Tag Archives: health

An invitation to An Evening with Death

Posted on April 4, 2013 | 2 Comments

Where do you want to die? How do you want to be remembered? What is it like to be present when someone dies?

Screen Shot 2013-04-03 at 22.08.09

Death is a subject that it is often difficult to talk about, but is something we all have in common. On this blog I have shared some of my thoughts and experiences as a healthcare professional, having seen death, dying and grief more than most people I know. I have advocated for more open discussions about the fragility of the human body, the limits of medical interventions, and the freedom to live life to the full that might be gained from embracing it’s finite nature.

As a teacher I believe I have a responsibility to prepare medical students to deal with death and grief, and wonder whether we need new ways to do this effectively. Can sharing our experiences with the public be a learning experience for all? Can the arts and humanities help us to cross the ‘us and them’ doctor-public divide?

Screen Shot 2013-04-03 at 21.27.21

On 16th May I will be hosting “An Evening with Death” with Hollie McNish, my good friend and UK Slam Poetry champion. It will be an evening of poetry, performance and discussion to support the Dying Matters Coalition’s aim “to support changing knowledge, attitudes and behaviours towards death, dying and bereavement, and through this to make living and dying well the norm.” I am very grateful to UCL SLMS Public Engagement unit for supporting this event.

We hope that the evening will be thought-provoking, life affirming and fun! The event is free, but booking is essential so book your ticket now and join us for drinks and discussion at the Printworks Cafe, UCL. I hope to see you there!

For further information, I have curated some links to related events such as Death Cafe’s, Dinner with Death and other Dying Matters Events.

→ 2 Comments

Posted in Death

Tagged , , , ,

Can we find the spirit of ’45 in 2013?

Posted on April 1, 2013 | Leave a comment

Today marks a defining moment in the history of Britain, but looking around you wouldn’t believe it. Today, April 1st 2013, sees the The Health and Social Care Act (HSCA) come into force.

The death certificate of the NHS, issued by the National Health Action Party

The death certificate of the NHS, issued by the National Health Action Party

Some still believe that those opposed to the HSCA are over-dramatic, reactionary or naive. They will probably dismiss the National Health Action Party as extreme and publicity-seeking as it has issued a death certificate for the NHS, citing the cause of death as the HSCA 2013, with contributing causes including Thatcherism and the failure of New Labour. But it is difficult to see how anything but extreme statements and gestures can capture the attention of the public. Our generation is standing by as the NHS is quietly privatised and I for one am ashamed.

In 1948 the Attlee Labour government founded the NHS “the greatest gift a nation ever gave itself.” Since then it has been gradually eroded and dismantled. The King’s Fund’s infographic depressingly visualises various points of attack by multiple governments, starting with the creation of the internal market in 1989 when Margaret Thatcher signed the paper “Working for patients”. New Labour also have a lot to answer for; their PFI legacy crippling many Trusts today. But no previous government has actually tried to privatise the NHS, knowing that there would be a public outcry. Cameron and Clegg have privatised by stealth; clouding their agenda in a language of ‘choice’ ‘clinician power’ and ‘patient centredness,’ and ensuring that the reform documents were so long and complex that no-one, including most Ministers, understood them. The British media failed to report the warnings of individual doctors, nurses and other healthcare workers, and the demands of traditionally silent bodies such as the Royal College of Physicians to drop the Bill.

Screen Shot 2013-04-01 at 18.33.01

The most worrying aspect of the reforms that come into force today are the Section 75 regulations, which state that all NHS services must be put out to competitive tender. This is not just allowing privatisation, it is mandating it. And all these profit-motivated private firms will be operating under the ‘brand’ of the NHS, so patients may not even know. Until the inevitable problems start to surface and it is too late.

Screen Shot 2013-04-01 at 18.34.44As I watched the welfare state being dismantled around me this week, I went to see Ken Loach’s film The Spirit of ’45 at The Barbican Cinema. It was a poignant reminder of a time full of hope and promise, and was a stark contrast to what I see today. In 1945 there seemed to be a collective vision of a society that could pull together for the benefit of all, with at least some people from all social classes believing that the State was a force for good, and that it had a responsibility to provide and protect the simple things most of us spend life striving for: purpose, dignity in work, family, safety, health, wellbeing, shelter, and comfort. 

Particularly powerful were interviews with doctors and patients who remembered a time before the NHS, when healthcare was only for the rich. In The Spirit of ’45 Dr Jacky Davis and Dr Jonathan Tomlinson, doctors working in the NHS today, talk eloquently about the doctor-patient relationship and about their fears about the future. Marketisation and competition change the relationship of doctors and patients to salesmen and consumers. I am no salesman and never will be.

The day after I saw The Spirit of ’45 I was on call in hospital. I was asked to speak to a patient about her medications before she went home, and quickly scanned through her notes before going to speak to her. She had had a tough few weeks, having been diagnosed with incurable (but treatable) lung cancer – only two weeks from having a chest x-ray revealing an unexpected abnormality to tissue diagnosis and treatment plan. This rapid diagnosis and treatment was an example of what happens every day in the NHS, and is a great example of the efficiency of our healthcare system, but it had left her little time to process the news. She was anxious about her medications prior to discharge so I spent a few minutes clarifying them and reassuring her.

As we ended the conversation she said thanks, and then hugged me tightly. It was nhs logoan unexpected level of physical contact and gratitude for a conversation that could only have lasted ten minutes. But it made me think. She wasn’t really thanking me. She was thanking the NHS: there for her from cradle to grave; at the most difficult time of her life; no questions asked; free at the point of need. Patients in the NHS are taken under the wing of an institution and cared for under an ideology. Today that ideology has suffered a fatal wound. Health is not a commodity, and markets will not make our NHS more efficient, more equitable or of higher quality.

Nye Bevan said “The NHS will last as long as there are folk left with the faith to fight for it”. As Owen Jones says “It is with huge regret that I must say that – however much faith we have – we did not fight to save it. The question now is – do we have enough faith to bring it back to life?”

As I look around the political landscape I fail to be inspired or energised by what I see. Attlee had vision, drive and a belief in the people.

I am looking for the Spirit of ’45 in 2013. Let me know if you find it.

→ Leave a comment

Posted in In Between

Tagged , , , , , , , ,

The human touch

Posted on November 11, 2012 | 7 Comments

I recently took a group of medical students to see Mrs Cole*. She was 88 and was in hospital due to a severe exacerbation of COPD. She was kind enough to let us talk to her and listen to her lungs, despite being quite breathless. As we talked I perched on the edge of the bed and, as I often do, held her hand.  She grasped it tightly and wouldn’t let go. I finished the teaching session, sent the students off to their lecture, and stayed with Mrs Cole longer than I had intended. It felt like she was clinging to me as we talked; clinging to my youth, my health, and my carefree existence.

