Statesman / politician

I’ll say, before I get going, that I have used the word Statesman rather than Statesperson* as I feel this system of nomenclature diminishes the word; so, when I write Statesman (heaven knows why the capital), please read – Stateswoman and Statesman.

Here are some who spring to mind:

Obama

Gandhi

Churchill

And once, again, I appear to have fallen into a gender faux pas. Oh.

When I think of women leaders of states – which I don’t believe equals stateswoman, I think Thatcher, Gandhi (Indira), Meir. I am leaving-off May as I think she is just a soldier of misfortune. I am not saying that these people were not Statespeople – I just don’t know enough about them.

Please, readers, send me your stateswomen. (I was all ready to include Aung San Suu Kyi until the recent events)

Anyway – my point…

Well, the distinction between statesman and politician.

There is clearly more to it than I can include here, but one important difference relates to the individual’s system of values – statesman; places the state, the interests of the people before themselves, politician; locates their own position before all else – their ability to finagle their way around local government and party politics, manipulating populism – ‘vote for me and I will give you…’ not the Kennedy, ‘Ask not what your country…’ type mantra (Oh – yes, let’s add JFK to the list).

Think Brexit – which group were dominant?

So, there it is. What comes first? You, your career, position, beliefs, or, the country, those you represent, the common good, national interest?

Is it as easy as that? Are leaders born? Don’t they have to rise-up through the ranks, perhaps utilising political strategies to reach a position of adequate influence to translate their ideas and understanding into action?

This I don’t know. I have never met, nor, am I likely to meet a statesman (there, I am more comfortable – I’ve dropped the capital), next I’ll be taking about people!**

xxx

*According to the computer’s spell-check, ‘Statesperson’ isn’t even a word… go figure.

**Nigel – please forgive the ‘S/s’ inconsistencies – i know this drives you crazy.

***There is no end to this… Even Cleopatra – ‘she who comes from glorious father’ Am I digging myself into a hole here?

malala

Just one more.

 

Just one more

Pill.

 

The medicine,

You see,

Is designed to… well…

help your symptoms,

make you live longer,

ease the pain,

alleviate the anxiety/depression/disorientation.

 

Chalky

calcite

caked on tongue;

dentures,

palate,

desiccated.

Mouth, a dry foam.

 

Lost look in the eyes of the old woman

As she smiles

despite

the calcium tablet,

part-dissolved.

 

She spits it into your hand.

crayola

Dementia

 

The man has dementia.

 

He is wearing

wrong-sized

hospital pyjamas

In a bed

That is tilted

Head-down, feet-up

to stop him getting out;

to somehow protect him

from himself.

 

This,

of course,

Restraint

and, against everything that is good and right

and perhaps

preventing him from falling,

but,

Doing him far more harm

by robbing him

of his self

and his autonomy.

Nursery*

All I have are dark memories.

 

An old, red-sandstone house,

narrow pathway

from front gate

to front door

and

mum

Not allowed inside

the nursery.

 

Then, thirty years later,

Mum is inside.

I am visiting her

And the bell is rung.

 

Big, brass monstrosity

Clanged,

Not by Nurse Ratched,

But,

Someone aspiring to that role.

 

And

the look of sadness in mum’s eyes,

As, one by one other relatives

Get-up and leave

and, eventually I am the last one

And mum,

Now anxious that I should go,

For fear

Of my getting in the way of the nurses

And this,

Somehow

Having repercussions on her care.

 

*Or, why I hate visiting times.

jack

I wonder

I wonder what it feels like to lie on a stretcher

In the resuscitation department

of any hospital

probably,

in any country

w/ adequate health and social care

and,

attached to a monitor

that is recording

Your heart rate, blood pressure, those things,

and,

Listen to the machine

alarming

as you look around

and see everyone

seemingly

ignoring the alert

and

You.

watson and the shark

Cushion

On the subject of cushions,

I remember,

1985

On El Al flight to Israel,

My mum asking the purser if I could see the cockpit.

 

I was allowed up-front,

Yes.

El Al jet,

and I was allowed-in.

 

And the captain,

Handsome,

Tanned,

Completing a crossword

In English.

 

How do you spell cushion?

He asked.

and,

I wasn’t sure.

Cockpit

Colin

I can remember

His name.

 

Colin lived down the road from me in Glasgow.

 

I think he was adopted,

or, perhaps,

Some other mystique.

 

He always reminded me of the actor from the Man from Uncle – Ilya Kuryakin*

Something

About his eyes

And hair.

 

Anyway.

 

I don’t know why,

I ended-up kicking him one day.

 

I had dog shit on my shoe.

 

Again, I don’t know why.

 

I can remember his green Parka

Smeared with poop.

 

Then, a short-time later,

His mum very pissed talking to my mum at our front door.

 

I don’t know what they said.

What can you say?

 

Illya-Kuryakin-man-from-uncle-13685470-415-500

*David McCallum

 

 

Apple-pie

Every time

my brother

Lloyd

returned from University,

back in the 70’s,

My mum would make him an apple pie.

 

She had a special tray that had wavy walls and

a base

that could lift-out.

 

It’s Lloyd’s favourite

was the excuse –

perhaps,

I can’t remember me or any of my other siblings having a signature dish.

 

How I wish, I wish, I could

have a bite,

perhaps

sitting next to my papa

In the kitchen,

back-door steamed-up with condensation,

net curtains,

reticulate on my tongue.

Swiss Cheese

They say*

That clinical error

is like

Swiss Cheese;

 

You line-up the holes,

twist and turn

through happenstance

and

bad luck

and

eventually

If you are lucky

You survive.

And, if you’re not,

the allergy is missed and the check and the dispense and the doctor and the nurse and the pharmacist are all perfectly aligned

like the stars

on

Skara Brae.

wintersolstice

*James Reason

Dr Who?

Although it was weird at work today, what with the snow and various unanticipated clinical events, yesterday was odder still – much of it starting with an encounter I had with one of the trainee doctors.

‘You know, Dr Who,’ I asked.

Blank.

‘Doctor Who – you know, off of the TV.’

Nothing.

‘The space and time-travelling guy?’

Remember, I am not English…

But… Dr Who – he’s international; the guy with the blue police-box, the alien time-lord?

I was trying to explain to my colleague – let’s call him Sam, about my three-heart model of acute hospital care; (don’t worry, I’ll get there…) – and, my strategy, or lead-up to this description was to begin with, Dr Who, who has, as we all know (except Sam), famously, two hearts.

‘The way I see it, is, that all acute hospitals in the UK have three hearts – all of which need to be healthy to maintain a functioning system of care and treatment.

Those hearts are the emergency (A&E), intensive care and the acute medical departments. You can do away with surgery, orthopaedics, maternity  and things can work – yet, without one of the three hearts you can’t have any of the other specialties.

So – imagine, the three hearts pumping away. Those hospitals with healthy hearts are able to cope with the demands of 21st Century care. Support teaching and training, plan for the future.

Nationally, many hospitals are in a precarious state, frequently because one of those hearts is diseased; not because of badness, but, workforce issues and recruitment.

If you can’t recruit enough nurses or doctors to provide intensive care, the rest of the model is unsustainable; the same goes for A&E and acute medicine.

Different areas have different challenges. Some places struggle to find enough A&E doctors – there was a hospital which had to temporarily close recently because of this, and consequently, the other services fall; if you can’t support someone who is critically ill by having access to an intensive care service, you can’t run an A&E – and, if you don’t have enough ‘intensivists’ – who are usually anaesthetists, the model collapses.

What you find across the UK are two groups of hospitals. Those, usually the biggest teaching hospitals and district generals who have managed, often because of geography, sometimes because of culture to attract and maintain a critical mass of the different disciplines; they are managing OK.

The others are the smaller teaching hospitals and district generals, who often have to compete with the larger hospitals for staffing.

This creates an imbalance.

What is equally consistent across the UK are the demands of the acute medical service – that is, the hospital work-horses who see the majority of admitted patients (falls, infection, confusion). They are all working at capacity, with no room for additional patients or demand.

You might think it straightforward – take those hospitals that are teetering because of staffing, close them and put all the staff into the other hospitals and you have a sustainable service; the caveat however is the admission and assessment units, none of which can cope with a 40 or 50 per cent increase in demand; hospital bed occupancy in most acute hospitals in the UK in 2018 is somewhere on average around 95% – most commentators say that for a system to operate efficiently – there needs to be capacity, room to manoeuvre at around 75% – beyond this people work in a crisis mode, and inefficiency (length-of stay, complications, incidents) increase.

So, if the answer is not to close the smaller hospitals, perhaps the answer is to look at the giants. It is not uncommon to attend a large teaching hospital that has 30 neurologists, 20 geriatricians, 15 acute physicians, with an equivalent district general seeing perhaps 60% of the patients with ten percent of the consultants in the relevant specialities.

Some of this reduction in size is not a bad thing – it creates efficiencies, workarounds, a greater focus on team working and lateral thinking, with closer relationships between individuals, allowing for more person-centred care; yet, the pressure mounts and just like the bed capacity being at a certain level, the potential for those smaller organisations to absorb challenges – perhaps one doctor leaves, another is one sick and, you have a crisis.

What we need are healthy, sustainable systems.

We need a degree of equity with workforce planning taking into account the needs of the population as well as the challenges faced by the people who provide the clinical and support services;

The next time you are admitted or visit hospital, check the wellbeing of each of its hearts; they should provide you a good estimate of quality and outcomes.

Something to consider.

Perhaps those who sit in positions of influence should take this into account when planning for tomorrow.

hearts of three by sergey ignatenkp

 

Let me know what you think! Retweet/share/comment…

p-value

I was left,

feeling,

like a bit of a prat.

 

It began with a video of

Peter Mittler

That I took last year

During a conference.

 

In the clip,

Which no one can hear

because I didn’t use the right equipment,

Peter is arguing the validity of statistical significance

in relation to a study on dementia.

 

Peter has dementia.

 

He is eloquent and engaging,

fascinating, with ideas and thoughts

scattergun.

 

I thought it a good means to demonstrate

Living well with dementia

Instead

As I say

I felt like a prat.

 

‘Here is Professor Mittler talking about p-values, has anyone ever heard of them?

…expecting at least one person in the hospital audience to have encountered this basic of statistics, my follow-on, does anyone understand p-values…

Alas.

…no response;

My plan had been to then quip,

that I had no idea either

and by this means

demonstrate the prof’s facility not just as a speaker, academic and writer

but, as an interpreter of statistics.

 

But, no, no one had, and it made me feel daft.

 

I moved-on quickly, to the next topic;

 

Perhaps this was the reason,

for the feedback

saying,

‘I couldn’t see the relevance of the talk’

and this, in relation to a day

of person-centred care.

 

You can never please everyone,

and,

Perhaps having someone

not get it

is a sign that I am on the right track.

 

Who knows?

 

I don’t think I will attempt Peter’s film again,

although,

If anyone wants to view it,

I have a copy

with good audio

on my phone.

p value.jpg

p_values.png

Grand-theft Junior

Before I begin, I want to clarify my situation in relation to junior doctors – well, let’s put it this way; I once was one and when I was, I never liked the term ‘junior’ and today, when I speak with doctors who have not yet reached the heady-heights of consultant or general practitioner, I usually say ‘trainees’ instead. Note – not all trainees are actually in ‘training posts’ a term developed by the academic masters sitting in nebulous ‘deaneries’ across the country, but, my take is, that everyone who isn’t yet a consultant or GP (by which point it is often too late), is still learning – growing, developing. (Yes, consultants can grow too – it is just a much slower and painful process).

Anyway…

On Thursday as I mentioned yesterday, I was back in Doncaster.

When there I saw lots of old friends and colleagues – some of whom knew about my departure, others who didn’t.

One former colleague, in joking, in passing, but sincerely, said, ‘I hope you aren’t stealing our juniors.’

What he meant by this relates to the massive pressure placed on specialist doctors in their final and penultimate years encouraging them to commit to a career in a certain hospital.

You see, doctors, especially physicians working in ‘acute’ specialties are in short supply and consequently, like any system of supply and demand are valuable. Some hospitals will do anything to attract new consultants (in place of the many locum doctors who populate the system today, supplying shareholders with holidays in Tenerife (see yesterday’s blog)).

And, here, was a suggestion that Doncaster, now it has come of age, gained the title ‘teaching hospital’ – any trainees passing through their doors are ‘theirs’ – when I first came to Doncaster the situation was different and only very recently has it changed, with trainees previously heeding the siren call of Sheffield – the local teaching hospital and adding to the very significant numbers of geriatricians, gastroenterologists, and so on there.

Well – my point, and this I guess is me taking part in the whole guilt / pressure game (which I am sure most medical registrars can cope with – pressure-management being a pre-requisite for the role) – is, that we have an imbalance across the South Yorkshire hospitals. And, like in nature, imbalance doesn’t tend to result in a positive state of wellbeing – too many caterpillars and the lettuce is gone;

Yes, I have already suggested – the future for the NHS is uncertain; will we one day have a two tier hospital system like in America – where the rich get state of the art, high cost (and likely medicalised) care and the poor are left with what is left-over, or, will we achieve some sort of balance where the specialist care, the research, the monoclonal antibodies, lasers and robot surgeons are at play and the majority of care where people receive care – are hospitals functioning at the level of the person, offering the best for all?

When I first went to Doncaster, ten years ago, the flow of new consultants was strongly towards Sheffield; this has now shifted, and the course is probably equal, Sheffield and Doncaster – what has happened is, the organisations in the middle, such as Rotherham have lost-out; for some reason, in terms of physicians more than anything, and the system has as a consequence struggled.

What is the answer?

Well, I feel it is a fair, equal distribution of new consultants working across the sites, perhaps sharing practice and expertise, a little like the model of person-centred care we are demonstrating in our education sessions – such that each hospital has what it needs to provide not just the safe care we and our patients deserve, but care that is of high quality.

I don’t want to pressurise anyone, and I doubt this blog has the power to sway people to any great extent, yet, I felt that I needed to explain here my position.

If we do nothing and the flow to Sheffield then Doncaster continues, Rotherham and, likely Barnsley will continue to struggle – this will mean their patients i.e. the people of South Yorkshire not receive equivalent care, ultimately resulting in a tipping-point that is bad for everyone;

This isn’t an advert for trainees, or an attempt to redress the ‘theft of juniors’ argument, more a conversation-starter, making the situation explicit, as without this we will bumble on, one step forwards, two back and no one will win.

There is a classic Game Theory game* –

‘The prize is $20. Everybody is free to bid; there are only two rules. The first is that bids are made in $1 increments. The second rule is, the winner of the auction, wins the $20, but the runner-up must still honour his or her bid while receiving nothing in return. In other words, if you are second best you lose everything.

Here is what happens:

At the beginning of the auction people bid… a flurry of offers.

The pattern is always the same – as soon as it reaches the $12 or $16 range… and, it is clear that everyone else has had the idea to bid and win the money for less than its value – people start getting jittery and drop-out; all except the two highest bidders.

Without realising it the bidders are locked in, one bids $16, the other $17; the $16 bidder must offer $18 or lose $16. At this point the participants aren’t playing to win, they are playing not to lose.

The auction continues… $18, $19, $20.

The rational decision would be to accept your loses and stop the auction, but, neither will back-down, the momentum keeps the bidding going.

Inevitably the bidding continues, $21, $22, $23, $50 – the record in one instance was $200.

This is loss aversion.

There are actually two phases to the auction… the $2 phase when everyone is wide-eyed and optimistic, expecting a quick-win, then the final phase where the bid passes $20 are the bidders are digging a deeper and deeper hole. This, is the loss aversion.

Is this what we want? One overall winner with everyone else losing?

Imagine the ‘South Yorkshire Trust’ – the mega hospital where you go for everything.

I can’t see into the future, but I reckon that this is a long-way off and the likely suffering particularly of patients, i.e. the failures required to reach that point will be so painful, I’d rather not contemplate.

So, let’s put egos aside, let’s instead think of the patients and the staff – for the latter, working in an unsustainable system is not much fun and, come together, instead of opting for winners and loser (this is healthcare after all!) – let us support one another for the benefit of all.

*Adapted from ‘Sway’ by Ori and Rom Brafman, Virgin Books, 2008.

fmri loss aversion

Silly hats, uniforms.

I went back to Doncaster yesterday, to take part in the Person-Centred Care training day we have been running for the past year.

On this occasion, I attended as a guest speaker, which was a novelty.

I also took with me some colleagues from Rotherham, so that they could get a feel for  the work we have done over the years developing services for older people in Doncaster.

At lunch I sat for a little while with Jo and Louise in the hospital dining room – discussing the morning’s events.

The cafeteria in Doncaster is undergoing a refurbishment – the organisation last year agreed to enter into a contract with Sodexo the multinational facilities giant, for the provision of catering. This has allowed investment in the hospital and has led to new food menus, delivery schedules, etc.

Half the room was closed to allow for building work.

That wasn’t however what caught my eye. Well, it was three things in fact.

  1. There was a very long, rolled-up sausage in the servery.
  2. They now have contactless payment for food
  3. Because of the takeover, all the catering staff instead of being employed by the hospital aka the NHS are now Sodexo employees.

It was strange, seeing the same people I had known over the years now wearing different uniforms with big badges and silly hats. I can’t remember whether the checkout staff used to wear hats, these ones however, stood-out.

I am not saying whether this is good or bad, it is just a thing.

I have seen this in Rotherham as well – there, the catering staff work for a different company, I think they are called ‘iss’ – which is another facilities conglomerate.

The staff didn’t seem unhappy. They just looked different.

I wonder how they feel.

I didn’t have an opportunity to ask – the queue was long and the cafeteria busy.

This is commonplace in the UK.

Cleaning, security, catering, all out-sourced to private companies. A significant proportion of the clinical workforce are also primarily employed by agencies – doctors, nurses, therapists, pharmacists.

Many of the buildings, most often the shiniest are built under the scheme of Private Finance Initiatives – that is, the hospital is owned by private companies and the NHS pays rent.

It is a good job we aren’t charging our patients yet.

But – azoy – is that not coming, is that not the government’s plan, to squeeze the health service, generating a sense of economy and effectiveness that somehow manages to support shareholders as well as keep the corridors clean?

