Archive for August 10th, 2010

If the world ends

This is the way the swine flu ends, not with a bang but a whimper

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Note to self: Don’t die

Atul Gawande is an endocrine surgeon in North American who has a good way with words. For a doctor at least.

His two books – Complications and Better are a wonderful inspiration for someone who genuinely cares about how the job is done (as an aside if you were a dermatologist with similar passions you could never get the stories to make the books interesting. That seems unfair). His call to audit our practice – to measure something got me all excited about audit and research.

He made news headlines (with lots of other folk) with the surgical safety checklist. A mixture of almost comedic routine and common sense that should help stop the surgeon leaving his car keys in your abdomen.

He writes regularly in the New Yorker and this piece about end-of-life care caught my eye. Both morally and personally I have an interest in this.

On the inability of medicine to consistently “save lives”

We’ve created a multitrillion-dollar edifice for dispensing the medical equivalent of lottery tickets—and have only the rudiments of a system to prepare patients for the near-certainty that those tickets will not win. Hope is not a plan, but hope is our plan.

The USA spends a colossal amount on people in the last 6 months of their lives. This would be great if it helped them but it’s not clear it does. The following comment belies the different attitude between the UK and the USA on ICU admission. I worked in ICU for a over a year and we were deliberately choosy about who we would bring to intensive care – partly a resource issue but largely because we put people through horrible things in ICU and for a lot of people it simply won’t work. In the US it seems as if ICU is a frequent option for those who might be allowed to pass on without a tube in their throats in the UK.

I spoke to Dr. Gregory Thompson, a critical-care specialist at Gundersen Lutheran Hospital, while he was on I.C.U. duty one recent evening, and he ran through his list of patients with me. In most respects, the patients were like those found in any I.C.U.—terribly sick and living through the most perilous days of their lives. There was a young woman with multiple organ failure from a devastating case of pneumonia, a man in his mid-sixties with a ruptured colon that had caused a rampaging infection and a heart attack. Yet these patients were completely different from those in other I.C.U.s I’d seen: none had a terminal disease; none battled the final stages of metastatic cancer or untreatable heart failure or dementia.

I find the article interesting as it’s one of the few articles that talks about how we deal with dying in the terminally ill as opposed to how we bring about death in the terminally ill.

Gawande nails the underlying issue that both the medical profession and society needs to learn:

But the issue isn’t merely a matter of financing. It arises from a still unresolved argument about what the function of medicine really is—what, in other words, we should and should not be paying for doctors to do.
The simple view is that medicine exists to fight death and disease, and that is, of course, its most basic task. Death is the enemy. But the enemy has superior forces. Eventually, it wins. And, in a war that you cannot win, you don’t want a general who fights to the point of total annihilation. You don’t want Custer. You want Robert E. Lee, someone who knew how to fight for territory when he could and how to surrender when he couldn’t, someone who understood that the damage is greatest if all you do is fight to the bitter end.
This is what I think what medicine is here to do (primairily and given here without thinking out all the implications) our role – is to relieve suffering in whatever form we find it.

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