I should write more

I've wanted to be a writer since  I was a child. I wanted to tell stories. At first I thought that I should tell the stories of my generation. But other people in my generation are telling those stories, better and more eloquently than I am. I then realised that the stories I need to tell are the stories all around me. The stories of my patients and my colleagues. 

It's about time I got my a**e into gear and started blogging more, and blogging better. 

'The Hardest Part of the Job'

'Thank you Doctor' Said my patient's wife after I told him that she wouldn't be a candidate for Intensive Care, and 'We understand this must be the hardest part of your job'.

We'd just told her that we weren't going to refer her husband to intensive care or try and treat his pneumonia more agressively, and were instead going to let him slip away  peacefully in the side room with his family around him. She seemed to be relieved, she'd been watching him suffer for days and was hoping he'd go peacefully. The drips for the antibiotics were getting more more difficult to site, and the antibiotics didn't seem to be working.

The decision not to put a femoral line into a patient who was obviously dying was not a difficult one. My only regret was why I didn't have the balls to stop the antibiotics a couple of days ago when it was bleeding obvious they weren't doing any good.

Being the Second In Command in the Medical Team means I get to make decisions about 'how far to go' and 'when to stop and let someone die peacefully'. There's some that are difficult, but most of the time I find them easy enough, because most of the time it's obvious what to do.

No - the hardest part of the job is something different.

The hardest part of the job is when you have a patient who is clearly dying and you want to keep them comfortable and not do anything unecessary or heroic but the family is wanting more and more effort. You either have to break the ribs of someone who is dying of something totally irreversible knowing that it will make their final minutes horrible and painful, or you have to tell a family that you are going not going to resussitate their relative whatever they say.

The other hardest part of the job is the cardiac arrest you can't afford to loose. Most cardiac arrests you're going through the motions - you know they will die anyway so you go through the motions, to 'give it a good go'. Say you did everything.

But when it's the 24 year old with long QT syndrome who had an out of hospital cardiac arrest, or the 43 year old with a treatable condition who arrested because of a slightly high pottassium. When you know that waiting for you in the relatives room is a young wife and child, or parents, just retired, facing burying their child.

That's when you pull the stops out and try anything, and everything. That's the time when you just can't stand up and utter the famliar words 'I think we should stop - is everyone in agreement?' 

This weeks NEJM: when oh when will we have something other than Warfarin?

I have an uncle that has just retired as a GP, a couple of months ago we were discussing the things that we thought would change before I retired. 

Here are some of my mystic predictions 

• Actually  thrombolysising strokes in the UK
• Finding out more about syndrome X and finding out exactly how being fat causes diabetes 
• I don't think I'll be using much Warfarin in 10 years time. 

Warfarin is an annoying drug. The thing is that it's useful, it saves lives. If you have Atrial Fibrillation warfarin will stop you having a stroke. But we all process warfarin differently - for instance I may need 3mg a day to thin my blood, but you may need 10mg. Also lots of medications interact with wafarin - some do, make it more effective, some make it less effective. 

So you need lots of monitoring to keep an eye on Warfarin, you have to go to Warfarin clinic every so often and record your results in your yellow book. Sometimes if you drink more than you normally do, or even eat lots of cranberries you find out that your blood isn't clotting enough. 

We don't  use Warfarin as much as we should - if we follow the guidelines, but lets face it that's because putting older people who fall over a lot on Warfarin is clearly a dumb idea. 

So if we could have something that did the job of Warfarin but had less risk of the blood not clotting properly then it would be great. Obviously Warfarin has to stop clotting a little bit, so that will cause some risk of bleeding. The problems with warfarin occur when the clotting is stopped too much, so the bleeding occurs too easily. 

If we could have something with a narrower theraputic window that would be just fantastic. We have injectable once daily varieties of Heparin, which are useful but lets face it rather expensive. Especially if you need a District Nurse to give the injection. We probably could teach patients to inject themselves though.. 

Well, so far so good. There's a study in the NEJM which indicates that there may be something new on the horizon. I consider this A Good Thing. I expect their will be problems with it soon enough. There always is with new drugs that look really good at the start. 

Here's a link to the abstract : LINK

Looking at the trial in more detail there's one rather obvious thing that strikes be - this isn't blinded. If there's one thing that annoys me is when people go to all the trouble of doing a trial but design it in a silly way. Of course they tried to analyse it separately and minimise the risk, and of course there are various reasons why randomising Warfarin is difficult. But I still think it would be possible. 

And for hevens sake we have blinding for a reason! It's standard practice. So why abandon it just because it's tricky. 

Otherwise it's a well conducted study with impressive results. We'll have to see how useful Dabigatran turns out to be, and whether or not it starts being used clinically. 

My first Med Reg Shift

My first registrar shift at The New Hospital was, well, interesting. I've actually been working as a Med Reg on and off for a while. So the first Med Reg Shift actually happened in a different hospital a long time ago. 

I had been holding the Med Reg Bleep for half an hour when I got a call from A and E. There was someone in who was in Type 2 Respiratory Failure easy enough, I knew how to set up NIV. I got her stablised and all seemed well. 

Just as I was back on the admissions ward, thinking how nice it was to be a Registrar I got a phone call from the A and E consultant. As an SHO I knew what A and E consultants wanted: they wanted me to admit their patients as soon as possible so they wouldn't breach the 4 hour target. Now he seemed to want my medical opinion. 

We had a patient - who seemed hot and sweaty with a very very low blood pressure. We weren't entirely sure why. Her ECG was an (Old) Left Bundle Branch block - so we couldn't tell much from that - sure an acute MI could cause this, but we had no way of telling whether it was old or new. 

We thought he might be septic - have an severe infection - so we gave some fluids and antibiotics, we persuaded a radiologist to check he didn't have a burst aortic aneurysm. 

