Act F.A.S.T.

Like dementia, strokes can be devastating to a person's personality and individuality. I spent today on an acute stroke ward working with patients that are often newly diagnosed and need rapid management.

A stroke is a result of an interruption of blood to the brain, either caused by a thrombus or embolus (resulting in ischaemia) or as a result of localised bleeding from a burst blood vessel. Patients can either have a full-blown stroke or a transient ischaemic attack (TIA). Early recognition is essential, and the Stroke Association recently funded some research to aid paramedics in diagnosis. The same research has formed part of a new NHS campaign to try and educate friends and relatives. It is based on the FAST mnemonic:

F - Face - Facial weakness, uni-lateral or bi-lateral, droop or reduced function.
A - Arms - Unable to use arms effectively, lack fine motor control.
S - Speech - Slurred, lack of comprehension or effective expression.
T - Time - It's time to call 999, and get to hospital.

The campaign has compared stroke to a fire; the earlier action is taken, the more of the person can be saved. Treatment is with thrombolysis; but as it is often too late, supportive therapy is often the course of action. Occupational therapy, speech and language therapy and physiotherapy service all have an input. Prevention can be with low dose anti-platelet drugs, statins. Blood pressure control is needed, and many patients receive anti-coagulation therapy or carotid endoarterectomy. There is a high cost for the care of patients after a stroke, and the current focus is on preventative therapies and lifestyle choices that are much cheaper in the long run. Stroke is the third highest cause of death behind heart disease and cancer in the UK. 450,000 people in the UK are severaly disabled as a result of stroke, and every year 130,000 people have a stroke.

Strokes are debilitating and can have a massive effect not only on the person, but on all of those around them. Remember the signs, and act FAST.

For more info and statistics, go see the good folks at the Stroke Association.

I think I'm losing my mind

The NHS seems to be full of older people most of the time. I suppose that's a side-effect of having a better health system and more developed medical technologies that is allowing people to live longer. We can now support organ systems almost indefinitely, through the use of ventilators and heart-lung machines, dialysis and transplants. The weakest link is one of the most important: the brain.

Your brain is what makes you who you are, and it controls all of the processes that go on in your body; from the secretion of cortisol, when you are stressed, to the contractions of your heart. If your brain breaks down, there's a great deal that can be done. Of all of the organs in the body, the brain is one of the ones we know the least about. It can morph and change following surgery or a stroke, and adapt and learn new processes, movements, feelings and experiences all the time.

Quite a remarkable thing really.

Which is why it is a catastrophy if someone gets dementia. Dementia is essentially a gradual decline in mental faculties that is due to cell death, more than what one would expect from the normal ageing process. Memories are lost, often the most recent ones first, and people can recede in age - sometimes believing they are waiting for their mother and father to come and collect them. Dementia so far has over a hundred identifiable causes, and only 10% are due to reversible causes.
From the Alzheimer's Society website:

• 700,000 people have Dementia in the UK.
• There are currently 15,000 younger people with dementia in the UK.
• There are over 11,500 people with dementia from black and minority ethnic groups in the UK.
• There will be over a million people with dementia by 2025.
• Two thirds of people with dementia are women.
• The proportion of people with dementia doubles for every 5 year age group.
• One third of people over 95 have dementia.
• 60,000 deaths a year are directly attributable to dementia.
• Delaying the onset of dementia by 5 years would reduce deaths directly attributable to dementia by 30,000 a year.
• The financial cost of dementia to the UK is over £17 billion a year.
• Family carers of people with dementia save the UK over £6 billion a year.
• 64% of people living in care homes have a form of dementia.
• Two thirds of people with dementia live in the community while one third live in a care home.

Clearly it's not something to be sniffed at. The major causes of dementia are Alzheimer's, Parkinson's, Lewy Body Dementia and Vascular Dementia, with Alzheimer's being the most common cause. Even such diverse things as CJD and AIDS can cause dementia.

Dementia is often first noticed through difficulty to do simple tasks, such as putting a coat on or finding your keys. Tests can be undertaken like the mini-mental state examination which are a good indicator as they rigorously test different functions. CT scans and MRI's are also often done which can lead to diagnosis, although these do not always show the diffuse changes that occur.

Treatments include donepezil hydrochloride, galantamine, memantine hydrochloride and rivastigmine. The most famous of which is donepezil hydrochloride, Aricept. Some alternative therapies are also used, including music therapy, acupuncture, herbal medicine, and aromatherapy. Discuss their effectiveness amongst yourselves. There is also talk of a special helmet that fires infra-red beams into the brain that can supposedly help. Sir Terry Pratchett, a famous author with the disease is trying it out. The Alzheimer's Society have reportedly said that it is an "interesting technique". Hmm.

