Sunday, 28 March 2010



Bit of a mix up this week, and I get to see a variety of different people. unfortunately I have been ill for the latter part of this week so missed out on going in during this time. You can't go into hospital and spread an infection to all the people who are already sick! Despite this I spend some time with a lovely lady who is currently undergoing chemotherapy for a cancer on her face, I sit in on a clinic run by a specialist heart failure nurse, who is Very good, and I clerk in a patient who has vomiting and pain on a background diagnosis if gastritis, but seems to just want morphine and gets very upset when he is denied it. A morphine seeker with a true medical condition?

I have spent some time this week seeing a patient who is having radiotherapy. Seeing as she has to come into hospital every week day to have a dose, I get a lot of chances to follow her up if I want to. She is a wonderfully optimistic individual, with a very positive outlook on life. She has a chronically ill son who she has to spend all of her time at home caring for, meaning she never really gets to go out of the house apart from these radiotherapy visits. These cause a lot of problems for her family and friends as they need to cover the care she usually provides whilst she is out of the house. The cancer was originally on her face, and she is receiving radiotherapy following surgery to reduce the risk of recurrence. This has left her with some scarring to the face, but she sees this in an optimistic light as well - telling me that it doesn't matter to her much at all, as she barely leaves the house any more. Seeing such a positive patient is really inspiring. Getting drawn such a poor hand and ending up with cancer whilst having to act as a full time carer must be very stressful for her, but she is still all smiles and laughter when I talk to her (she is in her mid 80s) and very positive about her health, her treatment and her life. Perhaps she is the real optimist? I hope she can keep such a positive demeanour as the radiotherapy progresses. Radiotherapy tends to get worse suddenly around the 3rd week, as it has a cumulative effect on the tissues. A bit like getting sunburnt on sunburn from the previous day. Then again. Then again. Then again. It takes a few weeks for the dose to start having bad effects, but then it gets worse til the end of the 6 week cycle. As of yet, she doesn't seem to be having any ill effects, no burn marks on her face, no hair loss and no pain or nausea, and I hope it stays like this, but I have a strong feeling it will not. I will keep you posted as to whether she manages to keep such an optimistic attitude as the treatment progresses.

I had the privilege of spending an afternoon with a heat failure specialist nurse. Specialist nurses have, surprise surprise, specialist knowledge about one specific area of medicine, and so tend to be able to run very good clinics for people who have been diagnosed with this condition. You can have nurses specialising in problems from heart failure, as seen here, to Parkinson's disease. While nurses lack the depth of knowledge in other subjects that doctors gain in their training, knowledge of other unrelated diseases is unimportant in this situation. Because of this concentration of knowledge these nurses often know a lot about their chosen speciality, and we had some of the patients who came into the clinic commenting that the nurse know a lot more about their condition than their consultant cardiologist. One of the patients we saw was a 40 year old ex English Premiership football player, who had started suffering from heart failure a few years ago following a heart attack.

Heart failure is where the heart cannot pump sufficient amounts of blood around the body, as it is not working efficiently enough. The three top causes of heart failure are

1) Heart attack. By damaging the heart muscle, the heart becomes less effective and so pumps less effectively

2) High blood pressure. The high blood pressure enlarges the heart, as it has to work harder to pump the blood, getting bigger (in a bad way, exercise makes it bigger in a good way). The enlarged heart has much less space in it, so pumps a lot less blood with each beat

3) Valvular disease. Diseases effecting the valves in the heart can cause heart failure, as with dysfunctional valves (not closing properly, or not opening fully) the heart is less efficient at pumping blood and can become enlarged again

Heart failure is a 'viscous circle' as the body's response to the lower blood pressure is to increase the amount of fluid circulating. This is because the body is acting as though it has lost a lot of blood (a common cause of low blood pressure in cave-man times) and so is trying to increase that fluid again. This just leads to the heart having even more problems pumping too much fluid, and so getting worse. It also causes some of the 'typical' signs of heart failure, such as pitting ankle oedema, where the ankles swell up with fluid because of this increase.

