Sleep

There is a science of sleep.

This evening as I was driving home, I heard Peter White discussing sleep disorders in those who are blind or have significant visual impairment.

Unlike our crepuscular cousins, humans are diurnal; we are designed to sleep when it is dark and potter during the day, creating industry, building things.

Central to this system is the function of the pineal gland and the hormone melatonin, which alongside an array of other chemicals regulates our sleep-wake cycle.

Light plays a central role in this which, via our retina which feeds directly into our brains,* makes us sleepy at bedtime and perky in the morning (for those early-birds like me.)

Sleep and wake are of huge importance to patients in hospital and, in particular those who have dementia and related disorders, where their sleep-wake cycle can be turned upside down; inverted. Added to this, reduced exposure to meaningful daylight and monotony, loneliness, immobility and frequent cat-napping and you have a perfect storm for sleeplessness.

The nurses on Mallard know all about sleeplessness; sometimes preceded by sun-downing – the change in behaviour experienced by people with dementia as light fades, cortisol falls and visitors head for home.

I sometimes jokingly refer to this experience as being akin to Night at the Museum – the Ben Stiller movie where the exhibits come to life as the lights go-down.

When my patients sleep during the day and are awake at night all sorts of bad things can happen. At night, with fewer staff, there is less supervision, with lower levels of light, the likelihood of falling increases, with night, shape-shifting illusions come-out of the dark, worsening confusion and disorientation; meals are missed (although we do our best to be flexible), as are tea-rounds; weight-loss and dehydration can ensue.

It is all a jumble. We aren’t designed to be up and about at three in the morning.

We try to rebalance sleep by increasing daytime activities, by talking, joking and engaging with our patients, getting them up and dressed, dancing, singing, drawing, painting.

Hospitalisation as well as being one of the highest risk experiences for older people can also be one of the most boring.

We try to break the monotony, I know however, despite some great work across the country, the standard experience for the average hospital patient – particularly someone who is older and trapped by pathway delays, is one of days that are long and uneventful and tedious.

Your pineal gland doesn’t get a look-in in these situations.

I sometimes resort to sleeping remedies, when the Horlicks hasn’t worked – Melatonin, the recent addition to the pharmacopoeia has shown some promise, but like all drugs, works for some but not others, more often than not the latter.

This is back to the start – it is shining the light on the complexity of care, on what it means to look holistically; to be responsible for the journey, beginning to end. Acknowledging that the old thinking – the doctor see, doctor do, is no longer adequate; only when all the dimensions of night and day, sickness and health are considered, in the round, can we hope to make a difference.

Enough is not good enough.

It is not just what you see that matters, but the hidden, the esoteric pathways of nursing and medicine, pharmacy and therapy, talking and listening. Night and the day; sleep and wake.

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*Never realised I was photovoltaic.

UTI

UTI – Urinary Tract Infection.

UTI has become part of everyday language. A meme that represents our changing society.

Twenty years ago, when I was at medical school UTIs existed, they were however still within the rarefied toolkit of doctors.

UTIs have grown and changed, morphed from something specialised, something that you needed a medical degree to diagnose, into a 21st Century commodity like Vapes or cans of Red Bull.

It is not uncommon for a relative to tell me that they think their mum or dad has a UTI.

‘They always behave like this when they have a UTI,’ or, ‘It’s a UTI – you can smell it a mile-off,’ and, words to this effect.

Relatives and carers aren’t to blame for this quick-fix, quick-fire method of diagnosis as the whole health and social care economy has jumped-on the bandwagon of UTIs, not as a panacea, but as an explanation for most that goes wrong with older people – falls, confusion, pain, immobility, fever, non-specific blood-test anomalies; you name it and it can be caused by a UTI.

Or not.

You see, when a scientific approach is taken and the situation analysed, we discover that there is more in the world of frailty and ageing than urine infections.

In reality, UTIs are actually more complicated than an older person smelling of pee.

Smell is not a UTI. Smell is just the smell of pee.

Falls. Older people fall. They also on occasion become confused; this is delirium – a reversible condition akin to dementia which is irreversible and, which can also be experienced by people with or without UTIs.

As we age, our microbiome evolves; the bugs living on our skin, in our bowel and bladder alter. Urine is meant to be sterile, although often, in older people, bacteria get in, but, instead of pathogens causing disease, are either commensals – living in harmony or, tourists in your urethra.

These aren’t UTIs; for this purpose, we invented Asymptomatic Bacteriuria.

Treating asymptomatic bacteriuria is a little like the tactics used by Texas police; Hands in the air. You look iffy… I’m taking you down the station.

Time has fuelled the growth in UTIs in A&E and, in 21st Century Healthcare in general. The numbers of people, seeking assessment, diagnosis and treatment, all, squeezed into a limited window of opportunity encourage quick fixes; botched jobs that take you nowhere;

This is the prescription for Trimethoprim, when, a person is lonely.

It doesn’t work.

Or, when an old woman is poisoned by other drugs prescribed decades before to treat real conditions and which are no longer a risk – statins, pain-killers and blood pressure treatments; the answer, another drug that isn’t needed and compounds the insult.

‘It’s a UTI,’ doctors and nurses become complicit in the scam. Often this is given as a diagnosis when nothing else fits, or, when what fits is not congruent with what is apparent. And then, with more time, more reflection and analysis the diagnosis is undone – de-diagnosed and the medicine de-prescribed, we find ourselves untangling the knot.

The overuse of antibiotics globally is considered by some, to be as great a threat as global warming, international terrorism or avian flu. These are boogeymen that capture the headlines.

Nitrofurantoin – how can that harm you; go on, just a little prescription, just a few tablets;

My request? Well, that is to slow down.

Think UTI by all means, but don’t allow it to overwhelm the senses.

Think linear.

In most instances it is straightforward, and here is the trick.

Stop, look and listen.

When in doubt, don’t UTI.

When in doubt, stop, look and listen.

The patient will almost always have the answer; the befuddlement of dementia or delirium or, aphasia is why we have doctors and nurses – to disentangle the narrative.

That is the challenge. That is the effort.

david prowse

 

Psst, over here…

Look,

Over here,

There is a door;

The lock has broken.

Off,

Off you go,

Yes, that way…

She immediately stepped into the wardrobe and got in among the coats and rubbed her face against them, leaving the door open, of course, because she knew that it is very foolish to shut oneself into any wardrobe.
Soon she went further in and found that there was a second row of coats hanging up behind the first one.

Off, to wherever you want.

Magical transportation that cuts-out the social-care assessment as middle-man and destroyer of hope, that fast-tracks you to home, or even, manipulating the magic of time and space, back to that happy July in the garden with mum, baggy shorts and old Celtic top, spinning though the moments of tot squeezing into the living-room chair, snuggling; kitchen table Friday night smells and creaking floorboards.

Back, back, to the farm, the milk round, back, to the days before the evacuation or the sirens, back to the place of comfort where mum and dad and baby are safely waiting.

Here it is, the bus to Upton.

Stuttering stop-start moments that are the present; your son, husband? Children, gathered round, concerned, smiling, vulnerable; the uncertainty between independence and locked away somewhere, with fifty other old men and women for the final days.

And, back with nurse, holding my hand as we negotiate the corridor, the dayroom, flower-bed, sensory garden.

Is it any wonder your frustration is occasionally perceived as anger and my compassion as hurt?

Website Through the Wardrobe

 

 

Home?

 

But, why can’t I go home?

Yes,

over there,

outside,

look!

 

I am 83 & not stupid & I want to go home & you

are stopping me

 

What is the matter with me?

Nothing fancy like deprivation of liberties, capacity or best-interests

Just, stuck inside a hot building in June

and

sunshine through the window

Good, old-fashioned pathway failure, waiting, wasted times

and people

looking-on;

patients & relatives & staff

 

Tuning-in to the conversation;

 

Empathising with me for the tight spot I am in;

 

An old woman challenging her liberty

& I am

the system slave

 

Powerless

Effete

Pathetic

 

I can organise a scan,

Prescribe medicines

even,

when needed,

get-out the needle and thread to repair your damaged scalp.

Our bad – you fell while waiting, stuck.

But, the simple things

like,

Letting an old woman home.

are beyond my ability.

 

Impotent.

And, you know what…

This is a growth industry.

 

I sneak-off;

Her attention distracted

for a moment

by someone

or something else

down the corridor;

 

A stutter in the monotony of her captivity.

 

 

June, 17th

He has big hair and stubble that is more than a couple of days old. And, as he squints from behind thick glasses he has a look that is questioning, uncertain and potentially disagreeable.

It was a few weeks ago.

The disposal room.

A place where service assistants, housekeepers and cleaning staff deposit their bags of clinical and regular waste – cups, tissues, bottles, that sort of thing.

The room is windowless, it has an automatic light.

Each day the porters arrive, take away the bags, leaving space for more rubbish.

Today the roll-cage had been removed and the bags chucked unceremoniously, randomly into a smelly heap.

The porter, I’ll call him Nick, wasn’t impressed. He was hugely pissed-off; he had to find an empty roll-cage from somewhere, load all the fetid, sweaty bags onto it before unloading them at the collection point for disposal.

You know how it is, there are some jobs no one likes, but which, we accept as being part of life – picking-up socks and pants from the bedroom floor, scraping burnt curry into the bin; mopping up child or dog or cat vomit – all these occupy a space of never much fun, always unpleasant.

The system, or, whoever had borrowed the original roll-cage and, subsequently collaborated in tossing the bags into the room were part of the same mechanism.

Nick was pissed.

Beside

Himself.

And, I got how he felt. I sensed his frustration, although, likely, not to the same extent; Soon, I was off, brewing my coffee, checking patients or replying to emails.

Last week I read the novel, The Girl Who Saved the King of Sweden, by Jonas Jonasson.

In the beginning, Nombeko, the protagonist is a latrine cleaner in Soweto, she moves swiftly to manager then nuclear scientist, refugee and king-saver; Nick isn’t moving.

Most people don’t move; they don’t find an escape that changes their fate. We walk along the road and keep on going until there is nowhere left.

Nick, frustrated, went away, found a cage, came back, loaded and unloaded and so it goes, so it goes-on.

I wanted to step-in, to help, express my empathy, show that he was not alone, in his frustration.

We have this special ability as humans to look at the lot of another and feel great compassion, overwhelming affinity and, at other times, nothing. Not even numbness, just blank.

Walking along Euston Road last week, the homeless men and women, grimy, dirty, tired in the gutters, didn’t trigger a response; I was protected, shielded by my alienation.

As I glanced at the ingrained dirt, the sun-beat wrinkles, flaking skin and exhaustion, I looked this way and that, diverted focus to my phone, to the surrounding, road signs, traffic lights.

Look away; don’t look here. Don’t look there, don’t let anyone see you are looking at them, for, if eyes connect, the reality escalates and you find it harder to back away, to turn around and pretend everything is OK.

Nick, who works as a different, but equally important cog in the mechanism of health and care that I inhabit, spins round in his own orbit, interfacing with friends and family, colleagues and acquaintances.

There is an iPhone game called ‘Geared’ – in it you have to move around different cogs in order to create the perfect balance, to establish a coordination that allows you to move-up to the next level.

I see Nick and I, like that, spinning around, rotating in our own worlds, dancing to our own rhythms.

It is funny. We cannot live alone. We all need to be a part of society in order to exist, to maintain our wellbeing and sanity; isolationism might be proposed by a certain US president, it is not, however reality, it is counter to our evolutionary spirit, our prime directive, which is be, feel, grow & connect.

Where is Nick now?

I am sitting in my garden; washing machine just finished its final cycle, song thrushes and sparrows beckoning the twilight.

Where is Nick?

Still, dishevelled, tired?

I have so much to appreciate, that, I don’t see it.

Most of us do not value what we have until it is gone, until it is too late, when the moment has passed. When, we are old, looking back on a life that might have been different, altered for the better or the worse; lighter, higher, more enlightened.

I’ll end by thinking back to Jo Cox who died a year ago today and all the celebrations of diversity and unity that have been held across the country.

We all serve as counterbalances to the good and bad of society, we all carry the can for the aspirations and failures of our friends, families and colleagues.

We are the branches of the tree that must keep growing, as the roots are forced deeper into the earth.

Nick, I would gladly trade places, at least for that moment, to diminish your frustration, to accede to the reality of that windowless room.

Is grass really greener, or is it just grass?
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Me, we, dementia and Donne

This year the Dementia Action Alliance, released a new set of ‘we’ statements relating to dementia.

This was a significant change in the way a disease – dementia is considered. The statements were generated through discussion and consultation with those living with dementia and those supporting them.

Here they are:

      We have the right to be recognised as who we are, to make choices about our lives including taking risks, and to contribute to society. Our diagnosis should not define us, nor should we be ashamed of it.
      We have the right to continue with day-to-day and family life, without discrimination or unfair cost, to be accepted and included in our communities and not live in isolation or loneliness.
     We have the right to an early and accurate diagnosis, and to receive evidence based, appropriate, compassionate and properly funded care and treatment, from trained people who understand us and how dementia affects us. This must meet our needs, wherever we live.
     We have the right to be respected, and recognised as partners in care, provided with education, support, services, and training which enables us to plan and make decisions about the future.
     We have the right to know about and decide if we want to be involved in research that looks at cause, cure and care for dementia and be supported to take part.

Disease, although it primarily affects the individual does not stop with them; it occupies a place central to friendship, family and society.

Dementia is a disease of neurones, one brain cell at a time malfunctions, spreading eventually to the whole person.

None of us can live in isolation (beyond the Aristotle/Nietzschean idyll) – I link to you who connects with me; I become us and we.

Perhaps this is an approach that should be taken to all disease – moving the expectation that whether you have eczema, asthma, diabetes or cancer – the monad of me alone, suffering in silence is not what we are about.

We, evolved to live in groups, societies, collaboratively, supportively – if we allow disease to affect just individuals, to peel them off from society, for whom does the bell toll?

My hay fever affects me; it is me who is sniffing and snuffling through the night, yet, it has affects beyond my person, it reverberates throughout the household.

My arthritic knee, or back or neck, causes me pain, yet, the experience ripples through my family and friends, it changes the dynamic.

Grenfell tower is a representation of me and we; me – the mansion owners of Kensington, somewhere in the world, living it up, their empty houses abandoned yet secure with the latest burglar and fire alarms. And, down the road, the people packaged into minimum square-space existence.

Brexit is another example; I am fine, thank you very much; We isn’t something that is part of the equation – you, you foreign, dark-skinned migrant, refugee, asylum-seeker are not part of we, you are peripheral to us.

The irony of the justification for TM not meeting victims of the fire because of concerns over her own safety.

The irony that so long as I have my car, my holidays, pension and day-time TV, things are alright, don’t bother me with the trivialities of Mogadishu or Damascus.

The we statements represent a shift, a movement away from me to us, from them to we;

Don’t peer too deeply inside; it’s not just about the medicine or the tablet, it is the relationship that counts.

This spills-over into patient safety; when I am considered first, and my patient second, when my troubles or preoccupations are allowed to dominate the narrative, when I forget that my place is to care, I risk forgetting the ‘we’ – I risk not seeing the patient, who by extension is me.

Person-centred care – seeing the person as central is as relevant as seeing that the person you are treating is you, could be you or, your mum or dad, brother or sister.

Once this shift, this change in perspective has occurred, nothing can ever be the same.

We not I.

Us not me.

xxxx

I learned yesterday a little about photons.

Photons are the smallest indivisible particles of light that exist without mass, without occupying space or volume.

Beyond this conception are different species of Photons. Entangled Photons are paired particles that are also indivisible. What makes them stand apart from anything else in the universe is that the two can never be entirely detached.

Stretch the entangled photons to different sides of the universe and what affects one will affect the other, no matter the distance or separation.

Like conjoined twins who share feelings or sensations regardless of distance or geography.

This takes us back to the notion that ‘we’ needs to be considered the smallest unit of society. And, this is not just ‘we’ in the sense of, my family, my town or tribe, but, ‘we’ in the sense that what affects one of us affects us all.

We are indivisible.

This is what makes us human.

photon

Life cycle

Mostly, we don’t pause and reflect on the speed of life;

Sure, the bad times often seem to drag-out for too long, and the good ones, whoosh. But, life?

Seeing life sped-up, accelerated and compressed, in your garden hedge is special.

Below is a narrative of the chicks who took-up residence.

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This in itself is amazing, but, when you consider the life of the chicks as a reflection of our own.

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Our children, until they are 18 spend most of their time asleep, at school or with technology. Beyond that, they are off into the world. Wherever they go; during those 18 years we, the parents have time with them. How many hours in a day?

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After the drop-off, our child-parent time diminishes dramatically.

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The first 18 years of your child’s life represent only 20 per cent of their time on Earth; for the remainder, you are only a bit-part.

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You will never spend as much time with your children in all the remaining time as you have the opportunity in the first 18.

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Make the moment count.

For Annie

Yesterday – disaster avoided.

It is hard to know whether yesterday’s election result was a disaster avoided, or, merely a detour round the wreck to another unexplored place of misery.

Despite the polls, I never allowed myself to believe that the Tories would win; I didn’t seek shelter underneath the impossibility of Labour doing so well. I kept going.

The results – I don’t understand – perhaps in time they will come clear.

My enemy’s enemy is my friend.

They say this all the time in diplomacy, in the world of subterfuge and double-meaning.

I can’t imagine this is a place I will find myself.

Who knows about tomorrow;

I note that Mr H has been left-off the list or ministers who will keep their jobs; this worries me, for, at least with H and I guess, you could say with M, you know where you are – you know that when they draw a breath, the next thing is unlikely to be true, or at the very least a recognisable distortion of Right-Wing ideology.

Dress the wolf-up in the clothes of your friend and the subterfuge might work.

Alright, I’ll admit it – I had been preparing myself for many months of misery; of positive thinking exercises to lift me out of the depression, to distract me sufficiently to drive in to work each day without an excess of despair.

I had been preparing to shut-off the radio (again), avoid the newspapers and retreat to my safe-place.

Now I am in-between;

If you read 11/22/63 by Stephen King, you find an alternative reality where JFK is not assassinated; only, this reality is worse. The outcome a greater disaster for humanity.

Fortunately or not, we don’t have time-travel; the Spare Oom door and the door in King’s novel do not exist and we can’t step back in time or travel to another world. The world can’t be changed by a manipulation of chronology.

The main feeling I am left-with, if, perhaps I look beyond the headlines and some of the pictures, is a sense of hope. For, regardless of where we end-up, the election demonstrated that there is a will in this country to move beyond me to we, from I to us.

Self-interest is seen as no interest, for you can’t live outside society, it is what keeps us afloat, the air that we breathe.

I still live in hope that before my kids have grown I can wake them, the next day, jumping on their beds with, ‘We’ve won’ – time is running-out, they won’t be young forever; by increments we can move away from number-one, to number-x, from my spot of shade to the gallantry of open-plains.

Go on Jezza.

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York – somewhere else;

I spent a few hours in York yesterday.

