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?”

 

 

 

 

Some basic taxonomy

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Exams are back. Or, we’re back at exams. There are a few distinct species of medical student who emerge at this time of year. Here’s your handy guide to recognising them:

The super-competitive one.

Says: “I was in the library ’til 1am last night, then my housemates and I went through all the Parkinson’s plus syndromes before practicing the hip, knee and elbow examinations. Do you know the chemotherapy regimens for myeloma? They’re easy, I did them this morning.”

Found: on the ward or in the common room, discussing rare syndromes with other members of same species. Usually wears shirt, ID badge, stethoscope and smug smile.

The self-depreciating panicker.

Says: “Oh my god, I’m definitely going to fail. I spent all of yesterday looking at cardiology and I can’t remember ANYTHING!”

Found: in the library, semi-visible behind huge pile of books, notes, highlighters and can of energy drink. Wears stressed expression.

The overly nonchalant one.

Says: “Oh yah, whatever, I never do that much revision. I was playing rugby/trampolining/running a half marathon yesterday. I got 82% last year though.”

Found: having a coffee and chatting loudly at table next to self-depreciating panicker.

Note: no matter which species you identify with, or even if – god forbid – you think you’re normal, it is never ok to adopt either an a) non-competitive or b) contented demeanour. Think revision sucks but you’ll probably be ok? Nope, no way. It’s just not said.

Me? Well, I’ve clearly developed a fetish for post-it notes and have pink and green spots swimming in front of my eyes. Now, what’s that syndrome called again?

 

Heart sounds

Clueless

The patient has a congenital heart defect, which means that when it comes to cardiology clinics he’s seen it all before. In stark and somewhat hilarious contrast to me.

The consultant hands me the ECG. “What do you make of this?”

“Um, well… there might be some right bundle branch block”.

This invites a glare. “What do you mean, there might be some bundle branch block? What year are you?”

He turns to the patient on the bed. “Alright if this student listens to your chest?”

“You might learn something interesting”. This is aimed at me, clearly. I pull out my stethoscope and start to listen.

“No, never do that! If I saw you doing that in an exam I’d fail you immediately! Do it like this.”

I replace the stethoscope, feel for the carotid pulse and listen again, until I’m distracted by an unexpected sound.

“Well, have you heard it yet?”

“Er, no… because the patient’s laughing.”

The consultant spins round. “What are you laughing at?”

“Oh, sorry. Sorry. It’s just that I’m a student too, so I know what it’s like to get shouted at.” The patient is trying to suppress a smirk. Unsuccessfully. “I’m just glad it’s being aimed at someone else for a change.”

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.

Signs

We trail into the small side room and draw the curtains across the door. The registrar leans over the bed. “Good afternoon Mr Smith. I’ve got some medical students with me, do you mind if they examine you?”

It happens all the time, in hospitals all over the world. Seven of us crowd into the tiny space as Mr Smith, age eighty eight, sits up on the bed and takes his shirt off.

“Observe the patient. What do you see?”

He’s gripping the edges of the bed with his hands and heaving his thin shoulders as he struggles to breathe.

“He has a raised respiratory rate. And look at his hands – a classic case of finger clubbing. Stage four I’d say.”

I wonder if Mr Smith knows his fingers are clubbed, if it worries him, if he’s scared to be in possession of a sign the doctor has thought worth pointing out. He’s looking at the floor, concentrating on breathing.

“And now for the chest examination. I’ll demonstrate, then you have a go.”

We line up by the bed; a new generation of medical students watching and learning in the time-honoured way.

“Do you mind if I put my hands on your chest Mr Smith?”

“Mr Smith, I’m just going to tap on your back, alright?”

“Mr Smith, I’m just going to listen to your chest.”

“Can you say ‘ninety nine’ please?”

We each try to be quick, hating to be a burden on someone doing us such a great favour, who looks so old and so ill. I listen, and thank him, and move away.

“No”, says the registrar. “Listen again here, and on the other side.”

“Sorry Mr Smith, I’m just going to listen again.” He looks tired. I want to put his shirt back on.

Afterwards, we make to file out of the room. He lifts his head and looks at us one by one. “Thank you so much, all of you. Thank you. I wish each of you the very best of luck.”

