Tuesday 30 December 2008

Side effects

Drugs have side effects. Heck, even placebo has side effects.

Some arise almost instantly (the one sticking in my mind was when, as a House Officer, I injected an IV penicillin on a weekend on-call to a surgical patient, who then went grey and collapsed). Some more typically arise after longer term use (especially in mental health, e.g. with lithium knackering kidneys/thyroid/parathyroid and antgipsychotics causing the movement disorder of tardive dyskinesia which lasts forever, even/especially when the offending drug is stopped). Some are serious (like neuroleptic malignant syndrome which unfortunately I've seen twice, now).

This has instilled a healthy scepticism of drugs. I like them, if they're used appropriately. But they're not a free lunch. Rational prescribing practice has to be central to use of medication.

But what about me? The Northern Doctor has posted about how busy life is in GP land at this time of year. He's a better man the me, hacking it in Primary Care. His last paragraph comments on the proportion of health care professionals who've used the 'flu vaccine.

Got me thinking. What're the bad medicines I've taken? A relatively short list, since I've not been to see my current GP ever (and last saw a GP some 20 years ago) on the premise that many doctors like to meddle/do stuff/fix things/intervene so are best avoided unless necessary. I delude myself into believing that not seeing a GP is fine because I can suss out myself if/when I need medical attention and, if that ever happens, that's when I'll darken their doors. But I know in my heart of hearts that mostly doctors are awful at looking after themselves.

Anyway, it means my exposure to prescribed medication has been modest. The last time I had a 'flu jab was when I worked in General Practice and, after that jab, I felt awful. It wasn't as bad as 'flu, I'm sure. But it was worse than any cold I'd ever had. So, for me, it seemed that the 'flu jab an a medication to take when well, to reduce risk of a possible infection, wasn't a smart idea for me. If I had health problems so the risk/benefit was different I'd think again, but for now, for me, it's nto something I'm keen on.

Rabies jabs were worse. I was abroad in a third world country, fiddling around in patients brains and spinal cords, so needed rabies jabs before going. They hurt. A lot. And made me feel really grotty.

The worst medication I've ever taken has been an antimalarial. I'm almost never nauseous/vomitting but my wife and I were so sick on them we were hurling up daily. Urgh. Felt so wretched on them we had to stop taking them, which made us much more paranoid about netting and safety so overall worked out well enough for us.

All this no doubt has coloured my conceptions of a medication's risk, benefit and role, which is why I'm wont to stop medication more often than I am to start it.

PS : Zealots in "proper" English, do tell . . . should a full stop go before or after the brackets in the opening sentences of the second paragraph?
I could write (with comments like this.)
Or, I could write (with comments like this).

Monday 29 December 2008


They say that absence makes the heart go fonder. I don't know which "they" said this, and in all my cardiology lectures at med school I can't recall anything 'bout separation from meaningful folk being good for it, but it's said a lot so it must be true.

I've seen a couple of folk of late who've been with relatives over the Christmas period, having not seen them for a year.

On meeting up, one year on, it struck the family how their parent seemed less able to concentrate, a bit slower in their thinking and a bit worse in their memory.

To a one, they're all normal.

We know that as we get older (Primary Ageing) that memory does get worse, when assessed objectively using different scales and rating instruments. This intuitively makes sense, too. As we're older, memory gets a bit ropy, okay, I'll buy that, it fits with what we all see and kind of makes sense. This is different to a disease process affecting brain structure and function (Secondary Ageing) when, in dementia, the brain literally physically shrinks as bits of it are lost, so brain function gets worse.

It can be hard to tell the two apart. Memory is getting worse, is it just old age or is it a neurodegenerative disorder needing assessment and interventions? Sometimes a lot of investigation, radiological and radionucleotide imaging is needed along with longditudinal data over time before it's valid to say it's normal ageing or Mild Cognitive Impairement rather than saying it's definitely dementia.

The key difference between Primary Ageing and Secondary Ageing changes, though, is one of impact. In normal ageing, although neuropsychiatric testing shows memory getting worse, function is preserved. You can still find your way to the shops and back. When in the shops, you can still remember most of what you went for. When paying, if short changed from a £20 note, you'll notice.

We have less than perfect memory all the time. A friend who's a school teacher says normal kids, with perfectly young and healthy brains, have appalling memories. Lunches forgotten, pencil cases left, PE stuff not taken home and washed, coats and cardigans left on chairs. She has loads of stuff every day that evidence how the childrens' poor concentration, attention span and memory result in forgetfulness.

Yet they're normal.

Too, when my wife asks me to go to the shops for one thing, I'm usually fine. If she asks for a dozen, I'll make a list. If she asks for 5 or 6 things, I'll remember most of them most of the time but often will forget something. My memory's not bad, but I forget things.

We can edit out this background forgetfulness when seeing our family. It's easy to identify memory's not great, but harder to frame it as not great long term and a little bit worse, not great long term and worse with impact meaning they're not coping, not great long term and a lot worse recently and so on.

Which interested me, since it's odd how we look at things, then what we see (or what we see as important) isn't based wholly on the reality of what's before us.

Families spotted their parents' memories changed and sought help for them, which was all wholly appropriate. What was heartening was that their parents' memories were changing through physiological Primary Ageing but none of the folk of late have had clinical, neuropsychiatric or radiological evidence to support a diagnosis of dementia. Now that's a reason for seasonal good cheer!


Christmas snuck up on me, this year.

I know, I know, it's still on December 25th this year so I could still have planned for it all in good time, but I didn't. Somehow it was upon me rather more swiftly than planned (erm, because it wasn't planned) so has all been a bit of a flurry. Ho hum. Or ho ho ho.

It's been healthy blogging for a year then taking some time out, but now I'm bored so it's time to start waffling on again, as is my wont. Thank you kindly for the comments and emails, which were surprisingly positive.

Just a brief aside. As folks will have gathered, I'm more than happy to be challenged on clinical opinions, indeed it's welcomed. What I think is a reasonable plan of action someone else may quibble with, the discourse that ensues is helpful and either helps me feel that my view is rational and sound, or that it isn't and helps me shift. When to give ECT, how long to be on an antidepressant for, what section 5 of the Mental Capacity Act 2005 should be used for, at what age to formally diagnose personality disorder, when to use a Supervised Community Treatment order . . . I'm happy to have offered views and chew the cud 'til the cows come home. What unsettled me wasn't when what I was saying was being challenged, but how I said things was being challenged.

Tricky one, that.

It's something I'm not easily going to change. Also, even if I stopped just posting on whim, and thought through and edited stuff, no matter how assiduously I tried I'd still cause affront to someone, somewhere, some of the time. One author of another blog rightly pointed out that a goodly number of their readers are patients (so things need to be framed in a suitably benign and universal way, presumably because patients are too fragile to exist in the really real world) which gave me food for thought. It'd be wrong for me to be saying things on other sites that could be taken as unhelpful.

I'm not a politician. I'm often wrong. Thus, I've never aspired to be "politically correct."

Medical blogs and medical student blogs I frequent seem to be liberal minded and haven't had issue with how things are said, so it seems sound to largely confine myself to such waters. And what better place to start than my own icy waters of Lake Cocytus . . .

. . . time to start blogging again.