Too much, too late.

Disease and late 20th century medicine.

Have we got it all wrong ?

Blog time : it’s a very wet and windy day in mid November so iv’e settled in to write some new material for the blog….this post will come under several categories as i’m going to be talking about nutrition and ‘modern’ diseases and our medical responses to those diseases : but first i just want to say a few words about the blog and what i’m doing with it this winter.

Firstly then, iv’e picked up several new followers recently and had a lot more post ‘likes’ than i usually get and all of those new followers and likes seem to be fellow dieters and exercisers so i’d just like to say thank you and welcome to the blog.   Most readers and visitors will notice that my blog has mainly been about boats, sailing and the sea but with a side order of men’s health, fitness and recently nutrition which iv’e been studying this year.   This year will the last time that i consistently write about small sailing boats until i start on my next project as iv’e just sold my own boat and for various reasons can’t tell the last chapter of that story.   Next year i hope to be starting on a small boat project under the ‘sail and oar’ category but this winter i want to focus on the health and nutrition posts and add some new material which looks at the disease side….cheery winter stuff eh ?

Next…..we’re coming up to a very important time in the year : Christmas and New Year, and it’s with that in mind that i am going to run a series about resolutions, intentions and fresh starts.  What i have in mind is that many people jump straight into exercise and diet regimes as a new year’s resolution and sadly most of them fail within a few weeks : i think that’s very sad and just seems to reinforce failure and, having been there myself, i want to see what i can do to help anyone to avoid the pitfalls.

Disease and medicine….an introduction to intensive care.

Early on in the life of the blog a visitor asked me why i didn’t write about the other side of my life as at that time i was still a practicing nurse with nearly 30 years of changing healthcare behind me. To this day iv’e only written about a few early experiences in just one post and even that is buried in a post about something else, to be completely honest the last few years of my nursing career were extremely dull and routine and i was glad to leave that behind….the really interesting stuff, at least to me, happened years before either in the world of an intensive care unit or when i worked as a nurse specialist, mainly dealing with acute pain.  Today though i want to take a backwards look at the strange world of the intensive care unit (ICU), in a way very topical as suddenly everyone seems to know something about ICU capacity due to the Covid pandemic.

It’s strange to think now that back in 1984, when i started my own ICU career, that it was a relatively new hospital specialty and that the ICU i was working in, one of the first, was originally put together ad hoc in an attempt to deal with a new problem.   A little bit of history here is that this was in the North-West of the UK and the original form of the as yet un-named ICU was the ‘bat cave’…a few beds in a room at the back of an orthopaedic ward in the old Preston Infirmary.  How that came about was because a young orthopaedic registrar was often the one trying to deal with the end results of high speed trauma from the newly opened M6 motorway.   By the time i came along we had actually moved into a slightly more planned area….a basement room in the new hospital : but these were still early days and most of the staff remembered the recent past when very little was known about how to deal with the new problems.

We weren’t the only ones either as a similar situation existed at the leading edge of the high end specialties such as cardiac surgery and neurosurgery : indeed just a few years later and we were still pioneering some of the techniques for post cardiac surgery recovery and once again in a couple of rooms in a ward cobbled together for the purpose.

Right from the start the real struggle in an ICU wasn’t the clinical one but the very real ignorance of other nurse managers and the non clinical hospital managers….how often have i had to try and explain to a senior nurse why we need such a high staff to patient ratio and smile politely, yet again, when a visiting manager calls it not an intensive care unit but an expensive care unit….well of course it’s expensive you muppet !.   Why it’s so expensive ?, well because it is….start with the expense of basic equipment per bed space and then the additional equipment and spares likely to be needed : i once roughly estimated that as greater than £50.000 per bed, and then the staffing…..to run one ICU bed for 24 hours over an average period needs a staff pool of 5 nurses, in a big ICU like our local one which runs at about 24 beds i wouldn’t even know the names of all of the staff.  Then of course there’s the simple fact that you need a consultant either on duty or nearby, one or 2 SPR’s on duty and maybe a junior doctor or 2 just to do the basics.

Today the public and government perception is that to cope with something like the Covid pandemic healthcare crisis that we would just need more ventilators, not the specialised areas to run them including the air, oxygen and power but the some 5 extra and specially trained staff nurses per ventilator just to run them.  Sadly for the government and hospital managers trained and experienced ICU nurses don’t grow on trees or even magically appear , ready for rock,n, roll from the general nurse population.

Intensive care is undoubtedly expensive, it’s difficult to pin down per case costs because that heavily depends on other procedures (cardiac surgery for example) but overall costs of intensive care are staggering : some 55 billion per year and 14% of all health costs as calculated in the USA  a few years ago.  One very major point to make is that total cost is spread across a surprisingly small patient population (in the US) and on the face of it does look like a huge resource being used on behalf of a lucky few but here’s the rub…..at or very near to the end of those patient’s lives. If you are wondering how i can justify or back up a statement like that it is because a lot of the ICU population is there post high end procedures : things like major surgery for cancer and complex/major surgery like open heart procedures.   Nearly all of those problems come late in life and not only that but as a direct result of the diseases of modern ‘civilisation’…..most of those diseases are new in that they hardly appeared in the medical literature as recent as 80 years ago.

As a medical friend once put it : too much too late !.

 

Editorial use only Patient in intensive care unit. This patient has been fitted with multiple intravenous infusions and pumps, and has been intubated. They are being ventilated on a Hamilton G-5 ventilator.

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