I travelled up to present some of the work we have done in Doncaster in relation to Quality Improvement, dementia and delirium (signing, dancing, dog-visits – that sort of thing).

Recently, I have been talking about the perpetual Narnia which the government has foisted on the NHS; walking into the reception of the York Racecourse – where the Quality Improvement event was held for the 600-odd delegates was like not just going back through the wardrobe, but shaking Aslan out of his stupor and having a jig.

york.jpg

The place was abuzz with positivity, can-do creativity and energy, I had to pause and question whether I had come to the right place.

There was a roomful of posters created by a multitude of departments across their organisation – discussing everything from falls prevention to operating theatres and happiness.

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Well-done York.

Perhaps the post-election disorientation affected my perceptions; on three floors staff from different departments demonstrated their work – showed-off what amazing things they have achieved and plan to accomplish; it was positive psychology in action.

Why I am telling this story, is not to big-up York, although I think they should be bigged-up, but, more, to explain that despite all the crap, regardless of the illegitimi carborundum, they managed to pull-off something special, something that demonstrated the reality that good begets good, which leads to great and, you sometimes need that step-up to proceed.

Thanks to York for opening the Land of Spare Oom door, If only we can harness this energy, there will be no crisis, we’ll be flying.

Magic money tree

Where is the tree? Has it been felled?

There are two versions of reality – the view that we don’t and can never have enough (the no MMT one), and the version of plenty, where there might be no MMT, but, there are all the amazing things around us.

My daughter was surprised this week when listening to the leaders debate with Mishal Husain, that the UK has the fifth largest economy. Yes, we, as a society have more wealth than almost all the other countries on the planet (the remaining 97 per cent).

But, there is no MMT.

Yet, when it is wintry outside, the snow is falling and A&E departments are overflowing, a hospital corridor becomes a reasonable source of accommodation for a 93 years old, yet, those leaving university with a better or worse degree are indebted to hedge fund managers for the next twenty years;

No MMT is seeing that we have little, when in reality we are overwhelmed by surplus – too much choice, too many daytime TV shows, cheap sugary lipid-laden drinks and treats. Too many car journeys and foreign flights or heating in the winter.

Perception is everything.

You look slim or fat or OK – it is perception; and perception is relative, it is also created by society. Listen to someone telling you how stupid you are and you’ll eventually believe it, listen to the narrative of weakness, laziness or failure and soon enough you will adopt that mantle.

It is not just the condescending use of the MMT concept – not just that the arrogance is not something I would direct towards my children when they ask me for more, it is the position of someone who is so detached from reality that they cannot perceive the viewpoint of the other, where their perspective is skewed to the point of perversion.

And back to the nurse who enquired about her year on year reduction in earnings at a time when moments later she is told the economy is booming. Booming sound-bites that I dearly hope people can see through.

I think back to Laurel and Hardy… That’s another fine mess you’ve got me into… The current government, which is still inveigled by the post-Cameron, Johnson and Hunt nastiness has handed our society a whopper; the post-Brexit mess that threatens to emasculate and diminish the society that they tell us is poor, but which we all see as being rich, rich from the contribution of migration and rich enough to accommodate any number of people in need, rich to the extent that the xenophobes should pack their bags and go back to their ancestral homes.

Balancing plenty with the communiques of austerity will be a lifetime’s work; I guess my prayer is that the MMT continues to flourish, has deep and strong enough roots to allow us to maintain the standards of living which we take for granted.

Look! Car, clean water, shelter, supermarket, education, health, social security – the MMT is vulnerable; let’s take back ownership.

Memory 3

I remember…

There are different forms of recollection – the first and most fundamental, is, ‘I remember,’ when we take images of the past and hold them in our mind’s eye. Ghosts, they dance before us, transient, temporary, some more vivid than others;

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The second recollection is when an old photo or film is shown; when you see yourself age eight, smiling – this is more concrete; you might see past events – the General Belgrano, Tiananmen Square, 1994 in South Africa.

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You can’t argue with what you see; the interpretation might be different – I see the man standing in front of the tank from one perspective; the official view of the Chinese Government is likely different; what did the man see? What did they think?

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Then, there are the memories that others have about you; these are the spirits that inhabit a nether-world of collective consciousness.

My grandfather running his fingers over my head-stubble; standing in the cockpit of the 1985 El Al plane and chatting with the purser; looking-up and seeing my two-year-old son approach as I lie on the resus trolley.

There is my memory of the events and the memory or not, of the other; when that other person has gone, the memory exists only with me, it an never fully be ratified; when another is involved, their perspective can influence the interpretation.

I remember you, you remember me. We see each other differently, yet the moment is the same.

Picasso painting the Three Dancers saw that the world is more than we see, it is what is in front and behind, it is what is before and after, all the dimensions including time convey the meaning.

So, what is real?

When can I rely on my memory?

Should we accept that we can never be certain about the past because of the effects of time, of impression, influence and interpretation. Or, should we go with what we believe to be true.

I heard the other day about a new digital concept. Imagine in the future, we are able, somehow, to integrate cameras into our eyes, so that everything we see, all that we look-at is captured in a cloud repository; add to that audio, and you have a film of your life experience;

And then, if you want, you can return to that event last year and re-play it; perhaps walking down the sunny street aired during the winter blues, swimming with dolphins when you are worried about the outcome of a test. Plug this in to VR and away you go.

Many say that this is fanciful and unlikely to ever be possible; let’s wait and see.

How I would love to feel or perceive once more the fingers running over my head, or squeezing into the armchair with my mum when I was four, or, or.

It is funny when I see people, particularly at this time, so very certain in their analyses. When the politicisation of everything is everywhere, where people try to manipulate perspectives and force upon others their beliefs.

How tangled and murky it becomes. Fake news, fake communique, you said that I said you said and, so on.

For the literalists, I have little to offer. The relativists, however, let’s keep going.

 

Forward and Back *two

Here is another interpretation of social media, the past and depression; there is a theory, that social media – Facebook in particular, acts like a memory and experiential sieve. It pulls-out predominantly good experiences and demotes the negatives.

This might sound like good and common sense; after all, is that not what we do with our memories naturally? The pain of my broken arm is lost somewhere in neurospace, the memory of flying over the handlebars, crashing and rough landing is ever present.

Facebook is predominantly filled with positive moments; it is a repository of happiness – mostly; yes, there are posts about disasters, tragedies and terrible events, but these tend not to occupy the body of the narrative.

I post a picture of the sunrise; (I don’t share my burned toast (unless it is spectacularly burned, or imprinted with an image of Jesus)) – instead, the party, happy day out, beach, graduation, and so on.

All of this is great, it is one of the modern wonders to be able to share these positive experiences (so long as the photo and the sharing don’t get between you and the moment) – in a time of societal impoverishment, this coming together is a human attempt to connect.

But, when I click and click and scroll-down and see the lives of others – the foreign travel, new car, new baby, party, happiness, it can result in a re-equilibration of my experience. ‘Everyone else is having a great time, what about me?’

Yet – we know this is not the case, we know that the moment was the moment and there is always more to a story than the photograph.

The concern relates to children and young people, particularly those who are socially isolated and heavily dependent on social media conceiving the world differently, seeing two worlds – theirs and the party everyone else is enjoying.

When I was 15, if I was alone, at home, reading a book and my friends were out partying, I may have known about the party, but the book could distract; bringing the pranks, antics and high-jinx into my handheld device surely would have magnified the isolation.

Do we follow our memories, or do they pursue us?

Let’s perhaps not go there on this sunny Saturday –

Let us instead do some tree hugging, or mini-beast watching (I have my own ant colony), let us taste, touch, hear and, see, let us perceive and contemplate, enjoy the sun or the rain or the clouds; moment by moment we see the passage of time –

Here is a quote I found this morning from Tim Ferris –

FullSizeRender 9.jpg(Such as assembling Billy bookcases??)

Whether the moment is good or bad, it is nothing but a moment.

IMG_1651.JPG

 

 

Forward and Back

There is an idea that if you spend too much time thinking about the past you risk depression and, too much in the future, anxiety.

This makes some sense.

The past – the way things were, the good old days, etmol; Our brains are fantastic at filtering-out the bad moments, the times of despair, pain or fear. We selectively recall the good, or at least when we look back on the bad, it is usually blurred, indistinct;

And, to the future, what might be, how, where, when? What if I… What will happen? The future-state possibilities are endless, limitless and, I imagine it is this lack of limit or boundary which makes anxiety so visceral.

We need the past and the future – forgetting the past and we just make the same old mistakes again. Forget the past and you are condemned to repeat it, so said Santayana.

Tomorrow, tomorrow, I’ll love ya tomorrow; It is difficult to determine whether any other species is able to create a picture of tomorrow and plan towards it; this is what allowed us to form tribes and clans, to hunt in groups, build cities and destroy the environment.

I’ve seen wolves and lions hunting in packs – is that the same thing? How are roles assigned in these animal groupings? (Lion 1 to lion 2, ‘You wait behind that big rock and jump-out at the zebra when I shout Bazinga.’)

Without a concept of tomorrow, the loss of expectancy, of looking forwards, would be a tragedy. The childhood night before your birthday; before a holiday; Christmas (or so I am told) –

We need the past and we need the future to maintain us in psychological wellbeing. It is likely when the past devours us, or the future overwhelms our present, things go wrong.

Yin & Yang; keeping in balance.

How do we balance the future and the past?

The likely answer is present.

Pause for a moment in the present; see the sky, the trees, the clock ticking, smell the cooking, feel the warmth. Taste the now.

This, going back to an old subject, is Mindfulness. Occupying the moment, not paying it lip-service; more, extracting the richness, the essence of now; grinding the spices, releasing the flavour.

Mind wandering, mind stop & focus.

We don’t have a word for obsessing about the moment; the moment is now, it is whatever is happening, be it good or bad. Regardless, in the moment all we have is action.

Let us toss the past, present and future into a bowl and mix, agitate, stir.

The past present and future gives us who we are; who we were and are yet to become, frozen in timelessness.

The only reality is the moment; everything else is myth, happenstance;

Enjoy the ephemeral.

Memory

Memory; as, quicksilver, unintelligible, hypnotic, intoxicating.

I remember, it was likely 1993, in a garden in Dundee.

A young woman said hello;

It’s Pxxx; how are you?

My expression blank; puzzled.

It appears that Pxxx and I were once classmates in primary school; that would have been in the early 1980’s. 13 years before.

I had no recollection of Pxxx. She didn’t look familiar. I couldn’t place her name. Nada.

I guess, had I been a different person, I would have pretended to know her, perhaps talked about the good old days, running around playgrounds with grey shorts and anorak. Instead, I said, Sorry, I don’t know you.

After a while, she walked-off.

I had a similar experience today, but, worse.

I met someone I knew, someone I had talked with maybe three or four years ago, and, I didn’t recognise them at all.

The person I met was so ill, had so deteriorated, physically, that I was unable to recognise them, even after we spoke; walking away, I wasn’t certain whether they weren’t someone else;

To compound this lack of recognition; when I first approached, I smiled – something I do frequently at work; smiling at people I do not know. Some smile-back, others less-so.

This person returned my smile times-ten.

My lack of recognition confused me; I returned a so-so smile and went on my way, later, I spoke with them.

I still did not recognise them. Now, I realise, I am pained to think, that they recognised me, but then, they saw that I had not remembered them, and they, insightfully, continued the ruse; they didn’t challenge my lack of recognition, they accepted it, as I imagine they have experienced before with others who were unable to see, for whatever reason.

I could not remember the classmate, nor the friend, yet, when I look back at moments of my past, some are frozen in time.

So many of those I have known then never seen again, from my childhood, my youth, adolescence; are still, in moments in time, their images hanging in perpetuity. They do not grow old, just as the soldiers, just as the film-stars and icons.

And I, who spend so much of my time surrounded by people whose memories have faded, who have lost the last 10 or 20 or 40 years of their lives, who exist in a vacuum of the 40’s and 50’s.

Perhaps my fallibility explains the affinity. Perhaps the recognition that I am no better or worse, no different to them, is what maintains me, is what enables me to continue like this.

In a moment, we all exist in moments. Bubbles of time. Perhaps.

And, this realisation gives me an impression of my place in the tableau;

I often talk of person-centred care; it forms the centre of much of my work, yet, when I unravel the meaning, when I unlock, and, look deeper, the realisation becomes more apparent – it is the awareness that this form of care is only possible when I do not just see the person, even, see them as my mother or father, but, as me.

When I see that the old woman who has fallen could be me, the young man with pneumonia, those with confusion, hospital acquired harm and disability, depression, anxiety, organ failure, deterioration and degradation could be me, that is when I can begin to provide more meaningful care.

It stops being us and them and transforms into us and we. Me. I might be the person that is forgotten, who a friend or colleague fails to recognise. It could be me. We must maintain this awareness to facilitate a balance. To ensure our humanness.

Dementia

OK.

It is Dementia Awareness Week 2017. Now, until Sunday the 21st.

If you want to see what was going-on last year, look here.

Today, we released to the world, via You Tube, our most recent film, focusing on Person-Centred Care and Dementia.

Just because you have dementia doesn’t mean you stop being you.

Dementia is a disease – it is horrible, vicious and, nasty; it robs you of your self, your identify, personality, memories, hopes & dreams.

It doesn’t need any help from us – the doctors, nurses or therapists, carers, advocates or supporters; let us un-do the disease, turn-back the clock. Let us look at what is disease and what is you.

You are everything; the alpha and omega of your existence. From the day of your birth, until you die, you is the essence; We start-out as babies. We acquire names, identities and personalities. We grow, develop and form into the people we become.

Disease is an add-on. A bit-part in the movie that is who we are.

Dementia is bad enough without being robbed of our identities.

Look… Here! Me…

Dementia is what has gone wrong; most of me is still right. Most of me is still here. Happy or sad, excited or frustrated, worried or…

When a person has dementia, most of them is still present; no matter the degradations; I am me and I will be me until I am no longer.

When you see and old man, look at the person; look at the 80 or 90 years of life that precedes the disease; the dementia must come second.

We are first-class citizens; let’s demote our diseases to second-class.

I am Albert and Oded, Yael and David, Donald and Jake;

I am myself, my family and friends, my work, my experience, love and laughter.

Once you have moved beyond all these elements, you can see me as a pathology, a falling apart, a loosening.

Come-on.

Let’s be having you!!!

Behind the scenes… (And other reasons why I struggle with DIY)

I have always loved getting behind the scenes; it is likely that others feel the same – I don’t know.

I was reflecting on this last week, in relation to technology; I think it was shortly after unscrewing my son’s bass guitar and peering inside at the (broken) wire (subsequently, successfully soldered by grandfather) that the thought came to me.

When I was young, this was something I loved – taking to bits, disassembling, particularly electrical items – TVs, radios, puzzles and games.

This is not to say I knew what I was doing – I am not and never have been particularly technical – I never understood what I was looking-at, it was more the taking apart and looking rather than the subsequent fiddling.

This is perhaps one of the many reasons I did not become a surgeon.

The theory has always ranked more highly in my estimation than the practice.

The point for me was not my ineptitude at practical matters, more my thoughts that the fiddling I got up to 40-odd years ago is no longer a meaningful option to my children.

You can’t readily take apart a Samsung, iPhone or X-box, and, if you did, you would likely find inside just tiny circuits that are equally inaccessible.

The innards of my TV, Sat-Nav or laptop are as unlikely to convey a story.

Transistors, vacuum tubes and cathode rays all hold a certain mystique – a gateway to something;

What will this loss or change mean to my children?

How will tomorrow differ mechanistically, disruptively, from today?

Time will tell. There are likely to be other insides they will find, other minutiae to pass the time.

I will always find a home at the bottom of my garden, under the rocks and rubble, examining, investigating the beetles and grubs as they wriggle in the earth.

That is me. Today, tomorrow, is different.

Again, genug.

cathode ray

 

 

I search for meaning (& patient safety)

It is likely that many reading this blog will be familiar with the Austrian Psychiatrist Victor Frankl and his book, Man’s Search for Meaning, published in 1946, soon after his liberation from Auschwitz.

The book describes Frankl’s experiences wedded with an interpretation of what he saw through a lens of Humanistic Psychology – this he later translated into his own field of Psychiatric theory, Logotherapy – literally, meaning-therapy.

First things first; if you haven’t read the book, please go to out and buy or borrow it.

Beyond this, the main principle of Logotherapy relates to the necessity for meaning in life; this is closely wedded to Nietzsche’s ‘He who has a why to live can bear almost any how’ – meaning beats method.

My reason for bringing this to my blog, other than to perhaps get people reading Frankl, is to reflect the similarity of this teaching, derived first from 19th Century European Philosophy, then 20th Century human suffering and now in use in 21st Century patient safety and quality improvement in healthcare.

The modern interpretation relates to a component described at the conference I attended the other week in London, hosted by the BMJ/IHI.

The session focused on joy in the workplace – and, it’s associations with high quality, safe care.

Happy staff provide safe care.

So, how do you keep your staff happy?

How do you create a culture of joy in the workplace?

Safety. Psychological, physical, occupational, spiritual safety.

Only when we are not on the lookout for threat can we begin to connect with our imagination, our creative spark. Fear sends people to the bunkers, you sit and wait for the storm, the fear or the threat to pass.

One element therefore of creating a safe, enjoyable, creative workplace is to allow people to be themselves, away from fear, away from criticism and analysis.

This links to another great work – To Err Is Human, published in 2000, which reflects the untold story of patient safety in healthcare – showing for the first time to a stunned public, the extent of the harm, predominantly through error, mistake and human factors in hospitals.

The title focuses on the reality of life in any complex system – we are all human, we all make mistakes; it so happens that the more fearful an environment, the more likely are people to err, inherent in this concept, is the way to fix the system – how to address the errors.

This suggests that punishment or retribution for those who err does not help – it just makes everyone else more fearful and creates a culture of deeper fear; you improve safety by acknowledging that we are all human and all prone to error and the response to error is early identification and learning.

In recent years with Albert Wu and others’ work on second victims we have learned that learning for the person, the team or organisation involved with the error is not enough – the individual caught-up in the mistake needs support.

And here is the connection back to Frankl. A safe workplace is joyful. Safety is achieved through the staff having a sense of control of their own lives and meaning for their efforts.

This is when we call on the famous quote – ‘I’m not mopping the floor, I am helping to put a man on the moon’ (sorry for all these male slanted references – most are from last century).

Allowing staff to understand their role, to see that whatever they do is part of an overall project of improvement, of patient recovery and wellbeing, is critical.

When staff are involved in helping determine the way to achieve that goal, one that is meaningful to them, we have something special. When an adequate sense of safety pervades the workplace so that anyone can ask anyone why? Without fear; or when people can propose solutions, work-arounds or fixes that are outside of the hierarchy, outside a systematic approach to management and organisations, that is when you are on to something.