I couldn’t offer her much: we were treating her exacerbation but no drugs could reverse her lung damage. No words could allay her very real fears for the future. But I felt what I could offer – a tiny piece of my time, and my hand to hold – meant something.

As my friends will attest I am no alternative medicine advocate, but it would be arrogant to suggest that there is nothing beyond the knowledge of ‘modern medicine.’ Thinking about Mrs Cole’s reaction I wondered if we underestimate the power of the human touch: the literal, physical connection of one person’s skin on another’s. Hospitals are dehumanising places and as doctors we put up barriers to protect ourselves from the daily site of pain, disease, and suffering. We are in danger of slipping  into an ‘us and them’ mentality, compounded by the differences in socioeconomic status and educational experiences of the average doctor and average patient. We examine and investigate people in a clinical and efficient way and try to fix them. But many patients we see, especially in general medicine, cannot be ‘fixed.’ They have chronic diseases that they will live with for many years. In all honesty, more often than I’d like to admit our treatments do very little to alter disease trajectories. I sometimes think a dose of compassion is a more effective intervention than any drug. The question examined in Intelligent Kindness, is whether NHS staff, in the current climate, have any compassion left after experiencing little themselves.

Despite the challenges, I see hope in the relationships we form in healthcare settings. The system around us shouts about targets, procedure times, and new-to-follow-up-ratios. It demands quality, without articulating what that is. But in the midst of this we find quiet moments of human connection, where people let their barriers down, hold hands and share an understanding of a shared human experience. ‘Us and them’ becomes ‘us’.

“Kindness is something that is generated by an intellectual and emotional understanding that self-interest and the interests of others are bound together, and acting upon that understanding“

A literature search on the effects of human touch disappointingly reveals little. A review article in The Journal of Holistic Nursing explores a conceptual model of intentional touch and highlights some relevant studies. It uses the term ‘touch hungry‘ to describe those individuals who are seldom or inadequately touched in a safe or appropriate way. They are often marginalised individuals: due to poverty, homelessness, age or disability. They may be separated from family and friends, or segregated from society because of stigma and fear. Healthcare professionals will be familiar with these groups and their complex needs. Some nursing practices, which can be as simple as providing hand and foot care, encourage the use of intentional therapeutic touch to offer comfort and promote healing as part of holistic nursing practice.

An interventional study by Moon & Cho, 2001, explored the effects of nurses providing handholding for patients undergoing cataract surgery. The study authors suggested that comfort touch conveyed empathy, had a soothing effect, reduced anxiety (as measured by patients subjective experience and by adrenaline levels), and provided both the nurse and the patient with a feeling of increased security. The authors encourage touch as an intervention because “it is a noninvasive, harmless, inexpensive, and easy to perform and because the patients’ responses to the intervention were very positive“.

Edvardsson et al. (2003) discusses the importance of intentional touch for the professional, in the context of caring for older people. The authors suggest that when nurses provide intentional touch to patients they perceive themselves as valuable as people and professionals, and feel a power inherent in the kind of touch that eases suffering. In addition, the experience of intentional touch has the potential to transform the way in which the nurse regards his or her patients. Rather than seeing a demanding patient, Edvardsson suggests that the use of intentional touch helps the nurse see the patient as a human being.

These descriptions are interesting, but they are limited by subjectivity and reporter bias. In a search for more concrete evidence of the therapeutic benefits of touch I came across a review ‘The skin as a social organ‘ in Experimental Brain Research, which “situates cutaneous perception within a social neuroscience framework by discussing evidence for considering touch…as a channel for social information.” The authors present data which they suggest indicates that specialised pathways for socially and affectively relevant touch may begin at the level of the skin with specialised nerve fibres. They also explore evidence for  higher processing of social touch sensation in specific brain areas such as the insula and orbitofrontal cortex. Of course such reductionist approaches have their own limitations when we examine such a complex phenomenon as the physiological, emotional and social effects of human touch.

Abraham Verghese, an Infectious Diseases physician articulates the power of touch specific to the doctor-patient interaction in his TED talk on the ritual of the physical examination. In this context the examination’s function is not to detect signs of disease, but to communicate compassionate and, he argues, this has a transformative effect. The ritual is cathartic and comforting and allows the  doctor to communicate a message to the patient: “I will always be there. I will see you through this. I will never abandon you. I will be with you through the end.”

I’m not sure where these thoughts should lead. I certainly wouldn’t advocate for NHS-funded touch therapy in place of other more evidence-based approaches, and clearly such an intervention could never be implemented on a large scale since the care-givers would need to truly feel the compassion they were trying to convey. But compassion, empathy and the human touch are central to holistic care, and it is worth reminding ourselves of their value. It comforts me that other physicians understand the power of this dimension of care, despite the difficulties in generating empirical evidence of its effects. Human touch can communicate in ways that go beyond the limitations of language, and articulate kindness more powerfully than any other action.

As GP Dr Jonathan Tomlinson says “Kindness in healthcare is how we communicate with and relate to our patients, our colleagues and ourselves. It is much more than how we listen, it is how we feel and how we respond and it is part of the culture we share.“

I hope that should I ever cross the divide from physician to patient, that someone will communicate their compassion through more than words; that they will take time to listen, to understand, and to hold my hand.

* name changed to maintain confidentiality

→ 7 Comments

Posted in Life

Tagged , , , , , ,

Life in my shoes

Posted on July 16, 2012 | Leave a comment

On a recent set of on call shifts I met James,* who my team treated for pulmonary emboli. He was a lovely man; visits to check he was on enough oxygen to maintain his saturations and to assess his haemodynamic status were a joy, due to his easy manner and good humour.

Pulse Oximeter, for monitoring oxygen saturations

One one occasion I was with my Consultant, who had known James for a while prior to this admission. At the end of the consultation he asked a very powerful question “is there anything else on your mind?” At this point I was closing the notes folder and putting my pen in my pocket, expecting to move on to the next patient. But James  did have something on his mind.

What I have not mentioned is that James is HIV positive. He has been living with HIV for many years and facing the challenges associated with this with resolve and good humour. His current problem was not directly related to his HIV status, but as is the usual practice whilst he was in hospital he was cared for by both the general medical team, and the “immune deficiency team” who were able to advise on potential interactions with his ARVs and give other specialist input.

One afternoon James was sat in his hospital bed, chatting to a visitor who was unaware of his HIV status. One of the immune deficiency team doctors had just been to see him and was writing up notes at a nearby desk. Another doctor called across the ward “hey, are you the HIV doctor?”