I don’t know.

Tereos Syral Marckolsheim - 11 / 03 / 2013

Bully / Arse

I read in the newspaper yesterday, a short entry about bullies.

The argument went, that a one-off episode of bullying doesn’t make someone a bully – the suggestion being, that anyone can lose their temper and strike-out at another, cause misery, torment.

I don’t know what I think about this.

What I know is, that all bullies are arses, whether they bully once or habitually;

I guess the corollary is –

Not all arses are bullies, but all bullies are arses.

For more on arses, see here.

bully

The long-tailed tits

The long-tailed tits

Move

erratically.

 

Jittering,

flighty,

Pecking at the peanuts.

 

The film,

running

at double time,

twice normal speed,

constant

alertness;

cortisol

through the roof.

 

Good job they only survive a season or two

or else

They’d be on Ramipril

Like, everyone else.

ramipril

Daddy, what did you do?

This was a recruitment poster from WWI – designed to create a feeling of guilt in young men, chivvying them to volunteer, head-off to Flanders, Ypres or somewhere on the Western Front and, likely die. At least they wouldn’t have to face their children… ‘I stayed at home, because I didn’t want to participate in a futile zero-sum game designed to fill the pockets of imperialists’ – or, something to that effect.

I don’t want to uncover old sores – there are plenty of new wounds to look at today.

I thought of this, when I thought about JH – I don’t know if he is married or has children (I can’t bring myself to Google him) – in five or ten years when things have settled-down, and, we are left with the two-tier privatised health-insurance driven system him and his cronies have been building, and, perhaps the headlines show the children – not perhaps of the poor people, (like the homeless), because, well, they are poor, but, the nice people, stacked-up in overcrowded A&E departments or limping along the road from poorly healing wounds for want of antibiotics to treat the infection (you see, tomorrow, when current antibiotics stop working, there will be effective treatments – they will just be available to the moneyed classes.)

Flucloxacillin 0.5p/treatment

Rangerovercillin 1000p/treatment (available via certain health insurance policies)

What will he say to his children?

The utilitarian response: Yes, I knew what I was doing. It was for the good of the country. I admit, individuals have suffered, they have died – but, you need to understand the bigger picture.

Or,

The outright lie: We are spending more on the health service than at any time in its history, Penelope (or whatever), the NHS failed because there were too many old people, too many who opted to smoke/drink/abuse sugar or, buy the latest iPhone rather than invest in health insurance.

Perhaps,

The diversion: Don’t ask what I did to destroy the NHS – ask, why was Corbyn talking with the Russians/Chinese/Mongolians?

You get the idea – this is defined, within psychological circles as, cognitive dissonance – it is how your mind disconnects from reality.

It is a psychological parachute that allows us to stay sane. Or at least, the pain of introspection/self-analysis is dulled.

The NHS was never going to continue – the ageing population/long-term conditions/credit-crunch/rising sea-levels/immigration/organised crime/corrupt charities/ thepossibilitiesareendless…

Well Penelope, fear not!

I am going to save you from having to ask this question, or at least, me and my pals, are not going to let the NHS fall into the sea.

I don’t want to get folk too excited, but, this is war.

The stakes are high.

We can’t lose!

And, perhaps instead of us scapegoating the clown who carries the tag, let us look to ourselves, let us determine how we can re-nationalise the NHS, take back control, examine the inequalities that are as dependent on survival as JH and the greed he invokes.

We have significant geographical variation in quality, outcomes and experience – we can no longer look away; pretend that everything is OK. Waltz into the establishment of care systems that have one inevitable outcome; death of the NHS. Two-tier; You can get your cancer looked at here if you have insurance, failing that you can go for just OK, over there. I am sure the outcomes are equivalent…

I am going to take the question away from Penelope and JH and direct it towards every one of us.

What did you do when the NHS was on a knife-edge? How did your efforts, your passion, dedication keep the organisation afloat?

When I was a new consultant, a favourite quote of a senior colleague was, ‘It’s like rearranging the deckchairs on the Titanic’ – the suggestion being ‘We are doomed, what is the point?’

Well, I wrote yesterday about the bright young things coming-through.

I am calling on them, calling on us, to dig-deep and step forward and stop taking no for an answer.

ypres

Temporal horns

Your horns

Are,

I am afraid to say,

too small

to be consistent with Alzheimer’s

I will need to

Consider

An alternative diagnosis,

Perhaps

I can squeeze

Something else out of the CT machine,

Or,

I need to pass you through the MRI

And/or

A lumbar puncture

And

Some serology

is always

worthwhile

To exclude,

Well, to exclude or refute.

 

Yes, your horns are just too normal.

 

*Temporal horns – Temporal-horn size estimation on a CT brain scan is said to correlate with a diagnosis of Alzheimer’s Type Dementia. See here for more.

Overflowing

It is funny.

A couple of weeks ago I returned to the old Taoist concept of the empty cup. The value of a vessel being its emptiness.

I have also been dipping in and out of the Eastern concept of flow, most well described by Hesse in relation to Siddhartha and never being able to step in the same river more than once.

Add to these Csikszentmihalyi’s reading of flow and you have a sense that there is a theme.

All of this talks to the NHS and its dysfunctions.

You take a cup, smash it, pollute the river and offer constant interruptions and the result is not tranquillity or effectiveness, it is, a mess.

And a mess is what I most frequently encounter.

Missed opportunities, days, weeks of activity missed, quality collapse, disintegration of the holistic vision we hold dear.

And here I am not just blaming the usual soft-targets – it isn’t the management bogeymen who stalk the corridors of power, determining who will live and who will not, no, it is the politicians who hide behind picket fences whitewashed with Nationalism and fear; ‘Our country is failing because of the Poles/Slovaks/Romanians/take your pick of minority group; Hitler manipulated the Jews/Gays/Priests with similar levelheadedness.

Vote UKIP/Tory/Brexit and everything will be fine; we will make the poor homeless and the homeless sick and everyone else can grow fat on high salt, high sugar McMeals.

People will arrive in good faith at the doors of A&E departments and have the heart torn out of their identity; they will be given a unit/nhs/hospital number and sent down various pathways that leave their personhood behind; ‘I know it is your chest that hurts, but hold still, let me do this blood test so we can find out if…’ ‘Lie still,’ Or, as I recently experienced, ‘Quick, move out the way, coming through, old man, I’ve dockets to fill, places to be, go on, shift!’

We dehumanise one another in the pursuit of immediate rewards; bed empty, bed filled, test taken, result acquired. The pressure continuously grows, increases, escalates until you have nowhere else to go except, pop.

Remember Tchernichovsky’s dumplings?

Well, in organisations that are operating at pressures beyond the accepted threshold, the same happens as when boilers, nuclear reactors and thermostats spend too long in the red; there follows a sudden release of tension followed by a clean-up procedure that is still ongoing, like Chernobyl 30 years later.

In most hospitals in the UK, there are bed-crisis meetings every few hours, something like 9am, 1pm, 4pm, 7pm. Day after day. How will we get through until the next time? How will we keep the pressure cooker from blowing? After all, you can hear the whistling (shrieking), from down the road.

People with inadequate resources are forced into reflex responses where analysis, meaningful, strategic calculation is taken out of the conversation in place of impulse, ‘Move, move, move,’ the army captain shouts at the recruit, all in an attempt to destabilise, disarm, remove from planned to unpredictable from elective to emergency.

And the consequence?

I posted last night about the realisation that our society has peaked; life-expectancy is now falling in the West, chivvied along by people sporting blue ties, as they arrive, in oversized Range Rovers, freshly polished for the golf club.

And the bright young things I met on Friday, approaching the end of their studies, on the tail-end of multiple A stars and successful examinations, debt laden and able to intuit disease at ten paces, not realising that they are moving from all that our society can provide to an environment that if not post-apocalyptic, is post-pressure drop, like when you turn on the hot water and all you get is cold;

Heaven forgive this society for the way it is eviscerating itself.

audrey-hepburn-quiet-sadness-olga-shvartsur

Why are you here?

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

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

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

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

I think there are two reasons for this situation.

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

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

No wonder the uncertainty.

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

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

 

‘You are in hospital because you fell.’

‘Can I go home – I am OK now.’

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

‘So – no?’

Next day…

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

 

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

Maybe I should find a better question?

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

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

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

Part of the flow series.

circles

 

Please re-tweet/share/let me know what you think esp. if you are from outside the UK!

Minor evolutionary hiccup.

I bought a bottle of full-fat Guernsey milk (in a milk-bottle shaped bottle), yesterday, and I am now sipping it, mixed in coffee.

It made me think, about the blue-tits I used to see in the 70’s.

The ones that learned about the lovely creaminess sitting at the top of milk bottles, on doorsteps, just after the milkman on electric float has moved-down the road.

Somehow – and this if for those of you from later generations, the birds had worked-out that if they sat on the bottle, the could peck through the silver-foil lid and get at the cream sitting on top of the milk. Perhaps a red squirrel had taught them this and it caught-on.

Anyway, my point is not this, but the years when this started and ended; first folk put lids, covers or metal pots on the milk to prevent beak-access, then slowly the whole milk-delivery thing died-out; we used to get milk delivered by the farmer when we lived in Crane Moor, even that ended when we grew exasperated by how quickly it spoiled… Not homogenised or ultra-filtered, you see.

And of course, our anxiety about fat when milk became first 3%, then 1% then zero, fat.

So, the birds had it good for a few years, they adapted – not for long enough that birds with peculiarly shaped beaks were flying over the UK and then, just as quickly gone.

I wonder today, had things not changed – evolved for the humans, how the birds would be faring – whether we would have accepted a little garden bird spittle so as to support their population and have more back-garden diversity?

milch

Camptocormia

I learned this word yesterday.

It is also known as bent spine syndrome, which helpfully says what it is rather than having to translate from Greek to English to Jargon and back to English (it comes from kampto which means ‘to bend’ and kormos – ‘trunk’).

Explained this way, it all adds-up.

Many of us will have seen people with this condition – usually older, often the result of Parkinson’s disease, it has complex origins (that is, at the level of an individual’s spine and nervous system).

If you want to learn more, there is always Wikipedia.

My interest in this word was sparked by the use of a long-confusing (obfuscating?) term, clearly word-processed into an outpatient letter, in comparison to the other form of miscommunication/befuddlement that is far more common in medicine – bad, messy, scrawly and hard to interpret handwriting.

The classic doctor’s handwriting.

I have never understood why this is either a thing or a joke.

typeface-dr.jpg

‘Oh! doctor Foster’s handwriting, who knows?! Sigh, guffaw…’

handwriting.PNG

I know this is a complicated area – which has haunted me all my life; I remember being pulled-up for bad writing in primary school – ‘messy’ often written in the margins of my jotter.

Today, my handwriting, is, as far as I am aware mostly legible. (I can see some raised eyebrows amongst nursing colleagues :-))

Yes, there are on occasion words you can’t read and the intermittent problems when my ‘n or m’ looks like a ‘u’ and ‘h; like a ‘n’, (thinking of Community Mental Health Team folks…). On the whole I think people can read my writing – and this not by chance, I have worked on it; on pen holding position, and so on. (I have reduced my abbreviations since moving to Rotherham as I know ‘TiM’ or ‘PCC’ might not be readily apparent – yet).

Yet, there are many, doctors out there who don’t seem to think this way – indeed, I don’t know what they are thinking; some of the biggest culprits in my experience, tend to be surgeons – ophthalmologists frequently being the worst offenders, which, I have always found doubly ironic.

Beyond these forms of error are the bad-habits that until recently I had thought gone – the old chestnuts where everyone (I thought), knew that you write ’10 units of Insulin’ not ’10u’ which can be misread as 100 units, resulting in death or brain-damage, (I am not aware of this happening recently, although it has in the past), or the person prescribed ‘Amoxycilin’ for a sore throat, who received ‘Amitriptyline’ in error, which helped her mood no end, but did little for the quinsy.

There is book of poetry by Adrienne Rich ‘The Dream of a Common Language’ – if only we not only possessed a common language, but also used common means of communication – a sort of babel-fish that isn’t dependent on us waiting for a digital Messiah.

An answer, well, it is good and probably reasonable for neurologists and psychiatrists to pull out of the bag old-fashioned and obscure terminology – it keeps us on our toes – flocculation, allodynia and bradyphrenia, it helps us stay grounded in our past, and, there is always Google to do the translating, yet, we need to have some sort of standard of documentation.

How many people over the past 100 years have died or come to harm because a nurse  or pharmacist couldn’t read a doctor’s handwriting? How many patients, nurses, pharmacists and eventually doctors has this harmed?

I get-it, not everyone possesses the ability to write clearly, neatly, succinctly. There are disabilities, inabilities, weaknesses and lack of insight, yet, is this not something that should be challenged or questioned? At the very least, provided with more of an overview than shrug, ‘Let’s skip-over what that doctor has written, I can never read their handwriting’ – would you accept this if people didn’t obey the Highway Code and drove their cars at random? If our food regulation was chaotic ‘may or may not contain nuts and sea-food’ or, even our spoken language, ‘they might have said, ‘I love you’ or, it could have been, ‘I loathe you’, no matter.’

IMG_9904

Guillaume_Apollinaire,_Poème_Calligramme.jpg

 

Generation

You might think it odd, (unless you know me, and you know that odd is my modus operandi), that only this morning, at 640 am to be precise, did it dawn on me that the age difference between my children and I is a generation.

A generation is usually considered to be somewhere around 25 years – I guess it varies depending on where you are living, life expectancy, birth rate and so on; this has been the figure I’ve heard mooted for… well, probably 25 years.

I am 45 and my son is 14.

That is more than a generation.

There was a similar age-gap between me and my parents.

I know this does not affect an individual’s feelings – I can’t imagine that being born when your mum and dad are 18 or 38 makes much difference to the love you have for them, it does, in all likelihood affect the way you see, interpret and understand the world.

This was the realisation.

That came, as I say early today.

I suspect this notion was augmented by my experience yesterday afternoon of participating in mock exams with final-year medical students.*

These folk, most of whom I imagine were 23 or 24 years old whilst not quite a generation different to me, were certainly living a university experience far removed from mine (they mostly seemed infinitely more competent) (if that is any reassurance).

Their sense of the world, experience of life, as with my son and daughter is so very different to mine that I cannot really understand what they are seeing, perceiving.

Yes, no one has any sense of another’s experience – we all live in head bubbles surrounded by constructed reality, but, the perceptions and interpretations – the nuances, subtleties of culture are far-apart.

None of this is new – it has been ongoing throughout our evolution, although likely more extreme now as, the gap between generations, at least in the UK is increasing, and, the rate of change is also accelerating.

Between my grandparents of eight generations ago and their parents, there was likely far less change.

When I ask (c.f. ‘tell’) my kids to eat their greens, it is with an eye on their future cardiovascular and cancer risk rather than concerns about malnutrition – this compared to my mum or dad growing-up in the war years.

When I worry that my kids aren’t reading enough, when I reflect on my days spent, solitary, discovering Garcia Marquez, Kafka or Salinger, I compare this to their gaze at a smartphone You-Tube loop.

And, it is always the case that older generations look at those who are younger and consider what has been lost – cycling to school, driving without seat-belts, Friday-night Red-Kola.

We face sunk-cost, loss aversion, rather than consider the benefits of fewer brain injuries, mashed cars and dental caries.

None of this is new, it just struck me as particular this morning.

There is nothing I can do about it.

Or is there?

Perhaps, the most important self-talk message should be to stop worrying.

Chill.

Realise that when I perceive the world, what I think, feel, fear will always be modified by time and age, understood differently by my children, just as the interactions I have with older people.

There are the commonalities – the golden threads of humour, love, fear, anxiety that haven’t evolved or changed over time, although I do find Laurel and Hardy funny, whereas my kids won’t go near a black and white movie.

Let’s celebrate what we have, let’s consider ourselves fortunate to have the time and space to consider, reflect on the past and future.

And, perhaps, pause a little before despairing over the younger generation. They really are, for most part, us, plus a little bit, not lesser, but, sharper, more nuanced in their tastes, quicker in the uptake of learning and concepts;

Let them be and let ourselves be, and, stop worrying.

xxx

*Their obsession with Purell, rolled-up sleeves and tielessness a particular feature.

hands

Jabotinsky

The wolf

wakes

as the sun sets

and, the family rest

before

traveling home.

I ask you, what was he thinking? Did he not consider discretion to be more appropriate at that moment than speaking his mind, or, perhaps, the occasion was confusing; afraid, knickers-in-a-twist. You can’t always tell. Some people. Some people just let rip; when impulsivity is combined with extraversion, stand back. If only we could all hush for a moment or two to allow our thoughts to catch up with our sensibilities.

I watched a documentary last night, about a man and his experiences following a massive stroke; at one point in the narrative he only had half his head after a craniotomy and surgery to remove a clot; then, followed several years of intense therapy – this is every day, several times a day, no breaks for Saturday and Sunday or NHS sleeping-out/step-down/re-ablement/social-assessment/we haven’t received a referral yet, kind of thing. And from immobility, hemianopia and mutism, he could talk, garden, smile and laugh. It was amazing.

It made me think, if only more people had the opportunity to participate in meaningful rehabilitation with mirror neurones firing and adequate nutrition, stimulation and exercise, how many might be saved from anguish and wasted lives.

The rush of modernity is sometimes so oppressive that the clamour to do overtakes the purpose of being, we do and do and in the absence of reflection time proceeds and history is made; and, each second that slips past is gone forever.

jabotinsky

 

Granny, what of your dreams?

Do Androids Dream of Electric Sheep? – is the name of Philip K Dick’s novella which was most recently translated into the Blade Runner 2049 movie. My son’s Blu-Ray DVD arrived in the post this afternoon.

It has been said that dreams are under attack from modernity – from our reduced and erratic sleep patterns, interference from artificial light, handheld devices and SSRIs all of which exert an effect on the shift from light to deep to REM sleep, the latter being where the business takes place.

Today, on a ward round, an older patient told me about her dream. The vivid notion that her husband had been to visit her, but who had in reality not been, nor had he called and, her anxiety that although this was a dream, she felt there was likely to be something amiss with him. She is 94 years old. I offered to ring him. She said he didn’t use the phone because of his hearing. She, stuck in bed, he, somewhere else, but, at least a dream.