There is no escape in the end, so I say just enjoy life. The majority of people with severe dementia are often sublimely delirious, sleep lots and have no worries. The worst thing is for those that are left behind.

Trackback to Mr A

I don't know how to do trackbacks on here just yet, so this will have to do. It turns out that Mr A, the man who I mentioned in a previous post, was very wealthy - he owned several businesses and homes; now the "complicated family situation" makes sense.

He left everything to RNLI.

5 a day is not just 5.78703704 × 10-5 hertz

I don't know whether any of you have ever attempted to discover your BMI, but there's more to it than you might think. BMI is a (some might say over- )simplistic measure of a person's weight, that is calculated using a person's height and weight. In standard units, it is weight divided by height squared.

Which is all fine and dandy provided that you are the correct proportions for your size. The downside with BMI is that you could be a muscly rugby player and have the same BMI as someone who is the a completely different height and has eaten rather a lot of pies. It is used frequently in healthcare especially when calculating anaesthetic risk; it can even modify your life insurance premium.

One of the ladies we've got at the moment has a BMI of 76. Now I know I might be being judgemental (especially as I am somewhat rotund myself), but that has to be one of the highest I have ever seen. Why do people let themselves to that stage? She certainly wasn't born that size. Fair enough some people have personality disorders or have developed habits that result in excessive eating.

The thing is, it's not just being overweight. When it gets to the stage that a person's BMI is 76, it begins to have a bearing upon other people. The person's family has to do heavy lifting as mobility is often reduced, and the risk of an earlier death through things like heart disease and diabetes increases significantly. Not only that, but the burden on Mr Brown's NHS increases. Our lady of BMI 76 takes up the space of two bed spaces, has a special bariatric bed that costs a fortune as it has to be rented, special weight-lifting equipment has to be installed, she needs an oversize electric chair to sit in, and an extra member of staff has to be on as she requires four people to roll her; and, to be honest, it's even easier if there's six of us.


In 2006, as part of a global snapshot, it was found that between half and two-thirds of men and women in 63 countries were overweight or obese. Eastern Asia was the exception, with just 7% being obese. Interestingly, the USA was not included in the report. Funny that.

So how does she rectify it? Well, there's the obvious eat less and exercise more. Counselling, gastric band surgery, and enforced diets are also options. The efficacy of certain tablets is still to be seen, and most GP's would recommend losing the weight gradually and through the first two: diet and exercise. Five fruit and vegetables a day are the way forward; we ought to eat less from fast food "restaurants" and take a sprightly walk for half an hour a day. Otherwise, we're going to have a real epidemic on our hands.

Here's a BMI Calculator for you to have a look at.

The importance of free healthcare

I came across a lady today in the community who was fairly unwell but undergoing rehabilitation. She had chronic kidney disease, and a lot of other complicated medical problems. Discussions were going on in multi-discliplinary team meetings regarding housing arrangements after discharge, and her family had been invited to discuss their input.

She lived in a three bedroom council house in a suburb of a medium-sized mining town. With four daughters, she had a good family support network. Her daughters played a major part in her care and she did not have to rely on having paid carers. What amazed me was that all four daughters saw their roles very clearly. Each one had a specific job to do - one did washing, one did cooking, another put her to bed and got her up and another took care of her financial situation. These women were empowered by helping their mother through a difficult period in her life which not only had a positive effect on their mother, but also upon them. They were also "banding together" and seeking reassurance in each other.

Their wish was to move their mother into a bungalow so that her access and safety was improved. They also wanted the support of paid carers which would be organised by the local council. Most councils offer a means-tested service where the service-user pays for the care they receive. Reportedly (and I say reportedly, as it is often spoken of as folk-lore) the only council that pays for home carers fully is Kirklees in West Yorkshire.

Could councils pay for it? I doubt they have any money left in their budget, especially in the current economic climate. Home-care is expensive, as it is often provided by agencies that charge premium rate for their services. Private finance initiatives (not just in the NHS, the MOD have also out-sourced much of their operations) have resulted in many services being privatised in the hope of saving money in the short term, but failing to do so in the long-term. Services as diverse as GP out of hours cover and catering are now provided by companies external to the NHS. Not only do they cost more money, but regular staff are often hostile due to contractors receiving higher wages. Some figures for you: NHS outsourcing is worth £8 billion annually, and this is predicted to rise by 164%. The Gershon Efficiency Review took place in 2004-2005 and was an attempt to save some money. Reportedly, £21.5bn had been saved by 2007 as a result of modification of services.

