They're Not The Priority But What Would You Do For The Carers?

There's another new medical blog, Diagnosis NFI. Magwitch is the author, and an Emergency Care Practitioner. The blog hasn't been up for long but has already provoked some interesting questions about policies that affect the lives of carers.

Magwitch tells us about a call out to an elderly woman who seems to be the Sad and Lonely of the title.

In the end it all seemed to boil down to depression. She was a proud and independent lady but now, due to arthritis and cancer, was confined to her own home. Most of her friends has passed away and, apart from the odd neighbour who popped in from time to time, she had no one to talk to during the day. She had a son, who now lived with her and was her main carer, but he went out to work and she was left to her own devices for 8 to 10 hours at a time. She felt she was becoming a burden on him and the more she thought about it the worse she got.

Now, she was very obviously the priority, and for various reasons, she was admitted to hospital for further assessment. However, it became apparent that the son had problems related to his role as a carer. His mother resented the times when he was not with her and had begun to phone him if he was 10 minutes late home from work. She was taking over his days-off.

What Is The Cost Of Doing Nothing?

Malcolm Gladwell has an extraordinary piece entitled Million Dollar Murray: Why problems like homelessness may be easier to solve than to manage. In a lengthy and fascinating read he effectively challenges some of my previous thinking about homelessness as a wicked problem causing honest paralysis over difficult issues. Wicked problems arose in the area of public policy and are described as "a set of problems that cannot be resolved with traditional analytical approaches". It is the nature of wicked problems that unanswered questions and chronic issues can take years to work out or never be satisfactorily resolved.

Two police officers in L.A. made an informal calculation as to the costs of managing "chronically homeless inebriates" like Murray Barr whom they had cared for over many years.

...Johns and O'Bryan realized that if you totted up all his hospital bills for the ten years that he had been on the streets—as well as substance-abuse-treatment costs, doctors' fees, and other expenses—Murray Barr probably ran up a medical bill as large as anyone in the state of Nevada.

"It cost us one million dollars not to do something about Murray," O'Bryan said.

Gladwell discusses the research into homelessness by Dennis Culhane.

What he discovered profoundly changed the way homelessness is understood. Homelessness doesn't have a normal distribution, it turned out. It has a power-law distribution. "We found that eighty per cent of the homeless were in and out really quickly," he said. "In Philadelphia, the most common length of time that someone is homeless is one day. And the second most common length is two days. And they never come back...

...The next ten per cent were what Culhane calls episodic users. They would come for three weeks at a time, and return periodically, particularly in the winter. They were quite young, and they were often heavy drug users. It was the last ten per cent—the group at the farthest edge of the curve—that interested Culhane the most. They were the chronically homeless, who lived in the shelters, sometimes for years at a time. They were older. Many were mentally ill or physically disabled, and when we think about homelessness as a social problem—the people sleeping on the sidewalk, aggressively panhandling, lying drunk in doorways, huddled on subway grates and under bridges—it's this group that we have in mind.

Culhane discovered that about despite the size of the homeless population in New York, there are 'only' 2500 who are chronically homeless. Culhane's most startling finding was that New York spent sixty-two million dollars p.a. to shelter just those 2500 hard-core homeless. Studies in both Boston and San Diego reported extraordinary levels of medical and social care spending on similar high-need populations that confirmed the calculations made by Johns and O'Bryan in L.A..

Caring For People With Schizophrenia

The excellent Dr. Crippen has posted a remarkable account of an elegy he gave at the funeral of his friend Emma, whose life came to a premature close after years of living with schizophrenia. The account of Emma's life would be incomplete without talking about the destructive force of schizophrenia, from the time when she was a teenager until her untimely death.

Schizophrenia. Perspectives on it vary so much. There is the demonising view of some popular news reporting that implies that all schizophrenics have the potential to become dangerous to all those around them. And yet, historically, it was not that long ago that schizophrenia (like severe depression) carried a romantic air about it - it was seen as the fine line between madness and creative genius. Schizophrenia has become the universal metaphor for conflicted duality. It stands for self-indulgence and stoicism, inferiority and perspicacity, alienation and virtuosi of empathy, victim and persecuter.

The eulogy is a poignant summary of Emma's life. Dr. Crippen's charts the decline of Emma with respect and much affection. It is particularly sad to read of the gradual loss of those activities that she enjoyed: and to learn that someone who loved reading so much gradually found herself unable to read. However, we learn to admire her resilience and that she retained her humour, and sometimes mined the vein of her insight into her condition: