Thick, oozy mud.
We can’t go over it.
We can’t go under it.
WE’VE GOT TO GO THROUGH IT!
And so, it begins.
Michael Rosen’s words from We’re going on a bear hunt seem apposite.
A couple of weeks ago I had a satori.
That is, a sudden moment of realisation, awakening.
It relates to my purpose, or, rather role as clinician and what I should be doing and how I should be deployed.
In many respects, this is not new. For the past 20 years I have been working to support the care and wellbeing of older people.
I know… Older people. Who would want to spend time with them?
This was the shock I encountered in my 20’s when announcing my intention to a room of relatives at the conclusion of a Passover Seder.
You are all old. I told them.
A moment of realisation.
It’s a truism; the greatest source of ageism is old or, older people.
I don’t know why. It is perhaps the secret of a healthy long life – never consider yourself old. Be young at heart. Your joints may ache, your vision may dim, but so long as your essence is in your teens, you will keep going.
And so, my focus is supporting older people.
Disease, time, and accidents are all major impediments.
In many respects you can’t do much to stop time; you can mitigate accidents by being careful although that can take away the fun and uncertainty from life which is what living is about (isn’t it?) and disease, well, it comes, it can also be mitigated but there is a limit. Yes, take your flu and Covid vaccine – none of these are one hundred per cent. Measure your lipids, take your statins, and regulate your blood pressure – none of this will stop the heart attack, only slow its advance.
If pneumonia or diabetes are coming, they will eventually get you, no matter your oropharyngeal health or body-mass index.
And so, much of this is responding, easing the passage. Prescribing the antibiotics and hoping a person has enough ‘cheshek’ internal energy to overcome the inanition, recover and keep going. Mostly we do, sometimes we don’t, and that, is life.
This wasn’t intended as a treatise on ageing, more a statement on mud.
Or my current thoughts on quicksand.
Quicksand, mud, and custard are non-Newtonian fluids. They are liquids that are also solids.
There is likely more to the physics than my simple description, you get my gist. If you have big enough feet you can run across a pool of custard; if you dally you will sink.
And so, hospitalisation for older people.
My realisation had been the disproportionate harm that befalls older people when in hospital.
For years I have been working to keep people well and at home or in their care homes.
Before Covid I took a colleague round the care home I support; she was surprised at the number of patients I had completed a ‘Please reconsider admission’ form.
The form, devised by me, this doctor and another colleague has operated locally as a moment of pause for out of hours GPs and paramedics when assessing an older person.
It says, ‘When ‘Herman’ becomes unwell, please consider the potential harms of admission to hospital. If Herman can be supported at home, please ensure this happens. If Herman is very unwell and likely not to recover, please provide him with palliative care at home. This is what Herman wishes. Please respect his aspiration.’
Or words to this effect.
The letter started as what I called my ‘Sherlock Letter’ as the template was based on a letter from Dr Watson concerning Sherlock Holmes.
In many parts of the UK this has been superseded by ReSPECT which stands for, Recommended Summary Plan for Emergency Care and Treatment. It is the same thing, just more official.
My colleague was surprised that I had completed the form for people who appeared fit.
‘Fit’ in my world can be misleading.
I exist in a realm of frailty and ill health, of dementia, delirium, falls and disorientation.
And so, my realisation that keeping people out of hospital if it can at all be avoided is almost always in their best interests.
This has never been as true as during the Pandemic and in the subsequent ‘failing NHS’ years.
Yesterday, I introduced our medical student to a patient who had been our Typhoid Mary. Her GP, working at another surgery, had (IMHO), admitted her to hospital during Covid – she was constipated. She returned to the care home a few days later with the infection and seven residents died.
This is extreme and most hospital admissions are only harmful for the individual, yet with infections as they are, anything can happen.
And so, to the quicksand.
Until now, most of the effort invested in the support of older people who land in hospital has been focused on either a) stopping them becoming damaged from hospital – preventing falls, pressure ulcers or hospital acquired infection and, b) getting them out of hospital once the antibiotics, transfusions or investigations have completed.
I am focusing on the latter.
Once an older person is in hospital the process of hospitalisation begins.
When I started my blog (2015), this wasn’t really a word – it has subsequently entered the mainstream.
It is the process of becoming a hospital patient with all the risks and associated hazards.
Recently, it has included the hours waiting on the kitchen floor after a fall, waiting for the ambulance, the hours outside A&E (in the back of ambulance), the hours inside A&E waiting to see a doctor and all the palaver involved in moving to a hospital bed – finding a ward, changing nursing and medical teams, repetition of events and so on.