This is when meaning and joy come together to create a happy, resourceful, sustainable and safe workplace.

whistlers mother

Geriatric fall

Yesterday, in the hospital, we had a talk about clinical coding. This is the language used by hospitals, care systems, the government, national and international organisations to tally, calculate, cost and analyse what goes-on. That is, how many patients, operations, and treatments a hospital is undertaking, this allows for individual ward or clinician level analysis – how many patients with pneumonia did Rod treat between May 2015 and 2016? How long did those patients remain in hospital? How many recovered, died?

It is unimaginably complicated and results in much feverish activity in the clinical coding department – this is a team of skilled analysers who plough-through medical records and assign codes which are then translated into numbers which are then collected by a cloud-like disease, morbidity and mortality tracker in the sky. From this you can work out the risk of you acquiring C. difficile from hospital A or B. See here for more.

As with all highly complex systems, it exists within a margin of error. Most people don’t know what that margin is, suffice it to say that it doesn’t matter, as when in doubt we endeavour to compare like with like instead.

‘They did 100 varicose vein operations in hospital A, but 150 in hospital B’ – is B better? Is A treating more complex veins? Do B work twice as fast yet have twice the number of complications – infection, pain, dissatisfied patients.

Tabloids love these figures as it allows them to get away with saying… ‘Hospital H – death rate is twice the national average!’ Subtlety is usually lost in these situations.

And from here I go to the title of this blog… Geriatric fall.

I was discussing this diagnosis with my team on Wednesday.

An older woman fell at home and was admitted to hospital; the initial diagnosis was ‘Geriatric fall’ – I guess to those of us who are less uptight than me, this might be OK – something to acknowledge and move-on; for me however, it stuck.

‘Geriatric fall, what is a geriatric fall? How does it differ from a non-geriatric fall? Do ‘geriatrics’ have a special way of falling (aside here – when I was young, in the 70’s I remember my dad talking about the falls my grandma experienced in her Southside tenement – somehow, despite her falls she never managed to harm herself; she had a special way of falling; ‘She would crumple,’ I think was the description.)

Anyway, here is my point –

I, an experienced doctor who has spent many years caring for older people doesn’t know what a geriatric fall is; specifically, how it differs from all the other falls – perhaps, someone reading this can help.

Does it matter?

*I don’t even know whether I should be writing, ‘Geriatric Fall,’ ‘Geriatric fall,’ or ‘geriatric fall,’ which is more correct or appropriate?

Will the system see Geriatric Fall and align this with better statistics? Will it allow those looking-on to understand the true complexity and challenge inherent in supporting a geriatric who has fallen, compared to someone else who is just old.

My preference is usually to say, ‘93-year-old man admitted with a fall,’ I might then explain why I think they have fallen – arthritis, dizziness, too many sedatives, and so on;

(I have just read the British Geriatrics Society Introduction to falls written by renowned geriatrician, Finbarr Martin in 2007 and revised in 2010 – he doesn’t mention ‘geriatric fall’ in that document, so, at least I am amongst good company)

Over and above this is my problem with geriatrics in general; the word translates from the Greek – Geri – old age and Iatros – doctor; Not too far away from ‘Paediatrics’, but that is another matter.

You see, in recent years the age thing has become less relevant to my work – age, in the chronological sense. Physical, physiological and psychological age yes, these are more closely associated with Anno Domini.

We are moving toward Medicine for Older People – Older being a relative term specific to each person; examining and addressing complexity, co-morbidity (what else you have wrong with you), frailty and fragility are all areas in which I have a level of skill.

Geriatric. I don’t know where that fits-in.

In my experience, most older people – and that is whether you are 40, 80 or 100, see the world through a set of ageing eyes. They don’t necessarily see themselves from outside – the wrinkles, liver-spots and greying hair; more often, people see themselves no different to the individual who was once 18. Adulthood. Away from the seven ages of man. There is just one age… Now.

And back to geriatric falls.

I am going to stick with the basic ‘fall’ – I may be doing myself a disservice; I might be losing my organisation millions and sullying its reputation for the quality of care we provide geriatrics.

I, however have my reasons.

In the end, although names are important, it is what you do with them that counts.

Ep34-Geriatric-EM-Pearls-Pitfalls.jpg

 

 

transaction or transformation?

So, what is it you want?

Where do you want to live, work and grow old? Transaction or transformation?

I guess I had better add more detail to this question – in its base form it is a little ambiguous.

I’ll begin with definitions:

Transaction – this relates to the physical and material transactions of everyday life; the give and take, the concrete. What we can count, add-up, subtract, and join together. It is the data; the binary digits whirring past on a Matrix screensaver, pass or fail, Littlewoods scorecard. Black and white.

Within transaction there is no grey – just good or bad. Yin and Yang. A world of absolutes and certainty. My way or the highway.

A transactional world is safe. It offers a veneer of certainty under which none of us know what is bubbling. Superfice. Plastic, mechanistic, Le Pen (in its extreme). I am on top and you are beneath.

Transformation – where to begin? It is the zephyr. Quixotic. Ever-changing cocktail – metamorphosis.

Butterflies transform – the rest of us just transact;

Transform is non-linear, it is embracing uncertainty; one and one can make Pueblo – not just within a Surreal fantasy, but actually. Here, in my living room. Now… yes, yes!

It is absurdum and deathly seriousness. Laughter. Tickles. Cackles and left field.

Transformation is iridescence; Neon Tetra. Free-running & Parkour. Jackson Pollock, Jean Genet and Mephistopheles in conversation; Mother Theresa and Christopher Hitchens. Unexpected and unpredictable. Wicked.

Where do you go? Where do you head? Which pathway is more effective, which will take you with more certainty into tomorrow?

Transaction will get you places, like a Zimmer it will get you to your doorstep and maybe the end of the street; that is likely to be it. Suffit.

It hasn’t yet been done – Pole to Pole on a Zimmer; it is possible, just not through transaction.

Transformation is the reality of our world; it is the unpredictable pattern of elections and disease spread, it is heretical and unexpected, Mandelbrot-sets and chaos. It is what makes a joke funny. It is what makes a Netflix original different from all the rest of the plots that pass before your eyes.

Transformation is explaining love or hate or fear. Anxiety, hope and tomorrow. It is the colour between me and you. It is the pattern my tropical fish follow when searching for food; current plus existential imperative.

Let me narrow-down the field. Let’s focus. On

Healthcare.

Here is a transactional equation…

Finite resource + Increasing demand = ?

More and more with less and less.

Where to go?

The answer, stepping into the fourth or fifth dimension (Heather), it is spiralling out of control, laughing and joking, dancing, singing, considering all alternatives and entertaining the absurd.

dr who

We need transaction.

Without the data, the documents, allergy status and past medical history, we are left in chaos. We are spinning, rootless.

With just the data we will walk the Earth eternally missing the shooting stars.

Transaction and transformation, now you are talking!

Wed them and you might just get somewhere.

All or nothing, left or right, you’ll walk round in circles until, tired from the effort you die.

Transform.

Acknowledge ambiguity.

Accept that you don’t always know what will happen tomorrow, When, how or why, and maybe, perhaps, maybe, you might just…

Quiet, quiet, then

SHOUT.

the-metamorphosis-kafka-detail.jpg

BMJ/IHI International patient safety conference 27th April 2017

 

Here are some reflections having attended the conference this year… I last went in 2015 with the Yorkshire and Humber Improvement Academy. This time some things were different, some better, others missing.

Principally – where was the yoga room?

  1. Don Berwick

Don, the IHI Patient Safety Magus discussed briefly an experience his brother had in a US hospital. Don mentioned that his brother has diabetes and is currently in rehabilitation – the two most common reasons for this (my assumption) are recovery from a stroke or amputation. I don’t know which.

The salient point of the story was that Don’s brother as part of his rehabilitation was strapped into his wheelchair; this would prevent him from getting up and going, it would also prevent him falling.

In the world of patient safety, falls are badso too is disempowerment.

Is independence worth a fall?

Should we anticipate more people falling in our rehabilitation settings so long as it is part of an attempt for them to regain independence?

  1. Ara Darzi – the UK head of many things including Darzi Fellows who also sits in the House of Lords discussed the concept of shared appointments – what would be the experience of 10 patients each spending an hour together with a doctor rather than individually just six minutes?

How much could they ask?

How different would be the balance of power?

This would bring new meaning to ‘The doctor will see you now’

Sure, there are times when you need to be one on one with the doctor; this new model could help learning, adaptation and growth for people with chronic illness.

Some other areas discussed:

  • Transitions of care – there has been a great deal of investment in clinical handover in the past few years. For as long as I can remember, nurses have practiced one to one handover – where the nurse looking after patient J speaks directly to the nurse on the other ward or unit who will be caring for J once they have moved.

Within medicine this has become formalised only recently.

It is now commonplace to have large meetings where multiple doctors (and, sometimes nurses and therapists) meet to hand-over from one shift to the next.

Yet… Patients are still moved around hospitals in a continuous flow of morbidity. Patient A to x-ray, B to phlebotomy, C to endoscopy and outpatients and so on.

It is during these transitions when harm can occur. When nurse A who handed-over to nurse B has gone on break and nurse C speaks directly to nurse D who is also transferring a patient.

It’s complicated and difficult and we are fortunate things don’t go wrong more often, yet, this is an area that we need to look at in a great deal more depth.

… Where are my dentures…. Oh, perhaps on ward A?

How about we involve patients, their relatives and carers more in transitions of care… A text to say your mum is in x-ray? A text to tell the patient when and where they are going and even, the name of their driver?

3.     Margaret Murphy – we heard the painful story of Margaret’s son Kevin who died of complications relating to primary hyperparathyroidism.

His corrected calcium level was 5.73 at time of admission to hospital – this was missed by the admitting medical team and not corrected before he died.

Systems failure, and Kevin died

4.      A team from South Eastern Health and Social Care Trust in Northern Ireland described their quality improvement journey.

Their message… Quality Improvement is a journey, not a destination.

You cannot have QI projects, QI task and finish groups. You can never complete QI – there is always better, more that can be done.

5.     Derek Feeley – Derek is the President and CEO of the IHI. He talked about joy at work.

Really, we should all, if we are hoping to be the best we can, to give the best care and support one another in an optimal fashion, experience joy at work.

An unhappy workplace is an unsafe one.

Components that lead to joy in the workplace are…

  • Does what I do make sense?
  • Do I have the skills to do my job?
  • Is my work meaningful?

What are the roles of leaders….?

  • Make work meaningful and purposeful
  • Allow individuals autonomy and a sense of control
  • Support camaraderie and team-working

Simples!

simples.jpeg

Some other aspects of leadership that Derek touched on, were – the immediacy of recognition – this always trumps magnitude.

Equally important, and, I suspect the conference organisers included this because of guilt over the yoga… looking after yourself – you as a leader cannot look after the wellbeing of others if you are not caring for yourself.

Steve Swensen from the Mayo Clinic discussed another aspect of joy…

How quickly do your wounds heal?

I imagine he means both physical and emotional – well, what speeds recovery, likely, more evidence based in the former, is kindness, love and joy.

If your patient experiences kindness, love and joy, their injury, wound or illness is more likely to recover. Anyone anywhere wanting to see kindness, love and joy, please visit Mallard Ward.

Remember the care home experiment with plants… those residents given plants to water, nurture and look after resulted in significantly improved outcomes – for the residents & the plants.

Love and you will be loved.

Detweiler, Mark B., et al. “What is the evidence to support the use of therapeutic gardens for the elderly?” Psychiatry investigation 9.2 (2012): 100-110.

It seems the bigger your signature, the bigger your ego and the less healthy your organisation. Watch-out Mr T!

  • Here are five leadership behaviours that improve outcomes…
  1. Provide appreciation and thanks – straight way, without thinking, calculating or weighing-up the politics
  2. Tell your staff what you think – from the heart; anything else is obviously made-up
  3. Be transparent… Here is everything I know – use it and be happy!
  4. What do you want to do in five years? It isn’t just you who is growing – everyone needs to grow and experience some form of progression
  5. Make people feel welcome and included. Don’t have a special keycode for special people, let everyone-in, even the cranks and weirdos – they often see the world differently and have the answers you seek!

>    What are the pebbles in your shoe? What things get in the way of you being your best, doing a good job? What are the frustrations or obstacles? What are the impediments that leave you in limbo… Find the pebbles, examine and sort them!

Be an architect of quality improvement, not a construction worker. If the model of care isn’t working or doesn’t meet the needs of those you treat, change it… get the blueprint and re-write the process.

Commensality – or, why my patients do so well… It transpires after all these years of Mallard providing such incredible care to patients, one of the reasons has been a means to the end rather than the end in itself… Let me explain –

We have long championed communal eating. Sitting at the dinner table, our patients together, sharing the salt, breaking the bread. We have mostly focused on nutrition – occasionally I have veered into evolutionary theories.

Now the IHI explains, you see, this is commensality – doing things together; it is good for us! Sitting together sharing food, sharing time and conversation has a positive effect on our brains, reducing the level of stress hormones and improving our sense of wellbeing.

I can’t find the reference in the 2015 Journal of General Internal Medicine – but trust me, it makes sense.

  1. Here is a business case for Quality improvement…

For every $1 you invest you get $5 back…

The safer, the happier, the more joyful the hospital or care environment, the greater the return.

This is what the evidence says… http://www.greatplacetowork.co.uk/

  • Here are some evidence-based practices to improve your wellbeing (and wellbeing at work…)
  1. Laugh
  2. Eat a healthy diet
  3. Celebrate success
  4. Get enough sunlight
  5. Move around
  6. Practice mindfulness
  7. Get enough sleep
  8. Forgive
  9. Spend time with family and friends

And… there you go.

Analysis paralysis… don’t be overwhelmed by concerns about data collection and analysis – just do the improvement!

What matters to you? – this is identifying patient and staff preferences

6) Derek Feeley & Jason Leitch – keynote speakers

The cobra effect… what happens when you performance manage cobra trackers; the more cobras the more we pay; bring us your cobras and we’ll give you a dollar. When the people start breeding cobras the incentive goes and cobras are released into the wild.

This is good intentions having negative outcomes

Rat tails… another form of payment for performance – give us a rats tail and we’ll give you a dollar. What happened… lots of tail-less rats running about.

As HL Mencken says: For every complex problem, there is an answer that is clear, simple and wrong.

Here are some top-tips for complex (wicked) problems:

  1. Address complexity with complexity
  2. Solutions are likely to be non-linear
  3. Be diverse in your approach
  4. You alone will never have all the answers
  5. The power to fix the problem is unlikely where you need it to be (i.e. with you)

Derek Introduced the current IHI model for improvement. When I attended two years ago, all the talk was about the IHI triple aim – improved quality and safety of health for more people with less waste; I suspect they are still sticking to this aim, although last week they introduced this graph…

It is the three phases of improvement; they call it getting to the third curve.

third curve.jpg

This starts with traditional target based performance management followed by Quality Improvement which is then superseded by Co-production….

Keeping power > sharing power > ceding power

Be humble in your enquiry – don’t talk; listen.

Ask more questions than you provide answers

Be curious.

15 Lessons for Leadership… http://www.barryovereem.com/15-lessons-in-leadership/

youtube.com/watch?v=BgRoiTWkBHU&ab_channel=Prudential

http://www.whatmatterstoyou.scot/ – let’s do it! (6/6/2017)

Do you want to break the rules for better care?

http://www.nhshighland.scot.nhs.uk/News/Pages/BreakingtheRulesforBetterCareWeekannounced.aspx

http://jamanetwork.com/journals/jama/fullarticle/2624332 (please read!)

Summary

I was perhaps a little harsh in my introduction. It was a great conference. Sure, I missed the yoga and I didn’t get an opportunity to cable-car across the Thames; I did have a great meal in the company of Albert Wu, Hugo Mascie-Taylor, Mike Durkin & Aloha.

What will I take away from this meeting?

I probably learned less new at this conference than I had expected; I have been given an extra level of energy to pursue some of those areas which I have not progressed; first among them is good to great.

It is no longer good enough that some of the wards in Doncaster are great – probably providing care that is amongst the best in the world – we need this care to be universal, global. The variation needs to end. If I cannot spread the effectiveness I have failed – we all have failed.

Equality means that everyone is equal, not just a select few.

Cogs turn slowly in organisations leading to shifts in care and treatment. A couple of wheels spinning round independently carry far less meaning.

  • Person-centred care for all patients
  • Open visiting on all wards
  • No C. difficile
  • No Pressure ulcers
  • Day on day, week on week improvement in falls
  • Engagement with patients and relatives
  • Real team working
  • Shared decision making
  • Finding-out what matters to patients and staff
  • Out of pyjamas
  • Away from the bedside
  • Minimisation of polypharmacy
  • Antibiotic rationalisation
  • Person-centred investigation and treatment
  • Reduced length of stay
  • Increased use of technology – let me facetime my patients!
  • Slipper amnesty

There are more… I am just running-out of steam:

Share your thoughts here… www.almondemotion.com

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Where do we go from here?

When Dr King published Chaos or Community in 1967 he perceived the future – either we come together as a community or we fall apart in chaos.

The past fifty years have seen lots of coming together and falling to pieces.

Community was a theme at this year’s BMJ/IHI conference – specifically in an approach to envisioning the delivery and provision of health and social care within a context of ever mounting pressure.

We can only improve the care of those we welcome in to our community – and this means re-defining community.

Doctors, nurses, therapists, patients, politicians, advocates. All groups aligned in tribal chaos.

It doesn’t matter how beautiful your organisational structure, how seamless the graphics the balance of boxes and lines; take one geometrically perfect structure – hospital – care home – university and mix it up, intertwine me with you – the patient who is a doctor, the doctor who is a carer, the patient who is more expert at their disease than the professor, mix and match – the Woolworths sweet selection and off you go; the system can’t cope.

Who is in charge? Who is responsible? Where is the permission? The rules and regulations; who will govern us!

xxx

One of the speakers at the conference was Tim Omer. He has type one diabetes. He is also a hacker – in the more modern, nuanced sense (cf Girl with Dragon Tattoo), in that he uses his skills to hack technology, translate the functionality of one gadget into something else, something potentially better that results in patient empowerment; the translation of the concepts of patient and disease into something else.

Moving from the pin-prick blood-sugar sampling that most people with diabetes experience, through the insulin pump and transdermal blood sugar monitor to Wi-Fi connectivity to phone then watch; All mixed-up into a device that monitors blood sugar, adjusts the amount of insulin released and informs the user of their glycaemic control.

Simples.

The device Tim showed us was a hack. The users, the patients, the diabetics engaging in what the regulator would perceive as chaos.

Prototypes used on people who have placed themselves and their wellbeing centre-stage.

At the conference, Tim was centre-stage and it was fantastic to hear someone talk about the move from the passivity of patient to the activism of hacker.

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I heard the term Wicked Problems used more than once during the conference;

An artificial pancreas isn’t a Wicked Problem – it is a tamed technology, homeostasis, linear processing, binary on and offs.

The Wicked aspect is freeing-up the capacity of the patients, their doctors and nurses, the health and social care system to allow the rules to be bent.