This question was clearly asked thoughtlessly, with a complete lack of awareness of the potential to breach a patient’s confidentiality. James told us that thankfully his visitor had not heard, but he was concerned that this situation could happen again to someone else. He offered to talk to the doctor involved, to explain the impact of a HIV diagnosis, and the significant anxieties felt by those affected, in particular around potential breaches of confidentiality and  discrimination within healthcare settings.

This conversation made me think about my own views on HIV, and I realised that I am incredibly naive. To me HIV is just another chronic disease; requiring early recognition, lifelong support, timely treatment, and awareness of associated morbidity and mortality. In my mind, it does not differ greatly from diabetes or COPD. Of course I am aware of the additional moral judgements that go along with sexually transmitted infections in general, and that the fear of contagion from ill-informed people coupled with value-judgements on lifestyle choices make living with HIV significantly different to living with diabetes, but I have not witnessed this myself. I watch films like Philadelphia and Angels in America, and listen to anecdotes from older Consultants, and feel completely disconnected from them: the AIDS epidemic of the 80s feels like a distant bygone age. Hasn’t society moved on? Isn’t my generation more liberal?

Giant leaps have been made in the last few decades in diagnosis, treatment and life expectancy, and my professional perception of HIV as “just another chronic disease” is in many ways a sign of success in overcoming the associated stigma. But meeting James provided a stark reminder that people living with HIV still face significant prejudice. As a throwaway comment he said “the curtains around the bedside aren’t exactly soundproof, and the visitors of the patient next door didn’t look particularly pleased when they overheard someone say ‘HIV’. I’d rather not have to deal with that while I’m struggling to breathe!“

HIV and AIDS gets less attention from the media in the UK than it did during the early years of the UK AIDS epidemic, but it’s far from an issue of the past. In fact, the epidemic has expanded, with the annual number of new HIV diagnoses nearly tripling between 1996 and 2005. Annual diagnoses have slightly declined since then with 6,150 people diagnosed HIV-positive in 2011. But despite rising numbers of people infected through sexual transmission, public knowledge of HIV and AIDS appears to have declined. Worryingly the UK HIV and AIDS statistics show that of the 91,500 people living with HIV in the UK at the end of 2010, approximately 24 percent were unaware of their infection. This is the result of multiple factors including a lack of physician awareness of indicator conditions, physician reluctance to test and patient fears and reluctance to get tested, in part due to myths, and negative societal attitudes.

AIDS 2012, an International AIDS Conference is being held in Washington this weekend. Part of the extensive programme includes the screening of a film made in Hackney, London by the charity Body and Soul, whose message is optimistic and inspirational:

“We refuse to let HIV decide who we are.”

“We believe in people not victims; brilliant individuals, not scary statistics.“

“HIV can exert a powerful impact on the lives of people living with and closely affected by the virus. However…with the right interventions at the right time, resilience and hope can be developed.“

The film Life in my Shoes celebrates difference by seeing life from other people’s perspectives. This wider message of the need to empathise with other people’s perspectives is powerful, beyond the context of this campaign, and I hope it receives a wide audience.

“There is one thing we all share, we are all different.”

* Name changed to maintain confidentiality. Story shared with consent.

→ Leave a comment

Posted in Life

Tagged , , , , , , , , , ,

How to die: CPR and the concept of futility

Posted on June 11, 2012 | 3 Comments

I recently cared for Ernest,* an 87 year old gentleman who spent around two weeks on my ward. Prior to admission his health was poor. He was bed-bound due to the late stages of a degenerative neurological disease, and had associated cognitive impairment. He had several other health complaints, and had been in hospital multiple times in the previous year with infections. He had always responded to antibiotics but his condition and level of interaction with the world had declined with each admission. On arrival to our ward I noticed that he did not have a DNAR order and, since he was not able to discuss his wishes, I looked to the family for information and to broach this subject. I was surprised to find that several vocal family members were adamantly against a DNAR. I had lengthy discussions explaining my reasons for believing that attempts at resuscitation would be futile and that setting limits of care was important to ensure we pursued quality, not just quantity of life. They listened, seemed to understand, and themselves identified his frailty, deterioration over the last year, and decline in his quality of life. However they strongly objected to us making him “not for attempted resuscitation.” As the end of the week approached I felt uncomfortable about the lack of a DNAR order, and about the possibility of this frail gentleman suffering a brutal and undignified exit to the world should his heart stop. I tried to communicate my personal discomfort to the family, and the reasons for it in the context of my experience of the realities of CPR attempts in those with poor underlying health. I also made it clear we were not asking for them to make this decision, but wanted to integrate their views into the medical decision-making process. I was aware of the potential to be seen as being coercive and paternalistic, but felt a duty to act in what I believed to be the best interests of my patient. We treated him with escalating regimes of iv antibiotics, iv fluids and nutritional supplements with no improvement, and by the end of the first week the family reluctantly withdrew their objections to a DNAR. Unfortunately he did not respond to treatment, his organs began to shut down and he drifted into a state of unconsciousness. At the end of the second week the Consultant and I had further difficult conversations with his family members about the withdrawal of antibiotics, fluids and nutrition. He died; peacefully and comfortably with his family present.

I thought a lot about Ernest and his family at the time and in the weeks since. I was taken aback by the strong objection to a DNAR order and, not for the first time, wondered about the expectations of the public of medical interventions. I also wondered what I could and should have done differently; where the line is between professional advice and personal opinion; and to what degree families’ wishes should be followed in the face of futility.

An article in the NEJM addressed the question “Is it always wrong to perform futile CPR?” and suggested that there are some circumstances in which it may beThe "Father of Modern Medicine" right to proceed with futile treatments at the end of life for the sake of the family: for those left behind. I recognise this argument, but my personal beliefs align more with those who contend that this is never right, as it treats the patient as a means to an end, rather than an end in themselves (see Kant), and causes harm to the patient. The Hippocratic Oath is very clear on the duty not to do harm and  to recognise one’s limits.

This quote from a 1988 letter to the editor of NEJM seems even more appropriate today, as the options for what can be done grow, whilst what should be done, is not always considered :

“It seems we have lost sight of the difference between patients who die because their hearts stop and patients whose hearts stop because they are dying.”

Conversations about the limits of medical intervention, the inevitability of death, and the need for priorities other than duration of life are not broached often enough or openly enough. The aim of talking more openly is not to remove hope, but to give patients the space to exercise true choice and autonomy, to define their own priorities, and to live out the time they have left in the way they choose. It also releases the medical team to do all we can with total conviction, comforted by appropriate limits. We live in an ageing society. More people now die from chronic conditions after a long period of declining health, or from a combination of factors best defined as frailty. Atul Gawande, Professor of Surgery at Harvard Medical School, when asked by a family member whether one of his patients was dying admits to struggling to know how to answer:

“I wasn’t even sure what the word “dying” meant anymore. In the past few decades, medical science has rendered obsolete centuries of experience, tradition, and language about our mortality, and created a new difficulty for mankind: how to die.”

