In praise of geriatrics

“Is that physio coming back today?”, asks Mrs Jones in bed three. “The dishy one? Oooh, he was so tall and dark. The most handsome young man you’ve ever seen.”

Mrs Jones is 91. “This is one of the many great things about geriatrics”, laughs the consultant. “You don’t hear this stuff anywhere else.”

I’m doing a three-week ‘career experience’ in geriatrics, and it’s great. It’s one of the fairly few specialities where you have to be a real generalist – old people come into hospital for lots of different, often interconnected, reasons. Perhaps they come to A&E because they’ve fallen over at home and broken their hip, but the geriatrician’s job is to work out why they fell and try to treat the cause. Did they have an arrhythmia, an abnormal heart rhythm? Does their blood pressure drop too much when they stand up? Are they unsteady on their feet because of cerebrovascular disease or Parkinson’s or arthritis? Do their medications need adjusting? Or is it just that they can’t see properly and their house is a bit cluttered? I love detective stories, so this kind of medical sleuthing really appeals.

It also takes more than just doctors to do the job. There’s no point in fixing Mrs Jones’s broken hip if there isn’t also a dishy physio to help her learn to walk again, an occupational therapist to make sure she can manage at home and a social services team to arrange carers to come and see her. And you have to care about people’s whole lives, not just their illness. What kind of house does Mrs Jones live in? Are there stairs? How many? Where? Who is at home with her? Does she have a husband who can help, or is she the one looking after him?

People say geriatrics must be depressing because your patients are old and so many of them will die. I don’t really see it like that though. We will all die, but these are people to whom small things make a huge and immediate difference. Like Mrs O, age 89, who cried with happiness the first time she walked again after her hip operation. Or Mr H who didn’t mind being in a residential home as long as it was close to his friends. We seem to fail so often in this country, in the way we treat our elderly. We need to get these things right – our parents and grandparents deserve this.

Of course there are sad things. My constant lament – that people come into hospital with some minor ailment and end up diagnosed with something worse – is ever present here. Like Mrs B, who complained of constipation and ended up with metastatic cancer.

And it is ethically fascinating. As my consultant says, “You can’t get as far as breakfast in our society without having to make dozens of ethical decisions.” And geriatrics is the same. Geriatricians decide on a daily basis whether patients can give informed consent for a treatment; when a procedure is in someone’s best interests; when it’s ethically right to withdraw active treatment and allow someone to die.

Mrs Brown is 95. She came in several weeks ago after a fall in her nursing home, and then developed pneumonia. She is frail and sick, and has dementia, and her family want her to be allowed to die peacefully without any more aggressive treatment. My consultant agrees, but for some reason she has been started on antibiotics anyway.

Mrs Brown has fallen to one side in her hospital bed, tiny against the pillows. A bag of antibiotics hangs from a drip stand by her bed, snaking into a cannula in her hand. My consultant tries to rouse her but she doesn’t speak, just grips his hand in both of hers and doesn’t let go. “It’s frustrating”, he says. “What benefit are we giving her with these antibiotics? Take them down. Take the cannula out.” He turns back to Mrs Brown and squeezes her hands. “Are you alright? Is there anything I can get you?” She opens her eyes for the first time and smiles. “Can I have a nice cup of tea?”

 

 

 

 

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God and the doctor

 

I love my textbook. It’s not often I say that, so I should explain. The Oxford Handbook of Clinical Medicine is a lifesaver for hundreds – no – thousands of harried medical students in their clinical years. Small enough to fit into a pocket or shoulder bag, it’s just about perfect for slipping out under the desk when the consultant has just asked you about the three main causes of hypercalcaemia. But that’s not why I love it.

I love it because I was expecting to hate it, and then I opened it and was confronted not just by medical text but by poetry. Yes, real actual poetry. Page 14 conjures Macbeth to console the tired junior doctor on call: “Come what come may, time and the hour runs through the roughest day”, while page 389 gives us a taste of Sherlock Holmes: “I see you have been hunting bushbuck in the Eastern Cape again, Mr S–. This eschar is the tell-tale tache noire of typhus.” This is how a textbook should be: bringing hope and inspiration and a good giggle in the most jaded moments.

This dreary Monday morning I really didn’t fancy talking to anyone, let alone patients, but page 14 brought respite (it’s a good page). “Patients are sources of renewal, not just devourers of your energies.” So, with that in mind, I went to see Mrs A.

Mrs A was sitting on the side of her bed in the respiratory ward, a beautiful orange scarf over her long grey hair. She told me about the pain in her chest and the way her heart beats strangely, and how she’s breathless all the time. “My heart isn’t good”, she said. “I think I’ll see Christmas, and then I’ll be done”. “Is there anyone at home?”, I asked. “No”, she replied. “All alone, apart from God and the doctor”.

Mrs A’s story shouldn’t really have brought me renewal, but somehow just the fact of talking to her, knowing that this is the meaning of my day-to-day, brought hope. If God and the doctor are all Mrs A has, well – I have no hope of being God, so I’d better become a damn good doctor.