We didn’t touch on the real nightmare of her being immobile in a hospital bed.

I had somehow considered that as people age they have fewer dreams.

Dreams – belonging to the youth, to people with a lifetime before them, both metaphorically ‘I have a dream,’ and physically – phasic movements of sleep, eyes fluttering, brain-wave patterns facilitating the emergence of our unconscious.

Older people also, because of the nature of their infirmities – perhaps lack of exercise, struggles with continence, pain, combined with daytime naps, leading to an altogether impoverished experience.

It seems my patient’s dream was genuine.

And, so too discussions about dreaming – there tend to be fewer topics as dull as listening to someone retell their dream (please see this episode of TAL). ‘I saw a shark talking with a wizard snake-man and the sky was blue before a priest sounded the matins prayers,’ kind of thing – incomprehensible, unless you are partnered though decades of Freudian Analysis.

Nevertheless, my patient’s experience was fascinating.

Revealing.

Perhaps the problem is that we don’t talk enough about dreams and, my patients in their 80s and 90s are getting along with just as many, if not more dreams than those of younger generations.

The purpose of dreams is not clear – it is apparent that most people dream most nights, our recollection is however, variable. Just because you can’t remember your dream doesn’t mean it hasn’t happened. What if, with dementia, or even mere forgetfulness your dream connection is extra-disjointed?

We know, or at least, so I have heard, if dreams are regularly disturbed – if, you take a person, a monkey or rat and shake them awake every time they enter REM sleep they subsequently develop depression and a variety of physical and psychological ailments; dreams serve a purpose, supposedly helping our unconscious minds re-run the day’s events or preoccupations; perhaps we should instead of dismissing, pursue them, integrate the dream-sequence into routine clinical history taking – for this you’d need to provide patients with dream diaries.

‘Hi Mrs Smith, here is your nurse call, over there the toilets and this is your dream diary.’

The lesson from this?

Our patients, whether they are young or old, or very, very old, experience the same range of emotional highs and lows as us; the objectification of ‘patient’ does not diminish an individual’s experience – in all likelihood, the opposite occurs; pain, feeling, fear, homesickness are all increased; and, what if dreams are too – during these periods of emotional and physical upheaval, approaching the end of life or a move to unfamiliar places; what if our dreams are enhanced?

My suggestion; the next time you are on the ward and you see an old man or woman, their eyes roving to and fro behind fluttering eyelids, imagine where they are; consider that their dream state is likely as transformational as ours and, start the conversation;

‘Did you sleep well last night Mrs Broon? Any interesting dreams?’

Sleep-deprivation-flowerpot-technique-jepoirrier

 

The Flower pot technique is sadly a real thing; if the rat falls asleep it loses muscle tone, drops into the water and wakes-up. Gah.

help ma boab.jpg

Post-diagnostic support in dementia

I thought I would get back to my origins this morning and write a little about what I am meant to be doing as a doctor.

Dementia – most of us hate the word; without mind. Bollocks.

The Japanese went as far as changing the name to their version of ‘disease of cognition’ – perhaps we in the West will get around to doing the same.

Anyway. In the meantime, we are stuck with Elizabethan terminology.

Diagnostic rates

If you look at diagnostic rates for dementia across the country, you might expect there to be variation – for, isn’t there always variation in healthcare, diagnosis, support and treatment?

You might anticipate higher rates of people living with dementia in more affluent or retirement areas – Bournemouth seems to stand-out to me as a place where folk go to retire; and, as dementia is predominantly a disease affecting older people, if you have lots of older people you will have proportionately more people who have dementia.

That seems to be the situation in Japan.

I know that some of you, the more discerning will have noticed my mention of rate and number – the two are different; if you have three people with a condition and only one is diagnosed the diagnostic rate is 33%, if you have 1000 people with the same condition and 33% diagnostic rate, that will be somewhere around 300 people, and so on. You get my meaning.

Well, in the UK we have variation not only in the numbers of people living with dementia, but also those receiving a diagnosis.

I will not tell you the places where diagnostic rates are low, but you can find out here.

What this in essence means is that there are people, going about their everyday affairs, perhaps struggling to pay bills, park their cars, remember their grandchildren’s birthdays, when they aren’t actually forgetful, but have something more significant underlying their behaviour.

Dementia as disease and metaphor

Yes, we know that dementia is more than forgetfulness – it is a disease of the self, of mood, behaviour, personality, but the hallmark in most cases is not remembering.

Dementia, is classified as a disability. Like hearing or visual impairment, cerebral palsy or immobility. Yes, you can get a blue badge, yes, the council, public places – hospitals, Meadowhall (?!) should all be adapted to support those living with dementia; we call this dementia friendly – I’ll just call it friendly – easy to navigate no matter your limitation.

If, therefore, there are people who have dementia – that is, perhaps, they have the disease, all the symptoms, behaviours, struggles, but, for whatever reason their GP is not referring them to the local clinic or the clinic is so difficult to reach or the waiting times so long that people are not receiving a diagnosis, they are potentially missing-out first, on support and secondly on anything that goes with the diagnosis.

I have written before about Susan Sontag’s allusion to TB then cancer and HIV as social diseases, not in the sense of STD, but more, in relation to the attachment of qualities to the person who has the disease – immorality or weakness of spirit.

Nowadays we know that this is nonsense; when I was growing-up, cancer was still a dirty-word.

In the 21st Century, dementia has acquired this mantle, if unconsciously.

Yet, you do not overcome stigma by pretending it is not there, you address it by cracking it over the head. ‘Let’s talk about…’

So, if the stigma can be overcome, there is the nihilism.

Nihilism & Care

‘Why diagnose people with dementia? It is incurable.’ That is the mantra rolled-out by the ill-informed, folk whose heads are buried up to their necks in sand.

Where to begin?

Yes, there is no cure for dementia, yet, there is care. There is support.

There is no cure for growing old either, it doesn’t mean we don’t talk about it, don’t plan for our retirement or what happens afterwards.

And it is the care and support that to me are most important.

Yes, we have medicines that work for some people some of the time; and they are fantastic. For many people, they don’t do anything, they don’t preserve ability, function or independence.

Yet, there is still much that we can do to support folk.

Loneliness is a pernicious 21st Century disease.

Take loneliness and combine it with dementia and you have a disaster.

Take dementia and add long-term multi-morbid conditions that are treated without consideration of an individual’s cognitive state and you have – a disaster.

Admit a person to hospital with something benign – chest infection or fall, add dementia that is not considered and… yes, disaster.

I know I have covered all these areas in previous blogs.

Too many unnecessary pain-killers and dementia… too long in bed… too long in pyjamas…

You get the idea.

Yes, dementia can result in bias all of its own –

‘Don’t ask them, they are gaga/senile/eyebrows raised…’ (have dementia) type of approach; don’t seek out their opinion, don’t try to address the visual or hearing impairment, just take your best guess as to their preferences; you look like ‘fish and chips on Friday’ or ‘bacon and eggs’ to the Pescatarian or Jew respectively.

Mostly, however, the more people we have identified as living with dementia, the more advocates will step forward, the more society, hospitals, libraries, shops, parks will be required to adapt, to change.

And now, to post-diagnostic support – that is where I began.

maw-and-paw-broon-screenprint-dc-thomson-shop_1

Post-diagnostic support

This is the support provided to people after they receive a diagnosis of dementia.

‘Mrs Broon, you have dementia. Goodbye.’

I am sure most clinical interactions aren’t that blunt, but there are many situations where people are given a diagnosis of dementia and provided no support, or the support that they receive, like the diagnostic rates I already mentioned is so variable that all you can expect is inconsistency.

The Admiral Service, sponsored by Dementia UK, for example, offers individualised, person-centred care planning for those who are diagnosed with dementia and, in particular their families and carers.

‘Your dad has dementia. Cheerio.’

What does this mean? What are the consequences? What is the prognosis? Who can help? What to expect? Why? And so on.

What to do when a person with dementia stops eating? Do you move on, watch them losing weight and fade away, or, do you consider that their appetite might have changed, their taste in food, their eating times, habits, energy levels might be different? You see, dementia is a new world, with rules that differ from everyday life, with a guide you have some chance of success, without it, the road can be impossible.

Traditionally, those people who have Alzheimer’s dementia received ongoing support as, there is an expectation, according to our friends at NICE that there will be ongoing review and assessment of the drugs prescribed; yet, if you have Vascular Dementia – the disease more often associated with stroke, heart disease, atrial fibrillation, hypertension and diabetes, as there is no treatment, you are diagnosed and sent on your way.

This is a focus of my work.

Dementia, no matter what you call it is an individualised, personalised condition that shares similarities but nothing more from one person to the next; it is the disease which focuses on our essence.

It is not adequate to take the, ‘What difference does it make,’ route, neither is it OK to say, ‘You have a life-limiting, life-changing, terminal disease; see you later.’

More has to be done, more support, ongoing, for the duration of the disease, be it two, five or ten years. Yes, dementia is a long-term condition. Which like diabetes, COPD or arthritis can go two ways – treatment, care and support, all of which reduce the burden on the individual or, neglect, looking the other way and make-believe with the consequences of pain, harm, trauma and cost to the individual and the system.

Let us move-on, let us come together and work towards a position where we don’t pretend that things are not a certain way – like children, shutting eyes, fingers in ears, stamping feet.

This is the reality of our world.

We can work with it, we can care, support, aspire to better or we can choose the alternative.

_99064980_14456792-high_res-blue-planet-ii

Sorry… this blog has nothing to do with penguins, sea-lions or Blue Planet 2, I just love this picture 🙂

Three weeks. What have I learned?

It is just over three weeks since I started working in Rotherham.

It has been an interesting time.

There have been highs and lows.

Some confusion.

Soupcon of anxiety.

Even, disorientation.

Lesson 1

When I was younger, it was routine to change jobs every year – that was the rotation which was the core of my higher specialist training to become a geriatrician.

I last rotated 10 years ago and from memory, I used to enjoy the changes of scenery, the different environments, procedures. After a decade of constancy – with, albeit lots of gradual changes, the sudden, flash in the pan, unanticipated dowsing of new experience has been overwhelming.

What has it taught me?

Well, essentially, change is possible, it is just exhausting. And, likely, it contributes to neuroplasticity which in the event of a stroke or major brain injury could stand me in good stead.

Lesson 2

Many years ago, I adopted the Confucian idea, communicated via Bruce Lee of the lesson of the overflowing cup:

tea

Courtesy of: http://bengtwendel.com/your-teacup-is-full-empty-your-cup/

You get the idea – leave your preconceptions at the door, prepare to learn new ways, don’t let past experience cloud your growth.

I’ve been thinking about that student frequently over the past few weeks.

It is interesting to see how readily we assume that our way is the way, and alternatives cannot possibly yield better outcomes.

Lesson 3

Amazing people everywhere.

This isn’t really a lesson as it was something I have always known, it was probably one of my reasons for becoming a doctor – the knowledge that no matter where you go, your situation, your vulnerability, there are always people with whom you can connect, empathise. Who see the world through a similar lens to you. Sure, we are all different and indeed, this can never be the majority, but those kindred spirits tend to stand-out from the crowd. Thank you for being so kind to me.

Lesson 4

The Man.

I never deluded myself into thinking that by moving from one big organisation to another, everything would be hunky-dory, a rose-garden of person-centred, kind, holistic empaths. People are people are… people. The Man is everywhere, controlling, manipulating, distorting peoples’ personalities and behaviours. The Man is not always the boss, they might not be the apex predator – their skills are sometimes more subtle, yet, they are there.

So, yes, the Man, the quintessence of hierarchical, organisational top-down coercion is a thing in Rotherham – nowhere near as bad as in Doncaster, but present nevertheless.

The Man is like the air we breathe; too little you’re are in trouble, too much you pop; let’s maintain a balance. Task and finish, process and procedure, all in their appropriate place.

Lesson 5

Side-rooms are hell everywhere.

Being isolated in a side-room is diabolical no matter the hospital.

On Mallard Ward we overcame this by utilising the dementia rationale – the psychological and physical harms of isolation are so much greater than the potential risk of MRSA colonisation, that, by taking special measures, people needn’t be locked-up. And, yes, our rates of infection were better than other places; that and our (successful) obsession at avoiding C. difficile.

I remember in Barnsley, Sheffield, and saw in Bassetlaw and Doncaster, and now, in Rotherham, the experience of predominantly older people, locked away in side-rooms because they either have or possibly have Norovirus, MRSA or C. difficile – the doors must be shut to prevent the bugs blowing-out, staff must wear tatty plastic aprons and blue gloves – if you are unlucky enough to be suspected of having the flu, folk are even made to don face masks.

This with no TV, radio, broadband; no decorations. Lonely, poorly; Argh.

Lesson 6

It is actually easier to discharge people from Rotherham.

Well, let me quantify this – the actual process of discharge decision, letter, take-home medicines, seems, to be many times more complicated than anywhere else I have worked, the actual ability to facilitate discharge, find someone to help the older person at home seems dramatically easier in Rotherham.

Perhaps the lesson here is that the systems can learn from one another.

Lesson 7

Measuring lying and standing blood pressure to investigate falls in older people is not yet a ‘thing’ in Rotherham… work to be done!

Lesson 8

Ward cleaners, in Rotherham are called Domestics, in Doncaster, Service Assistants. I know this might seem a trivial distinction, but, knowing an individual’s role, what they can and cannot do is important when working in a complex system. Who is it OK to ask for new hand-gel, who can remove a cannula, transfer a patient; sure, you can ask anyone anything, but I like to know what I am doing.

Lesson 9

Antibiotics – although the distance between Rotherham and Doncaster hospitals is only 19.2 miles, the antibiotic guidance for treating common infections is different. I can’t believe that the bacteria are that different from place to place, but, there you go.

Lesson 10

Rotherham folk seem to like Pregabalin and Gabapentin. These two drugs which are from a class called ‘neuromodulators’ are used to treat both epilepsy and neuropathic pain – that is, pain related to nerve damage. For nerve pain related to alcohol and diabetes they can be very effective, for other types of pain I am not sure; indeed, if you look at the list of side-effects, most people would be put-off, particularly those caring for older folk. Doncaster used to be known as the Gaba-capital of the country; perhaps those drugs are sourced from Rotherham – I have yet to determine.

*Yes, these are potentially ‘dodgy drugs‘ – they are great for some people. Never stop taking them without talking with your doctor.

side effects

 

Scared/Scarred

There was an occasion when I was maybe 13, my mum reading a short piece I had written for my English class with Jeanette, the big blonde sheitel wearing graduate of Carmel College who was our teacher back then. (Elor – remember?); the writing was in the form of a murder-mystery.

My poor command of English at the time had led me to write that one of the characters had been ‘scared for life’ – I had intended ‘scarred’ but, without Microsoft Word or Google, the fearful version came-out.

This made my mum laugh.

Fast-forward thirty years and I think I have a handle on the meaning and spelling of the words, or, if I don’t the spell-check will soon put me right.

Yet.

Scared and Scarred.

Is there more to these words than the number of ‘r’s?

Well, I felt it yesterday.

There was a situation where things were going a certain way, I was concerned about the patients and the staff and I expressed my opinion. Quite firmly I think. Removed from my usual modus operandi of sigh, head in hands and move-on.

Now. I said what I thought, and things went OK. Or, at least as far as I can tell.

But, and here is the point, I have just emerged from a scarring experience. Several years of not quite organisational bullying, but at the very least barriers and obstacles that have got in the way of my fulfilment. If anyone is interested, you can read about these in old blogs.

And so, yesterday, I was in a situation of saying ‘No – I don’t agree’ with the consequence of standing in the way of the plans of folk who felt they had things worked-out.

I said No, and I am still alive – that at least is a success (potentially Pyrrhic, but success nevertheless).

The thing is, and this is a hangover from the scarring, is the fear I felt at both my immediate actions and the period afterwards.

You see, from previous experience, had I followed the art of expressing yourself (as Bruce told us to do), in my old life I would now be walking around, or perhaps hobbling from the return blows, covered in the kind of defensive wounds that Alice Roberts or Nikki Alexander talk about in their respective TV programmes.

The scarring left me scared.

When you examine the words in more detail (sorry folks, you can stop reading here if you aren’t in to etymology) – scarred comes from the Norse word ‘sker’ which refers to a rock or promontory – I guess, a landscape scar, like ‘bluff’ and, scared has its origins also in Old Norse, being a derivative of the ‘skjarr’ which is frighten.

So, originally two different words with distinct origins, yet, it is interesting to reflect on the commonality of meaning.

How many of us have been scarred by previous experiences? And, what of the situations where that scarring keeps us fearful, afraid or scared of future events – fire, dog, parrots, confronting The Man?

I don’t want to suggest my mistake was intentional – my being too clever for my own good; I wasn’t – I just could not spell back then. Yet, it is something to consider the next time you are afraid of acting or stepping-out; why are you scared? Is it a consequence of a past trauma? Are things really still as precarious? Are you far enough away to live free of fear?

alice roberts

Dedicated to mum and my memory of laughing until it hurt.

 

 

I danced mid-week.

On Wednesday I was caught-up in some dancing.

OK – it only lasted for five minutes,

But, I gave it a go.

I was at the B:Friend training session in Doncaster College, where I participated in some early-evening chair-based dance exercise, to the tune of the Jacksons’ Blame It On the Boogie.

I haven’t danced in a while.

I can actually remember the last time I danced was during Richard Coaten’s Dance Movement Psychotherapy and Dementia Masterclass a few years ago.

Prior to that you probably have to rewind my life to the late nineties somewhere in Dundee, or perhaps the Highlands.

Dance is interesting. Funny.

Some people do it all the time.

Others, never.

My mum loved to dance; my dad was like me.

Perhaps it is genetic.

They say that dancing is good for you, it releases endorphins, it connects people, it raises your heart rate. We, as a species have been dancing in some form or other for hundreds of thousands of years.

Yet, today, you wouldn’t say it is central.

Why don’t I dance more? Mostly self-consciousness.