For patients in the late stages of chronic health conditions such as heart failure and COPD the week or month of their death is not predictable, but the fact that their lifespan is limited is fact. Starting these conversations is difficult, and communicating the concept of futility can be a huge challenge. What does futility really mean? What % survival from CPR does the public think is achievable and what would they define as futile? Is this the same definition as doctors? It is no wonder that we struggle to find the words, but this is no excuse. The medical profession must not collude in the conspiracy of eternal life, and the  perception of death as failure.

http://www.respectourwishes.com

So how do we move forward? A recent JAMA article has suggested a standardised approach to determining DNAR status. Reading the conclusions, the most striking thing is that they sound like simple common sense: “Whenever there is a reasonable chance that the benefits of CPR might outweigh its harms, CPR should be the default option. However, in imminently dying patients….The default option in this situation should be an order to not attempt CPR.” The problem is that life is rarely so black and white, and many patients arrive at hospital with a potentially life-threatening illness but are not imminent dying. It is these patients who still need appropriate limits of care setting, but this is not built into our day to day practice.

The conclusions of the NCEPOD report “Cardiac Arrest Procedures: Time to Intervene?” have been widely reported but often with a negative spin, painting doctors as the enemy of patients “fighting for life.” This is an emotive subject and the media are rarely helpful, fuelling fears of patients having decisions made for them and being abandoned at the end. The Daily Mail can always be relied upon to deal as insensitively as possible with these complex subjects (see here and here, where they conflate the question of the appropriateness of DNARs with communication issues and accusations of neglect, making it difficult for the public to consider the issue in isolation.) The Chair of the NCEPOD report has identified the fact the we all need to recognise and accept the limits of what medicine can achieve. But who does he mean by “all?” This is a societal issue, and discussions need to leave the hospital ward and GPs’ surgery and find their way into people’s homes.

Reflecting on my interactions with Ernest’s family, I was heartened by this quote from Atul Gawande in The New Yorker:

“People die only once. They have no experience to draw upon. They need doctors and nurses who are willing to have the hard discussions and say what they have seen, who will help people prepare for what is to come…”

I will continue to have these hard discussions, but hope that in time they will be made easier by a greater awareness and preparedness from the public. Death is a part of life and our continued silence only makes it more deafening when it arrives.

See The Health Culture blog: “Actions surrounding the moment of death are highly symbolic,” MedicalEthicsandMe‘s thoughts, and lots of posts on the Medical Futility blog for further insightful discussion.

* names changed to maintain confidentiality

→ 3 Comments

Posted in Death

Tagged , , , , , , , , , , , ,

Health, wealth and the centenarian

Posted on May 30, 2012 | 4 Comments

Recently I treated and discharged a 101 year old gentleman. Back to his own home. And not a care package in sight.

As a hospital physician I rarely meet this group of older people, living full and independent lives. My view of the over 65s is coloured by my frequent encounters with the most unlucky ones; suffering from chronic disease, dementia, cancer and frailty.  But they exist, these sprightly centenarians and in increasing numbers. And even more common are older people with a lot to contribute to society, but in need of a little support in order to maximise their potential. Between now and 2050 the number of people aged 80 years will almost quadruple to 395 million. At that point, there will be more people over 65 than children under 14.  Our world is changing, but are we ready for this global silver revolution?

As a broad generalisation “western society,” does not value age, experience and wisdom. Our culture is obsessed with youth and a narrow definition of beauty which has no time for those perceived as “past their prime.” But in the last few weeks I seem to have read an abundance of good news stories about older people doing incredible things. On Saturday Live on BBC R4 I listened in awe and fascination to Mary Hobson who took a degree in Russian in her 60s and now, in her 80s is winning awards for her version of Pushkin.

Nicholas Crace, a fantastic 83 year old, found that he couldn’t continue to give blood after 70, but he could donate a kidney. So he became the oldest live altruistic kidney donor in the UK.  He was back to gardening and cycling a week later.  For even more inspiring older people see here and here.

Despite these great examples I fear that in general we dismiss and ignore older generations and that, as a result, we are losing out. As I contemplate entering the later decades myself I am worried I will not have the means to enjoy “active ageing,” defined by the WHO as mechanisms through which “people can realize their potential for physical, social, and mental well-being throughout the life course and to participate in society, while having adequate protection, security and care when needed.“

So what are the necessary conditions for longevity, and what defines a happy life? Many people have attempted to answer this question. There is some evidence that those who live long healthy lives have higher levels of glutathione reductase (although I have not found any convincing evidence of a cause and effect relationship). Other research has idenfified genes that seem to influence longevity in multiple generations, including FOXO3A, which also correlates with lower rates of cardiovascular disease and cancer. But of course these reductionist theories miss the complex interaction of the individual, their genes, their childhood, their health choices, their socioeconomic status, their employment, their personality and risk taking behaviour, their social interactions, their self esteem and response to stress.

For over 70 years Harvard researchers have been following 268 men through their lives starting as “well-adjusted Harvard sophomores.” Half of them are still alive and now in their 80s. The study has documented narratives of the participants lives, in addition to collating questionnaires, psychological tests and medical examinations. The primary researcher George Vaillant has concluded that key components of a happy life include close relationships, access to a good education and good physical health. Perhaps more interesting are conclusions such as “objectively good physical health was less important to successful aging than subjective good health. By this I mean it is all right to be ill as long as you do not feel sick,” and “learning to have fun and create things after retirement, and learning to gain younger friends as we lose older ones, add more enjoyment to life than retirement income.” Dr Vaillant heavily emphasises the importance of social support and relationships in healthy ageing, which should ring alarm bells when we consider the lack of any sense of community in so many peoples’ lives, and the social isolation which often occurs with ageing.

The Okinawa Centenarian study in Japan identified several factors that contribute to the population’s high number of centenarians including: a diet very heavy on soya products, as well as fish and vegetables, and low on alcohol, dairy products and meat; commitment to frequent low impact exercise such as tai chi and gardening; close, supportive social networks; and a positive attitude that embraces and celebrates age. This group of people spend, on average, 97% of their lives disability-free. What a contrast to the common perception of the frail, dependant UK nursing home resident, unable to perform the most basic functions for themselves.  Ageing is not something to fear, if we remove the physical dependence and cognitive decline that we perhaps mistakenly see as inevitable.

I will continue to marvel at and celebrate the healthy older people I come into contact with, and aim to integrate some of the advice from Harvard and Japan to maximise my own chances of active ageing. But I also hope that the current period of austerity, coinciding with almost daily revelations of the degree of  inequality in society, and the entrenched corruption of power at the top  is bringing about a gradual reawakening; a shift in our materialistic and individualistic society towards a more caring, human, community-focused future. In my utopian future, age and wisdom are valued above youth and beauty, the gap between rich and poor is a fraction of what it is today, human interactions are treasured more than material possessions, and we all eat soya.