One of the founding principles of the NHS was that it would be free at the point of need. It would be wonderful if prescription charges didn't exist, and home-care was free. Wales have managed it on the prescription front, Scotland are doing a staged affair, but as yet there are no plans for England. The price only seems to rise yearly.

Best get your orders in now then!

Goodbye Mr A

I looked after a gent today, we'll call him Mr A - which, by the way, is not his real name. He had been generally deteriorating for a while, but had been fairly sprightly up until a couple of days ago. He had developed malignancies in his pelvis and bladder and wasn't given much longer to live, his treatment would be conservative and palliative. Mr A deteriorated further, was placed in a side room and his condition was monitored closely.

Sadly, Mr A died today. Mr A's family situation was very complex and his next of kin was a neighbour. He was visited by the Church of England Chaplain, and members of staff crowded around him in his last couple of hours. As the bells of the nearby church tolled, Mr A took his last breath. Members of staff paused for a moment in silence, and then the ward returned to normal.

The last few hours are often easily recognisable, and many NHS trusts have pathways to recognise the symptoms and determine the proper course of action. One such pathway, the Liverpool Care Pathway, has been long-established but formalised end-of-life care is a relatively new concept. Terminal care has been undertaken since nursing began. The symptoms that someone is approaching the end of their life, are as follows:

• Drowsiness
• Confusion
• Decreased socialisation
• Decreased need for food and drink
• Loss of bladder or bowel control
• Darkened urine, or decreased output
• Skin becomes cool to touch
• Rattling or gurgling sounds when breathing (often colloquially known as a "death rattle")
• Turning the head towards a light source
• Increased difficulty controlling pain
• Involuntary movements

Source: National Cancer Institute

Last offices is undertaken following death (more information can be found here) and, to be very brief, encompasses confirmation of death, washing of the body and transport to a mortuary. It is very ritualistic and is not neccessarily based upon a body of relevant evidence. It does, however, ensure holistic care right until the very end of a person's existence and beyond, and can offer closure to relatives and staff. Different protocols apply according to if the individual has a belief system, as religions often dictate certain methods or forbid others.

Patients often experience strange phenomenon, such as raising one arm towards the sky, turning upside down on the bed, or the sense that someone has come to collect them. As for the tunnel lights, patients probably do experience those too. It is not unknown for people to wait until an event such as a birthday, or christmas - people even appear to wait for certain relatives to come and visit before letting go.

End-of-life care is increasingly a more important aspect of modern practice and fast recognition of the signs is essential. As someone once said, life is a circle.

NYT Portraits

Whilst browsing the New York Times Magazine, I saw this slideshow from Paolo Pellegrin of eight people who "stood out" this year. There's some good images, definitely worth a look.

Image Copyright New York Times 2009

How the NHS can never find anything

A recent article on BBC News has reported that nurses spend up to two hours each shift trying to find items that are needed to provide care. That equates to 40 hours a month, which is basically one whole week in four worked spent ferreting around looking for lost bits and bobs. Their proposal was to use a scanning system that locates items, not unlike those used in a pharmacy.

I would, for the most part, agree that a lot of time is lost searching for things. Especially if the nurse is new on a ward, as items are often in completely different places on different wards, even if they have the same floor plan. A recent NHS initiative - the Productive Ward - is supposed to improve this by bringing all staff together and streamlining services and focussing on providing care. The tagline of the Productive Ward is "releasing time to care", which seems an apt description. There has been resistance to its infiltration of the NHS, but this has mostly been from older nurses, HCA's and auxiliaries.

The Productive Ward will be hitting a hospital near you soon - however anything that releases time for patients, and improves their care can only be a good thing.

Welcome...

...to my journey of self-discovery. Ok, so I might in fact be following a recently-fashionable trend of starting and maintaining a blog, but I thought it was about time to jump onto the band wagon, and join the masses. This blog will discuss lots of things; I have interest and experience in a lot of different areas and this blog will cover diverse things such as current affairs, reflections on my experiences and lots of over random nonsense.

I hope you enjoy reading it. Whilst you're here, why not have a look at some of the blogs that I've linked to on the right hand side; they are friends' blogs for the most part, but I'll also be compiling a list of blogs that have something interesting or different to say.