Lemmingaid

Wood and Trees were relaxing halfway through the ward round by means of a coffee and a biscuit. What had started as a very much Cardiac Surgical Intensive Care Unit compliant review of the critically ill by the most senior doctors in the hospital had rapidly degenerated. There was sickness amongst the trainees. There was a lot of sickness amongst the nurses. There were no ICU beds so theatre elective patients were being cancelled only to be replaced by ‘new’ cases which had become emergencies and looked suspiciously like the cancelled ones. One of the ICU Staff Grades had been pulled to cover an electroconvulsant therapy list. Wood and Trees were now ambling around the unit with the ICU Sister Holly and one trainee Dr Beech; it was actually a lot more pleasant and possibly more efficient!

They had limped on delivering the ward round when the client in bed 7, who had taken a mixed overdose and chaser, came to abruptly and aggressively. Having extubated himself, he had been through the customary f’ing and Jeffing and now wanted to sign his own discharge. The ward round descended upon him, and everyone was thinking capacity assessment, mental health team, and for crying out loud. The time honoured ‘you really shouldn’t and can’t blame us’ self-discharge form and ceremonial ball point pen was summoned. His next of kin, the young adult’s mother, was also very upset with the entire ICU team, NHS and GP as no one seemed able to explain why her son might have collapsed after injecting heroin … Wood and Trees really were flummoxed. They had been presented a question of such ridiculous ignorance that it may not have an answer. Nobody was judging this man nor ignoring the factors contributing to such self-destructive behaviour, but this adult patient and their mother had not even a flicker of recognition that collapse following illicit use of heroin was a hazardous situation. Put another way it was entirely a situation not of the making of Wood, Trees or anyone else who had saved his life, yet all these people were the target of our heroin using survivor. The patient had capacity, told Wood and Trees where they could put their forms and was assisted by security to leave the ICU. The cup of coffee was very much needed.

‘There is definitely something new happening isn’t there?’ said a very dazed Wood.

‘You’re damned right there is!’ exclaimed Trees. ‘This is getting beyond a joke. This ward round has been made up of the elderly, the psychiatric and self-harming and the rest of the hospital’s patients when they can’t cope. It wasn’t like this five years ago!’

Wood and Trees reflected on the change in patients and how the quality of bulk purchases of coffee hadn’t changed over the same time span.

‘We used to look after sepsis and people having operations. Now it’s people whose lives are coming to an end either because they are old or they are tearing themselves to pieces. I don’t think we can fix it’.

‘Well, no one lives forever do they?’ asked Trees stating the flaming obvious in a very unhelpful rhetorical question. But the problem was, it was flaming obvious and it remained a question lacking a palatable answer.

‘I don’t remember ward rounds being interrupted for people to self-discharge from ICU? It’s a new one on me – people used to be quite pleased to have their lives saved’.

Wood and Trees retreated again to their coffee.

‘That patient has complained the nurse looking after him was non-white and he refused to have a woman look after him’ and Sister Holly, who was both non-white and a woman, could scarcely conceal her anger. ‘I need to respond to his complaint’; now three of them were looking dejected. The trainee Dr Beech suggested a response to the complaint which was not captured by the minutes but was quite popular.

‘I will lose two hours dealing with this rubbish and probably get home late tonight, all because this character has no scruples and is happy to play the system. It is an absolute disgrace’. No one could argue with Sister Holly.

‘We’d better get this round finished’ said Wood, reminding them it was still pending. ‘We have the nursing home wing to visit’.

‘Don’t be naughty now …’. Trees gently tried to get things back on tack.

‘No really – look at this list!’ And they reviewed the handover sheet; just the first column with age. 78, 82, 86. ‘Oh, hang on … 36 … alcoholic liver disease’. ‘Some of these people are spending their twighlight years on ICU, having the corners knocked off them!’ Wood had that strange look on his face where the reality of things had just slapped him.

‘I don’t usually quote the Rt Honourable Jeremy Hunt MP too much but he said in the next 10 years we will have another million over 75’s coming. I’m guessing they might have some health needs looking at the shape of them round the city centre’. Trees had quite regularly highlighted the crisis in BMI, lack of exercise and self-abuse, while generally propping the stats up himself quite admirably.

There was no answer to this. It is changing and fast and had possibly already left Wood, Trees, Sister Holly and Dr Beech behind. It was of course inevitable and unavoidable that a tide of elderly patients would wash over the entire NHS.

Wood summarised: ‘Enlightened journals in this age of patient autonomy tell me medical paternalism is a civil rights abuse, even if the patient does not want to know. Even though there are millions out there who can’t read or write. The only topic for discussion that is off the agenda is a person’s right to chose the time and method of their own death’. There were no words used now, but all four of the participants acknowledged that they would exercise their right to choose time and method, and no one would ever stop that. Was this a burden or a perk of the job?

‘It’s amazing what we don’t let people decide despite all the time being told people can make any decision they please. I gather we might finally have an opt-out on organ donation. I wonder if that would overrule the next of kin? Society vs the family – it won’t end well, especially if you’re the doctor left to deal with the mess each time. I doubt my MP will have my back on that one’.

Wood was pleased he’d used a young person’s term.

‘Don’t talk like a young person, please’. Said Trees, and the apology was already half out.