Good health adds life to years 

→ 4 Comments

Posted in Life

Tagged , , , , , , , , , ,

A Grief Encounter

Posted on May 1, 2012 | 4 Comments

Last week was particularly stressful; marked by staff shortages, anguished relatives, conflict over complex discharge processes, and pressure to create beds. The amount of time I spent with each patient on my ward rounds was less that what I, or they, would have wanted but despite coming in early and leaving late there are only so many hours in a day. In weeks like these I often feel guilty as I leave work that I am unable to give more time to those patients and relatives facing the end of life.

More than many other people I know, I am acutely aware of the fragility of life.

Modern medicine is amazing and can achieve results and outcomes that continue to astound me. The satisfaction of discharging a patient with a smile on their face after an admission for respiratory failure that looked like it might be their last; or being able to tell a patient that their cancer is curable, is difficult to describe. But even more difficult to articulate is the sense that the days in which I have the greatest impact, the days that are most rewarding are those in which I’ve had to break really terrible news, and have done it well. Such conversations require patience, time, compassion and, I used to think, empathy. I have seen grief, and its many varying manifestations. But being close to grief is not the same as understanding it and I am often aware of the vast distance between myself and a patient’s relative as we sit side by side in a quiet room after I have delivered bad news. What do I really offer in this situation? I try to communicate the medical facts clearly and sensitively, and give patients and families a sense of what will happen next. I feel sympathy, but am unsure whether I can truly say that I empathise. I have limited life experience and, thankfully, very little personal experience of death, and I find it difficult to imagine what grief feels like.

I recently read a powerful blog from a woman who had seen friends, and acquaintances experience grief, helped them through it and thought she understood. Until her father died. “That night I fought off a panicked dream of the earth falling away under my feet. I realized then, that until that moment, I had never had the right to speak.”  This acknowledgement that there is a gulf of emotion between seeing and experiencing grief is something others have identified, including physicians.

I hope that I can continue to find the time, compassion and words to help patients and their families through the most difficult times in their lives. But, selfishly, I hope that for as long as possible I maintain a degree of distance and lack of understanding and that I continue to sympathise but not empathise.

“No one ever told me that grief felt so like fear.” C. S. Lewis (1898 – 1963)

→ 4 Comments

Posted in Death

Tagged , , , , , , , , , , ,

Discharges in the dead of night

Posted on April 15, 2012 | 1 Comment

NHS Hospital discharges: thousands claimed to occur overnight

The news this week has been full of horror stories of patients being discharged from hospital in the dead of night. “Where is the compassion?” they cried, “How could they, the supposed caring profession?”  The stories began after The Times discovered, via Freedom of Information requests, that 100 NHS trusts sent 239,233 patients home last year between 11pm and 6am

The immediate response of the press was to paint a picture of an army of ambulance drivers booting out frail 90 year olds; dumping them at their front doors, alone in the dead of night. This dramatic depiction fuelled discussions on various forums and news programmes. The callers on Radio 4s “Any answers” actually made me turn the radio off.

My major concern is that this data was released without proper analysis. As usual in the reporting of science news, and particularly health-related news, the headlines were more important than the content. It took me two minutes to think of a list of possible contributing factors which may have led to these numbers of supposed patient discharges overnight:

  • Deaths are often coded as discharges. These may happen overnight.
  • Sometimes patients self-discharge, especially those admitted due to intoxication. On sobering up they may decide that at 5am they’d rather sleep off the rest of their hangover in their own bed. Good for them.
  • Many patients are offered the chance of discharge after a period of observation in a short-stay ward. Such patients are not really “admitted” in the traditional sense, merely held somewhere outside A+E due to the constraints of the 4hour rule, often awaiting test results.
  • Patients may leave the hospital hours before the discharge is “declared” by the ward. Sometimes this is due to the ward staff prioritising patient care over paperwork, and only getting around to logging the event later. Sometimes this is a more overt tactic to prevent more ward admissions when ward staff are under pressure. This may not be best practice, or good for patient flow, but is better than what has been imagined by reporters.

It is disappointing that those at The Times didn’t construct a similar list, and is part of a worrying trend of negative NHS stories despite high patient satisfaction. In my more cynical moments I wonder about influences on reporters and editors and links between media execs, politicians and those with interests in private healthcare.

“Patients should only be discharged when it’s clinically appropriate, safe and convenient for them and their families.” says Sir Bruce Keogh. Absolutely. I know no-one working in the NHS who does not “believe in the principles of holistic care – thinking about the patient as so much more than a bed filler and considering their lives outside the microcosm of the hospital.”

There may be a very small number of cases which fit the picture painted by The Times, and each of these is a failing of the system, which requires investigation and action. But please can we stop the media driven NHS-bashing? Those of us who work in public service endure long hours in difficult circumstances, but do so because we care. Nurses, doctors, occupational therapists, physiotherapists, pharmacists, discharge co-ordinators and matrons spend our working lives assessing patients to ensure that at the end of their medical investigations and treatment they are safe for home. When they are not we engage social services to put in place care to achieve a safe discharge. I worry that the profit motive, competition and privatisation will bring pressure to change this, but for now compassion remains at the heart of what we do, and no-one vulnerable and alone is going home at 3am on my watch.

BBC article: Overnight discharges from NHS hospitals to be examined

Sensible analysis by FullFact.org

→ 1 Comment

Posted in In Between

Tagged , , , , , , , , , ,

The Dangers of DIY Diagnosis

Posted on April 4, 2012 | 6 Comments

I spend all day talking to patients about their health and disease, explaining the rationale for tests and discussing the possible outcomes of different treatment strategies. This is often difficult and complex. I struggle to articulate risk, uncertainty, and the art of medicine; the shades of grey that are a day to day reality, and which medical school does not necessarily prepare you for.  I was therefore outraged when, on my way home after a hard day at work, I saw this advert on the Tube:

An advert on London Underground for an over the counter blood test.

I should sue Myrios for emotional distress: I almost fell onto the tracks. What shocked me was the cynical, and cheerful, exploitation of people’s worries about their health.

On their website Myrios say “with all conditions, preventative medicine is key, so it is important to check your health and well-being periodically.” I have no objection to this statement and wholeheartedly endorse the “prevention is better than cure” message. But to suggest that this can be achieved by having a random panel of blood tests is outrageous.

The advert offers testing for a number of ailments, ranging from anaemia to syphilis. Below I offer my initial reaction to each of these, and a reason why you should not buy the test (I suggest you spend your hard-earned money on a giant Easter egg, lunch and an exhibition at the Tate Modern, a subscription to the LRB, or a nice bottle of red).

