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.

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.

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.

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.