Wednesday, 28 January 2009


In this profession you standardise you're level of success or failure based on how many patients are alive when you leave the ward. If you have worked a shift and none(or in critical care very few) of your patients have died then you mentally tick that off as a successful shift.

Many wards at any one time have patients who are palliative, they are dying and there is nothing that can be done medically to prevent this. Fortunately there are care pathways(protocols) in place for any patients who meet very specific criteria. This takes a lot of the difficult decisions out of the hands of doctors, nurses and the patients family. The standard care pathway in my trust is the Liverpool Care Pathway. Once a patient has started on this care pathway their treatment is purely for comfort. Analgesics, Anti-emetics, etc are administered
more or less constantly via a syringe driver. A device that slowly injects medications over a given period so rather than a patient getting a dose of morphine for their pain at 1300 and needing another dose at 1500, the driver releases the same dose into the body constantly over x amount of hours. This not only means the patient is constantly receiving pain and sickness relief but the nurse doesnt have to wake the patient up every three hours to administer the drug.

Once a patient is on the LCP and non-essential medications are discontinued(pretty much anything they wont die immediately if you take them off) and their observations are either ceased or taken only once a day as it is an uncomfortable thing to do to a patient but absolutely necessary for a patient who has a chance of recovery. In patients with no chance of recovery whats the point of waking them up at 0500 every morning to take their blood pressure, pulse, oxygen levels, etc. On a regular basis the patient is assessed for pain, agitation, nausea,
breathlessness, etc and if there is any variance on these then the medication the patient is on is adjusted so that they are as comfortable as possible.

This phrase always made me laugh "as comfortable as possible". The patient is dying, they are scared, exhausted, probably in pain. What we make the patient isnt anywhere near comfortable. And to add to the discomfort we take them off fluids and food and of course they are bed bound so they will be cathatarised. Ethically is this the right thing to do? they are dying and food, fluids, etc will prolong this however do we want their last hours to be spent, thirsty and hungry?

And back to my original point when you leave the ward and one of these patients has died how do decide if it was a success or a failure on your part?

Tuesday, 13 January 2009


I have returned. My abscence over the last month has been down to two things. Firstly I finished my third placement and thus didnt have a huge amount to talk about and secondly I spent a good couple of weeks over the christmas period in a state that some refer to as being 'bladdered'. But now I have returned and though I am not back on placement I am back to working (to earn money so I can afford to stay on my course).

I'll start with an old familiar topic just to ease my return. HIV and Population control.

Everyone knows what Human Immunodeficiency Virus is, admittedly the general populous have a very misguided interpretation of what it is and who it effects. The potential target group for this virus is EVERYBODY! not just homosexuals and drug addicts. Now we've cleared that little misunderstanding up lets move on.

There is a very similar virus that effects monkeys, Its called Simean Immunodifficiency Virus(SIV). Studies have suggested that the earliest outbreaks of this virus occured in africa. This isnt terribly shocking considering the earliest species of simean have been found in africa. Now, several thousand years after the first suggested outbreaks of this virus there are many native monkeys in africa which show absolutely zero uptake on this virus. They are either immune or resistant to the point where you might as well call it immunity. However if you expose for example an asian monkey to SIV they will almost certainly contract it with ease.

This leads us to beleive that there were monkies in africa which were both vulnerable and immune to SIV, the virus killed off all of the vulnerable monkies leaving behind just those which were immune, this immunity was passed on from generation to generation and from that point SIV was almost removed from africa. Should this also be the case for humans and there are those out there with an immunity to HIV(and there is no evidence that this is the case) then HIV could just be another one of mother natures population limiters.

In bacteria there are various principles of growth. Give a bacterium x amount of nutrients in a petris dish and expose it to the perfect amount of heat to promote growth and at first they spread at an incredible rate....then they slow as food becomes limited and excreted toxins start to build up, but at this point they are still in a state of population growth. They then stop, an equal amount of bacteria are dying due to lack of nutrition or exposure to toxins than are being created through further growth. And finally the culture starts to die, there are too little nutrients available and far too much toxic exposure. They have grown to their deaths.

Mankind is doing something similar, although we are still in a state of exponential growth. But the cause of all this 'global warming concern' is that we are facing the inevitable. In this history of this planet we have had an insane number of ice ages, then the ice melts(entirely) so even the polar caps are water, leaving only the highest of land above water. This has never really been a problem before because what few humans there were on the planet could fit into the visible land masses. Unfortunately now with 6,700,000,000 people on this planet we dont have any space to allow the entire species to survive a perfectly normal interglacial period. This period of defrosting is happening not because of us or our 'carbon footprint' but becuase it is meant to happen as it has always happened. Admittedly our effect on the environment may have expediated the defrosting but not by a huge amount.

There we go, Rant over. Have you all missed me?