What concerns me about this advert, and others like it, are the ethics of marketing to vulnerable individuals and the validity of consent to the tests.

I imagined I was one of the patients I often see in clinic and typed “do I have lung cancer?” into Google. The top hit (if you don’t have the wonderful Adblock installed) is Insight Medical offering “peace of mind” from a CT scan of the Chest. This test could indeed reveal a Lung Cancer, and if detected early the outlook is better. But the test involves exposure to radiation, and should only be offered to those with the right risk factors and symptoms or signs to make sure the potential benefit outweighs the known harm. In this context, the test will be offered by a Respiratory Physician, for free on the NHS.

An example of a particularly advanced CT scanner, capable of producing amazing images in seconds

Research is ongoing for an effective lung cancer screening programme for asymptomatic individuals, and progress has been made in the use of CT for screening (a low dose protocol). I hope that in my lifetime we create an effective programme to find early cancers, amenable to aggressive curative treatment. But disappointingly there is currently insufficient evidence that CT screening makes a difference to outcomes, even in carefully selected high risk populations, which is why it is not offered as an NHS screening programme, which are subject to rigorous controls and quality assurance.

I could go on for pages about the complexities of screening; about the need to evaluate the sensitivity and specificity of a test and to know the prevalence in the population you’re testing to have a good idea of false positive and false negative rates; about the need to have a good knowledge of the natural history of the disease you’re screening for and consider lead time; about the need for precise protocols on patient selection, frequency of screening; about  how important it is to know what the intervention will be if an abnormality is detected; about the need to have systems set up to manage and perform these interventions, with appropriate after-care. I recommend The Pod Delusion Episode 129 for a great discussion with GP Dr Margaret McCartney on this subject, and also her BMJ article.

What is not often talked about is the difficulty in dealing with incidental and indeterminate findings.  What if you go for a CT Chest looking for “complete peace of mind” and it identifies a small nodule? It doesn’t look like cancer, the rest of the scan is normal and you are otherwise well. But it’s there. And you’re “high risk” as you’re a smoker. It’s too small to biopsy and your doctor recommends “watching it” with a repeat scan in 6 months (which you pay for and have.) The nodule is unchanged and your doctor recommends a further scan at 12 months. It is again unchanged so, as per guidelines,  she recommends one further check CT at 24 months. The nodule is still unchanged so she says there is no need to watch it anymore. What started as a desire for “peace of mind” has resulted in 2 years of repeat scans (with the associated cost and radiation exposure) and the unquantifiable psychological cost of knowing there is something there. Even at the end of this period you may feel uneasy that this nodule exists and there may be longterm anxiety about it. I wonder whether a scenario like this is discussed in the consent process for the initial CT. I also wonder how many patients switch to NHS care after the initial scan, leaving the NHS to pick up the bill for ongoing care and tests. As always private companies want all the profit, none of the responsibility.

I absolutely encourage you to be an empowered patient, to take control of your health, to research your condition (from evidence-based and peer-reviewed sources) and to practice preventative medicine yourself. I encourage you to talk to your doctor about your concerns. In this model of healthcare delivery there is a partnership between the patient and physician; the physician providing the expertise necessary to evaluate and contextualise the evidence, in order to advise patients on their options. Admittedly not all doctors will respond well to this, and many are still uncomfortable with the “medical Googler” but as healthcare providers we need to get better at this – our duty of care extends to protecting patients from exploitation and worry. I expect to have more and more conversations that centre around critical analysis of evidence found on the Internet. I expect to be challenged and educated by my patients in the future, and hope to steer them far away from exploitation and harm.

Don’t be taken in by cynical marketing. If you are ill or are worried about your health see your doctor. The NHS is a wonderful system and, for now, remains free at the point of need. If you need it, use it, and save your money for enjoying life.

Below are the specific tests offered by Myrios and reasons why not to buy them. 

1. Anaemia. This is a condition in which the Haemoglobin (Hb) level is low. Hb carries oxygen from the lungs to the tissues and if it is low you may feel tired or breathless. Your GP would routinely do this test (for free) if you had these symptoms. There are many, many reasons for anaemia that would require your doctor to talk to you and examine you, in order to decide on subsequent tests.

2. Cholesterol. An important and necessary component of cell membranes, but high circulating levels of some forms of cholesterol (LDL) and relatively low levels of other forms (HDL) promote atherosclerosis and so are linked to cardiovascular disease (heart attacks, strokes). This test is offered for free in NHS Health Check schemes to everyone aged 40-74, and is part of a comprehensive assessment taking into consideration personal and family history, lifestyle factors and other risk factors.

3. Diabetes. A diabetes assessment forms part of the free NHS Health Check, and  is not just an isolated blood glucose test but takes into consideration other risk factors. An isolated single test of high blood sugar does not diagnose diabetes, so further tests such as an oral glucose tolerance test might be needed, in addition to lifestyle advice and support.

4. Glandular fever. This is a viral infection caused by Epstein Barr Virus, also known as infectious mononucleosis. It often affects young adults and is contagious. Common symptoms include fever, sore throat and swollen glands/lymph nodes. For most people this condition is unpleasant but not dangerous and they get better in a few weeks. There is no reason at all for a healthy person to be tested for this disease. A doctor can advise on when the test could be helpful (including when a simple monospot is appropriate, and when other antibody tests may be needed), as part of an overall assessment of a patients’ signs and symptoms. Available for free on the NHS.

5. Gout. A condition in which patients suffer from recurrent inflammatory arthritis. They have attacks of hot, swollen, painful, red joints; often the joint at the base of the big toe, but other joints can also be affected. It is caused by elevated uric acid levels in the blood, which crystallise in joints and cause inflammation. Unfortunately a blood test for uric acid levels is very inaccurate in the diagnosis of gout. High levels are not always associated with a patient suffering from gout, and low levels do not rule out gout. In fact in an acute attack the patient may have low levels as the crystals leave the blood and enter the tissue. A hot, swollen, painful joint needs assessment by a doctor as it may have many possible causes, requiring different tests and treatments. This is available for free on the NHS.

6. Hepatitis B and C. These are viruses which are transmitted through bodily fluids, including blood and sexual contact. They may cause chronic liver disease, which puts patients at risk of cirrhosis and liver cancer. There are vaccines available to help prevent transmission. If you think you are at risk of Hepatitis B or C you need a comprehensive assessment, taking into consideration risk factors, travel and sexual history, signs and symptoms. You may need tests for other blood-borne and sexually transmitted infections such as HIV. You may need further liver tests such as an ultrasound. All for free on the NHS.