When Michelle, Karen or Julie were singing and fox-trotting or waltzing with the patients on Mallard I invariably stayed out of the way, yet, I know, had I joined-in I would have enjoyed the experience.

Why do we stop ourselves doing what we want to do and what we know is good fun?

I watched a programme on the iPlayer last week with Rhod Gilbert where he explored his shyness. This, interpreted as a state whereby a person wants to join-in but is too anxious, worried or fearful to do so, compared to either solitude, where folk enjoy time-out alone or misanthropy.

Is perhaps the word, dance-shy?

The answer?

Probably, find someone, turn on the music and get with it.

You cannot dance when you are dead.

jack

Shout, shout, let it all out…

Sometimes you have to shout.

Ideally,

While standing on a chair or table.

At the top of your voice.

 

Injustice!

 

On other occasions,

Indeed,

Most of the time,

We go about,

We move from A to B;

We slouch,

Harrumph,

Contemplate.

 

Not very often we burst.

 

I think of Tchernichovsky’s dumplings.

Or the London Riots.

 

Pop.

 

Perhaps we need to shout more.

 

Yes,

Let’s change our ways

&

Scream.

fire-hell-inferno-auto-tune

When two tribes go to war…

Of all that has surprised me since starting work in Rotherham, the biggest has been the whole thing to do with the patients – who they are, which population they represent, and which hospitals provide their care.

For those of you unfamiliar with the geography of South Yorkshire, here is a map:

S Yorkshire

You can see how very close to one another Rotherham, Doncaster, Bassetlaw (Worksop), Barnsley and Sheffield are, each with either an associated teaching or district general hospital.

Socioeconomically the area is not that diverse – those families previously supported by mining and the steel industry are coping with the post-industrial fallout. Each area has its wealthy, many of whom live on average ten years longer than those in the poorest wards.

life expectancy

It is a microcosm of the UK.

Because of the proximity of the towns and city, there is great overlap between patients, hospitals, councils, GPs and other facilities.

People on the same street might have GPs who work for different commissioning groups; from one road to the next the bin-days and recycling rules differ as do the school holidays.

You might call it a mishmash. A hodgepodge.

I believe the Greeks called it a Megalopolis.

All of this is interesting if you are an epidemiologist or social scientist.

I’m looking at the nitty-gritty. The granularity – in other words, the patients.

Person A, B or C – Albert, Belinda and Colin.

The patients, like the school children or the bin-men don’t discriminate, particularly when there is an emergency. An ambulance is called and, you are taken to the nearest available A&E.

Because of logistics and hospital waiting times in particular, you might be taken to Doncaster Royal Infirmary on Monday when you have a stroke, then two weeks later when you slip in the bathroom find yourself in Rotherham, or Barnsley. You might have your heart surgery in Sheffield and receive treatment for heartburn in Bassetlaw.

And, if you read my two recent blogs, you will know what is coming next… None of the organisations have integrated systems; they aren’t quite at war – beyond that, there is so little interoperability that results, treatments, investigations aren’t shared.

And, all of this is made worse by the chaos of a health service that is being choked at source, which results in doctors and nurses working at double-time, without capacity to take the long-way around, go to source and find-out exactly what happened during the recent visit to the neighbouring hospital.

Please note – I am not calling for us all to merge into one big uber-organisation, as, what I have experienced is that the bigger these places get (hospitals) the more impersonal the care, the lesser the experience of both the staff and the patients.

Maintain your identity, localness. Preserve the Barnsley Chop (and accent)!

Mrs A who lives in Rotherham is equally a patient of Doncaster, Bassetlaw, Sheffield or Barnsley hospitals.

Consequently, we must all be working to the same or as equivalent as can be achieved, standards of care.

If I admit patient G (Gavin, Graham, Georgina?) to Mallard Ward in Doncaster, where no patient has experienced a pressure ulcer in something like 1500 days, I take exquisite care of their wellbeing and skin and, the nurses, healthcare assistants and therapists all work together in harmony to provide the best experience possible and, G, G or G then goes home and two months later develops a pressure ulcer within 24 hours of admission to a different ward with different quality, different standards, different staffing, then, all that effort on Mallard, was, to some extent wasted.

And, here I am getting to my point.

The tribalism.

And I will be brutally honest about this, as I feel the experience for the patients is not right.

Some areas, caring for certain patients will discourage staff from working or moving to other hospitals. They will say, ‘keep with us, we are the best in the area.’ That, I guess is OK if it is true. If however it is not true and you want to coerce people into staying or frighten them from going elsewhere that is not.

Don’t go to that place over there – because of all the kerfuffle with reorganisation of health and social care, they are going to close it down. Stay here. We are the biggest and best. Leave them. They will be OK and, what happens to them doesn’t matter; stick with us, we are your tribe, your clan. It’s all the same NHS anyway.

Yet, what I have just described is all of the organisations being within the NHS, but in relation to consistency of standards or experience there is variation and, whenever unwarranted variation is present, outcomes will be different.

Hip surgery in hospital A has a 1% wound infection rate. That is all very good, until you hear that in hospital B it is only 0.05% and you happen to be in hospital A and your wound is infected.

This is a difficult subject and I am not saying that those places that are well staffed should give-up folk to work in those that are less-so; I remember a very frosty email I received from a former professor of cardiology when I suggested something similar many years ago… Asking for equity was not what he wanted to hear. I think things changed after my knuckles were rapped.

Perhaps it is openness and transparency.

Perhaps it is people taking a stance and looking at the state of staffing and resources, perhaps it is saying to one another, ‘Let’s overcome this tribalism – for the patients’ sakes.’

If patient A is admitted to hospital B with condition C, their outcome should be as likely to be good as were they admitted to hospital D. Surely this is logical. And how do we achieve this equality? We look at staffing conditions and numbers, nurses, doctors, therapists, pharmacists, managers, technicians – determine which place is most efficient, most effective, share the learning and work together.

Who is the positive deviant?

Learn and share, engage, interact and communicate.

Take off the boxing-gloves and share a cup of tea or coffee – whatever your preference.

spitting image.jpg

 

Standard (2)

I wrote this morning about the concept of standardisation – how this helps people navigate their environment; learn how to travel on one underground system and you can be sure that you will be fairly consistent globally with the ways the trains run, the lines intersect and so on.

That is cool.

It is a step-up to uniformity; Babel-fish meets systems and process.

There is however a downside to this which you most likely see around teenagers; the drive for sameness risks creating carbon copies of the young, imagine Midwich Cuckoo gone mainstream where the peer-pressure is so great that everyone stands in line, no one straggles, gets ahead or falls behind.

It is fine that people aren’t left stranded, that the pack doesn’t run off and abandon the weakest, yet, what if there are those who see things differently, who want to strike-out, if they are constrained?

Standardisation has a crisis when it encounters individuality and this, I suspect is the most likely consequence of imposition of a norm. Where people evolve organically to walk in step that is OK – when you have to hobble some and hurry-along others to create orderliness, that isn’t.

I don’t have an answer to this, beyond the reality which demonstrates such a high level of variation that it is more akin to laying a carpet over the furniture than taking time to clear the room, lay the flooring then return the table and chairs to their original place.

I described it earlier as papering over the cracks, indeed, this doesn’t stop the house from falling apart, it doesn’t suggest strong foundations.

And it is the organic aspect that you can’t forget.

You can command an army to march in step but take away the sergeant-major and people soon fall out of line. Hospital wards, teams, work environments aren’t the military.

How do we achieve this?

The mechanism is co-creation.

It is through dialogue.

Involvement – and its bedfellow communication.

Impose rule and people rebel.

Communicate, explain, discuss, give and take and you find collaboration.

Teamwork, the only way to achieve meaningful human development at scale is the product of collaboration.

Little stick men and women running around with spears.

And following the collaboration, is a degree of flexibility.

‘I want to go left, I really believe if we walk left we will find the waterhole.’

You can impose rule; ‘No, we are going right, go left if you want but face our anger, beware our wrath!’

You can cede order, ‘Do what you want, I don’t care.’

Or, you can talk, listen, consider, ‘What makes you think that left is good? Haven’t we always gone right? Let’s talk about this.’

You don’t have to fall out over diversity of thought, you can remain in the same tribe, clan or class with variation, so long as there is a common understanding about the purpose of your effort.

We seek water, water keeps us alive, without water we are raisins.

That kind of thing.

‘Does going left help us achieve our commonly understood goal?’ If yes, let’s give it a try, no, then why?

Is this liberal social democracy?

I don’t know.

I don’t want to mix my improvement and sociological metaphors.

Suffice it to say, randomness works if you haven’t evolved beyond a certain level, after that, SatNav is best.

Choanoflagellates1

Please let me know what you think!

Standardisation

Let’s face it, us humans are not that adaptable*.

Sure, we can survive extremes, cope with trauma and insult, but, when it comes down to it, on a day to day basis we seek consistency, regularity.

How much of our world is designed to assist with habit? With doing the same thing the same way every day?

I was thinking this when reflecting on the wards and their layout, both in Rotherham and Doncaster. The theme is inconsistency, variation.

Let me explain.

I am not discussing the unwarranted variation that we see as an enemy of high-quality care – that is a discussion for another day, no, and neither is it the variation related to sick and poor, healthy and diseased, for, when you look at the patient population, and the staff, they are the same people – one patient’s mum works in Doncaster, the other’s sister is a patient in Rotherham. They are very much alike, sure, separated by organisational tribalism, which alongside the unwarranted variation is for a different blog.

I’ll begin with some non-medical examples.

If I hire a car in Zimbabwe, Istanbul or Shanghai, it is likely that the internal layout will be similar. Yes, there will be variations in design, but, in most instances, there will be an ignition, a steering wheel, if manual, a gear stick, windows that go up and down, lights, wipers, you get the picture.

If I walk into the kitchen of any house in the developed world – there is a high chance of me finding a toaster, with slots, a lever to press-down and a timer that pops when the toasting is done.

The same too with iPhones, tumble-dryers, computers, shoes, airports, you name it and, although they are all different shapes and colours, the basic navigation is similar, for, without this we tend to be lost.

How confusing at first, when you sit in a car without a place for the keys, no ignition; yes, you see the button or switch after a while, even with that, there is standardisation.

Well, let us return to the hospital wards. And here the similarities are both interesting and puzzling.

Walk on to ward A and look for say, fluid-balance charts; the documents used to measure a patient’s input and output, how much they drink, how much they pee.

The charts might be in a stack by the door, in a drawer marked ‘fluid-balance charts’ or filed under, ‘charts, fluid-balance’, there will be occasions where the charts aren’t filed at all, just shoved-down the side of a notes trolley.

Now, big deal you might think.

Look around, ask someone, ‘where are the … charts’ and there you go.

What if it is three in the morning, the staff are busy (see Night at the Hospital) and you are looking for blood form to send an emergency sample; the form might be under ‘blood forms’ ‘forms’ ‘samples’ ‘tests’ ‘chemistry’ ‘investigations’ again, you get the idea.

This I believe is classical unwarranted variation.

It is like stumbling into a kitchen at two in the morning, your thoughts on toast and instead of a lever, there is a passcode; passcode? I mean… a toast-code?

This was an area investigated and addressed several years ago in healthcare by applying principles of lean measurement and process mapping to the movement and function of nurses, therapists and doctors; how many times did the nurse walk backwards and forwards to achieve one simple task

Cut-out the steps that don’t add value, remove the waste, trim-down the fat and, voila, you can achieve 10 tasks with the effort you previously used on two.

This all became a little lost in translation with all the changes in the NHS. NHS Improving Quality (NHSIQ), which was all about what it says – improving quality was binned, the documents archived and NHS Improvement (NHSI) was born, a division of NHS England which had a very similar name but, was tainted with the role of regulator, monitor and target achiever. And, as we all know, when you can pass or fail, when there is punishment and retribution involved in a process, creativity and growth are suppressed and, you stop learning.

Perhaps this is why I can’t find the swabs on ward A, B or C and the emergency equipment on Doncaster Ward 1 is in a completely different place to Rotherham Ward 1, both of which have the same patients and, oftentimes the same staff.

If you take this variation and spread it out through South Yorkshire where are you?

Amplify it to the five million population of Yorkshire and the Humber and you have infinite variation; I am thinking Infinite Monkey Cages…

So, here is my request.

Let’s agree on some consistency.

Let us address these basics that don’t actually cost anything, let’s standardise.

Then, when we have managed this first basic, yet gruellingly complex step, we can move on to achieving a reduction in the unwarranted variation of outcome and experience that is an inevitable consequence of this.

Think McDonalds. Think Tesco. Think Yellow Submarine.

pic 24 rk.jpg

Please like/retweet/share 🙂

*I don’t know if adaptable is the best word here – if anyone can think of something better or more appropriate, let me know. Sure we inhabit the Tropics and the Arctic, but, give us a different toothbrush…

 

 

Medically UN-fit

I seem to have written lots about the state of ‘medically fit’ – the reason for this being my eternal struggle to understand the term which is matched only by the population as a whole’s complete lack of understanding as to what it means.

As I have already covered:

‘I mean doc, how can I be medically fit when I am dying?’

I am not going to explore this further – if you are interested to read more, please check-out these blogs.

My aspiration is to demonstrate that my perception has altered.

As to whether this is a consequence of my current circumstances or, as is more likely, a fallout of the decidedly unhealthy health service in which I work, I can’t say.

Let’s face it, although we are living through times of unbridled prosperity, with the average lifespan increasing, infant mortality dropping, better treatments for stroke, heart attack and cancer, it seems that the demand on healthcare is increasing – a little like a child who isn’t satisfied with one Haribo, but wants the whole packet and, when that is finished, the box.

I guess the words are inexhaustible, indefatigable and insatiable.

(Thank you Scrabble and Lyndsey).

How do you square the ever-growing need with the fixed provision?

The answer is, you change the terms of engagement, you alter the perception.

To start, you get rid of certain fixed ways of thinking that don’t help (and, we know, as thought follows language, we must begin there).

Tell yourself ‘I am crap/weak/angry/happy/sad’ 200 times and what do you feel inside?

First, I’d suggest we get-rid of the concept of ‘medically fit’ (for discharge) as, it is increasingly redundant.

I remember years ago, a senior doctor trying to convince me, a medical student at the time that the average number of legs was 1.9 – because of all the people with amputations. He succeeded for a while.

The average hospital inpatient is never medically fit – not in terms of their complete, holistic mental and physical health and wellbeing.

When was the last time you saw Usain Bolt in a hospital bed? (admittedly, although I am sure physically he is pristine, I don’t know what is happening in his head or soul).

The arbitrariness of fitness has to go. We are all at a certain point on the continuum of wellbeing, some less than others – with every existential positive at one extreme – joy, happiness, laughter, comfort, security, belonging, rest and, at the other, well, dead. (Unless you consider the states of being which some will argue are worse than death, although I don’t profess to know – there is an old blog however).

Perhaps I need a thought experiment…

Monday morning, before, during or after the ward round:

‘Who is medically fit?’

‘No one.’

‘No one?’

‘No one.’

The conversation will not end there, but you get the picture – a nonsensical game of ping-pong between consultant and discharge nurse, manager or co-ordinator.

‘You mean, there will be no one going home, no empty beds for new patients?’

‘Well – that is a different question, let’s talk…

We need to change the lens to determine who must be in hospital, after all, despite the work to make dementia and patient friendly environments, most folk still prefer to be at home. (Mallard Ward excepted).

Change the conversation – ‘Why is your patient in hospital?’ Or, better still, clarify with the patient, ‘Do you know why you are in hospital? What do you think is happening?’

Many people exist in a state of limbo based upon medical platitudes… ‘We are sorting things out.’ (What things?), ‘The physiotherapist is going to see you.’ (And what miraculous intervention will they make?), ‘We are waiting on the MRI report.’ (And, why wait, why is the report, or the scan not instantaneous?)

You see the point?

We have a hospital crisis when most of our what are perceived to be acutely unwell patients could be managed, supported or cared-for at home or, in the circumstances of the most frail and vulnerable a care home or facility.

Instead people sit, de-conditioning, acquiring infections, pressure ulcers, falls, depression, loneliness, losing important skills and abilities: ‘Nurse, I need the toilet.’ ‘Here, use this bottle/commode/bed-pan.’

Part of the failing relates to the pressure.

If I have 30 patients to review and treat in one morning session, I will spend half the amount of time problem-solving had I 15 patients, with more emphasis on plugging the gaps, papering-over the irregularities, the predominant symptoms and missing the point.

To address this superficiality, we use teams who support the delivery of care, but, often they are so pushed they apply an equally ineffective balm, moving-on or being called-on to the next crisis or situation.

We are running so very fast on the wheel that we don’t realise we are not actually moving or getting anywhere, other than exhausted.

So, time out. Slow down.

Pause.

Instead of five minutes skittering on the ice, let’s change our footwear, sit down and get to basics.

Does x need frequent observations as they might collapse?

            If they collapse, isn’t that the 96-year-old’s prerogative?

Does x need long-term oxygen?

            They smoke… Well, let’s talk the point of our intentions.

Does x need multiple administrations of intravenous antibiotics?

            Are there any bacteria around?

Do they really need blood tests every day?

            Were yesterday’s bloods different from the day before and the day before and the day before?

There are more situations than these, but, we could draw a list of the essentials of hospitalisation – who must be in hospital; Yes, those on ventilators, or, heart-lung bypass goes without saying – for the moment anyway (we used to think this of haemodialysis).

How many people would meet these criteria?

For how many could we find solutions that use the combined resources of community nurses, therapists, GPs, family and friends, heck we could even say to the hospital nurses and therapists – ‘You know what? Why don’t you go and see Mr or Mrs Y at their home? Get yourself some fresh-air!’

This was the model that was discussed years ago, it seems to have halted at an organisational hiatus where, like trams on the tracks we can only move in two directions; let us be like Daleks who, to contend with Christopher Eccleston evolved to cope with stairs…

‘I can’t see a patient in their home, I don’t have the equipment/resources/time/’

‘Fly!’

Inverting the model could be fun.

It will provide an extra level of challenge, but, not one that says the treadmill must run faster, but which seeks solutions from the bottomless pit of creativity, innovation and ideas that sit at the heart of every person. New, different, novel ways of approaching tried and tested problems, escape mechanisms we were previously too afraid to question.

