Then and Now

I was chatting this week to a nurse who works in the Catheter Laboratory at the Royal Infirmary of Edinburgh.  She painted a vivid picture of a 24-7 full-on, highly pressured, highly stressed and overpopulated environment.  When I was a medical student, and indeed a junior doctor, in that august institution, there was no such thing as a Cath Lab.  Now it is the sine qua non of acute cardiology.  In fact, cardiology exemplifies perhaps more than any other specialty the way that medicine has changed out of all recognition over the past 40 years.  In these far off days, there was no interventional medical treatment for patients suffering a heart attack.  Patients were given oxygen and morphine and the pathological process would run its course.  (Interestingly, patients in this situation are no longer given oxygen, unless they are blue, because the evidence suggests it results in further occlusion of narrowed coronary arteries.  In my day, failure to give oxygen would have been regarded as a “fatal error” – potentially fatal to the patient and therefore fatal to the medical student under examination.  Similarly, giving beta blockers to patients in heart failure was another fatal error; now it’s often fatal if you don’t!)

The purpose of the Coronary Care Unit (CCU) was to watch for complications such as a cardiac arrhythmia which might be corrected by a drug chosen from a modest pharmacopoeia.  I used to “cover” CCU on call at night, from an on-call room situated four storeys above the unit.  There was a bed, a phone, an ECG visual display unit by which you could observe the patients’ heart traces, a telly and, bizarrely, a drawer full of porno magazines.  There were large numbers of patients many of who smoked, were overweight, had bad diets and got little exercise.  Consequently many suffered major heart attacks and were left in heart failure, for which the stock drug was the loop diuretic frusemide.

Nowadays, the optimal treatment for acute coronary syndrome (see how the terminology changes) is restoration of the patency of the coronary arteries in a Cath Lab, where the vasculature is imaged and the occlusive lesion identified; a catheter is introduced either via the femoral or radial artery, guided into the coronary vasculature and the site of the lesion, and the vessel is reopened with implantation of a stent.  If this is done quickly, heart muscle does not die.  Time is muscle.  This reversal of a potentially fatal pathological process is little short of miraculous.

It wasn’t all doom and gloom in the 70s and early 80s.  The cardiothoracic surgeons were performing coronary artery bypass grafts (CABGs) – sometimes acutely – and valve replacements.  These procedures were highly invasive and in some patients extremely hazardous.  As medical students we had an option to select a subspecialty of our choice and join a unit for two weeks.  I chose cardiothoracic surgery.  My colleagues thought I was mad because the cardiothoracic surgeons had a reputation for being irascible psychopathic bullies.  In fact they themselves were so gobsmacked that a student should choose to spend time with them that they treated me with great kindness.  The morning ward round, in a remote and seldom visited location in the infirmary, began at 7 am.  I would assist in CABGs or valve ops that would take all morning or all afternoon.  After the split sternum had been wired back together the surgeon would depart and leave me laboriously to close up a ten inch skin incision with multiple interrupted sutures, to the great amusement of the anaesthetists.  “This operation is now in the hands of a medical student.”  The craziest of the cardiac surgeons gave me a lift home one night.  We paused at an Off Licence so he could buy a bottle of gin.  “Hold that.”  When I got dropped off I left the car still holding the gin, with the intention of getting out and then placing it on the seat.  He made a panicked dive to retrieve it.

Nowadays, it is getting more difficult to die of heart disease.  In addition to the stents, you will be offered an array of “secondary prevention” medicines.  If your conduction pathways are damaged you will have a permanent pacemaker implanted.  If you are liable to suffer fatal ventricular fibrillation, you can have an implanted automatic internal defibrillator.  This is why patients who have been through this route often end up dying of an entirely different disease, or of “pump failure”; eventually the heart just gets tired and gives up.

Practising medicine is a little like waging war.  You are liable to find yourself employing the tactics and strategies of the last war.  But you mustn’t do that.  The French Maginot Line was useless against Hitler’s blitzkrieg.  One of the reasons why the NHS is creaking and thus is never out of the news is that all these therapeutic options have become available during a time when so much has remained unchanged.  The model of delivery of care, the human resources, the budget, and the ethos are essentially as they were circa 1977.  That doctors and nurses should in any instance now offer a state-of-the-art service is, to say the least, valiant.  And it’s not just cardiology.  The same level of accelerated scientific progress could be demonstrated in respiratory, gastrointestinal, renal, endocrine, musculoskeletal, reproductive…  And the acceleration is accelerating.

We need to find a way of delivering health care such that doctors and nurses don’t go to work every day feeling as if they are organising an evacuation from Dunkirk.

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