Watching Dallas Buyers Club last week, demonstrated the same problem.

Patients deciding, they aren’t going to be cowed by the tricky relationships of hospitals, regulators and big-pharma; taking direct action. Coming together and shaping the future.

And how can I help?

How can I support this move inside my little microcosm of Doncaster?

A start might be another idea I heard at the conference – breaking the rules.

How many pseudo or made-up rules and regulations exist in our hospitals, health and social care systems?

There are the obvious – those which most wouldn’t challenge – smoking beside an oxygen tank, checking allergy status, smiling and being polite.

Beyond these no-brainers are the more opaque – visiting times, PJs and what you can and cannot wear or bring in to hospital (flowers, plants, puppies, miniature ponies?), using your mobile, listening to music, questioning the doctor or nurse; challenging. Enquiring. Costumes, uniforms, leaving early, working late, creative thinking outside the norms.

Question, question, ask and challenge, accept dissatisfaction – safe is never safe enough, better is not adequate; Chaos drives the Community.

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One thing new

I attended the BMJ/IHI conference in London this week.

It was an intense 48 hours of presentations, posters and chaotic queuing for coffee.

Leaving the event last night and now sitting to reflect on one new thing I learned what jumps-out is not the Ranulph Fiennes, Robert Winston or Don Berwick talks – which in themselves were great, but the little story I took off Twitter on the way home:

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This was shared by Brian Dolan. I have written about him before in the blogs, in relation to his patient safety, quality and improvement work.

I love the simplicity of the concept described in the tale.

One person at a time. Everyone matters. This is person-centred care translated through a seaside allegory. I love it.

It makes me reflect on the work I do – which at times can be frustrating, to the point of perceived futility.

Moving patients around the health and social care system, sending them down what turn-out to be blind alleys is frustrating. Rehabilitation, intermediate care, home from hospital, outpatient, A&E, OPD, ITU – all deteriorating sentiments of an overloaded system.

What is important and where we must return is the individual starfish.

The you and me encounter that is between doctor and patient, colleagues, innovators and laggards – one at a time, one on one.

Ignore the blur of transformation.

Focus.

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Medically Fit…

Your mum is medically fit.

Jane is medically fit.

Old man Abe is medically fit.

Medically fit.

Can you be un-medically fit?

To be fit must a doctor be involved?

Medical fitness is a 21st Century invention.

I am certain it wasn’t a subject covered at medical school, nor as part of the Royal College exams.

Who is medically fit, A, B or C?

You see, the big thing about being medically fit, is what it means in the context of modern-day medicine. It in effect translates as, ‘No longer needs to be in hospital,’ which, in the current world means, ‘Home.’

The problem arises predominantly for older people, when the gauntlet of ‘home’ is thrown-down within the hospital system. Home… Off you go. Taxi!

Because of the pervasive, overwhelming protectiveness and, likely, defensiveness of the NHS, ‘home’ doesn’t always mean, ‘home’

Home, but you are not felt to be safe to climb up and down your stairs, home, but you cannot wash or shave or put your clothes-on in an acceptable time-frame or manner; home, but you sometimes trip, stumble or fall on the way to or from the kitchen or living room.

Home, is grey.

Home and medical fitness are ideals. Pickett fence and apple pie.

Fall over, ambulance, A&E and, before you know it, tests and analyses, capacity assessment, tricky questions about competency, who is the Prime Minister, where are you and, which war is currently being fought in the Middle East?

We don’t make it easy.

And medical fitness is a little like a golden fleece.

Un-fit and the social workers and discharge folk can’t touch you. You can relax. Lounge in your hospital bed, enjoy the scenery. When medical fitness approaches, when it is written in your record, the process of detachment begins, Bowlby would have a hay-day.

And yet, my mum, she doesn’t seem right, she is still losing weight, unable to walk or toilet herself, she has a cough and occasional pain in the chest, how can she be? How is this fitness?

One man’s fitness is another’s morbidity.

Stability.

Not in imminent decline.

No need for thermometers and blood tests, or special manoeuvres to change your position in bed. You are your own person, society, or ‘the social’ takes over.

But… my mum, she doesn’t seem right.

Yes, your mum is dying, but, she doesn’t need the hospital right now, she doesn’t appear to be in the last days or weeks or months of life, she can keep on going for a good while yet, just, not here, not on our watch, on our hourly rounding or observations.

Let’s move forwards.

No good comes of hanging around, lingering in one spot.

Chick-chack.

Let’s go.

Ondalé!

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Care – Intermediate

I have been wanting to write this for ages, but have held-back because of the size of the issue.

You see, in Doncaster, we have been looking very closely at what is called ‘Intermediate Care’ over the past couple of years.

I will shortly explain what Intermediate Care (let’s call it IC) is – I have two main reasons for writing this– the first is because if reflects how our 21st Century NHS manages older people – particularly those who are frail and vulnerable, and, secondly, because most of the doctors, nurses, therapists I meet at work don’t understand what it is or how it works.

Frequently you will see something like this in the medical notes:

‘Waiting PSU’ – without anyone really know what PSU is (I’ll explain later), or knowing how long the waiting will be; patients consequently can be suspended in a state of not moving, not knowing why or where they are going or when.

I want to try to unravel some of this mystery here as it might help.

First, for some definition and explanations.

Intermediate Care

Intermediate Care (yes, IC), is any care (that is treatment, support or looking-after) that goes-on between a person’s home and the hospital; this therefore means the definition is broad, complicated, different in every area of the country, seen as a major way to improve care and save the NHS and, constantly changing.

This perhaps explains to some extent why many people don’t understand it.

The theory behind all of this is that most people want to live at home; they don’t like being away from their homes, they particularly don’t like being in hospital. This applies to most although not all. Following-on from this is the belief that not only are people happier in their own homes, they are healthier and more likely to remain independent – both of which reflect the tenets of the International Bill of Human Rights – a right to happiness, health and independence.

No one can argue with this reasoning.

It is perhaps a little unclear as to whether everyone is happier and healthier at home – the West’s solution to this has been the creation of nursing and residential homes; places where older people can be warehoused before they die.

There is much debate as to whether residential and nursing homes (let’s call them, RH & NH’s) are good or bad; most people know the model is unsustainable at it operates today because of issues such as quality of care, cost, staffing and the experience of many people living in residential and nursing homes being a model that is unlikely to survive the demographic changes of the next thirty years (when the Baby Boomers start to get very old).

This is not to say that many people currently living in RH and NH’s (usually more the former) are well cared-for, loved and supported and happy in their situation.

When my mum, for the last months of her life moved to a care home in Glasgow, although the initial ‘going into a home’ was traumatic, the experience was that mum loved the company.

I may be getting off the point.

Back to IC.

If we take as a given that people are happiest and healthiest in their own homes, as well as costing the health and social care system less money (there is some social economics here that says it is cheaper to be at home, that is, up until a certain point, when care is less expensive) – I am not going to delve into that area today.

A principle behind the existence of IC is that entry into healthcare is easy.

There are fewer aspects of modern living that are easier to do.

Much of this is predicated on the ability of our emergency services to respond in such an efficient and effective way to take people to hospital.

Chest pain, weakness down one side, high temperature and confusion – all will guarantee you a visit to hospital, potentially with blue-lights en-route.

Things often break-down when you arrive in hospital as the system is so complicated and under such unimaginable pressure (thanks for that Ms May et al).

Because of this efficiency meeting inefficiency, older people frequently become trapped in the system.

Managing well at home until they fall, the hospital system, modern chemical analyses and radiology can detect abnormalities that necessitate hospital admission; once an older person is in a hospital bed, that is when things start to go very wrong.

Pyjamas

Brian Dolan, a Professor in New Zealand began the now global campaign to #endPJParalysis – this is the belief that the longer a person, particularly someone who is older, remains in pyjamas, in bed, the more they are likely to lose independence and functional ability (that is, do things for themselves)

In Doncaster, we have signed-up. I wrote something along similar lines last year.

What to do when an older person is in hospital and who doesn’t really need to be there?

When all the sophisticated machinery and technology of modern medicine are potentially more of an encumbrance than a support? Well, we try to get the person home.

With each day that passes, an older person in most UK hospitals will become more dependent, less able to care and support themselves and more at risk of things going wrong – the falls, pressure sores and hospital acquired infections I have discussed before.

And there is the pressure to return people home.

The pressure also relates to the ongoing stream of people arriving at the hospital’s front door, thanks to the highly efficient system described above.

The problem is, getting out of hospital is much harder than getting-in.

One example might be ‘stairs assessment’ – this is a standard physiotherapy trope that is applied to anyone who lives in a house or has stairs somewhere they live. The theory being, if you aren’t safe on the stairs, you aren’t safe to go home, so you remain where you are until we get you safe on the stairs, or, as is sometimes the case, we board-up your stairs so you can’t see or feel the need to climb them (this is sometimes done with people who are living alone who have dementia or cognitive impairment) – (again, this subject is for another day) – which makes me think of my visit to Holland.

R and her steep Dutch stairs

For those people who are unable to return home – because their ability to walk has deteriorated – sometimes because of illness, other times because of hospitalisation alone, we start to think of other ways to facilitate discharge. (this is when the discharge teams – a growing body in our hospitals) get to work.

And now, this is where I intended to begin – an explanation of Intermediate Care…

The Intermediates & Generic Sybil

Let us take a generic old lady, we will call her Sybil. See above.

Sybil, after moving through the complexity that is the admission process to hospital is now considered ‘medically fit’ – for an explanation, see here.

Where can Sybil go?

Before suggesting next steps, let’s add some more detail to Sybil. (Sybil is fictional)

Sybil is 89 years old. Her husband Eddie died eight years ago. She has a son and a daughter, Jenny and Colin, who live in Ireland and London respectively.

Sybil lives in a three-bedroom house in a suburb of Doncaster.

Sybil used to work in the local clothing factory. Since she retired she has been involved supporting the work of the WI. She has friends who live close-by; many of them are becoming increasingly frail.

Sybil has type two diabetes, heart disease, asthma and bad osteoarthritis.

Do you get the picture?

She has shiny white hair which she has coiffed every Wednesday.

I won’t give you more information – I could go-on for many more pages, describing in more detail Sybil’s life, her interests, activities, worries, anxieties, hopes and fear, her health problems, the medicines, constipation; her falls.

Next steps for Sybil

Here are the options for Sybil – described in a stepwise fashion; I will describe them reflecting a generic Sybil who is progressively less fit, less independent and less able.

  1. Sybil after a few days in hospital goes home. She gets-back to her routine. Perhaps some help from one of the UK charities to start her up again with milk in the fridge. The voluntary sector might link-up with other services to deliver the newish concept of social prescribing – this is the creation of a plan to draw-on the various forms of support around in the form of a prescription – acknowledging that someone to talk to is frequently of more benefit to a socially isolated person than medicine to control cholesterol or blood sugar.
  2. It is felt that Sybil can go home – here, she requires more support than she had to begin; the concept care-packages (or, packages of care), is initiated. Potentially someone popping in once a day to ensure that all is well, home-care can go up to four or five times a day. This is means-tested, in other words, if you have the money, you must pay.
  3. Sybil is felt to need both support and some ongoing therapy – most places in the UK have initial short-term programmes, sometimes called ‘reablement’ – a word the NHS learned five years ago to describe the concept of helping someone return to normal with a minimum of support or interference, to facilitate independence. This is often free for six weeks.
  4. Sybil might already have some care (appreciate I didn’t say that above), we could therefore just re-start this or if it is felt that she needs more care, increase the number of visits – this again is means-tested.
  5. It could be that Sybil, after her few days in hospital has deteriorated – most often because of a change in her health and is not able to care for herself initially, even with many people visiting through the day; she might need some support at night. The next place, in Doncaster, at least is called PSU.

Positive Steps

PSU – Positive Step Unit (which I heard last week, ironically doesn’t have any steps) – PSU is a care home in Bentley, North Doncaster which can support people who are not adequately recovered to return straight home. It is run by the council and the care is delivered by social care staff – that is, people who are not clinically trained.

People can stay at PSU for somewhere in the region of six weeks – some stay less, others longer – the intention is to optimise independence; stop doing so much for patients as happens in hospital and do more, with; help washing and dressing rather than washing and dressing, support eating rather than feed. This is central to the UK’s social care philosophy.

This is free, paid-for by the council.

You can go to PSU so long as you don’t have any needs that might require the regular presence of a nurse or, you are not too dependent (that is, need too much support) or are too confused.

After PSU, you might go home with support from carers, equally, home might not be considered safe, feasible, or desired and you may have to move to a residential home.

Care Homes

Residential Homes – are residences licensed in the UK by the Care Quality Commission to provide residential care for people – this is, care and support that can be provided by staff who are not nurses or in possession of professional qualifications.

We also have EMI and non-EMI Residential Homes* – the later for people who are just old and struggling with independence, the former for people who are (usually) old and struggling with independence and who have dementia. (see below).

*thanks Drina for spotting the error!

As a significant proportion of people lining in non-EMI Residential Homes do have dementia, this distinction can be difficult to conceptualise.

Nursing Homes – as above, only the care is overseen by a nurse; there are two varieties of Nursing Home in the UK –

            Standard NH – for people with complex health and social care needs to are unable to live at home – for example, a person who cannot leave their bed, who has requirement for different nursing interventions – dressing changes, catheters, and so on.

            EMI NH – this old & antiquated term (Elderly Mentally Infirm) – describes nursing homes for those who have significant symptoms of dementia; there are many people with dementia in standard NH’s, it is just that they are less of a challenge to support. For example, the people because of their physical debility are less likely to get-dressed and leave the building and become lost. (as above)

Sorry for all this jumping up and down…

(I started writing this a few weeks ago and re-reading makes me see both the complicated overlapping nature of much I have described as well as the repetition.)

Complex Assessment

Another pathway we have been working-with in Doncaster for the past few years has is CAP – this stands for Complex Assessment Pathway. (Funnily, when describing to some medical students the history of IC in Doncaster I covered the original name for this – NRP – Non-Reablement Pathway (aka people we can’t get better or improve pathway) – it was as far as I know conceived by a manager somewhere.

What was funny to me was how obviously terrible a name NRP was to the students; I remember having to fight to change the name back then as the folk in charge couldn’t see the problem – perhaps this reflects a growing sense of understanding beyond the mechanics of medicine for our up and coming doctors of tomorrow.

CAP – this is for patients who are too ill or dependent for PSU – that is, residential care, but, who cannot go straight home (or, back to the Residential Home where they might have been living prior to their recent hospital admission) – they, then spend up to six weeks – sometimes less, often, more in one of several nursing homes in Doncaster.

As a further layer of treacle, CAP is also split, like RH and NH into EMI and Non-EMI* – that is, nursing homes for people with or without dementia; the former for people who have maybe experienced catastrophic strokes, who require support with eating and drinking, who have urinary catheters or feeding tubes, wounds or complicated medicine regimes.

(*Possible subject for next campaign name & concept change after we have addressed pyjamas.)

EMI CAP is for people with dementia who display behaviour that is sometimes difficult to manage – again, in Doncaster – and this, I think is special to our community, we have two tiers of EMI CAP – those who have (not sure of the term…) straightforward dementia and those who have more complicated symptoms. I support the care of the latter group of patients, some of whom it transpires do not have dementia but prolonged delirium, enabling them to eventually return home.

I have left-out two directions of hospital discharge that potentially precede PSU or CAP; these are:

Intermediate Care Hospital

Our Intermediate Care Hospital – this is based at Tickhill Road; it is a site run by the local mental-health trust who also run services delivering community care, that is, district nurses, therapy and so on.

There a ward support people who potentially no longer need to be in acute hospital (that is a building that has 24/7 medical presence, A&E, intensive care) but, still need some hospitalisation. Here they patients, and I use the term patients intentionally, rather than residents or clients receive medical, nursing and therapy support, in an environment that is supposedly less clinical. I haven’t been across in a couple of years to look around; I suspect there is likely not much difference architecturally or structurally to the acute hospital other than no doctors after 5pm. The aim of this service is to support people to return to health adequately to go home; some need to move to PSU, few need to move to CAP – I suspect the latter group are usually transferred back to the acute hospital prior to any discharge plans.

Two further concepts exist, particularly in relation to this hospital which are important to understand before moving-on:

Step-up and step-down.

Step-up is when a person moves into the hospital from the community without necessarily being admitted to hospital. The idea being that as compared to hospital admission (through A&E) this is a less dramatic transfer, potentially to support those whose needs are less medical and more social – that is to support convalescence after a chest or urine infection or a fall.

Step-down is when a patient moves from the acute hospital to the IC hospital – the concept being that the level of care lessens, facilitating independence; this is not hospital discharge, as the NHS is still providing care, but, potentially without the high-cost associations of Intensive Care or round-the-clock medical cover.

And then we have our rehabilitation hospital.

Rehabilitation Hospital

This is an interesting place, situated in the Don-Valley at the site of what is still today the Montagu-Mexborough Hospital; the Montagu part is named-after the wealthy family of landed gentry who helped establish the hospital in the 1800’s (with help from miners stipends).

More recently the hospital has focused on rehabilitation, day-case and outpatient services, much of which has been supported by the Fred and Ann Green Fund – named after Fred Green, the Mexborough Greengrocer who was a founder of Associated Dairies. Asda.

We opened the Fred and Ann Green Rehabilitation Centre in 2013, with the intention of providing rehabilitation facilities to people from the local and surrounding areas.

The place is great, lots of space and big windows.

The hospital provides care or support for those patients who it is felt have ongoing predominantly therapy needs – that is physio, occupational, speech and language needs. As a distinction from Tickhill Road hospital above, there are doctors on site seven days a week, although not through the night. The notion being that the patients here are sicker than those who might be at Tickhill Road but better than those who are at the main acute hospital.

Patients leaving this hospital can either move home, to PSU or CAP beds.

Mental Health

There are a group of other pathways for people who have predominantly mental health needs. I won’t go into this in any detail as it is outside the scope of this document.

Essentially, the mental health teams – that is those doctors, nurses and therapists supporting people who have primarily mental health diseases – depression, schizophrenia, dementia (again, this is complicated and probably for another day), bipolar disorder, do all they can to support people in the community – that is, in their own homes; this makes sense – if a person is not physically ill, they should not be in hospital.

This all blurs when people are no longer able to care for themselves because of their mental health condition or they are potentially a risk to themselves.

As I said, I am not going into this in too much – essentially, for those requiring inpatient care (within the catchment area of older people, which in the case of the mental health world, is anyone over 65 years old), there are two facilities – the organic ward and the functional ward, for organic and functional illnesses respectively.

Organic mental health relates to diseases that affect the structure of an individual’s brain and cause psychiatric illness – this in other words, is dementia, the other functional ward is for depression and anxiety.

To my mind this is all contentious as surely all mental health is organic – relating to levels of neurotransmitters. Perhaps this is also something for another day.

Last months of life

The final cohort of patient that you might want to consider within intermediate care are those who are determined to be at the end of their lives.