‘So how will it get sorted? Society wants the kidneys, the people around say no. Will it be a trip to court each time? All I can say is I don’t think I will ever treat a patient again between refereeing bouts like this, explaining the dangers of heroin to grown-ups or picking up their racist complaints. You remember “treating a patient”?!’ and suddenly everyone realised their working days had changed.

‘We can’t afford all this you know!’ and everyone knew this was true.

‘If we want to breach the 1% pay cap it will be in excess of a billion quid!’ threw in Dr Beech to spice things up.

‘I would earn more on the living wage than I would as a newly trained nurse in the NHS,’ added Sister Holly, pointing to the closed beds where nurses were not available. ‘And they’ve just put the rates up at the nursery’. Wood and Trees could scarcely remember their fertile days, but the grandkids seemed to come round a lot more as their own offspring rushed out to get to work.

‘Well you can’t afford to pay for the kids to be looked after – I know we can’t afford to look after the old ones at the far end. After we’ve got them through their ICU admission and hospital stay and nursing care beckons, there won’t be anything left in the pot for the communal lounge and Zimmer racing. They got most of their cash in free prescriptions, bus passes, heating allowance and pensions. I think we’ve sold the young ones short – we’ve squandered universities, owning your own home and professions or even just a normal working day. Zero hour contracts? I wonder if we might have the money going the wrong way?'

Wood didn’t shout too loud just in case any of the more elderly benefits were taken away before he got there. It wasn’t too far away after all.

‘It’s an odd thought my kids will have to work to 67 because I didn’t die when I should have’. And Trees pondered on the presumed gleeful acceptance of the burden by the younger generation.

‘They kicked off a bit recently didn’t they in the voting, and Brexit was hardly harmonious?’ Wood offered his best analysis.

‘Well it is a problem if we are waiting for the youngsters to pick up the bill and they aren’t even in the same restaurant’. Trees was pleased.

‘Don’t make up expressions’. Snapped Wood. ‘But you’re right. We assume if we take more out that more will go in. But they might just stop paying. We’ll be left in our big houses, waiting to sell them when we need to go into the nursing home’.

‘And the kids or grandkids will never visit because they are at the other end of the country and working weekends’. Trees was feeling lonely.

‘Stop it now, you are depressing me. It won’t be the same but there will be a way. There has to be a way’. Wood urged the ward round to get to their feet and visit the remainder of the patients.

They had just about managed to leave the coffee room, stagger down the corridor and were about to review the next patient when the sheer horror of the scene unfolding in front of them took their collective breath away. This, on top of the morning they had, was too much to take. There was a critical mass of middle management clad in polyester suits and corporate uniforms looking anxious and concerned. They were looking at nursing numbers, dependency and were most exorcised that the elective theatre case had not been accepted. Sister Holly pointed out the simple reality of full beds and no more room, but this did not appear to be the correct interpretation.

Wood and Trees had developed an approach to this scenario which had evolved in order to avoid violence and allow them to keep their jobs.

‘Well we will carry on the ward round and you good people can decide if the case goes ahead or not’; and with that, Wood stepped back.

‘But the policy says it is the Consultant and Senior Nurse on for the day who gives the go ahead’ said manager A.

‘Come now we all know this isn’t true. We will not waste any time on this – the case goes ahead if there are nurses and doctors to look after them and I am telling you there aren’t. If you pay the agency then you can decide the case gets done. Now we are off to see the patients we already have, thank you!’

Trees came in on the other half of the pincer.

And so with no decision on doing the elective case, management were left doing sums; Wood, Trees, Sister Holly and Dr Beech all continued the ward round. They visited the bed with an 82-year-old patient with bowel cancer and a likely liver metastasis, and no words were exchanged. Collectively, the grim social predictions of the coffee room were materialising on the ICU. They had even had their grim prejudices reinforced in Journal Club by some research suggesting ICU had nothing to offer the elderly or something like that. That’s what the abstract said anyway.

‘Good Morning. How are you today? That was a big operation – I’m sure you’re feeling pretty rough right now?’ and Wood meant it. He was talking to a nice old lady, her husband at the bed-space with nothing but worry and concern on his face for the single thing that mattered most in his life.

‘Thank you for everything you’ve done. This really is a brilliant hospital and everyone has been so kind’. The patient was not deluded or demented. The notes made it clear the surgeon had told them about the extent of their cancer and that cure probably wasn’t coming. Wood and Trees and the team hadn’t really done very much beyond a basic prescription and some monitoring.

‘You’ve all looked after her when she needed it’. The patient’s husband was clearly holding back tears, and his words were tripped up by overwhelming gratitude. And so the ICU ward round had gone a very long way. Wood and Trees started with self-discharge and self-harm, took refreshment and found little comfort and came out to discharge the frail and elderly; and just when they thought they had seen it all and knew everything, an old lady thanked them for doing their jobs and they felt wretched. They had allowed themselves to be distracted and they had stopped caring briefly.

‘I’m just looking forward to getting home’ said the patient. In that moment Wood, Trees, Holly and Beech could all see that whatever form that might take, whatever problems that might entail, getting one old lady home to spend whatever time she might have with her husband was the most important task of the day and they should start on it immediately.

The ward round was back on!