful for what we have

Brushfield spots. If you don't know what they are, look it up.

General practice certainly is a different kind of work to hospital medicine. The community comes to you with their health concerns. For certain, some people are unwell. Some need antibiotics, most don't. Most are happy just to be checked over and reassured. In hospital, you order every conceivable test in the hope that something rare will show up so you can impress your boss. In general practice, you avoid ordering unnecessary tests in case something shows up that wasn't clinically related to the patient.

You have to bear in mind that if you're born and raised in the UK and have a moderate income, you're probably part of the healthiest 0.1% in the world. Dr Genesis considers himself part of the most privileged 0.1% in the world: very healthy, intelligent, financially pretty well off and the proud owner of a happy and loving family. But then again, Dr Genesis has a huge ego. He has nurtured it carefully since attending an expensive secondary school.

Every now and then something happens in GP which makes Dr Genesis glad he is in his job. Just the other day a busy mum of 2 came in for a relatively minor enquiry. Her young baby looked a bit odd. Cute, but odd. He had Down's syndrome. Mum was quite happy to talk about it. She had used IVF, and was told her risk of Down's syndrome was "moderate" (less likely than 1 in 800) and didn't proceed to amniocentesis wisely enough. She still had her little bundle of joy and thankfully baby didn't have any major cardiac abnormalities. She pointed out to me the baby's Brushfield spots, wide gap between big toe and second toe, and prominent medial epicanthal folds.

What a cutie.

Master of the universe (not Dr Genesis)

Most doctors have odd personalities. As one of my house officers remarked a few months ago: "we must all be a bit odd, to ask people repeatedly when they last opened their bowels". One of the most stressful things Dr Genesis found about working in hospitals was dealing with difficult colleagues. That's one of the reasons he went into general practice (although there's still difficult colleagues there too). Doctors are often quite forceful people, on the aggressive, thirsty to climb the ladder, and working under stressful conditions. All this makes for a brewing pot of defensive behaviour and irascibility.

There's nothing a doctor likes more than proving another doctor wrong.

Dr Genesis is one of the more placid types. Dr Genesis doesn't like confrontation. But equally he has an enormous ego. It is difficult for him to agree he was wrong. Usually he thinks he is right. There are often several different ways to do things in medicine and so far Dr Genesis hasn't done anything disastrously wrong. Except once, a couple of years ago. Perhaps I will tell you about it soon.

But still, Dr Genesis finds it hard to accept criticism. He will nod, agree, and mutter something about "useful feedback" but inside his mind is arace with reasons why what he did was actually a good idea and why the other doctor was wrong. But even the ego of Dr Genesis knows that when the criticism comes from a senior, it is better for all involved to simply agree.

A nice furry white blood cell (not Dr Genesis')

At Dr Genesis' GP practice there are a number of nurses. Some of them run minor illness clinics. The sort of nonsense that doesn't require a busy doctor to lend their expertise to. Coughs and colds, earaches, sore joints etc. There is a list on the wall. Make an appointment with the minor illness nurse if you have: earache, a sore throat, dizziness, fatigue, lethargy, a rash, a nosebleed, a headache. The list covers at least 30 conditions. If Dr Genesis knew how to deal with all of them he would be a very proficient GP indeed.

When is a sore throat laryngeal cancer? When is a headache a brain tumour? When is a rash meningitis, or a vasculitis? When is a nosebleed a nasopharnyngeal tumour? When is lethargy a haematological malignancy like leukaemia? Wait a second, did you say leukaemia?

The nurses are actually pretty good. They know their limitations, on the whole. And they have a lot of respect for the GPs. Unlike hospitals nurses, who on the whole view doctors with disregard.

But one slipped through the net.

A 16 year old boy. Who hadn't been himself for a few weeks. He was pale, tired and hadn't been playing with his buddies like he normally does. The nurse had looked at his throat, his ears and taken his temperature. All were normal. But she didn't examine his abdomen.

If she had, she would have detected his massive hepatosplenomegaly.

The boy had acute lymphoblastic leukaemia.

Thankfully the parents took him to hospital within the next few days and he was administered the appropriate chemotherapy at a specialist centre. He is making a good recovery.

It wasn't the nurse's fault. She hadn't been trained to palpate abdomens. Doctors used to see patients exclusively, 20 years ago. But now they're too busy seeing the dozens of healthy people coming in each day, eager to have their risk factors assessed.

A life of solitude

I went on a home visit yesterday to an old lady. The district nurse had asked a doctor to see the scar from a vascular operation. ?keyloid, the referral had said. I drove round and rang the bell. The lovely old lady let me in. She lived alone. Her lay-about son, who sponges off the state for benefits, lives a while away and isn't much help. Her husband died 12 years ago.

She underwent an extensive vascular operation to open up the arteries in her leg a few months ago. The scar was well healed. Not keyloid, but slightly hypertrophied I do agree. She was exquisitely painful around the scar, even to a gentle wisp of a hand over the skin. This was neuropathic pain, I explained, probably from the nerves knitting together after the op. It should settle on its own, if not we can use some medicines (amitriptyline/gabapentin for the medics among you). No thank you doctor, I'm not much of a pill taker. Sensible woman.

While in hospital, practically immobile, she had developed a terrible pressure sore on her heel. She told me how she had asked the nurses to move her leg around, to relieve the pressure but she was ignored.

Dr Genesis can easily believe this. It's not that the nurses are malicious. But they are tied up in paperwork and spend most of their time at the nurses' station, data gathering and ticking boxes. They would almost certainly have asked this old lady her religion, her marital status and her dietary requirements. But they could not stretch to simple nursing care like washing and moving a patient. There is no form for that.