7. Hypothroidism. This refers to an underactive thyroid gland. It has many causes ranging from iodine deficiency (rare in the Western world), autoimmune diseases, to pituitary disease. Symptoms are often vague and include tiredness, cold intolerance, weight gain, constipation and depression. These symptoms also have many other possible causes. If you think you may have hypothyroidism you need to see your doctor so that they can consider other possible explanations for your symptoms, and arrange the appropriate tests. For free on the NHS.

8. Iron, Vitamin B12 and Folic acid. These are all substances needed for many functions, but specifically as part of the process producing red blood cells that carry oxygen to the tissues. If they are low you may become anaemic. There are many reasons why your iron, B12 or folic acid level may be low, ranging from dietary deficiencies, to stomach and bowel diseases, so you need to be seen by your doctor to evaluate what the most likely cause is in your case, and they can then suggest relevant further tests. For free on the NHS.

9. Menopause. This is a normal stage in the reproductive life of a woman, when menstruation stops. During the transition some women experience symptoms for which they seek help, such as hot flushes, sleep disturbance, vaginal and urinary symptoms. There is no definitive test for the menopause, although changes in hormone levels may be detectable. There is no reason to check hormone levels in most cases. If you are having distressing symptoms your GP would want to see you to talk and support you through them. For free on the NHS.

10. Stomach ulcer. A stomach ulcer (which can actually be in the stomach or first part of the small bowel, the duodenum) may lead to abdominal pain, nausea, bloating and blood in the vomit. It has a number of causes, but by far the most common is infection with Helicobacter pylori. A small minority are caused by gastric cancer. If you have symptoms you need to see your GP to assess you and consider whether a blood test (for H pylori serology) will be helpful, whether you would benefit from a trial of treatment, or whether you should have further tests such as an endoscopy. All this is available for free on the NHS.

11. Syphilis. This is a sexually transmitted infection caused by a spirochete, Treponema pallidum. The initial stage of infection stage presents with a single “chancre” a firm, painless, non-itchy skin ulceration. Syphilis is very easily cured with antibiotics. If left untreated it can eventually spread to other areas of the body, including the central nervous system, and cause serious illness. If you think you are at risk of having contracted syphilis you need to be tested for other sexually transmitted diseases and need to be seen at a GU Medicine or Sexual Health clinic. For free on the NHS.

12. Vitamin D. Humans get this from diet and from synthesis in the skin in response to sun exposure. Severe deficiency leads to rickets, a childhood bone disease (almost unheard of now in the Western world) or osteomalacia in adults. Your doctor may test your Vitamin D levels if you have certain bone diseases (for free, on the NHS). There has been recent interest in Vitamin D and its role in multiple health problems including cardiovascular disease, asthma, MS and neurodegenerative diseases. There is a lack of evidence to support Vitamin D supplements unless a patient is severely deficient (uncommon in those with a normal diet who occasionally see the sun), therefore there is little value in testing.

→ 6 Comments

Posted in In Between

Tagged , , , , , , , , , , ,

An alternative day: how technology could enhance healthcare

Posted on March 29, 2012 | Leave a comment

Real day: 

I arrive at work, and quickly check my emails on my phone before I enter the signal black hole that is the hospital where I spend my working life. The SHO is not in yet, so I persuade the ward clerk to briefly give up one of only 3 functional computers on the ward and update the patient list with the details of the 2 new patients, whose names are scrawled onto the whiteboard. I skim through their notes, and cast my eyes over them to make sure nothing urgent is required. I leave a note for the SHO requesting her to arrange some tests, before I go to the secretaries’ office to hunt for a working dictaphone and a spare tape.

I arrive in outpatient clinic 15minutes before the first patient’s appointment and turn on the PC. I find the printed lists of the expected patients and pick up the first set of notes, searching through the years of mis-filing to find the referral letter. I finally find it in between a yellowing letter from Ophthalmology in 1994 and one from General Surgery in 1990 that I’m sure was typed on a typewriter.

This closely resembles my NHS clinic computer

By the time I have read the referral letter the computer has loaded up as far as the login screen. I enter my details, listen to it whir, and watch the egg timer turn over and over. I call in the patient and start the consultation as I wait for the screenprompts to enter separate passwords for the Radiology and Pathology applications. I take a history and perform a physical examination. I finally get access to laboratory tests, but have to filter the results in several different ways to get all the results I need. I can then finally look at some recent imaging, although I can’t compare this to old xrays as they have been archived and I don’t have time to ask the computer system to retrieve them from the data store as this has all taken quite a while and there are many patients waiting in the corridor. I fill in the patients details on multiple separate forms for additional blood tests, a CT Chest, and a further clinic appointment, and fill in a form that I keep to one side to fax to the GP later to advise on new medications. I want to check whether the new medication will interact with one of the patients’ other regular medications but the BNF that should be in the clinic room is missing. I can’t check on my phone as there is no wifi and no 3G signal and I don’t even try the desktop. I run out to the corridor and thankfully the nurse finds me a paper copy and I confirm the new drug is safe.. The patient leaves the room and I dictate a letter. As I rewind to correct a phrase I realise the tape is not working. Thankfully I have learned this lesson the hard way before so have a spare. I feel under pressure as I am already starting to fall behind schedule, grab the next set of notes and call the next patient in.

The morning continues like this, with the Radiology system completely crashing at one point, leaving me unable to review one patients’ latest scan. I therefore have to apologise to them and promise to call them later with the result.

After clinic I return the dictaphone and tape to the secretary and ask her to fax the necessary forms. I check the wards are OK, see 2 patients who can potentially go home and then grab a quick lunch. I get a phone call asking for a respiratory opinion on a ward patient, and in preparation for seeing them try to look up the recently published guidelines for pleural disease to confirm the latest management advice . The intranet is being difficult and is blocking Google, so I find a patch of signal between the store room and the toilets and resort to reading the guidelines in tiny text on my phone before going to see the patient.

We start the Consultant ward round, pushing the notes trolley around the bays, trying to find the drug charts and observations charts for each patient. We explain to Mrs Jones* that the Chest CT has confirmed what we suspected from the chest xray and that she has a mass. We suspect cancer. She struggles to understand what we’re talking about, but we’re unable to show her the scan as she is bedbound and the “Computer On Wheels” on the ward has not been charged so can’t move from the wall where it’s plugged in.

We continue round to Mrs Brown* who has a pleural effusion under investigation. She has had this before, a few months ago, and was investigated at our sister site. She can’t remember what they told her about the results, and we do not have the old notes as they have not arrived from the off site store. We see from the pathology system that some abnormal cells were seen, but without any old letters or notes it’s difficult to know what the clinicians who have been managing her since then have planned. We make a plan that will at least relieve her symptoms in the short term, and hope the notes will arrive before the weekend so we can integrate previous management into our plan.

