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Monday, April 6, 2009

Sicker than Sick

Today at work another nurse was reading a health care related website and he snickered aloud at the conversational tone the author had chosen. The sentence he shared was something to the effect of "as health care workers you are up against higher acuity rates than ever before."

"I feel like they're really talking to me," he joked. I was about to say something equally disparaging about the writing when something else struck me about the sentence instead.

Ever since I started nursing school we've been told that the general acuity of patients is rising. Thanks to advances in the medical field birthrates are increasing, and people are living longer. Diseases that were once fatal are now considered chronic.
The equation looks like this:
more people surviving birth + people living longer lives
+ (maintained health disruptions)x( the number of health disruptions any given person is able to simultaneously maintain) = a "sicker" population.

Especially since I took a job in community health (outside of a traditional hospital setting) I have been told that "our patients are getting sicker." This is a factor of the aforementioned "sicker" population getting discharged from hospitals often before they are completely ready due to insurance coverage limitations. Thus creating a "sicker" group of people who need follow up and outpatient care.

The thought is overwhelming. It's used to impress a sense of duty and challenge in nursing students, and for the dual purpose of comforting and rallying health care workers.

But is it true? Like most things, only relatively. And not in the context that the sentiment is often expressed. In other words, no one should be panicking over people being sicker.

My first thought was of The Black Death. (I know, my mind just works this way in the morning on Mondays.) According to Wikipedia there is a modern day dispute over whether the pandemic that swept through Europe killing literally millions of people was a viral hemorrhagic fever (like Ebola) or whether it was bubonic plague.
I have found no other research supporting that this debate even exists and so we're going to assume here that it was bubonic plague.

Now. If you kindly turn your attention to the mental image of people's lymph glads swelling up painfully, distorting their bodies, their skin turning black and decaying even as the infected person is alive, agonizing pain, the vomiting of blood, the depletion of bodily fluids, the inability to move and astonishingly rapid and effect transmission methods, you might be tempted to think "I'm so glad that's over with."

The thing is, it isn't. Y. pestis, the bacteria that causes bubonic plague is alive and well. It has even been categorized by the CDC as a category A pathogen. But we know how to treat it now. In modern cases of bubonic plague a timely course of antibiotics will do the trick.

In the Middle Ages gentamicin was unheard of.

You probably already understand where I'm going with this, but I'm going to fast forward anyway to the Polio epidemic of the 1950s. People were panicked, and with good reason. Now, four simple doses of the killed virus can protect most people for life.

When the AIDS epidemic started, doctors all over the world were dismayed and perplexed at young, otherwise healthy people dying of generally non-fatal infections such as pneumocystis carinii pneumonia. It would be years before anyone realized the disease itself was causing immunodeficiency which could manifest in a variety of different opportunistic infections. It would be even longer before anyone stopped calling it GRID. And a whole lot of people would die before anyone figured out how it was transmitted or how it could be stopped.
Bigger and better strides are being made every day in the area of antiretroviral medications, which is increasing the life expectancy of many HIV positive people.

So my argument is that people are always sicker than ever before. The push of disease and illness against the advances of modern medicine will constantly lead to that conclusion. Things were never easy.
Hippocrates wasn't walking around thanking Zeus that he had all the answers.

Saying that we're facing the higher acuity rates than ever before is like saying that we all get older every year. It's profound, and might inspire some sort of emotional response but for the most part, it's not newsworthy. Football is football. People talk about strategy and outcome of, they don't sit around explaining to each other what shape the ball is.

People are living longer.
So they have more time to get sick.
Also, people who are sick who would have died years ago are now staying alive.
Therefore, we have more sick people hanging around. And some of them are more complicated than they would have been ten or twenty years ago.

I mentioned before that no one should panic over people being sicker. What you should panic about is overpopulation, doctors playing god and people's basic rights being stripped away from them when they are sick or old or both.

Debates about playing God, life support, assisted suicide and all of that naturally follow all of this.
But are not what I'm getting at.

Technically yes: acuity is up. But the same could have been said of every generation of patients. It's relative. The more we strive to protect, cure and save the more opportunities we create for complications. Acuity has been on an upward trend since the dawn of medicine. We can either examine the trend and change the way we practice (i.e make choices that would lead to decreases in population and longevity), or we can accept that patients getting "sicker," is only relative to our knowledge getting wider. Which makes it much less sensational.

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