I don’t suggest I have the solutions as each of them will be local, particular and person-centred; does the patient even want to have the operation? Where do their preferences sit in this relationship? What is in their best interests? What are their interests? Our patients are more than their GCS, Early Warning Score and urine output, what about the infinite complexity that is the human soul?

No, I probably won’t tell the bed-manager on Monday, ‘None of my patients are fit,’ as that might risk getting us both into trouble, it would also potentially end the conversation – ‘How many people must be in hospital for their treatment, care, support?’ Well – that is an altogether different question, let’s see…

880px-Joseph_Trumpeldor

Joseph Trumpeldor, founder of the Mule Corps in WW1 – famously told his commander after losing an arm in Russo-Japanese War – let me fight! I still have the other arm to give to the Motherland.

Death by drowning

Of the many ways to die,

Drowning, I imagine has to be one of the worst.

It is bad because it doesn’t happen immediately –

There are the seconds – minutes before unconsciousness takes over; the realisation even before the air stops of what will happen, then, the process itself – the panic, the fear, the desperate attempt to do something before…

It can’t be fun.

That’s all I’ll say.

We talk about a good death.

To most of us this doesn’t need explanation – sure, it is person-centred and will vary between individuals, but here, I suspect are some of the elements:

Pain-free

Family or friends

Favourite music

Warm

Gentle

Private

Your affairs in order

That kind of thing.

One of my patients died recently. His family were present, I don’t think he was in pain, he was likely warm. Music wasn’t playing, and he didn’t have adequate privacy.

He didn’t get to see his dog before the end.

That will stay with me.

Modernity has imagined all sorts of ways to interfere with dying – from ventilators, bypass machines and dialysis to oxygen supplies, intravenous additives and endless medicines.

Yet, we, that is the humans, or, any living thing, remain powerless. I find this reassuring. No matter how big your car or dominant your country, you, like me will one day die.

I am often caught-up in the end times when modernity, or perhaps better put, medicine, gets in the way, when it shifts from being a prop to an obstacle. When the oxygen mask is blowing dry air into your mouth and all you want is a drink. When the doctor or nurse at three in the morning is fiddling for the fourth time to insert a needle into your collapsed vein, when, all you want is sleep. When the medicines are dispensed, totted-up in a little paper cup and offered to you with Weetabix, and, you baulk at the notion.

Hurdles. Obstacles. Barriers to a good death that is the right of every person.

‘Doctor, their blood pressure is 200/120, what should we do?’

What is the correct response:

10mg of Amlodipine?

Repeat the test?

Ask, ‘What is wrong? How are you feeling?’

Panic?

Ask, ‘What am I doing? Why am I doing? Is the measuring helping my patient who is 96 and, staring at the wall opposite?’

We throw pathways at hospitals and clinical care – if this, then that, blood pressure low – do this, too high – go here; don’t stop at Go, pass direct to the bleep system, call for assistance.

Pathways are however, very often, the antithesis of person-centred. They take the experiences of the majority and create a map, a what should happen when, so long as you aren’t too unusual or, we haven’t measured you wrongly or the pathway belongs to someone else with a different condition.

It is like squeezing in to too small shoes. It can be done, it is awkward and, you can get about, but you look odd and you will soon get blisters.

Pathways stop up thinking, they allow hospitals to flow, as if patients are rivers and their lives water.

Jump in the boat and sail to the sea; what happens when you are paddling up-stream?

Pathways stop you thinking.

We used to have something called the Liverpool Care Pathway – I remember asking the doctors to follow the guide when my mum was dying, to stop with the needles and scans.

Eventually, like every test or standard given to the NHS, managers and teams of clinicians busied themselves and found ways to optimise the pathway – not so it was optimum for the person dying, but ideal for the system – to minimise variation. Soon, people were on conveyor belts and the love related to the original work was twisted into something ugly.

Equally, unwarranted variation is the enemy of quality.

The NHS has different challenges and resources in every area. Although the folk living on the Bishop’s Avenue are likely to pop in to BUPA for their care, if they break their ankle it is the local A&E they will approach.

The landscape is varied between deprivation and privilege, disease levels and lifespan, there is no consistency, there never has been and there is unlikely to ever be, at least until our society evolves. Yet, we can still expect unvarying care and attention, love and support.

We all deserve a good death.

inri

Sunset over Jaffa

We had several discussions about the origins of Jaffa Cakes when we were in Israel.

First there was the query as to whether the cakes came from Jaffa – no; then the realisation that Jaffa Oranges likely had something to do with Jaffa (aka Yaffo) although nowadays Jaffa Oranges are a brand name and can come from anywhere.

This I imagine to my kids was like my trying to understand Turkeys not coming from Turkey and Turkey in Hebrew being Hodoo, which means India, all mixed-up with Native Americans, Cowboys and Indians and the place where Gandhi and Buddha originated.

Language gets confusing.

This in turn takes me to Breughel’s Tower of Babel which is supposedly where all this complexity derives.

1200px-Pieter_Bruegel_the_Elder_-_The_Tower_of_Babel_(Vienna)_-_Google_Art_Project

Imagine we had a monoculture of human language, worse still belief or ideology.

Imagine the Eurasian Plain covering the entire planet, even-out the Himalayas, Alps and Rockies, raise-up the Dead Sea and Mariana. Flat. Uniform.

Cakes would just be cakes and we wouldn’t fret about whether the EU considered them biscuits. (Oh, for the days when that was all we had to worry about!)

I doubt a Jaffa Cake or a Jaffa Orange will ever taste the same to my children.

Nevertheless, we headed out on Saturday night, along the beach.

We ate at the Blue Haj restaurant on the corner of Clock Square.

A huge leg of lamb stuffed with seasoned rice. You can see a picture of the dish on Trip Advisor here if you like.

I really wanted to analyse the cultural aspects of my visit – the cocktail that is Israeli culture – the Jewish, Muslim, Arab, Christian, Armenian, Druze, Ethiopian, Sudanese, Eritrean, Russian, you name it and multicultural diversity is somewhere near the conical Christmas Tree in the square.

I tried to understand but quickly became confused with my thank you, todah, shukran and spasibo – a jumble of, who to thank and how.

More confusion came later when a doppelganger, one of the many busied himself in the pastry shop.

IMG_3073.JPG

And me,

Fluent in Hebrew, yet hesitant to use the language for fear of confusion, the struggle of lapsing into guttural idiom or remaining in tourist-mode.

I don’t seem to have these dilemmas when I visit London which is more diverse.

Most of us inhabit our four by four worlds of culture and identity that keep us safe, secure. We don’t understand the fears or aspirations of our neighbours.

Shut-off we watch the TV, cook our pancakes and drive to work.

And, in doing this we allow ourselves to diminish. To become less; for are we not who we are when we are with others? Isolation leads to madness. Akin to the aspirations of the populists. Keep us pure. Keep the Blacks, the Whites, the Pinks out.

Imagine Yad Vashem at the centre of this and you get a flavour for the insanity.

Jaffa.JPG

 

First in line

Votive

candles

in the dark.

 

Kitty wanted to light one.

 

I didn’t have a match

or a candle.

 

And so, we paused for a moment,

thinking,

considering.

 

Peaceful

despite the many

standing around;

Pointing at the mosaics,

the frescoes

the stonework.

 

We contemplated the tall candle,

the one

standing above all the others

and considered

who might have placed it there –

was this an attempt to gain special consideration?

 

Look at me!

I deserve salvation more than those other guys who could only bother to spend half a grush* on their lights;

 

A little like the folk buried

on the Mount of Olives

who believe

that the Messiah,

will follow a plan,

First stopping there before reaching the Holy City.

 

And they,

thanks to their diligence

or perhaps

Investments

Will return to life before the others,

and so,

Be first in line

for housing

or falafel.

Jerusalem from the Mount of Olives

*Grush = 10 mils; 1,000 mils = one Palestine pound during the British Mandate.

 

Kissing.

How long must you wait before a kiss?

 

Imagine

The duration

is not a minute,

a week or a month.

 

but, a geological timescale.

 

Not today or tomorrow –

Forever,

or, as good as.

 

That is the speed at which the calcium

in solution

takes

to trickle,

drizzle down

from on high

to lower and lower.

 

The stones can teach us about patience.

 

(None of this will mean much unless you can see the photo on my website – it is of the famous kissing stalactite and stalagmite at the Soreq Caves in the hills outside Jerusalem. It is estimated that they have taken a million years to reach their current level of relational maturity; let’s hope things last.)

Jerusalem 1

We were watching the woman stand

by the cross,

arms out-stretched.

Smiling.

Friends taking pictures

Smiling also,

outside

The Church of the Holy Sepulchre.

 

It was a strange moment.

 

Next door is Golgotha,

And around the corner the place of resurrection.

 

Unreal.

People queuing to have a moment.

It is hard to know what to make of belief when you are approaching an experience from an historical perspective; looking at the stones, analysing the rocks.

Some were crying.

 

 

Seeds.

Picture the scene.

Winter.

You are walking through a field, perhaps an overgrown patch of land that hasn’t been tended for years and, in your hand are a few dozen seeds. Mixed variety, some flowers, others fruit, grass, it doesn’t really matter. And, as you walk, you scatter the seeds, randomly. Some will fall on rocks, others in places where grass or weeds are already established. You walk on, not following any particular pattern, meandering you might say. The wind picks-up some and carries them further, a few might even land on the next-door field or a garden down the road. You don’t know what will happen, you have no way of divining the outcome of your actions other than to wait. Time will tell. If you return too soon, everything will look the same, unchanged. You won’t know if birds or mice have carried them off – the ones you had hoped would most likely succeed in establishing themselves, for, isn’t it likely – if you had your eye on a particular seed, maybe one that looked especially healthy, a passing sparrow might have had the same idea. If you return in a week or two, you might see the occasional green shoot. You have no way of telling whether the sapling had anything to do with you, as, it might have already started growing before your arrival; it is hard to distinguish between one tiny pair of green leaves and the next. In the meantime, you have work to do; the scattering was likely only part of your overall duties – perhaps a one-off, perhaps this is you forever, walking through fields scattering. Alternatively, you might be called to do something different – drive a car, listen to music, hold a hand. The possibilities are endless. In part, this uncertainty is likely to distance you further from the original scattering, you will likely be distracted or too preoccupied by other business to keep check on any plants that have managed to gain enough moisture, sunlight and space, who haven’t been eaten, carried-off or failed to germinate. Time passes.

Time.

The field you first encountered many months before will have changed, as have the seasons. When you first stepped-out it was winter, then spring, and now, the beginnings of summer; the days are longer, warmer, you feel a little more optimistic about life in general; perhaps the pressure for survival has abated. You start to breathe more easily. The weight of winter and frozen months has lifted.

And you remember the field.

At first you were not sure where it was that you walked on that day. You can’t quite remember, so, you set-out to find that first place.

You can’t find it.

All around you are fields and gardens, trees and plants that seem different; the environment has changed, you have changed.

You don’t remember the nettles or other stinging plants, you see flowers interspersed with weeds of suffocation; you don’t see much fruit.

Some of the plants are healthy, growing into the light, displaying flowers, some with beautiful scent; others are twisted. Malformed. Not seeming to serve a purpose.

It is impossible to tell which are the result of your actions, which the children of your seed and which were already established before your arrival.

It is not an idyllic scene; it is obscure, unclear, unsentimental.

You cannot establish your place in the geography, and no one else is around to tell you, to explain where to go.

You feel very tired and decide to rest.

As it is warm, and the ground dry, you look for a patch of grass, somewhere free from thorns and stinging plants.

Across the way.

You bend to your knees and lie on your back. The sun is shining. The sky blue with only an occasional cloud.

You think of your field. You have no idea whether you are lying in your field or that of another, the seeds you scattered may have all failed to grow, others might have become flowers, others twisted, broken, most will likely have been eaten or died.

You consider your place in the world, in this field, and you feel your smallness.

You realise you are a seed. Planted without intention, scattered without schedule or security.

No one is around to monitor your growth or actions, or to return and check on you as time passes.

And, we are all seeds scattered by the wind, trampled underfoot or lifted by the sun.

And that is the lot of humanity, the passage of time, random decisions and optimism.

storm

Are you looking at me?

I am trying to imagine

What it is like

to fall into a

wormhole

or

perhaps

topple

into a black hole.

Neither experience

can be much fun,

although,

I gather with the wormhole, there is, even though very remote,

the possibility of traveling in time and space,

Whereas,

with the black hole,

It is just

Darkness.

Last week, as my trip to Israel was coming to an end I visited the Israeli Children’s Museum in Holon; my brother, his wife and my children and I, were led through an exhibit called Dialogue in the Dark.

This is an experience of complete and utter darkness, where you spend an hour, guided by a visually impaired instructor through a cityscape, boat journey, jungle, market, living and sound room, finishing with a café (chocolate, Bamba and coke, all for 20 Shekels). In the darkness. No light, you see. Not black hole, but, insight into the darkness, getting to use your senses and talk with someone about their experiences of life, of stigma and empathy, kindness and inconsiderate over-attention; guide dog and Danny collecting his son from kindergarten.

No, this isn’t like a black hole, it is just black (specs, phones and other electronics are all locked away before you enter).

Wormhole is different –

This is when you are stretched into infinity.

I don’t even want to pretend I have any real sense of what either are, just as I have no concept of visual impairment or blindness.

The important aspect for me was however, the sense of loss and disorientation. The absurdity that we take for granted through our senses.

See, hear.

bamba

 

 

Speed

Everyone accepts that things happen fast nowadays.

Yet, some aspects of life can’t be sped-up; indeed, any attempt to cut-corners or accelerate the process usually has negative consequences… hangry, tired, listless – readmission.

No matter the speed, the turning-over of activity, there is a certain bandwidth that is constant; walking, driving, peeing.

The media – news stories come and go, flying into consciousness then, gone before you know it. Music – what was top ten is now flash in the pan.

The rhythm of Jazz.

Before the horse was domesticated, the fastest a human could travel was the speed of a sprint, unless you were a long-distance runner, in which case, you could travel at the speed of a trot; a Bushman shuffle.

Then, four or five millennia, and, the speed of horse, superseded by cars and trains and planes;

The world shrinking, coming together, East meets West and off we go.

We are still apart, our cultures separated by history.

How do we reconcile the shrinking of the microprocessor, the discovery of inner-space with the 24/7 day? Our movement through time is constant.

Inconsistent.

We lead a split existence.

Half rushing headlong into tomorrow, the other, dawdling in the past;

We can’t decide whether to stop or go; green light rapidly cycling with red. No amber. No pause, no collection.

And, time stops when we shut our eyes, when we drift to sleep.

black bear

Freedland and rules

Thank you, Jonathan Freedland, in yesterday’s Guardian for both writing an upbeat article about the NHS (actually thanks for the upbeat article, and thanks for it being about the NHS), and, for your coverage of WhatsApp in healthcare.

You see, we have a problem – the NHS – behemoth, leviathan, whatever you call it, cumbersome and at times lacklustre, fuelled by the passion, energy and magic of a million staff is I agree the brightest aspect of the UK today. It is a light that shows us, no matter the crap, the self-interest, Global Warming, populism; when you come-down to the individual, one person connecting with another at their time of need is what it is to be human.

What Freedland highlights is the intersection between technology and person-centred care; remove the middle-man, the organisation – NHS Trust, Commissioners, NHS England, the Department of Health and, you are left with the human spirit that has enabled us to exist within societies for millennia.

The rules are the way in which society, organisations and people operate.

Look left then right, then left.

Brush your teeth.

Wash your hands.

Hold the pencil properly.

Our societies exist because of rules, regulations and oversight that is passed-down father to son, grannie to grandchild, through the generations, sure they help, they prevent cars knocking your down, caries, infections and scabby handwriting. Yet, we, that is people, are so very good at rule-keeping and so terrified of rule-breaking that we miss the opportunities hiding alongside.

We jump to conclusions. We assume.

The patient must have the medicine because it is prescribed.

I know this hurts, but I need to do the test.

Are you asleep?

Whatever the silliness, we are very good at following instructions.

This is loss aversion.

If I break the rules, allow the patient to sleep, I might…

Evolution is breaking the rules.

It is trying new ways of living, being. It is experiment. It is embracing failure, when the alternative is failing anyway.

And back to the rules and setting yourself free.

The internet is there.

It is a thing.

No one knows enough.

Collective intelligence is the next step in our evolution.

Imagine if Darwin, Einstein, Marx and Freud had the Web at their disposal; imagine if they could have FaceTimed; sure, there might have been more dispute as to who had the idea, but these guys, and guys who are interested in finding meaning tend to care less about their legacy than the act of discovery.

So, get out your phones, Webchat, blog, finagle your way into the tech, all in the cause of improving.

I haven’t had a chance to thank everyone for the incredible send-off I received on Thursday. It was overwhelming and humbling. Such a group of amazing people – thank you and Namaste.

Dead

I know it is Christmas Eve Day & all, but, I couldn’t help myself – you see, the way it is, when I get these thoughts in my head, the options are either to put them to paper or allow them to dissolve; a little like dreams. Some thoughts hang around longer than others, for most, it is just sparkle, fizz and gone.

Here I am.

I don’t know whether I have been fortunate or not to have lived through the past few weeks – well, fortunate to be alive, sure, but, to have experienced them at all, I don’t know.

It is a little like grief, only I am the person who has died.

You see, me, passing through my notice period, then on Friday, the end, has been strange, overwhelming, frightening, painful.

Not many of us get to witness our own passing-on.

For me this time is like Kubler-Ross’ stages of grief:

denial/anger/bargaining/depression/acceptance

the feeling wheel

I know, yes, this is nothing at all similar, after all, here am I, seven am, sitting in boxers, typing at computer, and, yet.

I think of my friend’s uncle who after he died unexpectedly was showered with tributes from appreciative students – the quiet, sometimes taciturn guy who was not big on affection, was, it was discovered all too late, entirely the opposite.

I have been through this and, it feels a little like using your once-in a lifetime lucky charm; spent.

Grief is as much part of life as everything else; we say that one of the reasons we experience grief or, depression for that matter, is related to the way in which we connect with others, form close bonds and attach.

