The last year has been a tough year in my life as a doctor.
Would I say my toughest year? In some respects yes, but physically and emotionally probably not as tough as my years in training as a junior where shifts were longer and pay was poor with a dozen or two unpaid hours expected of you weekly.
More crucially, from a stress perspective, senior supervision wasn’t as forthcoming, or where offered, certainly not with a generosity that left you feeling secure of your onward positive reference.
I can still see the bead of sweat falling from my brow onto the forehead of the recently collapsed president of some financial institution, in full black tie, as I cannulated his neck to place a wire in his heart while just in the second part of my ‘see one, do one, teach one’ experiential training as it pertained to cardiac pacing for complete heart block.
Pacing heart block was the ultimate fear of any medical registrar on-call. Thankfully, there has been much necessary improvement in senior supervision since then and more is needed still. But it has been a very tough year in different ways.
Initially, there was the need to overcome the personal fear of a doctor who does an acute medical call, as we viewed the scenes of attrition in northern Italy on TV, like a soldier in the second line of advance watching the massacre before him.
This was compounded by a quickly diminishing supply of personal protective equipment, the realisation that neither myself nor my GP spouse had any guardianship plans in place for the children in case the worst happened, and just the sheer fear of the unknown.
In hindsight it is just another infectious respiratory disease, a very bad one, let’s be clear, but the fear of which I can now at least comprehend and contextualise, and in the unlikely but possible event, one which would not invoke an extraordinary fear in me personally to die from.
That is not a flippant statement of bravado, as both colleagues and colleagues’ loved ones have been lost in the latest wave of infection and this is a time of pain for many, but doctors are familiar with and witness many diseases and have their mortal fears like everyone else, which can often be a disease-specific terror informed by our intimate experiences of that disease.
But we all now know what this disease is, how serious it can be and what needs to be done by us all to reduce the chance of getting it. Add to that that our treatments are better, the majority of people will not get seriously ill and those that do will still, for the main part recover, that a vaccination programme has started, and overall 2021 is looking a lot better prospect, despite the sadness that has been and is also sadly yet to come for many people.
Bravery and selflessness has been a huge attribute of our health service personnel during this pandemic. In every corner of our hospital I see this in action.
You might obviously expect to cite all grades of healthcare staff on ICUs and Covid wards and in our EDs, but extraordinary work is going on in all areas to keep crucial services afloat and support patient morale in the toughest of conditions.
My eyes are opened to notice this more though now in our chaplaincy staff comforting the dying, our portering and mortuary staff in the difficult task of taking the fallen on their last journey back to their loved ones with such dignity and care; the physio student who took five minutes out to do a whatsapp on their own phone for an older patient to their spouse who hadn’t seen them in almost six weeks, to show that all was well and how much he was improving.
There was also the young nurse who quietly bore the insults and human secretions flung at her by the ravages of delirium, with even greater patience than before, if such was possible, in special recognition of the particular suffering and stress the pandemic has imposed on all our patients with such restrictions on family support and movement; the papers being bought daily so an older man could see his racing, and treats and birthday cakes still being brought in by staff for their patients caught in a medical lockdown.
I read a quote recently about the appalling saga of our mother and baby homes that read ‘when we were at our most Catholic we were at our least Christian’.
Well for this crisis for our health service staff I can bear witness to the fact that ‘when they had most to fear they were least afraid to be with the people’.
During the current crisis and with some degree of internal turmoil as a doctor who treats and advocates for older people, I found it hard to square away some of my inner gerontological beliefs with the public discourse on ‘rationing ventilation’ when ventilation should never be offered anyway, Covid or not, in many individual cases, as it would not be the best thing for the patient or their family.
This is a regular medical conundrum for us and we have all too frequently retreated to the ‘ventilation corner’ in the past given the vacuum of understanding of what ventilation can and cannot do for you amongst the wider public. Suffice to say, however, it should never be age but rather medical factors, which include a patient’s own preference, that dictate these complex decisions.
I critically questioned myself internally, had I empathy burn-out when a person voiced a very understandable concern that they ‘did not want their 98-year-old, but visibly very frail, mother to die from Covid’, when I found my mind wondering to itself ‘how did this obviously distraught man see his mum dying and from what?’.
Maybe Sir William Osler’s notion of pneumonia as ‘an old man’s friend’ is an anachronism in modern medicine and now to be seen as nihilistically ageist, but we are still mortal, right?
An interesting finding from our own research in this regard is many older people have a more pragmatic outlook about mortality, and during this pandemic have tended to express to us for the most part, prioritising needs of their family and society rather than their own survival.
Nevertheless and now in complete turmoil I almost ‘handed myself in’ to the Karma police when I found myself questioning the vaccination strategy.
We have no evidence medically the vaccine will produce a beneficial response in such frail people and it is uncertain whether the 100-year-old, bed-bound patient with advanced dementia would want her 70-year-old son living in the community to get the vaccine first, so he can come visit her and add real quality to her life.
During this pandemic there has been, at times, a reluctance to discuss our mortality and now is probably not the time for such analysis. For many people ‘mortality’ became a ‘thing’ with Atul Gawande’s great book “Being Mortal”.
Not in any way to minimise this great doctor-writer’s book, as everyone should read it, but for me as a geriatrician it was a summary of a lifelong philosophy that any medical treatment must have the realistic chance of benefitting your patient.
Adding life to years is at least as important a principle to consider as adding years to life when deciding on medical treatment. Deciding not to offer a treatment, however, should not to be confused with hastening death or assisted suicide.
There will be much debate on this topic over the coming months and let’s see how much our society will move meaningfully to protect older people then.