Thursday, September 07, 2006

Aiding and Abetting

Most of the time I'm inclined to think that medicine is a good. Most of the time I believe that it helps. Most of the time I see it as an advanced and ever-advancing science that daily extends its kingdom of the rational into the benighted territories of the unknown.

Occasionally, however, I think it's just plain shit.

Last night was such a moment. I arrived in A&E to find only name on the list waiting to be seen, and it was a name I knew. Georgina Hall. I had first met Georgina all the way back in April, when I had been the admitting SHO for Neurofuckedology. She had been accepted as an emergency with a few days history of weakness in her arms and legs; that was all I knew. Georgina was a 23 years-old law student. Tall, slim and elegant, she lay in the bed looked scared. Her history and examination were worrying: a rapidly progressive spastic quadroparesis with respiratory involvement (translation: profound weakness and stiffness of all four limbs with difficultly breathing due to weakness of the muscle that allows us to breathe, the diaphragm). This suggested a problem at the top of the spinal cord or higher. The scans showed extensive inflammation and destruction at the level where the spinal cord and the brainstem meet. No cause was (or indeed ever has been) found.

Inflammation often responds to steroids and this case, thankfully, was no exception. Georgina regained strength in her legs and arms and by the time she was ready to go home she was walking, albeit unsteadily, and could just about manipulate largish objects with her hands. I left neurofuckedology thinking we had done some good.

Two months later I heard that Georgina was back. She had relapsed. The inflammation had spread to new areas in the lower, ancient part of the brain and she was only semi-conscious on the high dependency unit. The steroids were started again at super-high doses and again there was improvement, but it was slow. The tests had shown that the inflammation and damage had caused some epilepsy and so anti-epileptics were started. And that's the last I heard...until last night.

I must confess I was quite taken aback when I walked into the cubicle. In place of the slim, elegant young lady was a fat lump of a human being. The super-high doses of steroids had done their work mercilessly: they massively increase appetite and promote the storage of fat around the face and trunk. Yet there was still had significant weakness of her arms and legs, especially of the functionally vital hands. She had difficultly seeing clearly as the same inflammatory process that had damaged her spinal cord had also damaged the optic nerve, partially blinding her right eye. In addition, the anti-epileptic drugs she had been given to control the fits had completely wiped out her infection fighting cells. She was defenceless against the constant stream of marauding microbes around us. Her temperature had risen to 39.8 degrees centigrade and heart raced to maintain her falling blood pressure. Infection had taken hold.

O for the wonders of modern medicine! So much harm, so little benefit.

And it was such a struggle to get things moving. The rehabilitation unit she had come from had realised she had realised the grave situation that she was in - ill and defenceless - and had even written down in the notes what needed to be done. Georgina needed the domestos of antibiotics and she needed them immediately. But they had not been given. Instead they had been written as if to be given the next day, by which time Georgina could quite easily have been dead. That said, it was perhaps a small mercy that they had not been given since the dose of one of the most toxic of the antibiotics that had been written up was 3 times the maximum dose permissible and would probably have caused her kidneys to fail and the loss of her hearing. The nurses in A&E were painfully slow. I asked three times if they would put up the fluid I had written up to support her blood pressure before I realised I'd be better off doing it myself. They took an age to give one of the antibiotics and told me that they didn't keep the other in A&E. The seriousness of condition was clearly lost on them.

By the time I finally got her up to the ward I felt thoroughly depressed. The drugs had failed her. The people had failed her. Medicine had failed her. And in every stage I was complicit. Another cog in a clumsy and decrepit system that as often harms as it does help.


Blogger Dazed & Confused said...

tragic, utterly tragic

is this is not the end point of a lot of the less understood medical specialties? i won't label neurology with the "make the diagnosis, do nothing" epithet because rheumatology, nephrology and dermatology are equally limited in their scope.

i remember a young lady when i was on renal (kidneys for the nonmedical) 22, secretary, no problems in life beforehand. presented with a 1 month history of flitting arthralgia, occasional rigors and presented with haematuria and raised Cr(pains in joints, shakes and blood in pee with poor kidney function).

got worse and worse, needed dialysis, lots of chin stroking, is this adult still's disease, was put onto immunosuppression, became septic, ARDS. i would spend most of my week of nights trying to keep her oxygenating on the HDU. transferred to ITU weekend after my nights, died there the following week.

no one ever found out what was wrong. family didn't want a PM. they were palmed off with the "sometimes young people get very sick and die and no one knows why."

death is undoubtedly awful. people go on about how awful a diagnosis cancer is because most normally die from it. i can't imagine what it must be like to be or be related to someone who deteriorates and dies and the world will never know why it happened.

9:44 pm  
Anonymous okaykabuki said...

i've been on the steroids, back in the day, prescribed by bewildered doctors who didn't know how to treat my "mystery illness", and am well acquainted with the side effects of prednisone.

i tend to have the same view of medicine as you. i'm glad you saw georgina hall and not someone else.

4:28 am  
Blogger Shiny Happy Person said...

I don't understand okaykabuki's response at all.

I know how you feel, VS. We've all been in that situation, and we've all felt like you. It's hard, but all you can do is try to remind yourself that for every Georgina Hall, there is a multitude of other people who are successfully treated of whatever ails them. Medicine is usually a good thing, and without it there'd be a lot more young dead people.

4:39 pm  
Blogger Note said...

O how ponderous our imperfect tools, and how defeating our inabilities, sad our limitations.

Doctors scare the hell out of me, you know; but the alternative is less attractive.

7:12 am  
Blogger vegas said...

Awful story. As for the slow nurses - when you prescribe fluids, just make sure you write the time on the prescription chart in the "time to start" box or similar. That way they will get started sooner as no nurse likes to look slow when everyone can see the difference between the time of prescription and the time the fluid is started. I do the same thing for "stat" doses of drugs - I write the exact time and then hand it to the nurse and tell them so. Then if it isn't given promptly at least it is obvious why. Patients continue to suffer. The truth is there aren't enough nurses because they are all being sacked.

12:46 am  
Blogger Melissa said...

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We will develop a bill payment system via the web:
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5:08 pm  

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