I seem to have written lots about the state of ‘medically fit’ – the reason for this being my eternal struggle to understand the term which is matched only by the population as a whole’s complete lack of understanding as to what it means.
As I have already covered:
‘I mean doc, how can I be medically fit when I am dying?’
I am not going to explore this further – if you are interested to read more, please check-out these blogs.
My aspiration is to demonstrate that my perception has altered.
As to whether this is a consequence of my current circumstances or, as is more likely, a fallout of the decidedly unhealthy health service in which I work, I can’t say.
Let’s face it, although we are living through times of unbridled prosperity, with the average lifespan increasing, infant mortality dropping, better treatments for stroke, heart attack and cancer, it seems that the demand on healthcare is increasing – a little like a child who isn’t satisfied with one Haribo, but wants the whole packet and, when that is finished, the box.
I guess the words are inexhaustible, indefatigable and insatiable.
(Thank you Scrabble and Lyndsey).
How do you square the ever-growing need with the fixed provision?
The answer is, you change the terms of engagement, you alter the perception.
To start, you get rid of certain fixed ways of thinking that don’t help (and, we know, as thought follows language, we must begin there).
Tell yourself ‘I am crap/weak/angry/happy/sad’ 200 times and what do you feel inside?
First, I’d suggest we get-rid of the concept of ‘medically fit’ (for discharge) as, it is increasingly redundant.
I remember years ago, a senior doctor trying to convince me, a medical student at the time that the average number of legs was 1.9 – because of all the people with amputations. He succeeded for a while.
The average hospital inpatient is never medically fit – not in terms of their complete, holistic mental and physical health and wellbeing.
When was the last time you saw Usain Bolt in a hospital bed? (admittedly, although I am sure physically he is pristine, I don’t know what is happening in his head or soul).
The arbitrariness of fitness has to go. We are all at a certain point on the continuum of wellbeing, some less than others – with every existential positive at one extreme – joy, happiness, laughter, comfort, security, belonging, rest and, at the other, well, dead. (Unless you consider the states of being which some will argue are worse than death, although I don’t profess to know – there is an old blog however).
Perhaps I need a thought experiment…
Monday morning, before, during or after the ward round:
‘Who is medically fit?’
The conversation will not end there, but you get the picture – a nonsensical game of ping-pong between consultant and discharge nurse, manager or co-ordinator.
‘You mean, there will be no one going home, no empty beds for new patients?’
‘Well – that is a different question, let’s talk…
We need to change the lens to determine who must be in hospital, after all, despite the work to make dementia and patient friendly environments, most folk still prefer to be at home. (Mallard Ward excepted).
Change the conversation – ‘Why is your patient in hospital?’ Or, better still, clarify with the patient, ‘Do you know why you are in hospital? What do you think is happening?’
Many people exist in a state of limbo based upon medical platitudes… ‘We are sorting things out.’ (What things?), ‘The physiotherapist is going to see you.’ (And what miraculous intervention will they make?), ‘We are waiting on the MRI report.’ (And, why wait, why is the report, or the scan not instantaneous?)
You see the point?
We have a hospital crisis when most of our what are perceived to be acutely unwell patients could be managed, supported or cared-for at home or, in the circumstances of the most frail and vulnerable a care home or facility.
Instead people sit, de-conditioning, acquiring infections, pressure ulcers, falls, depression, loneliness, losing important skills and abilities: ‘Nurse, I need the toilet.’ ‘Here, use this bottle/commode/bed-pan.’
Part of the failing relates to the pressure.
If I have 30 patients to review and treat in one morning session, I will spend half the amount of time problem-solving had I 15 patients, with more emphasis on plugging the gaps, papering-over the irregularities, the predominant symptoms and missing the point.
To address this superficiality, we use teams who support the delivery of care, but, often they are so pushed they apply an equally ineffective balm, moving-on or being called-on to the next crisis or situation.
We are running so very fast on the wheel that we don’t realise we are not actually moving or getting anywhere, other than exhausted.
So, time out. Slow down.
Instead of five minutes skittering on the ice, let’s change our footwear, sit down and get to basics.
Does x need frequent observations as they might collapse?
If they collapse, isn’t that the 96-year-old’s prerogative?
Does x need long-term oxygen?
They smoke… Well, let’s talk the point of our intentions.
Does x need multiple administrations of intravenous antibiotics?
Are there any bacteria around?
Do they really need blood tests every day?
Were yesterday’s bloods different from the day before and the day before and the day before?
There are more situations than these, but, we could draw a list of the essentials of hospitalisation – who must be in hospital; Yes, those on ventilators, or, heart-lung bypass goes without saying – for the moment anyway (we used to think this of haemodialysis).
How many people would meet these criteria?
For how many could we find solutions that use the combined resources of community nurses, therapists, GPs, family and friends, heck we could even say to the hospital nurses and therapists – ‘You know what? Why don’t you go and see Mr or Mrs Y at their home? Get yourself some fresh-air!’
This was the model that was discussed years ago, it seems to have halted at an organisational hiatus where, like trams on the tracks we can only move in two directions; let us be like Daleks who, to contend with Christopher Eccleston evolved to cope with stairs…
‘I can’t see a patient in their home, I don’t have the equipment/resources/time/’
Inverting the model could be fun.
It will provide an extra level of challenge, but, not one that says the treadmill must run faster, but which seeks solutions from the bottomless pit of creativity, innovation and ideas that sit at the heart of every person. New, different, novel ways of approaching tried and tested problems, escape mechanisms we were previously too afraid to question.
I don’t suggest I have the solutions as each of them will be local, particular and person-centred; does the patient even want to have the operation? Where do their preferences sit in this relationship? What is in their best interests? What are their interests? Our patients are more than their GCS, Early Warning Score and urine output, what about the infinite complexity that is the human soul?
No, I probably won’t tell the bed-manager on Monday, ‘None of my patients are fit,’ as that might risk getting us both into trouble, it would also potentially end the conversation – ‘How many people must be in hospital for their treatment, care, support?’ Well – that is an altogether different question, let’s see…
Joseph Trumpeldor, founder of the Mule Corps in WW1 – famously told his commander after losing an arm in Russo-Japanese War – let me fight! I still have the other arm to give to the Motherland.