You can’t have one without the other – the cost of love, is its end one day.

& I know, I am still here, Mallard Ward remains open for business, the show goes on. Yet.

How often do people live through an unimagined success, the creation of something wonderful that is greater than you – perhaps the birth of your children?

When we opened Mallard Ward, we had one quite clear objective – to improve the experiences for older patients in the hospital who were confused; delirious or living through complications of dementia.

We knew we would be taking-on significant challenge, this was not going to be easy. The management objected, the leadership irate. For, the patients that were often seen as trouble, we were like me at football – the last person to be picked for the team. No quite untouchables, but certainly to many un-desirable. And we took these folk and made something beautiful.

And I have passed-on, in transition, a Yuletide limbo that I knew I’d never enjoy. Then, that wouldn’t have been difficult to anticipate, for he who is never satisfied, never happy, always seeking a little bit more.

So, no, I am not dead.

I am experiencing a keto-flu; a transition, my psyche adjusting, just, as the Ward will adjust, the cracks papered-over and new things found.

The end is not the end, it is just the next phase.

kerouacwheel.jpg

 

Fall

The closest thing I can compare this to is falling,

Or,

Perhaps more accurately,

Free-fall.

Dropping from an unknown height

Without parachute

Or means of deceleration.

Like a stone.

A rock.

Instead of air rushing past it is people

and time

and

experiences.

Moments, achievements, changes,

doings.

beings.

Like being in a real-life Truman Show version of

Angry Birds.

The trajectory is?

Time of arrival?

So many images that capture the experience –

Attenborough’s little submarine plunging into the deep,

Stock Market’s crashing.

Should be more up-beat.

I keep thinking of my legacy – tortoise stuck to top of monitor and

Miniature Hornby man, lost.

Need to shift the imagery.

There be Dragons

maps used to say.

Crazy, unimaginable…

Yet.

The irony,

What is odd.

What is absurd,

Is what this says about me as a human.

A leaf clinging to tribe,

Family,

Belonging.

For, we are one tribe –

Whether you call it South Yorkshire,

Yorkshire,

England,

Britain,

Warm-blooded vertebrate.

It is funny how we so often see the difference, the separation as what keeps us together.

Let’s work towards family.

Let’s focus on the commonality.

Let’s not allow love to tear us apart,

Allow it to bring us together.

miniature figure.jpg

olaus magnus 1539.jpg

10 Years

I was blown away yesterday.

It has been 10 years since I first parked my car in the spot marked ‘Rod’

We often measure lifetimes in decades.

I’m in my fifth, my kids in their second.

The 20’s, 30’s, 60’s pick your favourite and off you go.

What will become of the 2010’s?

None of this is what blew me away.

I was talking with a patient who has cancer.

She is dying of the disease.

It is 10 years since she was first diagnosed and the fight began.

Indeed – you might consider that in the time period I have been knocking around in Doncaster, she has also been walking the boards, through investigations, diagnoses, prognosis and treatments. I have been bumbling along, living my life, growing my family and she has been living with the uncertainty of cells that have gone awry, moving through her body & likely, despite what we now know about molecular and cell biology, the consideration of some misdeed, as Susan Sontag related – first TB, then Cancer then HIV and now, Dementia – the diseases of morality, or perhaps, better, the diseases we think of when we think of God and retribution… What have I done to deserve this? Can’t I just get-on and live my life? If you travel to West Africa and talk to the populations affected by Ebola, it won’t take long to find someone who will associate the disease with upsetting God or the deity, a payback into suffering. And yet, we all know we are subjects of chance, of happenstance, of occurrence. I happened. It was. Just. Random acts of kindness we accept as making us feel more at home, disparate acts of illness, disease or tragedy, we try to find a meaning. We search. We likely blame, assign culpability, focus our energy and why? Why is because we have such short lives, our passage through the cosmos so insignificant, love is eternal but our impact on the world transient. We seek meaning, we seek a constant, something to cling-to, a mark to leave after we have passed, whether a love-heart carved in oak or a disintegration, condensation wiped-away. We apportion blame, we take responsibility, we weigh-up the good and the bad and the uncertain. No one really knows, no one has a clue, it is all reading in-between the lines; hoping that we’re on the right track.

  1. 20. #30.

ebola destroyer of worls

UTIs – myths, facts and what Wellbeing Workers need to do – with Helen Sanderson

Dr Rod Kersh’s first blog for us is about Urinary Tract Infections or UTI’s. At Dementia Congress this year, we both heard a presentation about how home carers should respond to issues like UTI’s. It is fair to say that Rod didn’t agree with all that was said, so I asked him to share his knowledge and expertise here.

UTI’s have become part of an older persons’ mythology – take an older person to an A&E department, and the likelihood is they will receive a diagnosis of UTI – whether or not this is the case. Or, someone living with dementia in a care home becomes more confused – phone the GP, describe the symptoms (more confused) and, voila, Trimethoprim – the most commonly used antibiotic to treat urine infections.

All of this does sometimes make sense – older people because of a variety of factors – dehydration, constipation, bladder stones, medicines and so on are prone to urine infections, with women being affected significantly more than men.

Urine infections can cause a state of delirium – temporary confusion or disorientation, particularly in older people and those who have dementia.

Yet, these facts do not mean that every older person who is temporarily confused or out of sorts has a urine infection – there are a multitude of other reasons, which by reaching for the antibiotics we can potentially miss.

This brings us to the question that people are likely to ask…

What to do when we suspect someone has a urine infection?

When I started-out in medicine there was a belief that older people were more prone to non-specific symptoms than other people, less likely to have a fever during illness or the other symptoms we know are associated with UTI’s. We now know this is not the case. Older people are as likely as anyone to experience symptoms; therefore, the first questions are – what are the symptoms?

  • Frequency – passing urine more often than usual
  • Urgency – the need to rush to the toilet urgently
  • Dysuria – pain on passing urine
  • Pain in the lower abdomen
  • New incontinence
  • Very high or low temperature
  • Blood in the urine
  • Worsening or new confusion

In order to diagnose a urinary tract infection, two or more symptoms are required – anything less and antibiotics can do more harm than good.

The only way to really diagnose a urine infection is by sending a sample to the labs for analysis – this can take a couple of days, which means, it is usually best to get a sample as early as you suspect something might be wrong.

To make this all more complicated, older people are prone to a condition called ‘asymptomatic bacteruria’ – this is the presence of bacteria in the urine which is not causing any symptoms and can be found in up to one third of people over the age of 65. Treating asymptomatic bacteruria does not help people and significantly increases the risk of side-effects from antibiotics and the development of bacterial resistance, so that when you really need an antibiotic it is less likely to work.

Here are some suggestions to prevent UTIs and maintain wellbeing…

  • Ensure people maintain an adequate fluid intake – older people often under-drink and exist in a state of dehydration (sometimes because of the false belief that not drinking lessens the need to pass water or experience incontinence – the opposite is actually true; more concentrated urine is more irritant and more likely to cause the need to pee).
  • Have a universal container available – these are specimen bottles that you can use to send a sample to the lab before a person becomes unwell.

Some questions from Helen…

When you say ‘adequate’ what does that mean in practice? Is it the 8 glasses a day?

Everyone is different – that is the essence of person-centred care; some people manage to get along on minimal amounts of fluid, others drink gallons. Perhaps the best barometer is whether a person is thirsty – although this can be affected by old age and certain conditions such as dementia.

Another way of measuring adequacy is to check the colour of urine – if it is too dark or concentrated, more fluid is required! There are scales that you can have where you can easily tell this.

An easy way to increase fluid intake is to count the number of drinks in a day and aim to increase the volume by a cup or two.

I have seen situations where relatives almost bully their parents or grandparents to drink more – as the saying goes, you can lead a horse to water. People will only drink what they want.

Do GPs accept any type of universal container? Does it need to be sterilised?

You can obtain a sterile universal container from the GP surgery – a sample is best taken at the first sign of an infection, before the older person has become unwell. The signs to look out for are described above.

I know of one home care organisation that routinely tests peoples urine each week- what do you think about that?

This to me is an incredible waste of time and likely overly intrusive. Samples should only be taken when a person has symptoms, otherwise you will detect asymptomatic bacteruria which if treated increases resistance and predisposes to complications like Clostridium difficile diarrhoea.

 A commissioner I work with mentioned some specific pants that detect urine infections so that testing is not necessary. What do you think of these? 

These are pants function a little like dipsticks – if they are in contact with urine that has bacteria the pads change colour. These like dipsticks have fallen out of favour as they are very inaccurate and likely to give false positives i.e. suggesting there is an infection present when there is not. The pads like dipsticks only suggest an infection, they also do not inform you as to which antibiotic would be best. Using the wrong antibiotic can prolong the illness and result in both bacterial resistance and side effects. Urine samples are best.

Sometimes, in the case of a person who is bedbound or incontinent, it is difficult to obtain a sample; often people are able to provide a sample if they are asked – we sometimes assume they are unable; in situations where no sample can be provided, I would suggest the local care of older people team or continence specialist should be involved.

I will cover situations where people have long-term indwelling urinary catheters in a separate blog.

 We were both at an event recently when the presenter talked about how difficult it was to persuade GP colleagues to see people quickly with suspected UTIs – and that it was better to do a urine test and tell the GP the result – what do you think of that?

Practice varies across the country. Most GPs want the best for their patients and will be happy to collaborate in determining the best way to treat a patient. I suspect what we are proposing is a change to the relationship whereby the Wellbeing Worker acts as an advocate for the person they are supporting and advises the GP – ‘I am worried that Enid has a urine infection as she is going to the loo more frequently. I have sent a sample. Can you help?’ – Wellbeing Workers will with time develop very close relationships with the people they support and this knowledge is invaluable to doctors and nurses in their assessments.

For more on urine infections (as if you could ever have enough…) – see Rod’s other blogs here: 

http://www.almondemotion.com/2017/06/26/uti/

http://www.almondemotion.com/2015/12/13/some-more-thoughts-on-urine-infections/

http://www.almondemotion.com/2015/09/20/asymptomatic-bacteruria-and-bear-grylls/

Please share and let me know what you think!

 

Colon

Today, I was asked for the first time, by someone who isn’t my patient, as to whether they should have a colonoscopy. This is, a fibre-optic camera inserted into their large bowel, preceded by powerful laxatives, sometimes accompanied by a hypnotic sedative and followed by, I imagine a smattering of wind.

I found the question interesting for a number of reasons, first, you might ask – if someone is scheduled to have such a potentially invasive investigation, surely there must be a good reason; it isn’t like a matter of taste;

‘Waiter, I’ll take the Chablis, oh dash, I’ll go for the Shiraz.’

Presumably, when someone is facing such a dilemma it is a matter of scientific judgement, or, at least something more concrete than a whim;

‘Mr Kafka, we have noticed that your red blood cell indices are a little low and that, combined with your recent bouts of diarrhoea have led us to conclude a colonoscopy would be an appropriate investigation.’

But no, from my understanding, the preceding history is of a vague, non-specific pain in their abdomen which has been investigated by multiple blood tests, ultrasound and CT.

The colonoscopy is really the next step in a logical process of ‘test until we find something.’

It is this approach that has me worried.

After all, no one is entirely normal.

All investigations and analyses are based on statistics, the normal population and in the case of radiological and endoscopic investigations, the skills (and sometimes focus/attention) of the operator.

Every couple of years I encounter a patient who asks for an excludogram – a test that can confirm they don’t have something – anything wrong. In general, the request is a ‘whole body scan’ – with the impression being that a) such a scan exists and b) I can easily arrange it.

‘Mrs Simpson, your whole-body scan was normal, you are in a state of complete (physical) wellbeing. Cheerio!’

It sounds daft when you hear it in this context, in reality, when an individual is faced with the demon of disease, a little like GK Chesterton’s allusion to God – when people are faced with an unanswerable question, they won’t take no answer, they will take any answer – this is behind the multi-billion-dollar alternative medicine marketplace.

‘Your tongue suggests black-bile, here, take these panda bone capsules, one a day for six weeks.’

It is also akin to the value of a map.

If you have a destination, a map is useful to help guide you, otherwise, as a tool, it is quite useless – if you don’t know where you are and where you want to go.

Back to the question… Should I have a colonoscopy?

I guess, when you look at it, there could be several possibilities. The most worrying of course, and the one which many people fear – do I have bowel cancer?

There has been a national screening programme running in the UK for the past decade which is dependent on people over the age of 60 sending-off a sample of stool for analysis – we call this faecal occult blood (or, FOB) testing.

When people are healthy, there shouldn’t be any blood in the stool. Sometimes this is accompanied by abnormalities in the blood screen – showing anaemia or a low iron (or its surrogate marker, ferritin) level.

A colonoscopy can detect a variety of abnormalities – including cancer, many of which are treatable, particularly if detected early.

As an investigation of the bowels it is very good and usually safe, but, we don’t send everyone for this test as not only are there not enough endoscopists – clinicians who wield the scope, it is likely that undertaking scopes in the population at large would yield many false positives – people being diagnosed with cancer when they don’t have anything wrong, as well as the risk of harm from the procedure – one in every three thousand people scoped can experience bowel perforation – a potentially serious complication.

To be honest, I don’t want to go into too many details about endoscopy as I am not an expert – you can find lots of information at this website.

What I am more of an expert at is working-out the rights and wrongs of tests.

And this is the point.

If a doctor proposes you have an investigation or not – invasive, painful, embarrassing or whatever, there should be a good reason for this.

As I have written before, the vast majority of clinicians – doctors, nurses, therapists and pharmacists care deeply about their patients and would never consider a treatment or test which could cause harm.

Different people have different interpretations of risk – others do not adequately perhaps consider a patient’s preferences.

What this comes-down to is the original questions.

‘Should I have a colonoscopy?’

My answer is truly, I don’t know, as I am not your doctor and I don’t have the whole picture.

What I can say with certainty is, if you are asking me the question, or you are not entirely sure whether a camera, CT, MRI or operation is right for you, you haven’t asked enough questions.

This leads to a mantra of patient safety.

Patients (and staff, and anyone for that matter), should be feel confident and adequately empowered to ask their doctor or nurse or therapist why.

Why do you think I need a CT?

Why don’t you think I need a CT?

You get the idea.

The days of the doctor sending an unquestioning patient for tests and treatments is over.

Empowered patients, who are informed, who share in their health care and treatment are those who are partnering in safe care and, if your doctor is unwilling to provide an adequate explanation, ‘I want you to have the test because I want you to have the test,’ then, my recommendation is to look beyond that individual who I am sure would not be satisfied with that approach were they the patient.

PS I am quite good at these non-answers; something they teach us in medical school!

bosch03w

Please share!

A response to Henry Marsh

In yesterday’s Guardian, Henry Marsh, the former neurosurgeon, wrote a short piece commenting on the treatment by the legal system and the media, of transplant surgeon Simon Bramhall – otherwise known as ‘SB’.

Marsh expressed his opinion that although Bramhall had been stupid to write his initials with an argon laser on the liver of a transplanted patient, as he says, ‘It is worth noting that Bramhall had done this in full view of all of the surgical team.’ As if it wasn’t just Bramhall who was culpable but all the other surgeons, anaesthetists and nurses present in the room.

Marsh continues with a defence of surgeons in their requirement to detach sentiment from emotion and the overall pressures of being a doctor in an overstretched 21st Century NHS.

It was the ‘view of all the surgical team’ that got me.

That and the consideration that an over empathic surgeon might be a bad, if not dangerous thing.

I have met many surgeons in my career and the only surgeon I would hope to have transplant my liver or any organ would be one who is not only highly skilled but also highly empathic.

Do you want someone rooting around inside your body, making life and death decisions who does not have a moral compass? After all, isn’t morality a bedfellow of empathy, in other words, humanity; otherwise, get rid of the surgeon and bring-on the transplant bots.

It was this and the team, who either silently stood by and said nothing as SB wrote his initials, complicit in their passivity or, who thought so little of his act, seeing it as within the realms of daft but not terrible, to say nothing.

This makes me think of the Korean Airlines pilot allowing the plane to fly into a mountain because the team were all too afraid to point-out the inevitable to the captain… Mitigated language as Malcolm Gladwell says – ‘Erm, I think we might be a little too close to that…’

Livers, organs in general and surgery whether the most expert or the seemingly trivial is not, at least in a modern NHS the accomplishment of one hero operator. It is the combination of tens, often hundreds of skilled individuals all working together in what is in general considered the ‘surgical team’ – and it is team that to me is inconsistent with ‘SB’ – he didn’t write ‘the surgical team at…’ but rather, his own name, forgetting the involvement of all the other people, forgetting the person who has died, their families and dependents, forgetting the patient.

Modern health and probably, social care, can only exist within the complexities and challenges we face through team working. As the King’s Fund described in a 2011 report, there are ‘No More Heroes’ in care.

Empathy is essential to teamwork, whether you are a top-notch surgeon, battle commander or airline pilot. Without empathy, you tend to have dysfunction which diminishes the outcome of a team’s ability to perform.

Great teams – whether in football, rugby or science succeed by the combined efforts of the whole, not the talent of a star performer.

The act of writing ‘SB’ wasn’t that terrible, it did the liver or even the patient no harm – we don’t know what effect this will have on other people opting to donate their livers or enter into discussions with transplant teams in the light of this case, yet, it talks to what is great, what is the only way the NHS will continue to grow and survive within the constraints of modernisation, integration and progress – that is, humility, empathy and collaboration.

collaboration

Medically fit – today and tomorrow (3)

You hear this term all the time nowadays, at least, if you work in an NHS hospital, are an inpatient or carer or relative of someone who is occupying a hospital bed.

Most often…

Are they medically fit?

When will they be medically fit?

If they are medically fit, have you done the take-home medicines?

And so on, you get the idea.

It is all to do with the proximity of the patient – person – usually older, but not always, who is occupying a hospital bed and their exit from the ward/unit/department – this in turn will allow for another patient/person to swap places and allow flow.

Flow is another word that has become bastardised by the NHS.

Flow in its original form as described by Mihaly Csikszentmihalyi is a state of mindful occupation where an individual exists almost outside of time and space in a bubble of creativity or doing.

Flow nowadays is how many patients are moving round the micro (hospital) or macro system (entire health and social care network).

