Tuesday 19 April 2011

Complementary Medicine

I can't recall who linked this YouTube video, it wasn't found by me. I chanced upon it on a blog which, to my shame, I can't recall. My wife thinks I read too many blogs. Meh.

Anyway, watch this :

"I'm like a rabbit suddenly trapped in the blinding headlights of vacuous crap."


Monday 18 April 2011

Art. Allegedly.

My wife persuaded me to see some art she was interested in. An effort for the poor lass, since my interest in culture seldom exceeds the remits of what's grown within a petri dish.

I'm no culture vulture and find my mind's attention when glancing at most modern art is roughly equivalent to my mind's attention when glancing at rows of bin bags in the supermaket. Which to choose? The work of but a moment, then time to move on. Unless it's Hunt, Millais or Rossetti. She effortlessly talked me to seeing Liverpool's pre-Raphaelite originals then impishly whooshed me along to the Tate Modern which regrettably lived up to my every expectation.

A few weekends ago we romped through London's museums and galleries, where I was pleasantly surprised, but she also fancied a trip to Yorkshire Sculpture Park to see some Henry Moore whatnots set out in the countryside. It looks interesting but what really got me was they'd the most weird Jaume Plensa creations.

Apologies for the images, they looked a lot sharper on my mobile 'phone!

Eerie, unnerving and unsettling, the glowing statues set in darkened rooms really were very powerful. Placing words like "Amnesia" and the like all over, to externalise what's usually internal, was lost on me and just seemed a bit naff, but the size, shape, structure, luminosity of it all was striking, with real impact.

Tuesday 12 April 2011

Diagnostic Formulation

The acute medical ward referred a patient to me, for urgent assessment.

The patient had been perfectly well until 2 weeks ago when she experienced left sided weakness and slurred speech that she and her husband have been very worried about. She'd become confused. The medical team referred her to me "with dementia" to sort it all out.

She's had a stroke.

The history, clinical course, clinical examination and structural brain imaging yield a diagnosis of a stroke.

She was perfectly well a fortnight ago. She does not have dementia.

The medical team (well to be fair, a junior doctor on the medical team) assert otherwise. She thinks I'm being unhelpful, not curing this woman or taking over her care "to manage her dementia." I explain she's not got dementia. The junior doctor continues to assert that she does.

I'd love to do this :

Monday 11 April 2011

Care Pathways

I've been throwing in my 2p worth to discussions 'bout how care pathways could be constructed. I was invited on whim. Folk thought I may know what was happening, what best practice guidance is and what could work. All that is true. They also thought that the discussions could then generate a care pathway so patients could receive services according to their oft repeated mantra of, "the right care, in the right place, at the right time, by the right person."


One small example was that of vascular dementia. People have poor blood supply to the brain, as time ticks by. In the UK, furring up of the arteries starts at an early age (with post mortem studies of road traffic accidents finding atheroma in children as young as 11 years old) so it's no surprise that decades on with common conditions such as hypertension and diabetes that, in the UK context of atheroma/shabby cardiovascular health, we've an older adult population that has shabby blood supply to the brain.

Chronic (long term) ischaemic changes emerge, with consequent changes in brain function. Or a furred blood vessel makes lots of blood clots (the high pressure as blood squeezes through a furred up narrow tube causes cracks on the furred atheromatous plaque, which causes lots of blood clotting to happen, these blood clots then whiz off and cause strokes). Acute (short term, immediate) ischaemic changes emerge, with changes in brain function.

The top and bottom of it is that folk have small or large strokes, gradually or suddenly. Unlike strokes causing slurred speech or muscle weakness, the strokes are in other bits of the brain and can cause memory problems, mood problems, changed personality, confusion and difficulty in making decisions. Vascular dementia.

Who is the expert at dealing with vascular damage? Maybe it's a neurologist Consultant, with expertise in strokes. Maybe it's a Consultant physician, with expertise in cholesterol levels, blood pressure, anticoagulation and managing hypertension/diabetes etc. Vascular Surgeons have a role in de-furring blood vessels (with carotid endarterectomy and the like) but rarely seem to coordinate vascular care more broadly. I think GPs with their context, longditudinal knowledge of their patient, broad understanding and consideration of multifactorial elements and most usefully their application of common sense not protocol/commissioned activities, GPs could have a key role to play (but locally a vocal vociferous few don't want to be involved at all, so none will be). A Consultant Psychiatrist arguably has a modest role in this; if you've had a stroke, nobody seems to think the right care pathway is refer to mental health services who ask you how you feel about it.

Locally most people with memory changes come to psychiatry. It may scream vascular damage, CT scans may evidence vascular damage and no atrophy, it still comes to my door.

Our commissioners chide me for seeing vascular patients, it's the responsibility of the acute Trust they claim, they're paid to do this work. Seeing the wrong patients means I can't do the work and see the patients the commissioners want me to.

Can all my GPs take a referral where there's a history of memory changes, assess whether it's clinically significant or not, exclude delirium, exclude mood disorder/physical health problems/medication impacting upon cognition, assess cognition to formally diagnose dementia and then determine the dementia subtype, to then refer neurodegenerative dementias to me and vascular dementias to the acute Trust? With the best will in the world, no, they're not all in a position to progress assessment, diagnosis and subtyping to then refer appropriately.

The commissioners found this frustrating news to hear. Too much truth. The "challenges" were too real.

Time passed. Nothing's changed. We still have no explicit (let alone resourced) dementia care pathway in our locality for these patients. It doesn't really matter, they all come to our service and get the right assessment and advice. It's frustrating we get chided for this, though. And we've no resources for this. With NHS changes and profit, especially when making a profit by healthcare organisations is legally required and they can be up on charges if they don't use all means to do so, whether patient care will still be a priority that well meaning organisations (that aren't funded or required to deliver on) still helpfully do is a more salient concern . . .

Sunday 10 April 2011

Crisis Team

I've had to work with a Crisis Team nurse, who was not Charlie Fairhead.

She was, in point of fact, a singularly unhelpful soul who would neither see a patient, nor give them advice, nor arrange any support what so ever.

Time for me to take deep breaths. Count to 10. Self medicate with alcohol, stat.