Dr Nick Read

Doing things by the book; the flawed excellence of the new NHS.

I should have listened to her dentist.  She cared enough to call me in London and tell me that the Xray had shown a small translucency around the root of the bottom right canine and there was a sinus pointing to the gum.  ‘Your mum will need that tooth out,’ she said.

I demurred.  I have an aversion to what I see as unnecessary fuss.  After all I had with a discharging sinus into my gum for the last five years and it hadn’t blown up.  And mum was already attending the ear clinic for deafness, the eye clinic for injections of Lucentis  (costing the NHS £1000 a shot); she was attending the memory clinic for Alzheimer’s and now her teeth were playing up. It was a running joke between us. 

‘Eyes, ears, teeth and memory.  At least your nose is alright, mum!’ 

‘No it’s not.  Feel it.  It’s so cold!’ 

She still had a sense of humour.  I was her feed. 

Anyway, that tooth flared up.  She got an abscess in it.  Her temperature didn’t go up more than a degree but she became drowsy, more confused, went off her food and wasn’t drinking enough.  The extremes of life are such vulnerable times.  For the very young and the seriously old, an infection can set in train a sequence of events that can lead to death. 

At first they tried Amoxycillin, but she became nauseous and the temperature didn’t shift.  So they changed it to Augmentin.   She rallied a bit, but then declined.  The day she fell asleep in her porridge, I finally decided that she needed more help.  I called the doctor.  She would not be able to visit for three hours and suggested I dial 999. 

‘Don’t give her any food or drink.  Collect all her medications together.  Call us immediately if she gets any chest pain.  Somebody will be with you in half an hour.’   They were as good as her word. 

The paramedic had a strong jaw and a decisive manner.  After just ten minutes, he gave his report. ‘Pulse 72 regular, BP 110/70, Blood sugar 5.1.  Temperature 37.8.  She’s a bit dehydrated. Respiration good.  Lungs clear.  No obvious pain.  Pupils equal.  Responding normally but drowsy.  I suspect she has an infection but we need to get her into hospital to get some fluid inside her, treat the infection and check her brain scan.’ 

My heart sank.  To my mind, hospital is where the elderly go to die.  It took three hours for her to be ‘processed’ through casualty while she sat propped up on a trolley in extreme discomfort and with nothing to drink.  

After an overnight stay in the noisy confusion of the Medical Assessment Unit, she was moved to the pride of the hospital,  the spacious, high-tech environment of the Hadfield Unit, a state of the art intensive care facility for the elderly. 

When next I visited the next day, mum lay adrift, cocooned in pillows in a bay the size of a large meeting room with enough space to wheel in Xray equipment, heavy duty cardiac resuscitators, scanners and whatever else was needed.  It seemed alien, impersonal, a futuristic medical facility on a starship, staffed by holograms.  It looked like she had already died and was in the departure lounge awaiting transportation to another dimension.  

The doctors, a pretty young woman with long hair, flaired trousers and short top that exposed a little too much midriff and a young man in jeans, an open necked check shirt and stethoscope draped around his neck, were posing for a photo-shoot at the entrance to the bay. 

Why don’t they wear white coats these days?   Perhaps I am just too old fashioned, but it would convey a degree of professionalism that would inspire confidence.  But they were approachable and friendly and offered their opinions with authority and tact.

It was the nursing that worried me.  The woman in the bed across the bay from mum was on the commode.  I had seen the orderly deliver it twenty minutes earlier. She was calling out in some distress.  ‘Is there anybody there?  Please help me.  Oh please help.  Is there anybody there?’  But the nurses strolled past and ignored her.  After another five minutes, I could stand it no longer.  I went up to the gossip of nurses busily sitting at their station.

‘Excuse me but the lady in bay three seems to be in trouble.  She has been calling out for the last half an hour.’

They stared at me crossly. I could have used my ‘I am a doctor’ ploy, but I didn’t want to.  Why shouldn’t they respond to me as a human being?  One of them, the most senior, I guess, her dark blue uniform buttoned up very tight, responded tersely.

‘Oh, that’s Eileen.  She’s always calling out!’

‘But I really think you should….’

‘Oh all right, then!’

Eileen had fallen off the commode on to the floor.  Later the senior nurse had the decency to thank me.

But why in this intensive care environment, did nobody seem to care enough?  Why did they leave meals in front of patients who couldn’t feed themselves and just return to take them away?  Why did nobody help people drink?  Why was mum never mobilised except when I took her to the window and back?  Why did nobody just sit and talk to her?  She was so terrified.