If I am admitted to hospital I am likely to survive, unless, the cause of my admission is something very bad e.g. massive heart attack; if someone living with frailty is admitted (in other words, an individual who perhaps is low in body weight (less than my 90Kg – many of my old folk weigh less than half of me), struggles to walk, to dress or even feed themselves) their chances of getting back home are far less and, when they do, they are likely to be diminished – further loss of weight, reduced ability to care or support themselves, to walk, to stand. These are the harms of hospitalisation, the harms of wearing PJs for a couple of weeks when you are 90 years old (prior to Covid, a national campaign ‘End-PJ Paralysis’ was growing in momentum; it has become lost in all the worry about contagion, infection and isolation.
And so, there is huge effort invested in supporting people to leave hospital.
This is the quicksand.
It is easy to get-into, less so to get out.
‘Chest pain’ you shout and before you know it, leads are attached and you are on your way to the cardiac catheter lab (which is great if you are having a heart attack), the way in is easy (although frequently delayed as above), it is the getting-out that is tricky.
Not just the arranging, preparing, and sorting of take-home medicines, outpatient appointments and transportation, for the older old, it is the assessments for moving and handling – how to help the previously independent older man get out of bed using a transfer aid ‘Rotunda’ or a sling or hoist. (Every doctor should sit in a hoist to understand the helplessness our patients encounter, frequently daily – the enforced passivity and its harms).
If it takes 1H (H being a unit of healthcare energy) for a person to get into hospital, it takes 100H to get them out.
And so, the necessity to ensure that only those who should be in hospital should be in hospital.
This might seem straightforward.
‘The people who are in hospital need to be in hospital,’ but no.
Remember the cliché, every hammer sees a nail? Well, every hospital doctor sees a vein that needs cannulating, blood testing and antibiotics giving.
‘They fell.’ Says the junior doctor.
‘Urine infection,’ says the senior.
‘Yes, better give then something strong.’
And so, it begins for the person who fell over their cat. What they need is a new light in their pantry not intravenous Cefuroxime.
People have a belief that when a hospital doctor says ‘heart attack’ or ‘pneumonia’ they indeed have these diagnoses. The reality is opaque.
Yesterday I had an odd experience.
I looked at one of my patient’s legs and informed the nurse, ‘I think it’s a basal cell carcinoma.’
Her grand-daughter who was sitting behind me leaned-in, ‘It looks like a squamous cell to me,’ she said, ‘I am a dermatology nurse.’
My point being, had the relative not been present, I would have written in the record ‘probable basal cell carcinoma’ that would have become the narrative; someone with a little more insight and perhaps better eyesight changed the plot.
Thus, one doctor might say ‘chest infection’ another ‘bronchitis’ another ‘pneumonia’ and a fourth, ‘chest clear, probable urine infection.’
People don’t realise the imprecision of medicine. It’s like that. It is complicated and uncertain, and this is the world our parents and grandparents discover when they leave A&E and are pushed along a corridor, skinny shins exposed, slumped on a trolley.
The extraction is the hard part and is why avoiding admission is so much more effective.
Keeping someone at home is not without cost.
It might equal 5 or 10H (using my earlier system) – yet this is 20x more efficient than allowing the other processes to play-out.
And yet we probably invest half an H.
Covid ended to a greater or lesser extent GP home visits, the Tory, austerity and all that has gone-on in the past decade (swingeing bureaucratisation of primary care) has eaten away at much of its added value, of relationship-based medicine of, ‘Yes, Tony often complains of chest pain, it’s is his hiatus hernia’ vs ‘Tony has chest pain – dial 999.’
Continuity of care is (to my mind) the most precious component of modern healthcare & it has been diminished.
The demolition started in the 2000’s with the introduction of the European Working Time Directive and has become worse with time. Tory put the nail in the coffin.
‘I see you,’ says Neytiri.
This, a fundamental of James Cameron’s alternative universe is the perception of one by another, the acknowledgment of their essence. By my encountering you, I am forever changed, as are you and that change continues, it grows and develops over time. (It is a bit of Ubuntu too).
A clinical relationship is the same; more profound for those of us working in the community, outside of hospital where we know our patient’s streets, houses, the pattern of their carpets, the names of their dogs. (Rudy, Goldie, Sandy, Brian).
And this the satori.
I have decided to leave the processes already established in helping people out of hospital (that 100H) and to spend my time, my focus on the admission avoidance, on keeping people well, on ensuring treatments and support are available in the community.
Yesterday (which was a normal busy Friday) I discovered one of my patients had been admitted onto our Virtual Ward.
93, she is an independent woman.
‘She’s probably been admitted,’ confessed her GP.
On closer examination of her clinical record, not only had she remained at home, but she had also received a detailed assessment by my team.
I visited her, she is getting better. She doesn’t need a moving and handling assessment to determine whether it is safe for her to sit in a chair – she is in a chair; she has her living room window to watch the day’s goings-on, she has her TV remote to hand and her medicines within reach, she was dressed in her usual old-lady garb, and all was well.
Beware the bog!