I always find this a difficult area – for several reasons; it is very emotive, it is something that is outside the routine of our 21st Century concepts of living and, it is very uncertain. The notion of, ‘Doctor, how long do I have,’ ‘Four weeks,’ belongs to Richard Gordon’s world.

Effectively we split a person’s remaining life into blocks of expected survival – this is those people who we can’t establish when they might die, those who have a year or less to live, those in the final three months and those with days to live.

It seems quite simple when described in this way; when you interpret the layers of emotion, health, pain and distress intertwined with this, you start to realise how hard it can be to take a person and assign them a timeline.

I will focus on those people who we perceive are in the final three months of life. I say three months, as anything more or longer, likely flows down a separate health and social care pathway.

If you have disseminated cancer, advanced dementia, or are frail to the extent that you cannot walk, eat or drink, most people would consider it appropriate to determine whether you meet ‘fast-track’ criteria – these predict whether you will live for three months or more.

If you meet these criteria (which are determined by some science, some experience and some guess-work), the system deems you to require Continuing Healthcare – all your care, treatment or support is considered to relate to health – the NHS therefore support wholly, without dependence on the social care system (although the social care system might provide physical support), the mean-testing I have mentioned above is kept-out. The NHS pays for all your care and treatment.

This in many ways is fantastic – it enables people and their families to focus on care and support in the last few months of life, rather than completing complex documents require of social care. People who are in the last months of life do not need to undertake a journey through PSU or CAP or any of the other steps that lie before an other older person who has found themselves in bed in hospital.

As to whether you meet the criteria as I have described, is a little grey and one person who receives the full fast-track service might have the same needs as another individual who must follow the confusing journey I have described above, to leave hospital.

Summary

I appreciate this document is not for everyone – I intend it to accompany some of the teaching I provide in the hospital and there are likely some errors of fact, for which I am solely responsible.

We are constantly working to refine the ways that people, particularly those who are older and frail interface with the health and social care system.

All this is increasingly difficult because of external pressures, predominantly from the government which has a certain trajectory, which, to many of those in the system is at odds with the best interests of those we support.

The system will continue to grow and expand, new ideas will be conceived, new ways of considering how we keep ourselves and our society and sanity together. If we continuously think people not patient, put the person first and the system second, we are likely to improve.

Anyone who feels I have wrongly represented or interpreted the system, please, let me know and I will amend. We are all seeking the same things – to care and be kind, to support, sustain and move forwards.

3 birds

 

Easdale

Easdale – pronounced ‘Ease-d’l’ by the locals

I spent a week with my family on the tiny slate island of Easdale over Easter. I don’t have much to say about the place other than it was beautiful, the trip from Seil with the friendly ferrymen took five minutes and we transported our bags from the dock to our cottage with the number 33 wheelbarrow – no cars; Maisie was off the lead, feeling like the dog she was born to be. The deep blue sea-pools – former slate quarries surround the Island. Oh, and there were two sheep-pigs.

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Seil – the island between the mainland and Easdale.

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Ferry

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The island is covered with slate containing Iron Pyrites

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Healthy air (i)

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Healthy air (ii)

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Healthy air (iii)

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Harbour

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Cottages & wheelbarrow

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Quarry (i)

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Quarry (ii)

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Quarry (iii)

 

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Sheep pigs….

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Free running

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Stone 1, 2 & 3

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Evening

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En route (i)

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En route (ii)

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Jonathan (i)

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Jonathan (ii)

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Jonathan (iii)

 

 

I, Daniel Blake

I watched Ken Loach’s film, I, Daniel Blake last night with Rami.

It was a difficult movie – it exists in a hinterland between entertainment, documentary and eye-opener.

I was probably won-over from the start given the film’s Newcastle location; I have a special soft spot for Geordies, possibly because I see them as token Scots, and, likely, because my grandfather, Ben, grew-up in Byker.

Mellifluous – that is, from the Greek, flowing with honey, is the word I most associate with the Newcastle accent; so, yes, I am biased. Yet, that aside, the story of Daniel Blake’s battle with bureaucracy is also close to my heart. In the NHS, we call that ‘medicalisation’ – when the person ceases to exist and they are replaced by a number, a disease or a symptom.

It feels like my life’s mission – unravelling medical objectivism from the people our patients are;

I don’t intend to return to person-centred care, today, at least; instead, for me, the focus of the film, was the reality that we are all equally vulnerable and, the change from person to object, is not something any of us ever expect or anticipate.

As I described recently, we mostly, tend to exist in a state of denial in relation to our own mortality, yet, the slip, from useful member of society, to hanger-on, can occur rapidly, particularly when this is a central tenet of the presiding government’s philosophy of, ‘we help those who help themselves’

Like sheep, most of us readily fall into line, when the system expects us to behave in a certain way.

Take the ticket and wait, tick the box, complete the assessment, the parking charge, stipend, go-around; we follow, we assume that the system has considered our needs, which in its wisdom always knows better. The system knows. The planners, machinators, organisers and coordinators have the power. When the traffic light is red we stop, green, we go. Society works well when we all keep to the path.

As does healthcare. Follow the instructions, take the medicines when prescribed, arrive for your appointment, scan or treatment and you’ll be ok.

‘As you failed to attend the clinic today, and, in line with hospital policy we have not arranged another appointment.’

This is something I see written in the medical notes all the time.

Sure, some people never wanted to see a doctor or visit the clinic in the first place; others are too afraid to attend – perhaps, their waiting-room anxiety, is too great, others are lost somewhere in the health and social care system and not at home when their appointment card arrives; they are sent back to the beginning, returned to GO without necessarily picking-up any cash-prizes.

Others, the depressed, the forgetful, the overly busy, plan to attend the appointment, but within the chaos of their disordered lives mis-schedule.

The system sometimes doesn’t have time for people; humans who behave in unexpected ways, and, are slower than processes, the ideal, the model; hurry along, don’t admire the scenery, there is too much to do for us to engage with your preferences, just take the medicine and shut up and I can move-on to treating someone else. And on, and on.

I remember Esther Rantzen in the 80’s awarding Jobsworth prizes to people who held the belief that is was more than their jobs were worth to allow humanity to enter into the equation, into the transaction; for some reason this has stuck with me.

In the movie, we see the security guard stopping Katie, and his boss, sympathetic, letting her leave; this made the guard’s manipulation of her vulnerability even more powerful.

Society is made-up of the good and bad, those with self-interest at the core, others, who see the bigger picture, whose lives are filled with proportionately more with love & happiness.

Magnanimity.

Going out of your way to prevent someone else from having to go out of theirs.

Selflessness. Empathy, compassion – experiencing the suffering of others. This was the message that resonated throughout the film. Whether the scene at the Job Centre, the Foodbank or during the final monologue.

There are always more of us than there will ever be of them.

For, this is what it is to be human.

This is what it is to be frail and vulnerable; mortal.

None of us are immune, none of us live lives beyond the grasp of disease or homelessness, loneliness, pain or grief.

I understand the film was rejected by the Tories, lauded by Jeremy.

The times we are living-in say much about who we are. We will be judged by our compassion, by the extent to which we see people as more than numbers.

And,

I can’t see it.

I just don’t get it or understand how it can be any different.

To me, and those I love, it just is, it is a given.

We are all equal, all part of the complex system of life on earth.

Everything under the sun exists within a cycle of homeostasis, give and take, talk and listen.

Nothing else is feasible.

nietz

Advance Care Plan, Human Rights & I want what I want

Most of us take our human rights for granted – that is, those who I imagine might read this; where and how to live, who to love and so on.

In the past I have written about advance care planning – this is figuring-out what you want to have happen to you in the future.

There is a tremendous amount of work taking place across the NHS examining ways to ensure that people plan ahead, for we know, when people are involved with choices about their care and treatment, the outcomes are better;

If you want a knee replacement, are motivated to have the surgery and have an orthopaedic surgeon who does a good job (without infection, DVT or other technical fault), the outcome is likely to be good. You are likely to have a second lease of life, free from pain, with increased independence and quality of life.

If someone orders a test or a treatment that you don’t want or do not even understand, the outcomes can be bad; people are generally able to accept the unpleasant side of medicine if they see the bigger picture, if they can conceptualise their temporary pain or suffering as part of a bigger goal – a cure or, improved symptoms.

When people are treated like objects, left out of the discussion, when the NHS engages with folk as if in a continual state of emergency (few of us are upset if a surgeon saves our lives when we arrive unconscious after a road traffic accident – these are times when preferences play second-fiddle to necessity), but, most situations are not like this, most of the time, a little bit of sensitivity, kindness, empathy and compassion can slow-down the interaction and afford a person a moment to reflect, ask questions so as to get their head around the issue.

Advance care plans fit within this schema.

There are some things I would or would not like.

I don’t think I would appreciate being kept alive on a ventilator indefinitely as happens in some countries, if I experience a massive stroke; for example.

Part of the problem is, none of us particularly enjoy imagining ourselves in horrible situations – like the Freudian concept of death. It isn’t a nice place to go. Even when we do talk of death, for example, in relation to life assurance – we tend (or at least I) tend to focus on the up-side – the cash my family or favourite charity might get in the event of my untimely demise.

As age and chronic disease encroach, as we encounter limitations in our abilities to engage with life, perhaps combined with a good innings – it is perhaps easier to consider what we would have or have not. We might not want to live in a care home, we might not want a PEG tube, chemotherapy, surgery, hospitalisation. Again – none of this is straightforward or easy to get your head around – it isn’t the way evolution designed us.

And what of the advance care plans that we construct for our husbands and wives, mothers or fathers – the situations when those we love exist in states beyond which we would conceive are enjoyable, satisfying or fun.

Here is a sketch of a life I might not like:

Nursing home; 25-watt light bulb, air mattress, indoor existence, stifling air; closed window, bland, pureed food that is not of my choice, bed-bath, strip-wash, catheter, insomnia, anxiety, enema, depression, monotony, noise, itch that can’t be scratched, day after day after day…

A recent article in the New Scientist revealed that some people with locked-in syndrome; like Bauby in my last blog, those people whose lives are potentially consistent with the description above, who cannot move a muscle, who cannot even blink, through new techniques to interpret brain-waves, have revealed that they are happy – that their existences are far less unpleasant that we might envisage;

There is a theory (constructed by us able-bodied souls), that being in such a state of perpetual physical torment or incapacity has a psychological effect that induces euphoria. Where our standards slip as to what is good, what is fun.

No one knows.

And this is the problem with advance care plans made by those who are capacitated, free from dementia or infirmity, us, who plan for our relatives during this time, when they cannot express what they want; or even for those of us who have the foresight to create such a document ahead of time – who is to say that the state we perceive when able-bodied is as bad as it appears;

This is the human rights. I want what I want now and I want what I want when I want it and – I want to be able to change my mind as often as I like as my mind is mine, as is my body and no one can tell me what I like or dislike, or want, etc.

Can we ever have such a thing as an advance care plan that is consistent with this reality?

Surely our will to live will always be too strong; evolution hasn’t designed us to easily give-up on life.

Something to think about.

17d881273116a87998bf01f1c925d0b3

Alone (aka levadi*)

You could have called yesterday’s blog something along the lines of… Long-lie – the consequences of loneliness.

There was some discussion on Facebook as to whether this was a societal or technological problem, or, both.

People have been writing about social isolation for centuries.

I think back to The Count of Monte Christo, where Villefort – Valentine’s  grandfather, is unable to communicate after a stroke, other than through blinking. A literary predecessor of Jean-Dominique Bauby’s, The Diving Bell and the Butterfly.

Trapped.

Isolated.

Many blogs ago I wrote about Alexander Trocchi (the Glaswegian Beatnik) and his description of the human condition.

It seems that we are moving more and more towards this existential isolationism.

Last night, I watched the Oasis documentary, Supersonic. It was a great re-living of the 90’s. Some of which I could remember.

In the film, they highlight the concert at Knebworth in 1996 with 250,000 people in a field singing along to Champagne Supernova.

This was before internet dominance and the iPhone, before we considered technological solutions to everything – how to prevent a long-lie… wear an accelerometer. How to stay in touch… Skype, Whatsapp, Twitter, Facebook.

This was even more meaningful to me as I watched an iPlayer documentary before the Oasis film, about schools and schooling in Scotland since the 1500s when John Knox led the Reformation and his Book of Common Order outlined the beginnings of standardised education.

The point isn’t about Mr Knox or Liam or Noel, but about the changes in society that have led us to where we are today.

In the 50’s, 60’s and 70’s there was so much more playing in the street, engaging with neighbours, society; I guess – there is likely to be a component of nostalgia in this, but predominantly, the explosion in single-person households, in people living alone, not talking to another soul for days on end, to the extent which this happens in 2017 is unique.

This metamorphosis in our ways of living also threatens the fabric of the health and social care system.

The solution today to an older person who has fallen and is socially isolated is to send them to a care home. There they will be looked-after; there they will have company. People to keep them safe, feed them, ensure clean clothes and cups of tea.

Some care homes are fantastic and indeed can be a solution to the very lonely.

The numbers of older people within this model who will require care in the next 20 years are however, too great for this system to ever manage.

Today, care homes are closing because of staffing and funding challenges. We undervalue this work as we undervalue the role of all people involved in health and social care; the government has over the past five years devastated social care – cut upon cut. What do we value?

Our phones, the internet, Amazon Prime?

Back to living alone.

Today, more of us live in single person households than at any time. You might struggle to get-on with your family, but, at least they are someone to talk to. At least they are someone to determine if you are down or dejected or poorly.

I do not see any systemic solutions to these changes; sleep-walking we shuffle towards the future.

I mentioned B:Friend yesterday; I have seen recent posts on Facebook showing care homes that are providing accommodation for students, where older people are welcomed back into society and their value appreciated. Young children spend hours in the company of people in their 80s and 90s.

Like the environment, let us not place all our eggs in one basket.

Most, at least those in the West who are gas-guzzling and landfill-filling either choose not to think about the planet, or, if they do, prefer to assume that a technological solution will be found to the bleaching of the coral or the poisoning of our oceans and atmosphere.

If we follow this path, assuming tech will save us; provide us with live-in robots, computers of wheels, electronic cats and dogs, we will have missed the point.

We still have a way to go.

*Levadi

knebworth

 

Long lie

 

I was talking with the medical students yesterday.

They were presenting their ‘long-cases’ – this is when a student doctor or nurse reviews, examines and presents a patient’s story to me.

Two of the cases related to older people who had fallen at home and become stuck on the floor.

In the world of medicine this is called a long lie.

As to how long you must be lying on the floor for your lie to become long, is I suspect relative.

Some long-lies can be very long.

One of the patients who fell, as described by a student, was on the floor for six hours before she could struggle to her feet; the other lay on the floor in his house for two days before neighbours alerted the police.

This says much about the place of older people in our society, and their associated frailty, fragility and vulnerability.

Two days.

That is a very long time.

I suspect there must have been times when he fell asleep, nodded-off on the carpet.

People who find themselves on the floor for this long experience several forms of trauma – the most significant which can occur rapidly is the psychical – unable to get-up, thinking, ‘How long will I be here?’ ‘When will someone come to help me…’ ‘What if I die like this.’

Traditionally, those living in flats or semi-detached houses, will bang on the wall; that must offer some sense of determination – a hope, that someone will hear, respond.

If you are on the floor in a detached house or bungalow, what is the feeling?

The postman might come – how inquisitive are posties these days? Your son or daughter might phone; what if you don’t have any family? What if the family you have don’t bother with you or have the ability or interest to maintain close contact?

You are stuck.

Before long, you will be incontinent; you will either need to go to the loo and let go which will result in becoming wet then sore, or, you will not go and you will get stuck – a condition we call urinary retention – where you cannot go. At all. Urine is stuck inside your bladder and over hours your kidneys swell then stop working; if you are stuck for long enough, your skin and muscles will become damaged and break-down – this is a further trauma to your kidneys, which will then fail.

Wet and sore then cold.

We give some of our old folk a hard time – forcing them to financially economise – heating switched-off to save money.

Wet and cold and sore.

And they might bang or shout or cry or lie silently trying to work-out what to do, how to save themselves, for, no matter how old or frail, most people have a connection to life that is tenacious – the fight to live. Most take a while before giving-up.

At what point does your thirst become an issue?

Cold, hungry and thirsty and, your muscles and skin are breaking-down. And you are afraid and wet and you do not know when or if anyone will come to get you. Will you die like this?

Loneliness is not a new concept; some of us like being alone – we seek solitude; this is however different. Solitude is a choice. Thoreau walked into the woods of his own volition.

Loneliness, that is, social isolation, not seeing or talking to another person for days at a time is a modern construct, a symptom of our ailing society.

It is hard to conceive of a grandparent falling at home 100 years ago and being left.

Sure, there has always been the occasional hermit or odd-bod; loneliness and social isolation is a 21st Century epidemic which, when tied-to falling and frailty, is a significant problem.

And the old man or woman, alone, isolated, long-lying; this perhaps adds a dimension of despair to the experience, to the trauma.

The consequences of a long-lie are significant – this can be the end of an older person living independently; the acute and post-trauma can have a devastating effect on an individual’s sense of self, sense or worth and autonomy. The experience likely echoes throughout what remains of their life.

I suppose the question we must ask, after we have learned about long-lies, older people living alone and social isolation, is, what can we do?

Just think; there is almost certainly an older person somewhere in the UK, possibly even along the road from you who is now stuck, trapped.

My friend Mike is helping to break-down some of the islands of isolation that are growing in our society – please check-out B:Friend. This is not a panacea for loneliness, social isolation or long-lies it is however a significant position statement on society and the trajectory we should all be following if we choose to support a society that is loving, person-centred and kind.

rol06_061_old_man_beaten_up_during_fit_of_the_dts._1975

 

 

 

 

Delirium and numbers

 

I been meaning to write this for a couple of years; the relationship between numbers and delirium… Let me explain.

You see, there is at times an incredible focus on the numbers associated with people who find themselves in hospital; I’ll give you an example –

Sodium 141

Potassium 4

Urea 7

Creatinine 98

Glucose 5.4

CRP 0.6

I could go-on. The bottom line, is, that these numbers are all within the normal range.

il_fullxfull.148567721

The normal range relates to something statisticians describe as being the numbers which are most common in a certain population. In other words, the normal might not be that normal if the population is odd.

If you take running speed.

For a class of 13 year olds, this might be a certain ‘x’ mph, whereas for 80 year olds the normal speed might be ‘y’ mph. The numbers don’t specifically matter.

Outside this normal distribution, you will have someone like Flying Philip Rabinowitz who, before he died in 2008 held the 100m record for a 100-year-old (30.86 seconds).

flying philip

You see, normal is as Hemingway says, a Moveable Feast.

Back to the numbers.

There are within certain branches of medicine a fixation with numbers – usually this is when those without an adequately deep understanding of sickness and health, where too high or too low a number isn’t normal, and is interpreted as not right.

This is medicalese for ‘the computer says no’

computer says

Translating all of this to the world of delirium –

One of the challenges we sometimes encounter in hospital is determining whether an individual’s behaviour relates to delirium or dementia.