We eventually worked out that he must be septic so we wondered if we should give inotropes - drugs that make the heart beat stronger,  the A and E consultant didn't think ITU would take him, but I thought if he was septic we should try inotropes. The ITU consultant came to see him and did agree we should do everything- I remember being pleased that I was making a valuable contribution.  

Then the blood tests came back and the cardiac enzymes were sky high: this meant that he had damaged most of his heart. The on call cardiologist thought it was too late for angioplasty so we gave some inotropes and transferred him to ITU. 

That all seems straightforward now, but at the time I just remember how alone I felt. I kept wanting to bleep the med reg, I think at one point I got as far as picking up the phone. 

I became a Doctor because I wanted to deal with sick people, I thought I would find it exciting. But it wasn't exciting, it was horrible. 

So why did I go back?

Partly because it was too much hassle to change career track and do something with less acutely ill people in it. And partly because as I got more confident I realised I could get people better at times, and that was satisfying. 

This week's Journals: Care homes - not for Profit v.Profit

Reading my BMJ this week I found a meta-analysis asking whether a nursing home that was 'for profit' or 'not for profit' makes a difference to quality of care. Of course to a dyed in the wool socialist like me the answer is obvious: if you are making profit then that means that profit is being made, and if profit is made then there is money going to shareholders that could go back to improving care. 

If you are less of a mad leftie than I am - then you can see that 'for profit' companies are often more effective that 'not for profit' charities.

The most obvious thing is 'How you do define good quality care in a Nursing Home?' Surely the answer to this depends on the question you ask. For instance do you define a good quality nursing home as one where the care is well documented? Or one where the residents have no bedsores. Or one where they don't have to share rooms.

I've not critically appraised a systematic review before. As Mark Crislip of Puscast is apt to say 'crap in, crap out' If you put together a lot of poor quality studies into a systematic review you get a poor quality systematic review. So I thought I should use a critical appraisal tool like this one. I didn't publish the full critical appraisal here, but I did work through most of it. 

This meta-analysis looked a studies with the outcomes of

1. Pressure ulcers. 

Seems sensible enough. Good quality care means you get less pressure ulcers, pressure ulcers are avoidable and painful. 

2. Quality / training of staff. 

Just having a nursing degree doesn't necessarily mean you are a better carer than someone who doesn't. But one could assume that it probably would mean you had more of a clue on how to nurse. 

3. Physical Restraint

The physical restraint thing is an interesting issue - would a nursing home that uses less physicial restraint have more falls, or would it use more sedative drugs. 

4. Regulatory Deficiencies 

This seems a valid way of comparing nursing homes. A poor nursing home would be picked up as poor by the regulatory body much more often. But this rather depends on who the regulators are and how they regulate. It would be difficult to compare regulatory assessments in the US in the 1970s to Holland in the 2000s. 

So what did it show?

Well not-for-profit owned homes were slightly better staffed and slightly less likely to have pressure sores, both of those results were statistically significant. The other outcomes didn't reach statistical significance. 

There was a big variation between the studies.  In lots of studies there wasn't any statistically significant difference between 'for-profit' and 'not-for-profit'.  I think that this must mean that there is a lot of overlap. Ie: that there are plenty of good 'for-profit' nursing homes and  plenty of poor 'not-for-profit' ones. I suspect it also means that at different times and different places things are difficult. 

I also thought it was interesting that this really only looks at quanitative outcomes, things you can measure. Would it be interesting to look at qualative outcomes? How happy were the clients? Difficult to assess in clients with dementia, I admit. 

Though if I was a relative the big question that I would want to ask would be:

'Do the staff care about my relative? - Not just go through the motions of care, but do they talk to her? do they care?' 

'Will she be happy there?' 

'Will the home smell of urine?' 

'Would I want to end my days here?'

Will this study change my practice?

No, not really. If a relative were to ask me 'Doctor, do you think I should choose a care home ran by a company or one ran by a charity?' I would say that it really depends on the home, there are good ones run by companies and poor ones ran by chairities. 

Also you know your relative the best. The most important thing to your relative might be close to home so their friends can visit them, or a home where they can continue to go to church in a taxi.

The MedWhat Blog

What am I doing here?

I've had the bright idea to record things that interest me during my Care of the Elderly training in a blog format.  I think that perhaps we should try and make Care of the Elderly sexy and exciting. Of course not sexy in the way that well, sex is, but sexy in the way that surgery is.

Only Doctors, (well surgeons) find doing a bowel resection kind of exciting, and lets face it surgery is sexy, glamorous and exciting. Care of The Elderly isn't is it?

I've just done my MRCP and after some long complex thoughts I decided to specialise in Care of The Elderly - or Geriatrics as it's still called.  And so far it's great.

So what is a Registrar anyway?

I've got no idea where the job title comes from. But in a Hospital in the UK the Registrar is the one below the consultant in the pecking order. Most Registrars are in training programmes to be become Consultants. Some Registrars are 'Staff Grades' so in permanent Registrar level jobs. The big thing about being a Registrar is that when the consultant is away from the hospital - from 5pm to 9am you are the most senior person there. This is fairly scary at first. I think my first two hours as a Reg were the worst two hours of my life. 

Introducing The Team 

I'm working at a Tiny DGH at the moment, we're a long way from other people. 

Mrs Consultant 

She's a relatively newly appointed Consultant, and she's lovely, I can sit and gossip with her in a way I couldn't with any other Consultant. 

The Much More Senior Reg 

She's about two months off being a Consultant so she's a fountain of knowledge on all things Geriatrics 

T'other Geri's Reg 

Appointed at the same time as me I've known him for years

The Minions 

I also have a SHO, who is very keen, but quite new to medicine in the UK, and a HousePlant, who's very keen.