Back to the patient, he used to be a very fit athlete, but due to circumstance had ended up in this position. A lovely man, he spent the time we were examining him telling us stories of the 'old days' when he used to play football, telling us about his young 'bit of stuff' he had at home, and how embarrassing it was that he couldn't even walk up his garden path any more without becoming acutely breathless. Heart failure has a terrible prognosis, worse than lung cancer, with little to do to 'cure' it other than by a heart transplant. it was a shame to see this lovely gent walk out of the clinic knowing that he might not have that much longer to live.

The final patient I will mention this week is someone I clerked in when I was on call. With a substantial past medical history, he had come in with severe pain above his belly button (epigastric) and had been vomiting almost continually for the past day. When I was clerking him he mentioned how morphine had managed to relieve his pain when he was in hospital about a year ago. This started ringing alarm bells, as he had been in hospital numerous times over the last year, and obviously hadn't been given morphine then, or he would mention it. While morphine is a great painkiller, I have heard many patients say they do not like it because of its side effects. But it does kill pain very effectively, so perhaps it was the only drug the patient had found that can touch the pain? While I was there, he wasn't being given the morphine because the doctors didn't think that the patient's signs of pain warranted such a severe drug. He wasn't doubling over or wincing in the pain, just complaining of it whilst sitting there and vomiting. He was very insistent that he wanted the morphine, threatening negligence claims against the hospital should he not get it, which I think was putting the doctors off of giving him the drug. Another problem, should he get the drug because he is complaining of pain and feels it would help him? Even if he is is displaying addicted behaviour towards the drug, withdrawing is painful and should the doctors be helping him with this pain? There was no question that he was ill, with the quantity he was vomiting and the previous medical history. I don't know what happened, because of the weekend, but I do know that he was not being given morphine when I left the take, so he hadn't been given it for the first few hours of admission.

Time limitations mean a shorter, blunter, less flowery blog I am afraid. Have a great Easter, for those who get a holiday!


  1. With regards to heart failure (and other chronic diseases) I sometimes find it more heartbreaking when I see someone who gets breathless getting on and off the bed or just walking around it, particularly after they've told you how they used to cycle 20 miles three times a week

  2. Pain is subjective. Not everyone "winces" with pain or will sit there doubled over. It is inappropriate to try to judge a patient's pain level from only outward signs, indeed pain essentially cannot be measured. If a patient is not throwing themselves around with dramatic pain gestures, that does not mean they are in any less pain than one whom is. In fact, the ones who are seeking drugs, tend in fact to exaggerate things to make their case for drugs more convincing.

    Pain management is a specialist function. It is one of the worst managed entities in the healthcare system. Anyone aspiring to be a doctor or indeed existing clinicians, whom are too frightened to treat pain or believe it is acceptable to take a position in judging a patient's pain level, without specialist assistance, simply should look for another career.

    A patient asking for morphine does not necessarily constitute "addicted behaviour" and labelling such patients in this manner is at best, unprofessional, at worst, negligent. such patients should be reviewed by pain management teams rather than simply being dismissed as "addicts", which is a terrible cop out on the clinician's part.

    Addiction is a complex disease, requiring specialist assessment, diagnosis and intervention. It simply can not and should not be alluded to every time a patient pleads for pain management and/or refers to a drug that in the past, has been prescribed and they have found to be of benefit for their symptoms. The position of addiction is not suddenly taken when patients ask for other drugs, despite them also having addiction "potential" and therefore it is the stigma of morphine and other opioids, that lead to these unqualified and inappropriate judgments over addiction. Morphine slows the digestive tract, indeed in many GI (and other) disorders, it expediates the patient's symptoms not only from a pain perspective but from its actual mechanism of action improving their organic symptomatology.

    Many doctors are terrified of treating pain properly. As a consequence, they undertreat it or indeed label the patient inappropriately and the patient suffers, all because of the clinician's failures. For many patients, morphine or similar drugs in the same pharmacological family, ARE the only drugs that afford them any relief. This is because morphine for example, is a fully agonist opioid and works on certain receptors, as opposed to, say, partial agonist opioids. Certainly for gastric pain, morphine can afford superb pain relief to appropriately selected patients because of its action within the digestive tract.

    Undertreating pain and falsely labelling patients is, for the patient, a worse proposition, than at least attempting to get their pain under control. If in doubt, bring the properly pain resources into matters and elucidate a qualified opinion and do not simply go labelling patients as addicts.