This is important to establish, as I have previously described – those experiencing delirium often, given great care and support, are able to fully recover, whereas, for those who have dementia, the prognosis is different.

In most situations, you can compare this with a standard reference chart found in text-books which differentiate delirium from dementia:

delirium dementia

 

In a hospital setting, this is complicated, as the entire experience is delirioigenic – (a word I have invented, meaning ‘inducing or leading to delirium’) – the changes of staff, the light, the bed-moves, medicines, doctors, therapists, nurses; cardiac arrests, or shift-changes; phlebotomists, radiographers, coordinators or social workers, all passing in and out of your experience, unpredictably, erratically, inconsistently.

st seneca

Were you to seek a recipe for delirium – admission to hospital would be the primary ingredient.

Michel-Roux-Jr-chicken-salt-768x1024

Therefore, trying to determine whether an individual’s confusion is because of delirium or dementia can be difficult.

My most frequent management plan in these situations is to advise discharge – get the person home and allow normality to sort them out.

Sometimes, this is not straightforward.

A complication relates to the situations where the clinical team needs to decide… delirium or dementia…

This is when the numbers game is played.

Sodium or urea too high > dehydration > delirium > > >

For certain mental-health teams, this is a point of disconnection, where the psychiatrists say – physical and the physicians who asked for help from the psychiatrists are left floundering (I met someone like this today – hence the blog) (aka diagnostic/therapeutic tug-of-war)

Brooker, Harry, 1848-1940; A Group of Children Playing at 'Tug of War' in a Domestic Interior

This goes to the core of the mental and physical health divide.

Most might not realise this exists; you see, some conditions are considered physical (at times called organic), others functional;

Here is a list of the medical and physical conditions:

Physical (organic)

Pneumonia, Diabetes, Epilepsy, Schizophrenia, Dementia, Bipolar Disorder; delirium

Psychological (functional)

Depression, anxiety, Irritable Bowel Syndrome, Fibromyalgia, Chronic Fatigue.

I don’t know that much about the pathogenesis of either – physical or psychological; my understanding however is that in this modern age of genomics & men on the moon, everything is organic.

If I feel fed-up – this is organic; there are strands of RNA inside cells in my brain replicating and sub-dividing, secreting chemicals and hormones that make me feel or perceive the situation a certain way; if, I have septic-shock because my immune system is overwhelmed by the meningococcus, different cells will be replicating, dividing, responding.

It is all cells & chemicals.

Yet, when it comes to the way health is interpreted, dementia is considered a mental health condition (with various causes – Alzheimer’s, Vascular, Alcohol, etc) and delirium, a physical health condition (like, Pneumonia, Epilepsy, Stroke).

I appreciate this is confusing. I often find myself struggling.

I think what I am trying to express is my exasperation at the divide between physical and mental health, functional and organic disease.

You see, everyone who is in a state of dis-ease or ill-health needs the same things;

For those conditions which respond to treatments or remedies, we need tablets and love; for those without the tablets, whether in the form of placebo or not, we need at the very least, love.

Love – this is care, support, attention and a sensitive ear.

And back to the numbers – those which are sometimes used to define a pathway or an individual;

You are my patient because your CRP (C-Reactive Protein – a marker of infection or inflammation which often increases in situations of physiological stress or distress) is elevated – this is something medical; I can’t help you because your CRP is normal – this must be within the sphere of the head-shrinker.

No, no, no.

Let us all come together and acknowledge what is self-evident; what is before our eyes.

People are more than their numbers.

Sure; you can tell a lot from the numbers:

T 39, P120, BP 80/50, Sat 88, BM 2, GCS 13… All say something to those doctors and nurses out there who can recognise critical illness, yet when the numbers are normal, this does not necessarily mean all is well. Numbers are just statistical aberrations.

I began writing about numbers and here I will end.

Let us not make enemies of the numbers.

Let us remember that they have brought us wonderful things;

At the same time, let’s not be limited by them, let us not obsess or forget where the numbers have come-from.

Numbers are relative, people are absolute.

 

 

Genomics* & Personcentredness

Yesterday, I attended a lecture in the hospital. The two speakers, one from Leeds the other from Sheffield discussed the 100,000 Genome project.

I’d heard about Genomics prior to that talk, but never really understood what it was about. I likely now still don’t understand; I will try to impart what I heard…

Most of us will have heard of DNA. This is Deoxyribonucleic acid – the structure of which was described by Crick and Watson in the 1950’s. DNA consists of chemicals – cytosine, guanine, adenine and thymine which in various combinations results in everything that is life on earth.

When the chemicals arrange in a certain way, they create a gene which then provides a template for the creation of proteins. And, most of us, or at least, the interesting parts are proteins.

I may be wrong with this explanation; if there is anyone reading this who has a better grasp, please let me know. I am a talker and sensitivist of old people, not a biochemist.

Anyway,

The idea behind the Genome project is to sequence (see below) all the genes we have in our cells – most cells have nuclei which contain DNA – and the genes; some don’t, but we will leave that aside (I am not even going to consider Mitochondrial DNA which is a whole other area I don’t understand);

Each person has one, or sometimes two – if they have cancer, Genomes. Today, as I sit here, to the best of my knowledge, I have just one. I hope that there aren’t any rogue cells inside my body in the process of mutation – time will tell. If you have cancer, because this is caused by a change to your DNA – certain rogue genes replicate erroneously, faster or slower than they should, you then have two Genomes – the one you we born with and the one your now cancerous body-part possesses.

Sequencing the Genome, as I understand, is to somehow put the whole Genome (from a cheek swab or biopsied section of cancer, or abnormal blood cell), through a special computer which processes the chemicals and translates them into code which can then be analysed and interpreted.

For example, if I have a specific variant of say, lung cancer, there are likely to be changes in my Genome that will be found in someone else who has the same type of cancer.

What all this is getting to, which I found most interesting was the aspect of the project relating to personalised medicine – you see, currently we have quite a crude approach to disease – we consider everyone is the same.

My high blood pressure is the same as yours, is the same as 100,000 other people, when, we know that every person is unique – this is a form of person-centredness at the level of genes; which is kind of cool – PCC isn’t just clinical hippies saying so; the lab folk can prove it.

My high blood pressure will be caused by a host of environmental and genetic factors – as will yours, as to whether the genetic factors are the same, or similar, currently, we have no idea.

Equally if I have high blood pressure, my doctor is likely to prescribe an Ace Inhibitor, which we know works very well to sort blood pressure; it doesn’t work for everyone. We even know that certain ethnic groups – African Americans, South Asians have a propensity for specific patterns of blood pressure and diabetes, yet everyone is treated the same – 10mg of Ramipril, or as close to that dose as you can get without falling-over or your kidneys packing-in.

The idea of the personalisation aspect is to work-out which drug will work best for you or me, acknowledging that although we are all the same (sans passport & the right to free speech), the differences in the genes that contribute to our diseases can result in different responses to medicines.

The project is starting with people who have cancer – one day, if we get there, you are likely to see the doctor who will first tell you you have diabetes, refer to your Genome, then determine which specific medicine you should take; for some, that might mean happily living without medicines – for others, you might have to take more, but all in all, it should prevent the strokes, heart attacks and dementia that are the blight of being an older 21st Century human.

The scientists are starting with cancer – finding-out which cancers are caused by which genes – they might even, in time, have gene therapy which can mean that people will receive treatment to prevent them acquiring the cancer, dementia or motor-neurone disease they have inherited from their parents. (Unfortunately (fortunately?), most forms of dementia and MND are not genetic – so these treatments will have to wait longer to be solved.)

I don’t know if this has made the subject of Genomics clear. This is very far from my usual subject area, although I can’t say I wasn’t psyched by the notion that science is demonstrating which we all know in our hearts to be true – we are all unique, we are all precious with individual stories laid-down in our life history as much as in our genes.

Listen, learn, care and be kind.

To find-out more about Genomics, Yorkshire & the Humber – see here

Primula_aka

I was listening

today,

I was listening as a nurse

shouted at one of the patients.

 

She wasn’t shouting in anger,

more, because she felt that he couldn’t hear.

 

Indeed,

He could not hear.

 

His hearing aids were missing.

Lost

Somewhere.

 

It was however odd,

that when, I spoke with him,

He seemed to hear what I said.

I didn’t shout,

I didn’t resort to pen and paper.

He could hear.

 

He was most upset about the loss of his hearing aids.

He was equally

frustrated

at his nurse-call being tidily

out of the way

and out of reach,

on the wall.

 

For a moment,

I imagined

myself in his place,

and was frightened.

the-zombies-just-out-of-reach-decca

 

Ransacking

Ransacking my past,

Picking moments

that are fizzing

in the nooks

and

Crannies

of

my memory.

 

A

Nugget.

 

Sitting with Andy in Queen’s Park.

Outside the Glass Houses.

Him smoking,

Me,

just filling my mouth with

Smoke.

and teaching me

How to.

 

How to

Inhale.

 

Breathe-in

Hold.

Supress the cough.

Cough.

and

Again.

 

That was me at 17

 

And that was me for the next seven years.

las criadas

Heather

We spend the night out in Glasgow.

 

Texas.

 

The band.

 

I’m sure that’s who it was.

 

Heather got the tickets from her brother

who

was a tabloid journalist

at the time.

At the end of the 80’s.

 

and.

for whatever reason,

Heather came home with me afterwards.

 

To our sandstone tenement.

 

Thick carpets

and I can remember the full-length mirror in the hall

that had no light.

 

and she stayed the night.

 

And my mum

was not impressed.

 

We spooned.

 

Nothing happened.

Moshe

Moshe was our sandy-haired head-teacher.

 

I thought he was wonderful.

 

Freckled with a wry smile

and,

A friendly punch

to the shoulder of us boys who passed too close.

 

and,

 

I remember the day of the storm

when school flooded

and the water was more than a meter deep.

 

I am talking, muddy soup, swirling with wood and dirt and bracken.

 

and Moshe

in the playground, the next day

sweeping-up.

 

This was no photo-opportunity moment.

This was him doing,

him doing

& caring.

 

I later learned of the embezzlement

and today

thirty years later

I still cannot work-out what happened.

 

And reconciling one image with another,

It is the man

blue crocheted Kippa, balanced precariously on his freckled head

sincere

and kind

that remains with me.

 

For Yael.

Ice (Rouken Glen)

There is a picture of me somewhere, I must have been seven or eight, standing in the centre of the pond in Rouken Glen, which is a big green place in the South Side of Glasgow.

It was one of those winters we had in the 70’s when everything froze. I am wearing red welly-boots and a grey balaclava knitted by my mum.

And, a few years ago, I think it must have been 2010 when I was back in Glasgow, visiting with my son who at the time must also have been seven or eight. It was another harsh winter, and the pond had frozen. With ice, thick enough not to crack underfoot.

And as I posed my son in the same place I had stood 40 years before, I could hear criticism from the side, as more safety-conscious parents tutted and sighed at my irresponsibility, for risking the life of my son for a once in a lifetime photo opportunity.

And today, I think back and wonder whether my dad received the same criticism from other parents then, or if, as I suspect, everyone just got on with it and tried to slide as fast as they could from one side to the other.

Ronen El-Kabir

Ronen wasn’t so great.

 

Sure enough,

he laid me flat, on the ground,

split my frenulum

which required

a stitch

and I learned a lesson

not to have a

square-go

with a lad

who is

bigger

and

faster

and

stronger

than me,

even,

if,

the honour of my friends is at stake,

even if,

there are rude words

and

stand-offs.

 

Keep your head down

if you want to keep

your head attached

to your

Neck.

Digging

Scottish summer holiday

Digging,

excavating the dried-out cement.

 

Deeper and deeper

we go.

 

to where?

 

Record player;

Stranglers & Golden Brown

 

Funny music

for

nine-year olds.

 

And safe in the knowledge

that we are exploring,

getting somewhere.

 

Chipping away,

Scraping,

small rocks and pebbles, undermining

the wall’s foundations

 

And the owner

threatening

legal action

as his wall

threatens

to topple

 

Worried

about

criminality

and

compensation.

 

My friend’s parents paid.

The cardboard night

You see, one day when I was a student,

I got fed-up.

I can’t remember what is was that caused me to feel that way –

Likely, something to do with people,

As people

Are my currency.

 

I headed out,

having just finished

On the Road

And hitched a lift to Edinburgh.

 

Barely any money.

The days before cash-machine overdrafts.

 

It was winter,

I know the season as I remember the cold.

 

And buddying-up with sleeping-rough man.

 

In those days, the conversations seemed less about homelessness

And more about

Lifestyle.

 

Edinburgh can be very cold at night,

Particularly if it is damp.

And the wind is blowing.

 

And, now I remember, all I had was the Postman Jacket

I had bought from the second-hand store.

The one that Cliff wore in Cheers

Not the actual one,

But a lookalike.

 

Not the best for winter in Scotland.

 

And cold, so very cold and nowhere to go and nowhere to sleep

And we bedded down on flattened cardboard boxes

In the underpass

 

of the bus station.

 

I was always a bit dramatic.

TCDCHEE EC035

Trees

I love looking at the late winter trees.

Naked.

Branches sketching an intricate skeleton

Just like

The lungs or the brain

of a Gunther von Hagens

Exposed

For all

to see.

birds settle on the branches.

they lark and fight for space,

taking comfort in the company of the flock

That is

until it is morning

when they fly away to look

for

Food.

Delirium

 

There must be a psychological reason to explain why some people more readily respond by saying yes when asked to do something, compared with others who either reply with an outright no, an evasive, why, what… Let me see, or an oblique, Look at that chaffinch over there.

I fall into the former category every time.

Yes.

I said yes when Nic asked me whether I would like to run a webinar discussing delirium on the 15th of March, to celebrate World Delirium Day.

It could be that the pathways in my brain are unstable, live-wires with inadequate insulation. There you go. Spark.

I was woken this morning at 530 when my phone buzzed with a tweet from a well-known professor of deliriumology who was re-tweeting about the webinar.

You see, the problem is, although I pretty-much live delirium – I have spent more time talking to people with delirium or the relatives of people experiencing delirium than most, I still am not entirely sure I know much about it.

This is because no one really knows or understands. (Except perhaps the professor).

You see, we don’t understand why some people are more likely to become delirious compared with others, that is, why some are more susceptible. People who have dementia, for example, are many times more at risk of developing delirium secondary to relatively minor insults – changes in environment, pain, dehydration, or, constipation, whereas others, require far greater physiological upsets – septicaemia, major surgery, trauma or, an adequate dosage of LSD or Psilocybin.

That is less perhaps of concern, as the more any of us learn , the less we all realise we know.

I should probably offer some reassurance; we do have an idea about some aspects of delirium, at least, we know what works – or at least, what probably works most of the time, although it is so complicated that what works for one person is likely to not work for another.

There are however common themes:

   Person-centred care – I have yet to encounter a patient where treating them as an individual, providing them a sensitive ear, caring touch or individualised plan of care has been harmful.

   Keeping people safe – you can’t argue that when people have delirium they are vulnerable, and, equally, if those vulnerable people injure themselves – fall, trip or otherwise experience harm, they are likely to have a less favourable outcome.

   Ensuring hydration and adequate nutrition – this is, avoiding dehydration or malnutrition, hunger or thirst, these can contribute to a worsening of the delirium.

   Involving family and friends – ensuring that loved-ones have as much access as desired to their delirious mum, dad or grandparent. You are more likely to trust your son or daughter than a stranger in a uniform.

   Sleep – disturbance of the sleep-wake cycle is often a key component of delirium – this as part of my translation of the hospital at night (sometimes trendily referred to as H@N), which in my experience is more like, Night at the Museum, with drowsy, confused patients, fewer staff, strange shadows and the additional impact of sleeping tablets. Establishing good sleep at night and wakefulness by day – that is having adequate stimulus, entertainment and engagement during can all help.

There are many more what we call ‘multi-component interventions’ some of which work, some of which do not, to help a person who is delirious.

We still haven’t figured-out which medicines work for delirium. It seems that although many drugs can contribute to its development, (pain-killers, sleeping tablets, bladder medicines) we haven’t found a pill than can prevent it or even stop it happening.

If only delirium were more like stroke, heart attacks or pneumonia. We could provide the aspirin, thrombolysis or antibiotics and wait for nature to run its course. It is not that simple.

And amidst all this I have offered to say a few words about delirium on the 15th. You are welcome to tune-in; the link is here.

If you can’t or don’t sign-up to listen, I hope what I have written will help to explain some of the morass. It is what keeps me busy. That, and all the other things I am too mentally slow to respond with anything other than ‘yes’.

065_3_alexander_oscilate

Just by looking

Can you tell if someone has dementia just by looking?

I sometimes put this question to medical students. I am always fascinated by the answer.

Everyone knows that you can’t diagnose by looking (historically clinical textbooks have included signs – the hands of Acromegaly, the flush of lupus or, the drooping eyelids of Myasthenia.) – medicine has veered away from this approach given that we now live in times more accepting of diversity.

Some of us have big hands (or abnormally small ones, Mr T), high colour and droopy eyes and are in perfect health. Attaching a disease to a look can be dangerous.

But, there is something in it.

I can usually work out who has dementia or cognitive impairment when I am on the admissions unit at my hospital. People with dementia are more likely to be in bed, wearing pyjamas, and, not obeying the buzzer rules. They are more likely to have a sippy-cup, not have eaten their meal and have cot-sides-up during the day. (We are working to fix this through #endPJParalysis).

I suspect part of this is the damage inflicted on doctors in medical school where we are taught to be vigilant, to utilise our Sherlock.

The empty inhaler box… asthma, diabetic jam, waking stick, hearing aid. Part of understanding how we can help our patients is by enhanced communication, that is, using what is not being said to explain what is.

The other week I met a patient, we discussed her fall – what had led-up to her coming to hospital and so on; there was nothing out of the ordinary. It was only afterwards when reflecting on our conversation, I considered that there was something not quite right with her speech or manner. I therefore did what doctors do and assumed there must be more afoot; not a straightforward trip, slip or tumble.

I organised a CT scan. It showed cancer.

In Malcolm Gladwell’s book, ‘Blink’ he describes the value of reflection, intuition and non-linear cognition. We all operate at a highly evolved conscious level of thoughts and ideas – we also have within us a deeper, more atavistic sense which connects us to one another.

When one of my patients is anxious or sad, I cannot necessarily fit them into a set of pathologies, I can’t always articulate what I am feeling, but I have a sense that something is not right, just as is often the case, my patients (and very often their relatives) when ill can have an ineffable sense that something is wrong.

Whether we call this intuition, experience or the unconscious, I don’t know, most of us, when given enough time and space, away from multimedia distractions and work-pressures are able to connect in this way.

And, to the point.

I originally wanted to open this by talking about Billy Connolly’s recent DVD – High Horse Tour.

Billy has Parkinson’s disease and he covers some of his experiences in the set.

