Tag Archives: medicine

Healing wounds

My partner recently injured his hand on a faulty ladder. This took off an area of skin over a proximal finger joint resulting in a dramatic amount of bleeding and an inability to use the finger. Over the days and weeks since we have watched the healing process with fascination, noticing the stages of recovery of both form and function. Normal wound healing has four recognised stages: haemostasis, inflammation, proliferation, and remodelling. For a wound to heal successfully, the four phases must occur in the right sequence and time frame. Many factors can interfere with this process, risking impaired wound healing.

As we watched the re-epitheliation and remodelling of his physical wound it made me think about the unseen wounds many of us have suffered since the start of the pandemic, and the impaired wound healing we have been experiencing. So many people have been harmed not only by the virus itself but also by the lockdowns and the lack of a social safety net, eroded for decades by austerity. I see wounded people often in my work. They are incredibly adaptive and resilient but the body keeps the score, and many chronic diseases and distressing physical symptoms have their roots in emotional and social distress. I cannot speak for these people but I see them. I see their suffering and their strength.

Neither can I speak for all NHS staff, but is is well recognised that the pandemic traumatised healthcare workers. We experienced moral injury long before COVID-19, when we did not have the resources to provide the quality of care we wished to, were let down by a decimated social care system, or were forced to turn people in need away due to factors such as their immigration status. The pandemic brought us challenges that were all too familiar, but, more than that, it highlighted the pervasiveness, severity and proximity of this harm.

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Can we find the spirit of ’45 in 2013?

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.

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What’s in a name?

At work recently I felt like a broken record. “What’s their name?” I said again and again with increasing frustration as I received calls about patients who were referred to as “bed 3,” “side room 1,” and “bed 9.”

Of course, at times it is convenient and even desirable to omit a patient’s name in a conversation. It was suggested on Twitter that it may be better to overhear what ‘bed 9’ needs rather than ‘John Doe is ready for his haemorrhoidectomy,’ and in this case I agree! My worry is that in most cases there is no explicit intent to maintain confidentiality. Instead the convenience of referring to people by their bed number slips into routine communication. I have certainly been guilty of this myself. I worry that this is not merely disrespectful, but that it contributes to the dehumanising experience of being a patient, and negatively impacts on the doctor-patient relationship.

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When the lights go out

Most people I know have never watched a person die. Even those that have been to funerals and therefore have seen and been in physical proximity to a body, have rarely been present at the moment of death. The moment when in the eyes of the dying person the lights go out.

I have been there, in the moment, a number of times and remember every time with eerie clarity. Sometimes I have known the patient well; other times I have only met them in their last minutes or seconds. Sometimes it has been almost ethereally peaceful. Other times it has been frantic, chaotic or distressing despite our best efforts to treat end of life symptoms. Most often it has just happened.

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How to die: CPR and the concept of futility

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.

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A Grief Encounter

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.

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The Dangers of DIY Diagnosis

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.

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An alternative day: how technology could enhance healthcare

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.

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What is the NHS for?

At a party this week I got talking to a friend of a friend who quickly discovered I was a doctor. The conversation changed from which tube lines were running and who had made the delicious chocolate brownies, to the NHS: specifically its failings. I become, not for the first time, an embodiment not only of the medical profession, but of the entire health and social care system. I was charged with defending the lack of care shown by GPs, the apparent willingness of doctors to prescribe pills for anything and everything but never to listen, the lack of a nutritional perspective from NHS practitioners and the poor funding of mental health services.

The NHS is not perfect. I have heard many stories from dissatisfied individuals, and wouldn’t for a moment dismiss their grievances. I have even been known on occasion to spend an entire dinner party lambasting its’ deficiencies. But conversations like this make me wonder about the expectations of the public of this institution of which I am extremely proud. What do they think the NHS is for?

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Last week a man asked me to kill him

I had just told Mr George* that his end-stage heart failure had become refractory to treatment, and I thought it likely he would not survive this hospital admission. He looked at me carefully and said, “Well that’s it then. Can’t you just give me something…end it for me?”

This is not the first time a patient has asked me such a question, and will not be the last. Often the question is more ambiguous, and it is unclear exactly what they are asking for: “can you just put me to sleep?” could be interpreted as a plea to end their life, but could equally be a request for a break from their symptoms or thoughts, with the hope of a more energised remaining time afterwards. It is a constant challenge to interpret such questions appropriately and personalise support and treatment for the needs of the individual.

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