Critical to flow is medically fit.

Too many people who are not medically fit, and you have a problem. People keep arriving at the front door and not enough are exiting stage left. Things become crowded.

It is funny. Just a few years ago we used to talk about hospital bed occupancy; there was considered to be an optimum level – somewhere in the mid 80 per-cents, which allowed for flexibility, accurate and appropriate allocation of patients to specialist areas, now, the system only exists at something like 100%.

Like the rush-hour Tube – bursting at the seams, the last person squeezed-in as the doors shut.

An overflowing train may help move people, it might even earn Virgin Trains lots of money, it isn’t however much fun or pleasant for the folk who are knackered, leaning against the toilet door on the six-o-five from Paddington.

We know the reason for the obsession with medical fitness (which I don’t think I have explained, but, you can read more here and here.) – it isn’t that there are not enough hospital beds (although some people would disagree), it is not that the system isn’t slick, effective and efficient (after all, isn’t that the essence of the NHS?), it is that we have lots and lots and lots of older people who have nowhere else to go when they fall or become sick.

And, you ain’t seen nothing yet, as Bachman Turner Overdrive might have said in the 70’s.

The baby-boom generation are still babies. Still young, fit, healthy, vital. Leading independent, productive lives, net contributors to society and the economy.

Take a seventy-year-old, make them 90 add three or more long-term conditions… diabetes, arthritis, dementia, cancer and, you have someone who is potentially frail, existing in a precarious state where the health and social care system has a greater impact.

This is the world of today and will be the UK in 10 or twenty years.

The system is not coping now, how will it manage tomorrow?

Again, there are likely enough hospital beds, it is what is before and after that is inadequate – an older man who falls, bangs their head and can’t get off the floor. This happens all the time, countless times every day across the country. The system often struggles. The standard –

Fall alarm > paramedic > hospital

Breaks-down as the fingers of medicalisation examine and dissect the man, checking his blood pressure and oxygen levels, scanning his brain and testing his urine, the encroachment of a disorganised health and social care system reverts to what is best for the system and risks a flip to ‘not medically fit’ with pyjamas, lost dentures and more investigations.

And, that man who fell, becomes trapped in the flow, moving around a system which is under extreme pressure, and, as with all pressurised systems, the risk is that he will become first systematised, then crushed. Boxed-into a diagnostic formulary and processed.

And the systems that perhaps overzealously brought that man to hospital, despite their usual, although variable efficiency, will break-down when we try to find somewhere for him to go, now that he has acquired a urinary catheter, delirium, hospital acquired infection and increased dependency.

Is he medically fit?

Home? Intermediate Care (Neverland)? Care Home? Rehabilitation?

You see the problem?

He probably can go home, but, the issues that were present before he arrived at hospital, that potentially led to him falling at the outset are still evident – loneliness, social isolation, lack of community.

He sits in his chair, smiling carers, not necessarily focused (or, obsessed as they should be), with his wellbeing popping in an out.

We didn’t evolve to be 90 and sitting alone for 22 hours a day.

We didn’t probably evolve to live to 90, but, that is where we are, we are unlikely to develop a healthy adaptation to a solitary existence which would kill us when we are 40 or 50 years old.

Strip society of community, every person for themselves, Right-Wing dogma and you are left with this fragmentation.

Are they medically fit? They were never medically unfit – they were just socially isolated.

I sometimes think back to my mum’s last months of life, where she was supported in an amazing care home in Glasgow.

My mum, the inveterate talker, the person who thrived on social company and interaction, who found new friends for the first time in years after a slow deterioration from the isolation of living alone.

Were my mum to be within the system nowadays, for all the improvements, all the realisation that person-centre care is the only meaningful care, she would likely have been swept-up in the drives of efficiency to maintain independence (no matter how little was possible or desired), she would have moved or been moved around health and social care, flowing, probably unhappily, becoming more disorientated with each transition, until eventually all options were exhausted and she would be left with care. That is, long-term care, the Holy Land.

You see the disconnection?

Medically fit, pressurised bed occupancy, older people trapped in systems that don’t work and there you are, lonely.

We are social creatures.

Aristotle, quoted by Nietzsche said that to live alone one must be either a beast or a god… well, you probably better add the growing numbers of older people to that list, for that is the picture.

I hope this hasn’t been too gloom and doom, particularly for those of you reading this on Saturday morning, where here in Doncaster the sun is shining.

We are doing great things locally to redress this imbalance, you can go here to check out more!

bachman.jpg

Medically fit

This is from last year also – going-back to my perception of medically fit, which over the winter months has become a new hospital (care?) mantra.

Dr Rod’s Odd Blog (almondemotion)

You are fit… medically fit.

This isn’t something that you often hear doctors or nurses telling their patients. Instead, it is a communication tool used inside hospitals to convey certain information between different people. What does it mean? Does medically unfit mean that there is something terribly wrong, and, does medically fit signify that all is well and there is no longer any disease?

There are formal, internationally recognised definitions of health – for example, the World Health Organisation described it back in 1946 as a ‘state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity’

Reading this definition, how many of us are healthy? I suspect, very few. I mean, I don’t see myself as being ‘unhealthy’, but I certainly don’t tick all the requirements of the definition, and that is me… and I don’t have that much wrong with me.

Does…

View original post 811 more words

Medically Fit…

Keep going back to this… it is as if I can’t escape the term which over recent months has become overwhelming, to the point that it is used in hospital far more than… Is the patient well? Are they better? How are they feeling?

Dr Rod’s Odd Blog (almondemotion)

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…

View original post 305 more words

Acute

Acute.

Not cute.

Not sassy, silly or enlightening.

Acute;

When things happen all at once, with a sense of urgency, that, if you’re not careful, can overwhelm. (Our Iceberg is Melting).

Acute care

Acute ward

Acute nurse

These are some of the acutes you might encounter in a UK hospital.

They are a shade off emergency –

When there is an emergency, you had better stand-back – blue-light, cardiac arrest and battle-stations.

Acute, is a degree less critical, less threatening to life,

But still very serious.

Indeed.

It is when acute blends with care that, like hot and cold waters mixing in the sea, there is turbulence; eddies of not quite hot, not quite cold – no, not tepid, you mustn’t get complacent!

Acute, is pulling-out the stops, getting things done straight away – pressure, it is the dumplings exploding in the boiling broth, the edge of Compassion Fatigue and exhaustion.

It is when it cannot wait, when you must get on with the job as the workload is mounting – the ambulances are queuing, the referrers on hold and threatening to go elsewhere; the customers in revolt!

Acute is when soon or shortly is no good, when ‘in a minute’ is perceived as procrastination, poorly prepared, disorganised; inadequate. NoW!

Call the porter, the technician, phlebotomist, assistant, move, move, move – think Navy SEALs under fire, running fast, the fire-fight hasn’t broken-out yet, but things can go awry at any moment.

It is exam-time pressure that has become part of life, a component of nine to five, when you better get a move-on or there will be repercussions!

Not enough time to chat; eye-contact is a distraction; calm, smooth, flowing; the melody of human interaction is left on the side-lines and you had better get on and complete the discharge letter, order the medicines, call the transport, the family, the care home; ondale! No time to waste…

Like the blur you sometimes see in movies when the central character is frozen and around them is a blur of movement; I am thinking Donnie Darko. I am reaching-out to the split that sits at the heart of a personality breakdown.

The pressures, tectonic plates pulling you apart, requiring resilience that is not always forthcoming.

Again and again and like a treadmill, the processing keeps on going.

Acute, now, get on with it, and before you do this, do that, and here is another thing, and the pile of to-dos gets so high you do the urgent and important and the other aspects of the role are demoted.

Hand holding, discussing the olden times, family, a joke, a smile; cup of tea – listening, learning, hearing, tasting – sensations, moments that add-up to experience.

Rush.

You can’t step in the same river twice.

You can’t lie in the same hospital bed for more than the average length of stay which in your case, for your disease, disorder or condition is 3.76 days.

I am now thinking that A-ha video – the one that is all pencil drawing.

Sketchy.

Smudges of grey as the light fades.

Let’s see if we can’t reinvent,

If we can determine a better way to care,

To provide hospitality.

I remember a few years ago asking a group of medical students whether patients should have the same experience as those staying in a hotel.

Strangely the students thought you couldn’t – perhaps even, shouldn’t, provide the same standards of care and support as say the Hilton or even the Holiday Inn. No, the NHS, cash-strapped and pressurised, acute in care and nature.

My belief was the opposite – hospital care should be the model that the hotel industry follows (it certainly is on Mallard Ward) – our standards of improvement, innovation and creativity maintain a perpetual culture of growth and love.

Acute is a threat to love.

You can’t love someone when the clock is ticking.

You need somehow to separate the experience, the compassion and caring from the process, the deadlines and targets;

I don’t have an answer to this beyond my usual… Person-Centred Care – The Golden Rule, Would I appreciate a trip to the X-ray department in the middle of my minestrone soup? Multiple needle-pricks at three in the morning, an enema when four other people can hear the outcome? A hospital gown where by bottom is showing and rushed to the ambulance to carry me not home?

If not for me, then not for my patient.

I see my patient as me.

Acute leads to the patient becoming an object. An item whizzing past on a conveyor belt.

Think Brucie and the Generation Game – ‘Clock Radio… VCR… Teasmaid… Cuddly…’

Slow down.

You can still operate at high speed with compassion, with care.

Remember… more haste, less speed?

Remember… look left and right, then cross.

Don’t just jump-in and not live to regret it.

bruce

 

 

DToC

Most readers of my blog will not have heard of this term. I suspect most of those working inside the NHS don’t know of its existence either… DToC – Delayed Transfer of Care.

This is how groups of mostly older people are categorised once they are deemed medically fit – (another NHS neologism which too readily induces objectification), before they go home.

I know the people who invented (discovered/created?) this term probably didn’t intend for it to be used in a negative way – a little like Alfred Nobel and TNT; you think-up something novel, a new way to consider the workings of a system – even a person-centred interpretation of what it is to be prevented from getting home from hospital and suddenly it becomes a weapon, where the person is forgotten and the process (usually called pathway) takes-over.

Delayed Transfers of Care (I really can’t cope with saying ‘DToCs’) happen, in hospital, when a doctor deems a person fit for discharge. That is, in the eyes of the hospital, or the clinical team, there is nothing more that can be done to improve an individual’s health or wellbeing – indeed, the longer they remain in hospital the greater the likelihood of harm from all the risks of being somewhere you shouldn’t – medicalization, over-diagnosis, over-investigation, falls, hospital acquired infection and so on.

From the point the doctor says ‘MFFD’ (Medically Fit for Discharge – another term I don’t really like), the clock starts, with discharge teams, collaborations of health and social care, management and pathway staff rushing around in flurries of waiting times, lists and numbers to ensure that the usually older person is moved out of their hospital bed as quickly as possible.

Sometimes the next step is a discharge lounge – a sort of transient Neverland between hospital and home, or rehabilitation, intermediate care or step-down bed – alternatives which are a little longer lasting but just as discombobulating to older people, particularly those who have delirium, dementia or cognitive impairment:

‘Can you tell me where you are?’

‘Hospital’

‘No, actually we are in an off-site Discharge to Assess (D2A!) care facility somewhere in the North of England.’

‘Oh’

The reason some people have begun discussing Delayed Transfers of Care (which on reflection is a bit of a mouthful), is because of the Tory government’s crippling squeeze on social care – councils across the country having millions of pounds taken from their budgets which is an indirect cutback on healthcare; I know this sounds cynical – it is hard not to be a cynic when people are dying in hospital instead of living at home.

Because of this financial emasculation (too extreme a word?) of health and social care, older people are stuck in a limbo between hospital and home, with the delays becoming DToCs.

‘You are experiencing a DToC because there is no room in the intermediate/ rehab/ interim care/ step-down facility.’

You see the problem?

The person slips from experiencing a DToC to being a DToC.

You can spend lots of time and effort re-educating staff on the meaning of a word – for example, DNACPR – Do Not Attempt Cardio-Pulmonary Resuscitation, which does not mean ‘don’t treat/care’ – just don’t defibrillate or chest compress, or you can change the word and then work on the grammar, terminology and meaning later.

‘I’ve come to visit my dad, you know – bed six’

‘When is the next appendix?’

‘How many DToCs today?’

I don’t really have an answer to this, beyond a new government who doesn’t interpret balancing the books as screwing the sick, old and disadvantaged; in the meantime, perhaps, we can collaborate on finding a workaround to DToCs and a better way to keep the patients and staff people.

DODH-R6X4AEhFNn

The Perfect Patient Pathway?*

On Friday, I attended an event where I learned about the Perfect Patient Pathway – I will call it PPP, or perhaps 3P for short, as it is a little bit of a mouthful, although entertaining in an alliterative sort of way.

The event, run by the Good Things Foundation focused on examining the ways in which those working in health and social care use, relate, understand and promote technology.

One of the first interesting aspects of the event was revealed in a table-top exercise where we expressed our feelings in relation to tech – unsurprisingly, many of us reflected the negative or downside – feelings** of alienation, disempowerment, fear and risk – when the internet goes bad, toxic websites, data scams, the superficiality, exclusivity and competitiveness of the next new gadget; despite this, the majority (in fact, all of us) in the room spend most of our lives immersed in technology – from the electricity that powers our toothbrushes to the kettle, microwave or Satnav; none of us were digital natives, but most of us have gone native.

The purpose of the lesson was to let us examine how much we are dependent on tech, although more specifically, to demonstrate how our lives are simplified, improved, streamlined by technology.

For most of human history the fastest a person could move was the speed of a horse – the modern world would be inconceivable without the cars which bring with them all the fun of commuting, holidaying and road-tripping (and crashes, pollution & congestion).

So, if we, those living in and benefiting from technology integrate devices into our lives with such facility that we struggle to move from A to B without the help of Google Maps, why do we not do more to support or at least encourage our patients to become digital?

We talked a little about barriers – with most people expressing that in healthcare, although there are the traditional obstacles that some might perceive – old folk struggling to remember control-alt-delete or, upgrade to the latest iOS, for example, the most frustrating and limiting obstacle most of us (that is, health and social care professions) encounter is the antediluvian relationship the NHS has to technology and Information Governance. ***

I have written about the fax absurdity before – the way in which I see a patient in clinic, dictate a letter electronically which is then typed by my secretary who prints it and posts it through the mail to a GP surgery where it is scanned into a different system before being seen by the GP.

You see, email is considered unsafe. Dodgy websites, phone-lines, data storage mechanisms – all threats, real or imagined that keep us buying Fax cartridges from Staples.

One of the demonstrations I provided to the room was the use of WhatsApp within my team in Mallard Ward – we have used this tech for a couple of years (we were early adopters, I believe :-)). Communicating where things have gone wrong and right, celebrations and appreciations, reminders to be mindful of hand hygiene or documentation from scrupulous healthcare assistants help maintain a healthy ecosystem that ultimately provides fantastic, high-quality, safe, patient care.

The takeaway message? Do something! Reduce the glacial divide between technology and patient care. Acknowledge the ability of people young and old to take advantage of their own health and wellbeing through technology. See it as a partnership. Know your conditions – explore and learn – get informed! Challenge the doctor or nurse, ask questions, don’t remain passive in your relationship, adopt the power of the net to shrink the hierarchy.

Not all tech is good, much isn’t useful. We can however collaborate, become ambassadors for the future.

The present and the future are all about people, human relationships, connection and communication. The latest gadget from Microsoft or Apple cannot replace this, even when the robots begin to talk and dance, they will still be machines. Cutlery is a technological advance on using our fingers, let’s apply this wisdom to health and care and see where we can go.

* I haven’t really talked much about the 3P – I’ll come back to this in a later blog once I have learned more.

*Which makes an interesting question… How do you feel about technology vs what do you think about it… different sides of the brain – different perceptions perhaps?

** Referred to twice on the day as ‘behemoth’.

This Blog is mindfully dedicated to our number one healthcare assistant Michelle Appleton.

dog-pretend-vet-1

the doctor by sir luke fildes 1891.jpg

CRP – aka un-person-centred care

I won’t go into details, but here is the scenario – when the health service, and the divide between mental and physical health goes wrong.

An older man, say in his 80s has deteriorating memory, changes to his personality, perhaps his sleep-wake cycle is reversed.

His family have been helping him at home for the past six months, but, finding it more and more difficult they decide to transfer him to a care home for respite, at their own expense.

Four weeks after transfer to the care home his behaviour, let’s call him Nigel, to make this more personal, has deteriorated. He isn’t sleeping. He refuses to wash and on one occasion he punched another resident.

The GP is called who calls the psychiatrist.

GP: ‘We believe Nigel has Vascular Dementia, the care home staff are struggling to support him, despite all their best person-centred interventions – diversion, distraction, relaxation, he is becoming more anxious, more distressed. We can’t cope.’

Psychiatrist: ‘This man doesn’t have a diagnosis of dementia, he hasn’t been through the memory clinic, he has red legs, I don’t feel this is a psychiatric issue – it is medical; send him to A&E’

24 hours later, Nigel is admitted to a ward, let’s call it ‘Merlin Ward’ at the local acute hospital, he is seen by the physician who checks Nigel over and feels that there isn’t anything majorly wrong with him other than his 88 years and several long-term health conditions; perhaps, diabetes, heart disease and asthma.

‘We need to get Nigel home, although he can’t go back to the care home as they said they can’t cope and he can’t go home as his family can’t cope… What do we do? Let’s wait for the social workers to sort him.’

72 hours after admission Nigel has become distressed. Anxious and fearful, he wants to leave the hospital, he can’t understand why we won’t let him go, he feels we are trying to harm him, poison him, deprive him of his liberty.

The next day Nigel has smashed a computer, a window and punched a member of the nursing staff. Nigel is not a bad man, he isn’t violent, he is distressed, terrified.

The staff do their best to calm him. He throws a plate against the wall. It smashes.

We try to administer medicines, overt and covert, Nigel refuses.

Eventually, for his own safety, we sedate Nigel. He becomes tranquillised.

The hospital staff are distressed, his family are distraught.

‘We can’t look after Nigel, we feel he needs to be sectioned – for his own safety,’ Says the hospital doctor, sad, feeling defeated, inadequate.