It didn’t take me long to see his bradykinesia. Unlike many with the disease, Billy has a form of Parkinson’s that slows-down his movements more than causing the characteristic shakes. I remember watching Billy years ago where he would stride across the stage, using his arms as legs as part of his Big Yin persona. No longer.

Sharp as a tack and as mentally dextrous as ever it was fantastic watching him (with very strong language) in action, he has lost none of his wit.

And back to the original question. What can you tell from looking?

I guess, very little.

You can skim the surface, leave with impressions or intuitions – it is only when we delve deeper, question, talk, chat, joke (smile) that the complexity of who and what we are comes across.

Don’t rely on a look to tell you the answer. Sure, reflect, weigh and integrate ideas and impressions, equally, do not base your management solely on the facts on the page, ensure you are aware that there is far more to every person than their sodium, potassium or haemoglobin level.

The next time a smart young doctor quotes an obscure study in the New England Journal of Medicine, slow down, insert a pause; ensure that they also have spent a moment connecting with something deeper.

Billy Connolly pictured in 1977

Doing to and with

I had a brief exchange with a colleague yesterday – it was really a clarification, yet it provided an insight into the way we both approach patients, treatment and care.

The discussion related to a patient who was struggling to swallow liquids and solids because of her underlying disease; this is not an uncommon phenomenon when treating those with advanced physical, and, particularly, neurological disease.

The usual sequence of events is a person who develops recurrent chest infections; the speech and language therapist (pathologist in America), then undertakes an examination and determines that the cause of the infections is likely ‘aspiration’ – that is, food entering the lungs because of a failure in the mechanics or coordination of swallowing.

The next stage is a decision as to how best to support the person. Sometimes acute illness or drugs can cause aspiration and time for recovery, or stopping a culprit medicine can improve the situation. Often, it is the progression of disease. We need however to work-out what to do to ensure the patient is receiving adequate nutrition in the meantime – particularly, as, when a patient is ill, this is usually a time to increase their nutrition to help them fight an infection or disease.

There are various options – adding thickener to food, pureeing, mashing, ensuring they are sitting upright. For those who have severe aspiration, when all alternatives have been considered, we sometimes use a nasogastric (NG) feed – this is a tube inserted through the nose, down the throat into the stomach, to provide food and fluid directly into the body.

I have never had an NG tube myself, although I have spoken to many patients and the process of insertion can be unpleasant, they are also easy to dislodge (pull-out) and there sometimes is a risk the tube is misplaced resulting in food entering the lungs directly causing severe pneumonia.

(Some clinical areas utilise nasal bridles – this is a way of tying the tube into place – see here.)

NG tubes are therefore a lifesaving treatment in some instances, for example, following a stroke or surgery. For people with more progressive conditions, particularly in the case of dementia, where aspiration tends to be associated with late-stage disease, patients are unlikely to understand the purpose of the intervention.

Other forms of feeding – using per-cutaneous gastrostomy (PEG) – a tube directly into the stomach is also usually inappropriate for people who have advanced dementia for similar reasons (for an insight into PEGs, I suggest you read John Diamond’s book ‘C’).

The final most sophisticated form of nutritional support is total parenteral nutrition (TPN), where nutrients are provided directly into the bloodstream. This is usually only appropriate in certain situations, for example, after gastrointestinal surgery or recovery from critical illness.

What to do when there is no option for an NG, a PEG or TPN?

One possibility is starvation.

Not allowing the patient any food or drink at all. (Long-term treatment with intravenous fluids is also unsustainable as a means of hydration for other technical reasons).

We don’t do this.

We need to decide how we can support – as often people are still hungry or thirsty, assuming they are conscious.

It is this decision that started me off today – in particular, how we talk about it.

The consensus with my colleague was that there were no alternatives other than allowing the person to eat and drink at risk. This is the phrase we use on my ward, which implies that we support a person to eat and drink as they are able, providing as much support as we can to reduce the risk of aspiration – ensuring they are fully awake, alert, sitting upright, out of bed, small sips, and so on.

When asked for his opinion, my colleagues suggestion was ‘ethical feeding’ – it transpired he meant the same as me i.e. eating at risk, although I needed to clarify the situation, after all, what is ethical? One might interpret ‘ethical’ as restraining a patient and feeding them against their will to prevent starvation, as sometimes happens in some psychiatric conditions.

It transpired that ethical and at risk are the same.

The difference to me was the feeding.

As adults, we eat our food. When we are unable or incompetent, we are fed. I feed my cat or dog or a baby, I eat my McDonalds.

This subtle distinction has little to do with food or nutrition but, locus of control.

The essence of doing to a person and doing with. The latter assumes autonomy or capacity, empowers, looks to an independent future state, the former, to dependency.

This translates across many aspects of health and social care, indeed, it is one of the philosophical differences between the two, where health is more often a doing to, social care, a doing with, one dependence, the other independence. Paternalism and Autonomy.

There will always be times when a paternal approach is required, when we are so unwell, sick or poorly that we want to be looked-after, when we are happy to handover control; as a model for the future, we need to always consider first with before to.

autonomy-1

Restraint.

Tie-up your confused, vulnerable, fallers.

That is a quick and easy way to save yourself trouble.

It’s unethical, but it gets results.

Target achievement is a fundamental at the heart of this.

In a complex adaptive system, there is often less scrutiny of the journey than the outcome. We broadcast our successes – quick wins and triumphs. We bury (literally at times) our failures.

On a trip to Holland last year, I was met with scepticism when I explained to the hospital staff our policy of not restraining confused older people. I suspect they either thought I was lying, or perhaps joking. I mean, how else, can you keep those old folk safe?

In the UK, we believe that restraint is bad. Tying someone to their chair or bed might be effective, it might prevent wandering, it might even result in fewer patients falling, but it leads to a greater harm – damage to an individual’s sense of self and likely, the spirit of those caring for them.

We tie-up horses and donkeys, I use a lead when walking my dog. We shackle slaves.

A subtler form of restraint can sometimes be found in our hospitals; head down (in bed), or table blocking. Yes, this is restraint. If you look for them, there are even some ‘bucket’ chairs out there, a form of mechanical straightjacket that disrupts an individual’s volition.

I suspect certain world leaders wouldn’t have a problem with restraint (so long as it doesn’t affect them or their family) – yet, we have surely evolved past this interpretation of humanity.

Care.

Care can be easily abused.

I care for you, you care for me, we care for you as a person.

Care and love are what make us human.

If we disregard or disrespect care, if we fall back into mechanistic patterns of behaviour, we become worse than robots, we become free-will fascists.

Let’s sit and listen to what our patients’ are saying. Let’s try to understand their needs – their hunger or thirst, their tiredness or pain; let us not objectify their experience – let us weigh their feelings, emotions and perceptions.

If I step barefoot on a pin, that is my pain, it is the same pain that has echoed throughout our evolution. More is expected of us in the 21st Century.

Today, when you suffer, I feel pain. I can’t shut out your experience.

We exist as a community, if not we perish as individuals.

Pilgrim State Hospital

 

Barbara Robb – Sans Everything

Yesterday, at the Dementia 2017 Conference in London I heard one of the most stunning – devastating and uplifting stories in years.

Claire Hilton, Consultant in Old Age Psychiatry in North West London, discussed Barbara Robb, describing her battle to improve conditions for long-term residents in psychiatric hospitals in the UK in the 1960s and 70s.

Claire screened an excerpt of the 1968 World In Action documentary which revealed, possibly for the first time the unimaginable horror inside a British long-stay psychiatric hospital towards the end of the 20th Century.

You can watch the film, Ward F:13 here.

Barbara Robb, a psychotherapist and campaigner born 1912 in Yorkshire was contacted by Amy Gibbs, at the time an inpatient at Friern Hospital in London.

Gibbs introduced Robb to the appalling situation facing mostly older people during their prolonged hospital stays; this let to Robb both writing the book ‘Sans Everything’ which described the experiences of similar people to Gibbs and campaigning to improve conditions inside the institutions.

The book describes older people, mostly women, stripped of all sense of identity or dignity, treated with disrespect and disregard for their humanity, locked in Victorian sanataria for decades.

Following this, Robb battled with officialdom for recognition of the situation described in her book – facing challenge and opposition – most stunningly from Kenneth Robinson, the then Minister of Health.

It was only after the publication of the White Paper, support from the media and eventually Richard Crossman, the Secretary of State for Health and Social Security, did recognition grow – with the realisation that Robb’s book was not exaggeration or fiction, that the situation was as appalling as she described.

Claire ended her lecture by discussing some of the recent (and perhaps, current) tragedies that have risen to prominence in the UK Health and Care Sector – Mid-Staffs, Winterbourne View, for example – where, through an over reliance on budgets, targets, process and objectification, people (staff, patients and residents) became dehumanised, and where, with the current extreme pressures within the system, fixating on waiting times, bed-occupancy and length of stay, we risk falling into a similar trope.

I have just now ordered Sans Everything, which appears to no longer been in print. I am left wondering why the NHS has not done more to celebrate Barbara Robb’s story.

Claire Hilton’s account of this story, Improving Psychiatric Care for Older People: Barbara Robb’s Campaign 1965-1975 is scheduled to be published soon (free ebook).

f13

Dementias 2017

This is a quick one.

I usually write on Saturday or Sunday mornings…

Currently, I am in a hotel somewhere in London. I am attending the ‘Dementias 2017’ conference, at the Royal College of General Practitioners.

Alistair Burns chaired this morning in his inimitable West Coast style. It was great.

One of the lecturers, Professor Michael Hornberger from the University of East Anglia talked about radiological techniques to diagnose dementia, specifically comparing Alzheimer’s with Fronto-Temporal Dementia (FTD).

I am sure that most of you have heard of Alzheimer’s; FTD is a much rarer form of the disease that can develop in younger people and is characterised by changes in the frontal lobes – those parts of the brain that control abstract thought, emotion, planning and self-control. (Yes, like our current US President; Not).

One of the fascinating differences was within Alzheimer’s, which characteristically affects first the hippocampus – the part of our brains controlling memory; it then moves-on to the Amygdala, the namesake of this blog, which controls emotions.

In FTD, the Amygdala is often affected first then the hippocampus; resulting in blunting of mood, emotion and empathy before memory. The former leading to a persistence of spacial-orientation (not getting lost), with those living with Alzheimer’s characteristically losing track of time and space earlier.

Michael has used an app – ‘Sea Quest Hero’ to investigate this.

It is incredible the extent to which physical changes in your brain can be translated into alterations in behaviour, personality or mood. I know this should be obvious, but seeing the shadowy images, projected onto the screen somehow made it more real more…

I remember a recent patient, G. who became lost after a couple of seconds of redirection, ‘Where am I?’ He had Alzheimer’s.

Some of my patients struggle.

The battle between overwhelming neurological deficits, added to the constraints of hospitalisation can be too much. ‘I want to go home,’ is one of the most painful phrases I hear. Especially when repeated again, and again and again.

We are the subjects of our brains and neuropathology.

Let us one day understand better who we are.

 

10 years

I wasn’t sure how it would go. I was a little anxious.

Today I spent a few hours working as the medical registrar.

This was part of my pay-back for J helping me a few months ago.

I didn’t know what to expect.

I didn’t know whether I’d be up for the job.

It was funny.

In medicine, we spend years working through different phases of training – acquiring skills, talents and techniques that are useful at the time. Some of these we carry with us – how to listen, communicate, think outside the diagnostic box; others, which fade with time.

It is these latter skills that had me most worried.

I knew I’d be OK if I had to lead a cardiac arrest – I did this a few months ago, although not with the finesse of my registrar years…

For those of you unfamiliar with the chronology of a doctor – here is a template:

1998 to 1999 house officer*

1999 to 2002 senior house officer*

2002 to 2007 registrar*

2007 to date consultant

*We get told-off for using these old-fashioned designations; as this is my blog, I don’t care.

That is the run-through. Some people take a different path; for me, I didn’t know what I wanted to do when I finished medical school & as the lines of the song go, I still don’t.

The skills you lose when you become a consultant – in my case, one who spends his time listening-to and supporting older people are the practical procedures – taking blood, siting cannulas, central lines, temporary pacemakers and chest drains.

I know if it came to it and I had to do any of these procedures I could muddle through; perhaps not with the same aplomb as 10 years ago, but I’d be good-enough (which in UK – the Bolam* Test, is all you need).

Over a few hours I encountered a stunning array of patients and diseases; old and young; meningococcal septicaemia, leukaemia, renal failure, pneumonia, delirium, dementia, overdose, heart, lung and liver failure, arthritis, migraine… the list goes on. We sometimes forget how broad is the panoply of human disease, how many dimensions there are to suffering.

Different to the role of a consultant, as a transient registrar, I could spend time talking with patients – time that in my usual life is so squeezed. In this job, with my trusty bleeper, I was adrift in the system, no longer solely responsible for my actions.

Sure, there was prioritisation, ordering and organising, but different to my day-job.

Crap. I found it fun.

I remember struggling with the transition from senior house officer to registrar – not because of the increase in workload or other challenges, but because of the loss of intimacy, the loss of me and the patient, us, together, within the ranks.

I know it was just for a few hours and I was lucky that nothing went wrong and I suspect none of the patients realised they were being supported by a much older version of a doctor than would normally have spoken with them.

As with my day-job, it was an honour. It was a pleasure. It was fun.

This is what we need to hold-on to when the bastards are getting us down. When the system is upturning our values, when the resources are finite and the demand overwhelming.

Could there be a better job than one in which we can connect with people during their time of need, of vulnerability and fear, and offer a solution or a support?

I have spent so long recently crying over our beloved system, this was more like a time to celebrate.

horses

*The Bolam Test – suggests that doctors need to be as good as the standard set by a ‘responsible body of medical opinion’ – they don’t have to be the best. (Although we all aspire to be the best – that is ego; a separate principle)

Chess moves, the NHS & Being There

I shouldn’t start by blaming the NHS for this, as, I imagine chess is played across the world by people in all sorts of management positions.

          If I do this; reduce here, shift that; increase A, stop B or C, then, they can go there and things will happen.

There is a cause and effect assumption within health and likely, social care, that if you go through the process; start with a good idea, you will end-up with a result.

The latter is true. You will always have a result. As to whether it is the outcome you intended is another matter.

The mechanistic – probably minimalist assumption that strategic gameplay with people and services is as straightforward as chess, remains a cornerstone of healthcare reforms, changes and developments.

The concept that the minimal viable resources available – aka our staff, are pawns is consistent throughout the system.

I don’t want to labour the analogy any further – I’m sure you get what I am saying.

No matter the degree of sophistication of the management in any organisation, the notion that people can be shipped around, moved or reallocated without consequence or repercussion is flawed.

First, because people don’t like it.

And, secondly, because most of the movers and shakers – the game players – strategists – senior managers, have so little understanding of what it is the pawns do, there is a huge underestimate as to the complexity of relationships and of role, to the extent that people are minimised to modules. Pawns.

The only meaningful strategic planning that I have seen and can conceive is where the management shift. Where they don’t do to, but do with, when they take-off their (bowlers), suits, roll-up their sleeves and join-in. When they in effect become pawns. When the work alongside the doctors, nurses or therapists. When they are faced with the good and the bad. When the time they would have spent in meetings is deconstructed – pulled apart into something more serviceable.

When the managers have undone themselves to such an extent that they are unidentifiable from the rest. And their job no longer becomes one of scrabbling for position or results (achievement of targets), but one of facilitating, coaching, maintaining and sustaining.

I have written before about Chauncey Gardiner. The character in Jerzy Kosinski’s ‘Being There’ – the gardener who becomes a candidate for US president. His approach to management and leadership is one of tending his plants. Making sure their basic needs are addressed; the right soil, light and water, and beyond that just being there. Being available, nurturing, supporting, comforting, understanding.

This is all to say that the problems faced by those providing the care, support and treatment are problems that can only be solved by those inside. That the management support can only be determined by those inside the work.

This is teal.

This is having a sense of purpose, accepting the responsibility to grow, adapt and evolve and being able to self-determine.

This is the hope for the Wellbeing teams (see advert) and likely, the hope for any services operational in health, social care or whatever area of our society that helps, supports, works-with and involves people.

the-chess-game-by-sofonisba-anguissola

Want to make a difference to the wellbeing of people in Doncaster? (Advert)

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Working with us

You will work as a team to create your schedule for the hours that you need.

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To learn more about Wellbeing Teams approach to care and support, visit www.youtube.com/watch?v=sM4Inoe-KZA

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Stick

Yesterday I was talking with a colleague who has a bad knee as she hobbled along one of the hospital corridors. I suggested she use a walking stick. She didn’t think this a great idea and limped off.

I also have a family member with a bad knee. She won’t entertain using a stick either.

Knees can be tricky things, especially when they go wrong.

My mum had a bad knee also. She didn’t seem to have a problem using a walking stick. I bought her a carbon-fibre one which is now in my garden shed. She never wanted to consider a wheelchair however.

It is odd that different people have varying perceptions of what is OK to use as a support or prop.

It might be OK to hold-on to your friend or partner’s shoulder as you navigate some tricky steps; it might even be considered acceptable to display your pain for all to see. But, a stick. No.

I haven’t seen many walking sticks on the ward recently.

Indeed, the last walking stick I saw came to a bad end when it wasn’t used as a walking stick.

 

I was talking with medical students last week about ageing and what I do. We discussed falls – an ever-present theme in the life of a Geriatrician. The reality being that as people age, they are more likely to fall-over, at some point, than not. We – that is humans didn’t evolve to be 95 years old with arthritis. Our balance, proprioception and coordination mechanisms haven’t had a chance to adapt to advanced age. And so, falling is a big thing.

I was talking with a patient yesterday who was navigating the ward using a Zimmer Frame (I see far more of these than sticks); she was quite steady and although I wouldn’t go as far as calling her ‘nimble’, she could get where she wanted to go.

Many of my patients who should be using Zimmer’s to support their walking forget to use them.

You need to have the capacity to remember that you are unsteady when you walk, that you might fall and that you need to get hold of a four-legged aluminium prop. If you forget this and you are off and your balance is bad or your knee or hip weak, over you go.

Fall or worse, fracture.

I wrote before Christmas about Cognitive Dissonance – I think this is an example. People who dissociate the reality of their unsteadiness with the belief that using a walking aid would perhaps reveal an infirmity that they don’t want to accept.

I can sort of get this.

But it is a shame.

We, that is everyone, who struggles through life needs as much help and support as possible.

Independence is fantastic, but you can only achieve independence through the support of others.

We did not gain world domination on our own. We live in societies, within networks of families, friends and colleagues, nation states, unions and organisations. Going it alone isn’t an option.

So, if anyone wants to borrow my mum’s old stick, give me a shout.

otto-dix

Funny… De-diagnosing (&de-prescribing)

It’s funny – well, at least to me, in my world of not so funny things; I was going to start this with, ‘Most people will have heard of de-prescribing…’ Then, I realised I didn’t know what I was talking about.

This is groupthink & being a specialist all congealed into one.