Mr Smith has progressive pulmonary fibrosis. He needs oxygen to breathe and might not live very long. I wonder if he knows. I wonder how it must feel to see these young people at the beginnings of their lives and careers, to know that he’s helping them by letting them examine his body – the very same one that is giving up on him.

This goes out to all the patients. We could not do this without you, and neither would we want to.

Deep-sea diving for the non swimmer

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About this time last year I was wondering about the way medicine changes you. I’ve spent the whole year fighting the idea. We’ve learned how medical students are actively socialised into the profession (medical schools isolated from the rest of the university, long working hours, separation from other students, specialised jargon that renders us incapable of communicating with normal people etc) and it just backed up my instinct (read: fear) that after a while of studying medicine I would never be quite the same again.

Of course we all change throughout the courses of our lives. Sometimes we can’t see what’s coming at all until a bend in the road reveals an exciting new path taking us somewhere new, never to return. Any profession might do that. But I can’t help feeling that medicine is exceptional. Once we’ve deliberately pierced a person’s skin or put a hand inside their bowels or seen them die, surely that gives a new view on life and humanity that’s difficult to unlearn.

That’s why, every now and then, I feel the need to say STOP! Hang on just a sec… wait there! This’ll all become old pretty soon and unremarkable, but right now I’m in my very first week of clinical medicine and I want to remember it while it’s still strange and new. While the old me is still here. After all, this is apparently the rest of my life.

After a day in the hospital I emerge as if from a long immersion into deep water. That’s how it feels. From within, everything outside is muffled, blurry, forgotten. I’m in some sea so deep and wide I can’t see the bottom. It’s murky and full of things I can’t see properly and don’t quite understand: acronyms and measurements and anatomy and vital signs, all linked by mysterious threads. I’m trying to find my way about through the gloom and I haven’t learned how to use my gills and fins yet. I have no idea how far the unknown goes. Pretty damn far I think.

That really is it right now; a vastness of unknowns. I’ve been pushed in and am only just about swimming. The mysterious threads are a tangled mess. It seems all-enveloping: to grasp it I’ll need to immerse myself completely, let go of the side and dive, and just trust that the oxygen holds. This is nothing like any university that came before. I’m studying with new people in a new place in a totally new way. Rather than learning the biology of the body I’m suddenly dealing with histories and clinical signs and examinations. And meeting patients, imagining they could be my dad or my grandmother but also recognising that perspective that a doctor has to have. The idea that I might untangle things enough to make a diagnosis one day seems absurd.

And all those medic-y things are starting to come true: I’ve already had some very early mornings, been put on the spot by scary consultants and found the short-cut to Costa. I almost can’t believe it’s me but at the same time it’s brilliant and fascinating and it makes me want to learn and be really, really good at it. God knows if I can, but every time something makes sense it’s as if I’ve just dived into blackness and brought up a pearl. I’m so surprised to hear myself say it but if you asked me if I’m happy and inspired, if I really can imagine doing the job, I’d say yes.

PS Needle update:
Hours spent in lectures on venepuncture theory: 2.
Sessions practicing venepuncture on fake arm: 1.
Disgusting videos about chest drains watched: 1.
Actual chest drains seen: 1.
Anecdotes about amputations endured: 1.
Fainting episodes: 0. But the worst is definitely still to come.

Taking back the night

Whenever I’m working, I daydream about being able to sit up for half the night. All those musky, quiet, late night hours where you sit listening to music, perhaps at a desk, doodling, or with a laptop, writing, or browsing webpages, and the time stretches around you completely. No obligation, nowhere to be but here. Perhaps some coffee to keep you awake and no sense of guilt that coffee is exactly the wrong thing right now.

Before I started medical school I daydreamed about studying again, being able to stay up all night studying and that sense of freedom, being able to read and learn, delve into, become engaged by anything I wanted, late at night because I didn’t have to get up at seven for work. Taking back my own late nights. I missed that. I had rosy memories of how it’d been before.

Of course when it came to it I remembered that studying is never rosy in that way. You always feel resentful because you’re studying something you have to study, and of course you’re not free. The night is not your own, the night becomes the battleground where you’re fighting a deadline, or pushing your way into the dark, towards the late hours against resistance, and coffee is there not as a friendly companion but as a necessity to keep your eyes open.

I’m working now for the summer so I have to be up early in the morning. And yet here it is again, it’s half twelve and I’m daydreaming about being able to stay awake all night. Writing a blog perhaps. Listening to this.