January 14, 2011 10:01 pm

Why medicine is all a matter of time

Many familiar medical scenes no longer exist in hospital. You rarely see a doctor timing a pulse with a wristwatch, for example. Most British hospitals require clinical staff to come to work “bare below the elbows”, which means sleeves rolled up, no bracelets, no watches. You still hold your patient’s wrist to take their pulse, but now you look off into the middle distance and estimate the rate – or you look up at the wall clock, which rarely has a second hand, or down into the screen of your mobile phone. I once certified a death on my mobile, putting my BlackBerry on the sheet next to the body and waiting for the screen to count down the minute needed to diagnose death – no breath sounds, no heart sounds, no palpable pulse.

Although doctors have lost their watches (and even when wearing them, always run late), hospital medicine is obsessed with time. The briefest moment is measured. Each of the smallest pink squares on an ECG represents 40 milliseconds. Counting these squares allows you to determine the timespan between the different phases of the heartbeat, and determine if there is an arrhythmia. Seconds are also useful. Squeeze your fingertip for a few moments so that it looks white when you release it. If it takes longer than two seconds to flash back to pink, that is a sign either that you are extremely cold, or that you have less circulating blood available to refill your finger: you may be bleeding from somewhere. Newborn babies are measured in minutes, with the Apgar score (Appearance, Pulse, Grimace, Activity and Respiration) carried out at one and five minutes after birth. With an hour, you can perform an ESR, or Erythrocyte Sedimentation Rate, a very old blood test that still provides a useful, though non-specific, measure of inflammation in the body (it tells you that some inflammation is occurring, it doesn’t tell you why, or where). The ESR measures the rate at which red blood cells separate out of a tube of blood in one hour – as mud will settle to the bottom of a bucket of pond water. When inflammation is present, the body produces more of a protein called fibrinogen, which sticks the red cells together into stacks. These stacks, being heavy, fall faster than individual cells, so the ESR will be raised.

Even less defined periods of time have diagnostic uses. A pain that lasts a few moments, and then goes away without coming back (and without anything bad happening next) is less likely to be serious than a pain that lasts for half an hour or more. Chest pain is assessed in these terms, as hospital staff try to differentiate heart attacks from anxiety attacks; both conditions present with palpitations, shortness of breath, sweating and a feeling of doom, but panic usually settles quicker. All day, through the curtains in A&E, you can hear “What time did it start? How long did it last?”.

Time according to doctors is different from time as experienced by patients. Patients spend much of their time waiting: for pain relief, for visitors, for test results, for someone to take them to the bathroom. And they wait for the doctor, who will not be there on time. In the 12 hours – or 720 minutes – of an on-call shift, a doctor may be responsible for 200 or more ill people. They will need diagnosing, cannulating, catheterising, X-raying, examining; and possibly sedating, if – like a confused elderly man I once looked after – they decide to set fire to their bed curtains. There is never enough time.

Sophie Harrison is a hospital doctor in South Yorkshire.

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