I’ll start at the beginning.

And, in the beginning, there was de-prescribing.

This is the relatively new concept (outside of the world of Geriatricians) that says that it is often better to stop medicines than to start them; although there are many wonderful drugs out there, making pharmaceutical companies and stock-holders rich; there are also pills, potions and lotions which are not only ineffective, but harmful.

One of the joys of graduating from medical school relates to the pleasure of prescribing drugs – especially those which people can’t ordinarily access without a doctor’s say so. (or a non-medical prescriber, but, let’s not go there just now) (I think my first script was for Morphine on the HDU at Raigmore Hospital)

And so, it goes – doctors are the folk you approach if you want medicine; antibiotics, pain-killers, antidepressants or antipsychotics. They are the gate-keepers. It you aren’t busy prescribing, as a doctor, what are you doing?

Anyone who has visited the installation in the British Museum which displays the pills/tablets/drugs/medicines tableau of what a person might take in a lifetime to ensure their wellbeing, will understand that we, that is, society, are drowning underneath a mountain of enteric-coated, water-soluble products.

And, to de-prescribing.

This is the art of stopping those medicines that are no longer necessary to maintain health – for example, the 96-year-old’s Simvastatin.

Yes, when I have my heart attack, load me with these agents – saturate my bloodstream with reductase inhibitors; bombard my kidneys with agents to inhibit enzymatic and microcellular pathways, but, when I have reaped the benefit, let me move on. Grant me more than day-release from the prescriptions; set me free.

This is when I take my Bic and stop the statin, the ace-inhibitor, analgesic, anxiolytic, antihypertensive or sedative. When I set people free from the constraints of care.

On most occasions – that is, something like 99.9% of the time, patients are grateful. They appreciate that someone has stopped and considered their therapeutic burden, who has talked with them, involved them and their families in decision-making about the extent to which medicines control life.

And on to de-diagnosing.

I haven’t heard this term before – it came-out during a meeting this afternoon with colleagues who are looking with me at strategies to expand the knowledge and awareness of delirium.

A funny thing; well, not necessarily funny if you are the patient, but funny in an ironic sort of way, is the eagerness of doctors to provide diagnoses.

I suspect patients are complicit in this.

No one likes to deal with uncertainty –

– Can I have a bunch of those things?… What are they?

– Oh, I don’t really know, I am sure they taste good

That sort of thing.

We seek assurance, orientation and guidance.

– Doctor, what is causing my pain?

– Oh, it must be your sciatica.

– Ah… sciatica. I have sciatica.

This is different to –

– Doctor, I am struggling to sleep

– Oh…

The onus often falls on the doctor to deliver. To perform.

De-diagnosing comes from this;

– Doctor, why is my mother so very confused

– She has dementia

– Oh dear, I didn’t realise that.

Three months later… Memory clinic at local mental health organisation –

– How can I help you?

– The doctor asked us to see you about mum’s dementia

>>>Tests>>>

– Your mum doesn’t have dementia. Mrs A, you don’t have dementia, I think you were delirious.

– Oh – so, no dementia?

– No

This is de-diagnosis; when one doctor provides a watertight diagnosis that is adopted by patient, family and friends, which is then overturned because of the actions of time and, the thoroughness of the assessment conducted by someone who knows what they are doing.

How many of us could be de-diagnosed?

How many asthmatic, depressive, arthritics at some point in time had a wheeze followed by sadness and stiff joints.

A dance macabre.

There is so much urgency within our health service and our 24/7 society that the immediacy of results, diagnosis and prognosis is considered core business.

Time is a component of health and social care that people have tried to sweep under the carpet.

What we need is time and space to breathe, think and recover.

OLYMPUS DIGITAL CAMERA

I may be right?

I think, probably, I know what I am doing.

I agree with what you have said.

Move in direction A, indicate, prognosticate, plan or decide; determine, direct, suggest or propose.

This is how it should be; this is the solution.

Yet, there is something inside of me, gnawing,

making me question.

Everything.

Yes. Question whether the certitude I possess is appropriate or feasible.

Surely, most of us have a certainty quotient.

The Earth is flat. It will take a certain amount of evidence to convince me otherwise.

It is raining, cloudy or cold. All of this, determined by my sensations – we exist in a world controlled by our perceptions.

Yet, some will walk around (in the cold) and feel (or, at least, profess) warm. Their perceptions  differing to mine. (Usually, generally, cold, so long as it isn’t July)

And, left or right; my political affiliations. Benefit of the doubt or shoot first and ask questions later, corporal or capital punishment or establishing the causes of crime and remediating. (aka a social disease)

Equality or competition. Standing on the shoulders of giants or the faces of peers.

Elbowing the competition or considering the needs of others.

There is me and you; Chaos or Community.

How can I be confident of my solution? What directs my compass towards the North, when you, you feel the pull of the South?

There is the objective. Objectivity is relative. If ten people think you are crazy, are you mad? A thousand? A million?

At a point, you must cast-off and accept it doesn’t matter what anyone else thinks, it is what you determine; taking fate in your hands and stepping-out. Risk.

Either flattened by the reality juggernaut or crossed to the other side.

Some of us must do something.

Sitting around, is certainly worse.

Do, do, do.

leonard_bernstein_larger_than_life_top_7

 

I step out and fall back in time

Yesterday.

Last year.

1980.

Dozing on speckled carpet.

Icy windscreen of rusting Mini.

Cocoon of Friday afternoon in front of the telly,

after school,

winter.

Heavy,

cherry-wood sideboard

under the stairs

and

mysterious books lining the walls;

Shakespeare

the eternal

Bard,

dark curtains

hiding the entrance;

behind which

an old-fashioned Singer sewing machine;

w/ foot-plate.

concealed drawers with

Bobbins.

Dark

mustiness of coats and blankets & lambs-wool.

Ice on the inside

of the sky-light

&

skinny radiator

straining

to maintain

homeostasis.

mini

It’s hard not to be rude

It’s hard not to be rude when you listen to the news.

Headlines from the Conservative Party telling GPs that the answer to the problem* is their opening longer hours. (*not that there is a problem)

I mean. Come on.

It is not GP access that is the problem. It isn’t even the junior doctors who work defeated, in A&E departments across the country. It is the dogged approach to where money is directed.

Yes.

As my last blog said, we are rich. We have the fifth largest economy in the world. I mean – that is, people driving around in too big cars and living in too expensive houses – we have a lot. Sure, not everyone can amble around Waitrose on an empty stomach; but we have multitudes.

Scapegoat.

The origins of this word come from biblical times. In the Temple in Jerusalem, the priests would sacrifice the Paschal Lamb – the scapegoat. This was the animal barbecued instead of a person. Burn the lamb and God will be happy. God will think that the lamb is the people saying, ‘Sorry,’ and, all will be forgiven. Tabula rasa.

It is a form of bullying.

Hitler blamed the Jews for the ills of society and the rest of his country followed; Trump blames the Mexicans or the Muslims and voila. Let me see who I can blame to take the pressure off me…

The thing is, within the mixed-up world of healthcare (I am leaving social care out of this), blaming the usual suspect doesn’t get you very far. I might blame the pain my patient is experiencing on a broken rib – if they have a clot in their lung instead, the outcome will not be good; if I prescribe drug A instead of B for condition C instead of D, my patient is unlikely to recover.

Let us apportion blame and responsibility at those responsible.

Our current crisis relates to the government draining funds from social care – that is, councils across the country, a bizarre cost-saving measure based on the principles of conservatism.

Not only is the money allocated to councils squeezed; the funds provided to those delivering healthcare is left to stagnate.

The wheels keep turning – there is always more business and if you take from Peter, who robs from Paul, you are no further forwards.

A zero-sum game.

Let’s not blame the GPs. Let’s not move the responsibility to the doctors or nurses who wake and head to work with a sense of calling – a summation of what it is to be human.

Let’s go after the real baddies… avarice, greed, ego & accumulation.

eve

 

 

There is no money

There is no money, the coffers are empty.

I hear this so often at work, it has become a mantra. The flip side is, when the coffers were full (the good old days) we were too busy spending to appreciate what we had.

Austerity versus plenty.

Two sides of the same reality. Both jangling in your pocket as you work-out where to go.

The UK is one of the richest countries in the world – a world that is experiencing unprecedented wealth. Massive riches simultaneous with swingeing poverty.

Wealth and poverty.

And, despite our experience of plenty, we also feel restricted, put-upon. Limited by what we can or cannot do because of…

Much of this boils-down to creativity.

How creative are you? How big is your imagination? Can you dream-up new ways of organising at the same time as running from the storm?

We have no money.

I bracket this with the same ideology that makes people shudder at new ways of working or collaborating , adopting concepts of risk-taking or thinking differently.

Don’t suggest, do, think or even look in that direction (of new idea, methodology, practice, approach) – keep your bowler balanced straight and keep moving forwards. Deviate and you become a deviant. Too dangerous, too new, too unusual, too risky, too little or too much. Just… don’t.

This is at the core of conservative orthodoxy that keeps people sheltering in caves; that maintains the status quo.

And,

We have no money.

Is another form of this, it is another constraint on action or thinking; instead of viewing our situation as being one of prosperity, we live in limitation.

Our health service is considered cash-strapped and battles are fought over what are perceived as the last remaining scraps.

To grow, create, evolve, you need to take risk, you need to feel safe, you need to not have someone saying – ‘We have no money!’

Park the money, park the fear and experiment; it is surprising how far you can go on the back of ideas and enthusiasm.

laurelhardybowler

 

Under Pressure

Pressure pushing down on me

pressing down on you

No man ask for

Under Pressure.

If the NHS were a pressure cooker I suspect it would have popped a while ago.

I don’t see many pressure cookers nowadays. I remember my mum used to have one back in the 80’s. It was a heavy, freckled, stainless steel pot that locked and had a weighted whistle that would blow when whatever was cooking was ready; I can see in my mind’s eye the steam shooting out the side as mum in apron tended cooking, baking, household chores and keeping an eye on me.

If the NHS were a pressure cooker it would have burst by now. Like a crazy, stretched-out, incendiary bomb, a tired flame-dragon wheezing and popping. Such a shame. So unnecessary. Such an incredible, unimaginable act of good, the NHS; but how much can it take?

Moving from cookery to Star Trek – the engine can only cope with so many jumps, keep pushing the components, the scanners, analysers, nurses, doctors, therapists, and there is a point at which no more can be gained; the horse still shows up in the morning but it no longer whinnies, it no longer pulls the extra load; just accepts the beating, ignoring the pain.

I think of the dream from Crime and Punishment when the nag is being flayed; beaten; it can give no more, yet the owner continues to batter and punch, continues to shout and scream and demand from a creature that is already spent. How much more whipping, beating, berating, bullying, tormenting, can we accept before we succumb to the inevitable, before we give-up. And what follows? Where do we go when we have run-out of places to hide? When, we, in our heart know that we should keep going, keep toiling in the face of the fire, but our limbs will no longer drag us forwards.

As for the alternatives. Candide.

We are living in the best of best possible worlds, universes or existences. There are no more conceivable options or opportunities open to us, we are at the helm of the most incredible organisation ever created; we are at the bridge, watching, and we are privy to the fantastical reality that is the cooperative, collaborative, engaging, listening, respecting, sensing system in which we operate.

Let’s keep going a little longer.

If you close your eyes it might not happen.

raskolnikov_and_sofia_by_ireneirene

Let’s pretend

Let’s pretend I know more

about you

than you know about me.

 

Let’s imagine I can think-up

or, perhaps

generate in my mind’s eye

scenarios that you don’t realise are possible –

Yes,

a little like I am running at full speed and you are ambling.

45 vs 78

distorted, but not enough for anyone to worry

or

get uptight

or anxious

or call-out, call foul, shout for a penalty.

 

Let’s imagine

I can see a little bit further into the future

than you,

I can see around the corners

through cracks

that are mostly obscured

by soot

and dust

that to you are just things

but to me are more than, that are.

 

Just imagine

I can jump from a cliff across the ocean,

That I can take a breath and draw-in the world

everything

all memory, past, experience present and future.

 

I will laugh.

I bet I will

and what expression will pass over your face.

your punim.

Happy or sad

Perplexed?

 

It is just a game

where we each must accept

there is no first or second place

there is no better or worse

There just – is

I am

you are

we go, we stay, we hope or wish.

 

Twisted and tangled

caught-up

struggling

to escape.

 

We one day will come together

and find a solution

a way

Out

of this mess

of the

Morass.

 

Quick!

Whilst there is time, gain the advantage, take cover and move with stealth.

If you don’t, if you do not, who is to know

?

manatee

It flows down

It flows down. I have been sent to find out how many beds you have available in your department. How many discharges. How many people can go and are going. How many people are waiting to move to A or B or C. I don’t necessarily want the details, I don’t want to hear excuses or things gone wrong or waiting for this or that, I want to hear when there will be a bed, I need to move from the trolley in A&E to the bed in AMU to the ward to the rehab to the home to home and I am adequately detached from the end or net result to be too concerned about whether Mr A or Mrs B or C don’t quite make it and have to come back three days later via blue-light ambulance as they were sent home too soon before everything was sorted-out, and hospitals are like pressure cookers – a point is reached beyond which nothing helps but blowing the whistle and you have to be careful that you don’t make people make decisions in haste that result in harm for what is the point of being able to save a life one day only to screw up the care two weeks later – the journey is one, it is all connected and whatever happens in one part has knock-on effects on another and I really do believe it is the mind-sets of those trying to lead or deliver results or achieve targets that once distorted become difficult if not impossible to unravel; untangle like the metabolic pathways of an addict brain, like the grooves worn in ice or grass flattened sheep paths, we run, we run down one alley and even though it is the wrong direction, it is at least somewhere to go, it is at least perceived as movement in one direction – despite the reality it might be taking you in reverse, you keep going, you keep going, deluding yourself into the belief that as you are busy, as you are occupied, you are doing and doing is good, for the alternative, not-doing is unacceptable and must be challenged – it is the action which cannot be spoken-of, it is the management plan, process, strategy, task and finish, executive board decision that makes everyone feel better as there is a sense of something being done even though that which is being done is closer to destruction than creation, even though those who get in the way risk becoming new victims of the analysis, becoming statistical anomalies of health or social care and everyone wants to do the right thing – this isn’t about bad people being malicious or wanting to stir-up the dirt or slow down the improvement, this is well-meaning people, well-intentioned, usually very bright and inspired individuals who a little like rabbits in headlights don’t quite know which way to turn when the car approaches at speed out of the darkness and you go left or right or stay where you are & the results will be the same, so why I guess, worry, why not let it flow over what you experience, let it drift over you, lie low, and wait for the seasons to change – this is self-preservation and so long as you are able to hold-on to your little clod of earth, to maintain adequate input, output and turnover, you don’t have to grow or change or look for a way out, you will get by and the growth or attrition or change takes place at such a rate that no one really notices, that no one is aware of any encroachment. We move right, we go left, we wait, to move forwards, no one is looking, no one cares, for everyone holds at their own private centre. Centre. Stay centred. Stay sane. & breathe.

flow

Dream

There are few things worse than listening to someone talk about their dreams; unless you are a soothsayer, a Pharaoh, or, perhaps, chatting with your children as they relate their anxieties.

A few days ago, I had a strange dream – I wouldn’t go as far as saying it was ‘vivid’ – suffice to say, the next day I couldn’t tell whether it was real or not.

Here’s what has been happening…

Over the holidays my family gathered in Doncaster; it has been an amazing week, with more Kershes in one household than at any time since the 1980’s.

Part of our gathering involved looking through old photos.

I have an album full of black and white photos; starting with my siblings when they were young, going-back in time to the 40’s and 50’s when my parents were children and further back to their parents’ childhoods.

Most of the pictures were of family in Glasgow or Manchester. Some taken in the countryside – perhaps Troon or Ayr, others at celebrations – Passover or Chanukah.

It is funny how much of the past is crystallised in these images. There is even one of my mum, with a man stepping-out in the background, a sort of homage to Henri Cartier Bresson.

stepping-out

What led to my dream however was the frustration at our inability to name, place or identify so many of the people. Most have now died; their children or grandchildren are likely in later life. The majority now lost to the past. Nameless. Voiceless.

And it is this link between the present and the past that captures my imagination. Specifically connecting with my job. Old people, still young.

I love it when patients come to my clinic with their sons and daughters, grandchildren and occasionally great-grandchildren; seeing the generational reflections.

For those of us whose families have been wrenched apart by geography, migration, education and profession, who live in communities that are made-up of friends and acquaintances rather than people who knew you when you were a tot, before you cut your first tooth, changed your name or learned to drive, it is not the same.

Without family around you, your connection to the past is different – less concrete.

And so, to the dream.

I dreamed that I had another photo album; only in this one, I had written-down the names of all my relations – with my mum and dad before they died; fitting each image into a yesteryear family tree; supporting who I am today – not a fish out of water.

There was no album.

This was perhaps one of those things I had wished I had done when I was younger but never got around to;

Some people think this is silly – looking back on the past; translating facial features, interests or behaviours to those who have gone before, preferring instead to remain in the present, or, prepare for the future.

For me, I can’t resist. One foot in the present, the other in yesterday.

Genug!

img_20170101_0032

Old

I met a very, very old woman yesterday.

She was, in fact, the oldest person I have ever encountered.

I won’t go into the details as, I haven’t gained consent and, that is not my focus; what I was trying to get my head around was the span of her life.

She was born in 1907.

She was seven when the First World War began.

She lived-through the Spanish Flu and Hiroshima.

109 Christmases, January the firsts and birthdays.

How can we begin to imagine the scope or span of her life?

Martin Luther King Jr, JFK, Gandhi and Mandela; moon landings.

Diana, 9/11, Global Warming, the birth of Israel and India and the NHS.

She was in her thirties at the outbreak of World War two. Imagine.

The Falklands, Thatcher, IRA, ANC and the PLO.

We mostly forget the span of our lives; her grandmother, had she lived to the same or similar an age might have been born in the 1700s; that is, Bach, Captain Cook, and Napoleon. Her mum, Walt Whitman, Queen Victoria, Darwin and the Eiffel Tower.

It is funny how the moment can sometimes seem eternal – 5.36 in the morning, the wait for a shift or a journey to end.

We become swept-up in the machinations of relativity and forget our interconnectedness.

And my patient, lying in bed, her first hospital stay, ever?

We forget our proximity to one another, focusing instead on separation – the divisions of race and gender, occupation, clan and creed; there is more in common between two people than any difference.

The same happiness, anxiety, fear and aspiration – the same struggles, hopes and dreams.

Sitting with my hand on her arm, I am reminded of how close I am not just to my family and friends, but to my patients.

And I wonder about the span of my life and that of my children.

Yesterday, sitting with my family, looking through old photos – dating back to the end of the 1800’s; faded images of stiff suits and reticulated shawls. Many of the names now forgotten; lost with the vanished memories of my parents and grandparents. Sparks faded.

Our past, our present and future –

web-ashkenazi-jews-1-getty