Another twelve hours pass.

The psychiatrist arrives, mental health social worker in tow.

This man is not psychiatrically ill – he is medically ill, he should stay here. You are doing a great job. After all, his CRP – a test for infection, inflammation and innumerable other conditions is slightly high, his blood count low and kidneys sluggish.

‘We are not trained or equipped to support this man,’ says the matron.

‘I’m sorry – the law is the law, he is medically ill; it’s not his psyche.’

The psychiatrist departs, the social worker leaves the building.

The nurses are left with a ward full of older people, frail and vulnerable, they call security, guys in stab-jackets with thickset necks; they sit sweating in the corner.

Everyone feels disappointed, let-down, exasperated.

Nigel is still zonked from the sedation from earlier.

The computer monitor, still smashed, the broken crockery has been swept away.

This doesn’t seem right.

This doesn’t seem person-centred.

Not holistic, or collaborative.

What do we do? Where do we go?

This is a failure of the system, a failure of standards, inadequacy of care and lack of love – it is not considering what is best for the person, it is playing organisational games where the patient is piggy in the middle and no one goes home satisfied.

Nigel remains locked in the ward. Asleep.

 

This is a fictionalised account.

Nigel is not a real patient.

There is no Merlin Ward.

There are psychiatric teams who see the medical/psychiatric dualism of modern medicine as an impassable obstacle.

Not many years left

I had another interesting discussion with a colleague today.

She had heard about my plans to move hospitals and she wished me good luck.

‘I thought about leaving, but as I only have a few years left I am going to stick it out. I understand you have much longer… Go for it.’

This wasn’t a ringing endorsement of the organisation. Yet, it seems to be something I hear mentioned often – counting-down the days to retirement…

My brother, who is not yet 60 is scheduled to retire from his job as a GP within the next couple of years, many nurses can still leave the profession at 55 albeit with a reduced pension.

What does this say about the state of the workplace? What does this say about the future of our society and our system?

My starting point is the conception of ‘work’, which tends to be defined simply as an activity involving mental or physical effort done in order to achieve a result. I suspect most people would like to attach ‘and which you get paid for’ at the end, or else, what do you have… Slavery?

If anyone has caught my One-Page Profile doing the rounds of social media recently, in relation to Wellbeing Teams, you might have noticed that it says, I ‘don’t see work as work,’ this means that when I am at work – at least, when I am doing the work I love (doctoring & innovating), I am in a state of flow* – time doesn’t matter – the effort is taken away and I am usually having fun (as are those around me).

How sad to be in a situation where instead of flow you encounter plodding, a countdown towards the end of the shift, day or career. I know that many find themselves in situations where they dislike their work, where the idea of being in the moment and recognising the overlap between your job and meaning in life is not a thing.

I have a long list of reasons for my change of situation and close to the top is the essence of first, person-centred care, and, alongside that, the way you achieve this level of clinical or therapeutic care – through working in person-centred teams inside person-centred organisations.

If I am to spend the next twenty years in a role (and it will likely be longer unless I develop a life or function-limiting illness), surely it should allow me to be me, and not just me, but all those around me. Colleagues should be recognised as people, cared-for, supported, accepted for all their foibles, worries and anxieties.

We are people with likes and dislikes, with strengths and weaknesses and the results of our labour can be phenomenal if we are supported and allowed to flourish – if the same person-centred, holistic care that is provided to patients is also central to the organisational processes you have magic.

Every year there is an NHS staff survey which asks questions to determine how happy staff are, how contented, how safe to both speak-up for patient care as for themselves – the result vary across the county.

Decades of evidence suggest that the safest organisations are those in which staff feel valued and happy, able to work in teams that provide them with the tools to do the job as well as the emotional and psychological supports when things are tough.

‘Three years to my retirement and I am counting,’ doesn’t fit within this schema.

We are not talking Utopia or Candide – everyone has good and bad days, our experiences and opinions change with time and season, yet, when you have a moment to step-back and evaluate, you should at least see an upward trend – flat-line or a fall aren’t the conditions for fun and growth.

The NHS is limping through the second decade of this millennium. The Tories are smothering one of the greatest systems in human history, and yes, that will make times tough, it will even encourage bad behaviour – bullying and pressurising. It is however a truism – evidence based, if you like, that those organisations or departments that live and die by the sword of care (and love) are the most able to innovate their way out of the choke-hold of austerity, cost improvement programmes and cut-backs.

Presenteeism is the scourge of doing better, of caring more, of effectiveness and diligence. It is usually a failure of leadership.

Come now. If you are lucky enough to have a role in whatever organisation where you are well paid or in a position of authority, don’t just mark-off the days until you can move to Australia or the Costa del Sol, stand-up for those around you who aren’t so fortunate. Take a stance! Down your tools and accept nothing less for yourself and your colleagues to be treated with respect, dignity and care, encouraged to fulfil their potential, acknowledging who they are and what they want to be.

*Flow – Mihaly Csikszentmihalyi who has one of the best surnames in the world has also written a book about this experience, which is funnily enough, called ‘Flow’.

trois femmes 1907

Please share/comment/let me know what you think!

Stuck

I am stuck.

I don’t know if this is because I am in a work-limbo; in the transition between the end of a decade working in Doncaster and a shift to Rotherham, or whether there is something deeper, perhaps more sinister going on.

What, if I have run out of ideas?

Many years ago, a friend gave me a copy of Alice in Wonderland – she wrote across the DVD, ‘Six impossible things before breakfast.’

My relationship with that sentiment is a little like the fog of forgetting that writers such as CS Lewis capture in his tales – the change of focus accompanied by growing up, what was once real, live, vivid, becomes a dream… Returning to Narnia.

Sure, I know there were times when, head buzzing, I would conceive of multitudes before mid-day, scribbling in notepad, bouncing ideas, but those were the past, those were before, now, they don’t seem real.

Once there was such a concatenation of circumstances, everything aligning, people who championed me and whom I could support, new adventures, novel concepts, back in the day when saying ‘person-centred’ out-loud in a clinical setting was likely to get you shot, when the evidence-base ruled and all were subservient to the science.

Perhaps the world has changed so much, that radicalism is no longer required – what does a revolutionary do after the overthrow, when things are moving to a new-order, when the trains are running on time and the rich no longer take everything? Do you keep fighting, fighting for what?

Do you become redundant, forgotten and washed-up? No longer necessary to the Zeitgeist?

The Native Americans talk about war and peacetime leaders – individuals with very different characters, personalities which are required at different phases of a society’s evolution, perhaps my lack of inspiration is because I have evolved myself out of a job? The person-centred, holistic, multidisciplinary behemoth has started to gain traction and there is nothing for me to do but stand aside and watch; those driving the bus are only indirectly dependent on the engineers who designed it.

Alternatively, this is just a temporary hiatus. After all, most of us live long these days, and a decade is not what it used to be. Time speeding up, and living longer lives – funny, it makes me think of the speed of a vehicle travelling across London at rush-hour, in 2017 we move a little slower than the speed of a horse thanks to congestion, running to stand still.

Was it worth it?

You wouldn’t and couldn’t un-invent the motorcar, just as you would not want to return to the bad old days; we might have variation in practice now, before, the variation was so wide it was as if different teams were on separate planets… Patient A is on Ward 2, their experience is 23, what more can you expect?

It’s was arbitrary and today there is more involved than the luck of the draw.

I suppose, the lessons of history show that we evolve, grow at the speed of thought, through periods of rapid change allied with slowdowns, when yesterday was the same as the day before and next week. These phases – we used to call them biorhythms, the waxing and waning of development are likely necessary to avoid burnout – think of 2007 and the iPhone; since its inception, we still have weighty, mostly black, metal objects that can do a little bit more – there is nothing magical about the latest app, as when Steven Jobs held his phone up to the audience ten years ago.

One of my favourite songs contains the line, ‘Worrying about the future is as good as chewing gum to solve an algebra equation,’ yes, we can’t anticipate or expect when the next mass-extinction event or our move to a higher form of society; there might be signals, but there can be no certainty.

So, I guess, let it be.

Accept that I have slowed-down, just as others are accelerating.

It is hard, it is sometimes frustrating; at least there is always another book to read or game of Scrabble to play.

CheHigh-56a58ab25f9b58b7d0dd4d30

Please share or comment!

And the award goes to…

‘Congratulations Dr Kersh, you and your team have won the award for best Quality Improvement Plan 2020!’

We hear things like this from time to time.

Awards in healthcare are funny.

Essentially, if you don’t apply, you have no chance of winning. If you apply, your chance of winning is dependent on the competition. None of this necessarily reflects the actual effectiveness of what you have done.

Much of this can be condensed to two questions: Effectiveness – how meaningful is the improvement? And, Sustainability – how long have you been improving for?

With the former, if the improvement is meaningless to patient care and the award supports patient care, you haven’t really improved, equally, if the improvement is only ongoing so long as you are beating the drum, it is not sustainable and unlikely to spread.

Last week, I had a moment with the Costa people.

I was standing in the dining room at Bassetlaw Hospital – two of the coffee people were servicing one of the machines while I waited for my latte.

Costa person one opened the machine and all the sugar sachets fell on the floor.

Costa person two said, ‘They always fall out, there isn’t a lip on the door.’

Costa person one, ‘We’d better tell the continuous improvement team about that.’

And, there was I momentarily mesmerised by the interaction.

This was followed by an email I was privy to reading at the end of the week, sent by one of my colleagues in relation to a call to participate in Quality Improvement (QI).

‘I can’t believe the management can find the money to waste on such bs. All I want are my notes in clinic!’

You see the issue?

One system – the Costa, has somehow embedded, or at least introduced QI into their culture, the other, certain elements of the NHS (most often senior doctors it seems), don’t see the wood for the trees.

The response to the email was the Winnie-the-Pooh quote from Christopher Robin bumping Edward Bear down the stairs.

edward bear

I thought this quite clever. But, not necessarily a sustainable way of changing behaviours or attitudes.

You see the problem?

This is all compounded by awards –

‘Do what we are doing as we won the award for best xxxx,’ ‘Our way is the best,’ this becomes what Bruce Lee worried about in relation to his martial art Jeet Kune Do – a Classical Mess (for this reason, he initially didn’t want to give it a name – The Way that is No Way).

Once a name is ascribed to a system or process and once awards are notched-up the organism starts to calcify, growth ends and any initial value becomes diluted.

Bruce Lee in the 1960’s applied QI to his method for self-defence – he famously said, ‘It is not daily increase but daily decrease – hack away the unessential!’

Perhaps this is a lesson we could adopt within the NHS.

51997b_lg

Please share or let me know what you think!

 

 

Evidence-free zone

The big thing in modern medicine is evidence.

The story goes, so long as there is no evidence, what you are doing could be wrong.

This is philosophy based upon the null hypothesis – a scientific method where you start with a position that pepper, drug P, or whatever has no effect on lifespan, symptoms or length of stay and you either prove or disprove the theory.

The less likely an event is to happen by chance the more likely there is an effect. In science, we take less than one time in 20 as being ‘statistically significant’ – sometimes we refer to this as a p value of <0.05.

I won’t go into this in any more detail as it is likely some of what I have already said is wrong. If in doubt, perhaps check Google.

The thing with medicine is that despite our beliefs that so much of what we do is evidence-based, so much consistent with the rigours of the scientific method, it is only the very tip of the iceberg (or the tip of a Polar Bear standing on a very long ladder on an iceberg).

Most of what we do is based upon experience, best practice, feeling, hunch.

I have covered this before – the impression patients have that the word of a doctor is anything approaching absolute:

Doc (2)

‘You have a nasty case of pneumonia.’

‘The other doctor told me it was a chest infection.’

‘No, definitely pneumonia.’

 

Doc (3)

‘You have a urine infection.’

‘Doctor 2 told me pneumonia.’

‘No, your chest is clear, it is bugs in the urine.’

 

Doc (4)

‘Why am I breathless?’

‘It is a blood clot’

‘Doctor 1 said chest infection, doc 2 pneumonia, doc 3 urine and you are telling me a clot?’

‘Yes, a clot.’

 

This is not a demonstration of incompetence, it is just the uncertainty, the greyness that is central to many aspects of clinical medicine.

And this is why I am always surprised when I hear colleagues in their certainty, quoting evidence – particularly when they don’t stop there, as in, ‘There is evidence that drug A is better than drug B,’ but, go into detail, ‘Drug A is 2.12 times better at treating your infection than drug B’ – the more you up the ante, the more confident folk become, ‘In a 2012 study published by O’Hare et al in the Lancet, drug A in a double-blind, placebo-controlled trial was shown to be 2.12 times better than drug B at treating pneumonia. Here, have drug A.’

That is OK so long as you have pneumonia and it isn’t a blood-clot that is causing your symptoms, then drugs A and B are equivalent and the researchers needn’t have bothered.

Again, I am not trying to diminish the importance of this work – it is how we learn and progress; what is key however is that we don’t lose sight of uncertainty, of what we don’t know.

Strip away law and order, the internet and microwave ovens and you will soon discover that essentially, we are still the same vulnerable humanoids that left East Africa two million years ago.

Sure, you want a degree of confidence from your doctor – you don’t want them expressing uncertainty when you are feeling vulnerable, but, and here are the two main points – don’t overly focus on the evidence, for this is just part of an unfolding story that one day we will look back upon and laugh, and, no matter the evidence, it is first the context, then far more important the preferences, the interpersonal that makes all the difference.

Why is my prescription for paracetamol so much more effective than a blister-pack from Tesco? It is the ceremony, the performance, the medicalised placebo.

So, yes, I’m a doctor, part scientist, part shaman, and a little bit trickster.

Trust me.

bosch

Please re-tweet, criticise, comment, share!

 

 

 

Dementia – dream state

There is a phrase that is consistent across the fields of dementia, delirium and person-centred care, that is, if you have seen one person with dementia (or delirium, or pain), you have seen one person with dementia (or delirium, etc).

Statistics, data, evidence have little to do with the interpersonal one-to-one relationships with people experiencing the extremes of cognition or humanity.

This might suggest that consequently, there is little to be learned from individual experience – this is equally wrong. We interact, engage, care, support and treat people based upon a synthesis of our experiences and those of others.

This brings me to the dream state.

Recently, I have been involved in the care of a man who has dementia and the component of his self that has been mostly affected by the disease is short-term memory. Those who have read Oliver Sacks will be familiar with the patients he has described who lose the ability to lay-down short-term memory.

Sitting and talking with someone living this is remarkable.

The closest I can relate is perhaps the state of dreaming.

During our dreams, we can have vivid, full-colour, auditory, tactile, HD experiences – happy or sad, frightening or tranquil, as our eyes flicker during sleep, we recreate reality inside our heads.

Yet, upon waking, the memories rapidly fade and mostly within half an hour we have forgotten altogether the content of our dreams. And, once they are gone, recollection is mostly impossible.

What is it like to be living in an eternal dream state, a night without end?

For most the image is frightening. All of your personality, intelligence, and, sensitivity remains, your interests and competencies live-on, yet, your ability to build or construct life going forwards is insecure, like building on sand, the foundations disappear with the tide.

What to do?

I haven’t yet found an answer beyond our usual fall-back which is person-centred practices; listening, caring, engaging, and connecting.

Again, although certain aspects of memory are gone, others persist – the ability to integrate sound and touch, feeling, emotion.

Perhaps we need to move from an over-reliance on our logical, methodical 21st Century brains and revert to a simpler time where information overload was not synonymous with getting-buy.

Pause.

Spend time listening. Examine and analyse behaviours.

Be present, gift your time and attention.

 

Schlaf / Shlof

For the past thirty years or so I have been living in guilt. Perhaps, shame or self-reproach are better words, all to do with my weekend nap.

I love a nap.

Indeed, any opportunity I can get, I nap.

In the past I have even napped at work – something that were I not a doctor, I would likely receive severe reprimand (I can remember walking-in on a night-shift nurse having a nap many years ago… that’s not something that happens much these days). (And, why shouldn’t it?).

So, yes, the nap.

For decades, the nap, or as he would term-it, Shlof, which is Yiddish from the German Schlaf for sleep was an integral part of my dad’s weekend. An hour or two in bed on Saturday afternoon, and, Bazinga he was back in action.

I seemed to have inherited this behaviour, which in and of itself is not necessarily bad, but when you see everyone else going out and about, busying themselves with shopping, gardening, walking, chores and so on, you feel that you shouldn’t be sleeping, you should be out there doing.

I worked-out the answer this morning while driving my son and his friend home from a rugby match. Stan, Rami’s friend is an early-bird, like me. He said that he usually wakes-up at six in the mornings, weekends or weekdays and has a couple of hours down-time before the rest of the household get going. He struggles to stay-up at night. Also, like me. My son is the opposite, he struggles to haul his tired body out of bed in the mornings.

It was then, thinking and calculating that I on average wake-up an hour earlier than everyone else in my household – dog walking and early getting-in to work are two of the main activities I use to fill the time. Yet, when you add this up, one hour a day, is five a week and over the course of the year, something in the region of 200 hours a year. I miss almost eight days of sleep a year compared to a normal person.

And, perhaps when you consider Early-Morning Waking, a cardinal symptom of depression and anxiety, you realise why in addition to all its other woes, depression makes you feel knackered.

And here is where my Shlof comes-into its own.

We all have different patterns of sleep.

In a recent study, examining the sleeping patterns of tribal people it was found that through the night there is always someone who is awake. Equally, there are always people who are genetically predisposed to stay-up late and those like me who are early-birds.

It is evolution.

We are there in the morning to tip off clansmen to the approaching Neanderthals, my buddies are up late, to watch for evening raids and, the sabre-tooth tiger will be interrupted by the on and off sleepers in the middle of the night. (This is in part a reason for dogs evolving alongside humans – to act as early warning systems).

And there it is.

It is my DNA.

I may nap, I may Shlof, but overall, I probably do some good from my much-needed earliness and overall, I may look like a lazy-bum, but my hours of sleep are the same or even possibly less than yours as you sit up late watching re-runs of Life on Mars.

A gute nakht.

Please feel free to comment/like/share – thanks!

8e1fd06094abf97b4b8a94d457e48d1b