Why are you here?

Leaving blue-tits to one side and, getting back to my main focus…

A frequent question I ask my patients, usually when trying to establish their orientation, but also to clarify their understanding of the situation, is, ‘Do you know why you are here?’

I leave the question purposefully vague – ‘here’ – where is here? But, not so obscure as to tip people into existentialism.

And, mostly, perhaps, 80 per cent of responses are – ‘I don’t know’ – remember, this group is a subset; I usually don’t ask it of a person who has come-in with a solitary problem… Fall… broken leg… why are you here? ‘It’s my leg dumb-dumb.’ Although, frequently, when talking with older people, the query – fall… broken hip… why are you here? Is met with a questioning look.

I think there are two reasons for this situation.

The first, being, many of our patients have so many conditions – usually called ‘multiple-long-term conditions’ – heart disease, arthritis, diabetes, eczema, asthma, that, it is sometimes hard for the patient to determine where one condition ends, and another starts – my blood pressure tablet is to treat my blood pressure, but it also helps my diabetes and heart disease and kidney function. So, what is the tablet for?

Your mum has fallen and is admitted to hospital. In an instant we have worked-out that her blood pressure is low, her white count raised, drugs interacting, and we aren’t entirely certain whether or not she’s had a heart attack.

No wonder the uncertainty.

Most hospital inpatients these days are either very sick – sepsis, multi-organ failure, pneumonia or, are just old with the multitude of long-term conditions a person acquires as they age, all with a tipping-point crisis – fall, infection, funny-do.

Secondly, the system is never that sure why a person is in hospital – and, when I say system, I include the doctor or nurse with their many years of training and experience.

‘You are in hospital because you fell.’

‘Can I go home – I am OK now.’

‘No, we have found that your sodium is low, there is a patch on your chest x-ray, there might be a drug-drug-drug interaction and, oh, you haven’t seen the physiotherapist yet.’

‘So – no?’

Next day…

‘Hello, Mrs Broon. Can you tell me why you are in hospital?’

The first is complexity of disease, the second system convolutions.

Maybe I should find a better question?

Alternatively, instead of trying to establish why a person is stuck in hospital, I should force the metaphysical… So, you are here; where are you? Are you sure you are here? How do you know you are not somewhere else?

Perhaps this explains to an extent the ongoing challenge faced by the hospital system – managers are constantly looking to achieve ‘flow’ – this idealised state where patients are going home at a slightly faster rate than they are arriving; flow is physical, like a river, the actual process however is beyond physical, it is spiritual, metaphysical.

Therefore, I suggest if those obsessed with flow were to change their position and, instead of focusing on flow as something substantial, something to measure with numbers on interactive screens, and, instead focused on the what, why and where of flow they might get somewhere more meaningful than ‘move bed A to ward B and bring-up patient C.’

Part of the flow series.