The pressure sore went black and needed debridement. The helpful district nurse has attended to it very well. It has nearly healed, three months after the operation.

Dr Genesis enjoys home visits as a GP registrar. It is a real privilege to be allowed into people's homes, when it is truly necessary of course. As we said goodbye, we exchanged some pleasantries about the area and had a little chat. Then Dr Genesis swooped out the maisonette and back to his busy life.

I did feel a little sad that this nice old lady spends most of her days alone.

Walking among the snoring classes

A&E on a typical Saturday night

Believe it or not, Dr Genesis is back on nights. Thank goodness it is his last night shifts before he becomes a GP registrar. You know, that's the one where they write your name in pen above the other GPs and you think "I hope I don't have to see that useless junior". That's me.

Dr Genesis worked from 9pm until 10am yesterday. Despite not getting a wink of sleep and drawing back an old man from the abyss of a diabetic coma, he didn't receive a single word of thanks from the consultant on the ward round. In fact, there is barely an utterance of appreciation from the powers that be in medicine. There seems to be a culture to studiously avoid positive feedback. It takes a great senior to say thank you to his junior.

A&E was packed last night. Most of them were degenerate scumbags who just got too drunk, hit someone/something inanimate, broke/cut/squashed some part of their body then got their free slice of the NHS cake. Dr Genesis has worked in A&E. On his first shift, a drunk teenager came in practically comatose. "What shall we do?" a fresh faced Dr Genesis asked the charge nurse. "Fill them up till they piss themselves, then chuck them out". With a few years of experience, Dr Genesis thinks that is too good for them. Why does intoxication necessitate a trip to A&E? These people have barely paid any tax in their lives. When something is free, it tends to be abused.

Bear in mind, in Australia you have to pay $30 to see your GP. Pay on the day and receive a discount to $27. Use the other $3 to buy a "tinnie".

Happy just to relax

Dr Genesis has wanted to be a doctor since watching Sam. I suppose he wanted to be a hero. And to be well versed in human physiology. I suppose I am now, although sometimes my knowledge of the human body seems too simple. But then compared to the average Joe in the street, Dr Genesis' knowledge is vast. Most people don't even know where their liver is. I thought at medical school that once I qualified I would know a lot about the body and have a zest for knowledge. But now I find that I'm not that interested in esoteric diagnostic medicine. Most of it isn't thought-provoking. A lot of it is just running dozens of tests and hoping one will come up positive.

So when an elderly lady came in, having fallen over, with a few cuts and bruises on her legs, Dr Genesis didn't take blood. The lady was in her 90s, with advanced dementia and had been bed bound for two years. What would the bloods show? Mildly impaired renal function, a slightly high CRP, a mild anaemia? I knew it was cheeky. How would I explain myself at the ward round the next day?

As it was, in the morning I found that Mad Female Medical Registrar (every hospital has them: they are single, irate, not that attractive, totally obsessed by detail and unlikely to ever settle down with a husband and children, even though that is actually what they really want...) had taken blood from the old lady at 1am. Guess what they showed?

Life: as fragile as a petal blowing in the wind

Difficult day. Emotional day.

An unfortunate, previously well, late middle aged gentleman had a brainstem haemorrhage. Just doing what middle aged men do...a bit of DIY. Then his voice went slurred, he fell to the ground and started fitting. A quick scan showed a burst blood vessel in the most important part of his brain: the brainstem. This is why Dr Genesis doesn't do DIY.

Unable to talk, swallow, see or move, he lay there breathing through the tracheostomy that the ITU doctors had put in before he came to the ward. To a side room.

Three weeks later, he was still breathing. And was being fed through a nasogastric tube.

The wife and family were in agreement: Dad wouldn't want to be like this. He was such a fun-loving guy, always doing things in the garden, always active. He wouldn't want to be a vegetable. Dr Genesis always finds it a coincidence that people who are seriously incapacitated used to be remarkably active beforehand. The family never say "Dad was actually a bit lazy, he probably would quite like being grossly neurologically impaired."

We decided to pull out all treatment avenues...and allow him to die. It fell to Dr Genesis to do this, it was too much to ask of the nurses. He took out the NG tube easily enough. But removing the tracheostomy. That was tough. That was an active removal of the route of breathing for this man. Even Dr Genesis' confidence buckled and he administered some sedation to the patient. Why sedate a man with a Glasgow Coma Score of 3? To calm the doctor of course.

He continued to breathe for the next 36 hours. The family were very grateful for Dr Genesis' help. They knew there was no hope. They knew as soon as he came into hospital.

New role for the Isle of Wight

The average appearance of Dr Genesis' patients

Dr Genesis has had two weeks off work. He slept for the first two days. Then he remembered what it is like to be human again. Any junior doctor knows how he feels. You forget there is a normal world outside the hospital walls. A world where people aren't continually abrupt.

Dr Genesis came back to work today. Within 15 minutes of the ward round, Dr Genesis was despairing. There were a couple of middle aged people with acute medical problems which we could actually treat. The rest were over the age of 85. And this isn't even an elderly care team. Most of them had minor medical problems, consistent with old age. Normal. In any other country they would be tucked up in bed by their family and fed porridge. Then they would die in a few months, peacefully, with their family around them.

But in the UK, death is an avoidable pathology. It must be delayed as long as possible. No stone must be unturned to discover why a patient's sodium level of slightly lower than it should be. Or why their CRP (a marker of inflammation/infection) is slightly higher than it should be. The patient must be cannulated, catheterised, fed with intravenous fluid and antibiotics, bombarded with radiation and "coded".

Then and only then can they be allowed to die. With their dignity strippped from them.

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.