Saturday, October 12, 2013

Not there yet....

Our efforts at healthcare are aimed at returning people to pleasurable, productive lives. But in determining who receives what healthcare we only terminally consider quality of life. Elsewise the healthcare available and provided depends very much on geography. 

Further in those quality of life assessments people do not expressly consider pleasure, but rather an absence of pain, the ability to eat, to mobilise, to socialise and to sleep. These activities are intrinsically pleasurable but not necessarily so and where they are pleasurable the pleasure is variable.

As far as productivity is concerned, assessments are necessarily retrospective. In disease, treatment seeks to return one to a premorbid state, but such states are never calibrated and so we rely on our very fallible memories to decide whether or not we function as we did before. So, treatment aims to return the capacity for productivity, but no-one would argue that someone who has gone through three cycles of chemotherapy has the same intellectual capacity as previously. The same could be said of someone who has recovered from a serious heart attack or stroke even if such recovery seems remarkably complete. The point here being that all serious illness and the chemicals and procedures we use to return human bodies to functional status have costs in intellectual performance. I know that the activities of daily living do not need or demand a towering intellect but it is nevertheless true that such towers lose both breadth and height in serious illness. Most times irrecoverably so.

I say all this because despite the remarkable and dramatic strides that the technologies of healthcare have made, contemporary healthcare remains very crude in it's diagnostics and it's treatments. We know that we will be able to do better but we are far from implanted cybernetics and designer babies.

Thursday, October 10, 2013

Vignettes: Emotional Contagion

A daughter wrote a letter of complaint, essentially about my lack of empathy. I was reminded of this reading The Managed Heart which discusses the work of feeling and feeling rules.

The daughter brought her mother to A&E on a Monday, which is almost always busy, because she had fallen and sustained several gruesome looking soft tissue injuries, most dramatically of her face. This happened early on Saturday morning after she had been out drinking on Friday night.

There was some urgency to attend to her because her husband was dying, literally, in a palliative care facility due to a metastatic brain malignancy and they wanted to be with him for his last few hours. All understandable.

Being the conscientious doctor that I am, I reviewed her previous attendance records and found that she had been discharged the afternoon previous after a thorough assessment, including CT scans of her brain and cervical spine, and a lengthy period of observation.

So, after introducing myself and acknowledging that she was being seen immediately because of her husband's pending death, I asked, "Why have you come back today?" Quite reasonable I think considering that she had been discharged less than 24 hours earlier.

It turns out that she had been drinking excessively because of her husband's health problems; that she had fallen down drunk and then lost consciousness on a public road, from whence an ambulance brought her to A&E. When she was well enough, in the department, she was asked, as per protocol, who to contact regarding her admission. She listed her daughter as next of kin but refused to have her contacted. She refused again at discharge, declaring a preference for a taxi hire. She did not want her daughter to know that she had been admitted to hospital for more than 24 hours because of injuries sustained due to acute alcohol poisoning.

So, her daughter who had last seen her a week before was entirely unaware of the events of that weekend. Concerned and already grieving for her father she brought her mother in for treatment.

I examined the mother and found nothing substantially different from the afternoon before and explained that the injuries looked much worse than they were and that once the swelling resolved - another three or four days - things would look considerably better.

During this conversation the daughter had burst into tears. And I had failed to acknowledge her obvious distress. In explanation, it was the first anniversary of my father's death and managing my own grief without expressing it at work was already hard work without the additional stress of her emotional contagion.

And I did not believe that I owed her an exposition of my own loss or it's expression. It was not my fault that their family dynamics had become so dysfunctional under the stress of her father's dying and her mother's inability to cope and her lack of sibling support.

She was angry and guilty and afraid and anxious and quite overwhelmed. I know.

Neither her mother nor her father were legitimate targets and so she took the time to write a letter about my lack of human feeling, which lack was particularly egregious given my profession.

I wrote a letter of apology for my perceived lack of expressed empathy and/or sympathy. It said nothing about my own grief and the work of managing it. And it very deliberately said nothing about the communication failures within their family.

Patients, their relations and their friends pay lip service to the humanity of doctors and nurses without accepting the frailties that lead to such failures of communication as I have described.

Knowing is never enough. We all fail sometimes....

Monday, October 07, 2013

Vignettes, An Introduction?

I work in the Emergency Department. It used to be called Casualty, but, of course, very little of what comes through the doors has anything to do with significant trauma. Having said that, I work in Wales, but I trained in South Africa and the same is not true of that sunny, gorgeous land.

Emergencies in South Africa very rarely involve strokes or heart attacks or sudden incapacitating palpitations. They certainly do not involve panic attacks. Or major depressive episodes with suicidal ideation. I am not entirely convinced that either of the last two constitute emergencies. I may just be biased especially considering that there are about 8.45 deaths per 100000 people per year in the UK due to suicide and depressed people present to hospital very frequently thinking about suicide but not actively planning it.

I am not insensitive. You will probably disagree. I do think that statistics are important in resource allocation. Utilities. QALYs. Numbers.

This is not, however, intended to be about numbers; or at least not to any significant extent. This is intended to be a series of vignettes.

I have been encouraged to write. And activity is generally inconducive to depression, especially brief reactive episodes.

So, this is a beginning. It is telling that it begins with depression, but circumstances being what they are, it is understandable.