Mum’s mental state just deteriorated in hospital.  Always a proud, private person, she seemed to give up all sense of dignity and self.  There was an outbreak of diarrhoea on the ward.  Mum got it and for the first time since infancy, suffered from incontinence.  Then she got a urinary infection.

It was two weeks before her physical condition had stabilised sufficiently to get her out of hospital, but by then, she had become part of the routine; she was terrified to go. 

Mum was no better after her stay in hospital.  She returned just as confused as when she went in.  She didn’t seem to know where she was anymore.  As the days past, her agitation increased.  I called her GP.  He was kind and prepared to take time to assess the situation. We decided to stop the Cipramil she had been on since before she got ill and start Lorazepam, a short acting tranquilliser with sedative properties.  It didn’t help. She became more drowsy and one day she didn’t wake up at all, but when we eased back on the dose, she became very agitated and confused.

I called the memory clinic.  At first they couldn’t remember her.  I was put through to ‘Mick the Memory’, the kindly clinical psychologist who knew mum well.  He didn’t think their prescription of Cipramil was part of mum’s deterioration had suggested I bring her in for an urgent appointment.  I explained again that she was too weak and confused to leave her flat.  Could they come and see her?

‘Oh’, he laughed,  ’We don’t do domiciliaries.  Let me speak to Dr McDonald and I’ll ring you back.’ 

He was back within the hour with a solution.  ‘Dr McDonald has referred your mother to ‘the rapid response dementia team’.   They will come and see her in a few days.’ 

They were late!  Nevertheless I was impressed.  They had sent a consultant psychiatrist and a senior psychiatric nurse.  Dr Patel wore a black suit, white shirt and tie and an expensive perfume.  His black shoes gleamed while he stroked his smooth chin thoughtfully, pondering whether it was a good idea not to treat mum for a urinary tract infection and whether we should try to cut the Lorazepam tablets in half.  But Dr Patel seemed was singularly reluctant to go into the bedroom and see mum.  His nurse did, but was bothered that mum was not awake enough to collect a urine sample, but she had forgotten to bring any sample bottles. They left after ninety minutes with the recommendation we continue with the same treatment and a promise to return every day over the weekend. 

That night while attempting to reach the commode, mum fell.  The carer, who was due to watch her, was working in the sitting room and did not hear her try to get out of bed on the baby alarm I had bought from Lewis’s that morning.  She dialled 999.  It was protocol. 

The paramedics checked her, decided there was no injury, and left suggesting that we fit her bed with cot sides and call ‘the urgency and incontinence team’.

The urgency and incontinence team can’t come until next Wednesday.  Clearly my call wasn’t urgent enough.  I went out and bought a pack of incontinence pads and three absorbent waterproof bed covers, called, somewhat curiously, Kylies.  Although quite compact, they claimed to absorb 3 litres of fluid.               

 

I don’t wish to be too critical of the NHS.  Any organisation that has intensive care wards for the dying and professionally staffed rapid-response dementia service, cannot be that bad. My concern is that our much vaunted nationalised health care system seems to have misunderstood that the most sophisticated technology, the most highly trained staff do not necessarily equate with quality of care.  Hospital nurses seem to have lost the ability to look after patients.  The real personal care has now been devolved to orderlies and cleaners while the nurses sit behind their desk writing reports and organising treatment plans. Mum’s GP is good; he balances his scientific understanding of medicine with the  art of compassion and healing.  He is an exception.  There are others; Mick the Memory, Liz the dentist, but too many others adhere slavishly to evidence-based practice without engaging their minds.    

We hear all the time about how expensive the NHS is, but just a cursory glance will reveal how much resource is wasted for how little gain.   Is it necessary to have such a high tech unit to keep the dying alive?   Isn’t it better to provide a caring environment to ease the last days of life and allow people to die in dignity surrounded by their family.  The Hadfield Unit only allowed visitors in for an hour in the afternoon and two hours in the early evening.  Mum was lonely and frightened. in there.  No wonder her mental state deteriorated.  And the consultant on the dementia team may have smelt nice, but would the nurse have done the job just as well by herself? 

Evidence based treatments, expensive drugs that over-treat the problem and cause too many unwanted effects, the rigid reliance of management protocols and algorithms; they all fail because they don’t take account of peoples’ individual needs.  And in the gap between efficiency and compassion lies a lonely person, often abandoned by their family and reduced by the state to the status of a machine past its sell by date.