Mr Low* is next. He has recovered well from his pneumonia but is less mobile and more dependant that he was prior to admission. He has been ready to go home for 2 days from a medical point of view but social services claim they never received the assessments we faxed and therefore have not put in place the package of care he needs to go home. We apologise to Mr Low for the delay and promise to do our best to get him home before the weekend. The sun is shining and he’d prefer a view of his garden to our car park.

After all the patients have been seen and everything documented, the SHO writes a request form for an urgent xray and walks two floors to drop off the form in the Radiology department. After searching 2 control rooms she finds a Radiographer who accepts the form and promises to make sure the xray is done that evening on call. She then returns to the ward, checks the blood tests and chest xrays that were pending, writes discharge summaries for the patients due to go home the next day, and updates the patient list. Since all these systems are separate it takes a while, but finally it’s done. The medical students she had promised to teach got bored waiting for her to complete all her paperwork and went home. She feels guilty for letting them down.

I have misplaced my patient list, but retrieve it from between 2 sets of notes in the trolley and take it with me to the office. I check the x-rays from the morning clinic and call the patient who’s scan I was unable to see. Thankfully it’s reassuring, so I do not have to break any bad news over the phone (what I was fearing all day). I check and sign the letters typed by the secretaries from a clinic earlier in the week and they are posted out. I write myself a to-do list for the next day, take off my stethoscope and head home, late again.

Imagined day:

I arrive at work. The SHO is not in yet so I grab my personal work iPad from its charging station and login. It opens immediately and I click the app for our patient list to see that the integrated system has automatically updated to feature our 2 new patients, whose names are highlighted in bold. I click on each of them in term and rapidly review their electronic admission notes, imaging and lab results. I have some time before clinic so introduce myself and chat to each of them, checking that each test required has been requested. The system shows an allocated slot for the echocardiogram, which I feedback to the patient. A CT has not yet been requested so I click on this, the system automatically inputting the patient’s details and latest blood results, and input my password to sign off the request. It appears as “pending” in the patient folder so the SHO will not waste time also requesting it if I don’t catch her before I head to clinic.

I arrive in outpatient clinic 15minutes before the first patient’s appointment and login. I pull up the clinic list, and due to the integrated system am able to directly link to all results and previous clinic letters. I read the first patients’ referral letter, check any recent results and review recent chest xrays. I compare to old xrays which is invaluable in this case, revealing a new shadow. I am thankful that old imaging is easily accessible since the hospital solved its data storage problems.

I have a lot of information before I call the patient is, allowing me to take extra time taking a history and performing a physical examination. There is time to explore the patients’ worries and answer questions. With a few clicks I request the additional blood tests, a CT Chest, and a further clinic appointment, and complete a template “urgent GP letter to advise on new medications”. This is automatically saved in my email outbox, with the relevant GP practices email address completed, for me to review and send later.  I click on the BNF app and quickly confirm that the new medication will not interact with one of the patients’ other regular medications. The patient leaves the room and I dictate a letter onto the voice recognition system. I notice a few typos but I elect to save the letter and review at the end of clinic before it is sent.

An example app, developed In London by North East London, North Central London and Essex Health Innovation and Education Cluster (NECLES HIEC) in partnership with Asthma UK, Queen Mary University London, Solar Software.

I am on time, and review the next patients’ recent letters and results before calling them in. I see that they have asthma and have started a new inhaler. I notice that they have been using an app to record their peak flow, which allows the patient, respiratory nurse and me to access the recorded data. I click to view the graph and feel well prepared to have some important discussions on treatment plans with the patient. The morning runs smoothly and I finish clinic with time to grab a coffee on my way up to the ward. I check my twitter feed in the lift and see a link to an article on new evidence on pulmonary fibrosis treatment that I save as a favourite to read later.

I  review and approve the letters from clinic and them and dock the iPad to charge. The letters automatically download and email themselves to the relevant GP practices. I check the wards are OK, see 2 patients who can potentially go home and then grab a quick lunch. While I eat I read the article I saved from my Twitter feed and think about a recent patient I saw that I must discuss with my Consultant. I get a phone call asking for a respiratory opinion on a ward patient, and in preparation for seeing them I look up the recently published guidelines for pleural disease to confirm the latest management advice. I have these guidelines saved as a link in my browser bookmarks so they’re easy to access.

We start the Consultant ward round, entering our comments onto the electronic notes system using our iPads. The drug charts are also electronic, allowing us to make changes at the same time that the nurses are logged in, dispensing drugs from the cupboard. The intelligent prescribing system prompts us to reduce the dose of a patients medication whilst they are on a particular antibiotic. We explain to Mrs Jones* that the Chest CT has confirmed what we suspected from the chest xray and that she has a mass. We suspect cancer. She struggles to understand what we’re talking about but since we’re able to show her the scan on the iPad she is better informed and is able to understand what will happen at the proposed lung biopsy.

We continue round to Mrs Brown* who has a pleural effusion under investigation. She has had this before, a year ago, and was investigated at our sister site. She can’t remember what they told her about the results, but we are able to pull up the old notes on the electronic system and can see what decisions were made before, and what the clinicians’ opinions were. We see from the pathology system that some abnormal cells were previously seen, but that after discussion with the patient and her family it was felt inappropriate to further investigate due to her frailty. We therefore make a plan that will relieve her symptoms and are able to start planning a supported discharge with community support.

Mr Low* is next. He has recovered well from his pneumonia but is less mobile and more dependant that he was prior to admission. He has been ready to go home for 2 days from a medical point of view, and since the relevant forms were sent to social services electronically they logged them on the day they were sent and immediately put in place the package of care he needs to go home. The hospital transport arrives as we are saying goodbye to him and he thanks us for getting him home to enjoy the sunshine in his garden, rather than forcing him to spend any longer staring out at our car park.

After all the patients have been seen and everything documented, the SHO clicks to request an urgent xray and calls the “hot room” where the on call Radiographer is keeping an eye on the urgent referral work stream. He looks at the request on his screen and promises to make sure the xray is done that evening on call. The SHO then checks the outstanding blood tests and chest xrays that were pending, completes the discharge summaries for the patients due to go home the next day (which have results of blood tests and scans auto-populated into them), and updates the patient list. She is then free to do the teaching she promised the medical students, and still finishes on time.

I check the x-rays from the morning clinic and pop in to see my consultant to discuss  a patient I saw earlier in the week. I bring up the new evidence I read at lunchtime and we discuss how this relates to this patient. We complete an assessment on my e-portfolio, and I add an entry to TILT, which I also post on Twitter.

I write myself a to-do list for the next day, take off my stethoscope and head home, on time.

→ Leave a comment

Posted in In Between

Tagged , , , , , , , , ,