Intended for healthcare professionals

Soundings Soundings

The laws of thermodynamics

BMJ 1999; 319 doi: (Published 14 August 1999) Cite this as: BMJ 1999;319:459
  1. Kevin Barraclough, general practitioner
  1. Painswick, Gloucestershire

    I was sitting on the end of the old man's bed listening to stories of his life. I was a medical student at the time. The odd thing, he had said, was that the world made no more sense to him then than it had when he was a boy. He had thought that things would become clearer with age. I remember the perplexity in his watery eyes. Somehow, time had crept up on him before he had sorted things out, before he fully understood what it was all about.

    Not long after our talk he arrested, and I watched, mute, as the crash team tried unsuccessfully to resuscitate him. I considered his enigmatic comments as I watched his viscera being examined in the mortuary. But I gave the matter little more thought because I was a young man in a hurry, more concerned with the relationships of the lateral cutaneous nerve of the thigh than with arcane questions of purpose

    In those days patients were distant, frail creatures, far removed from the confident certainty of my own youth. They passed through the wards like shoals of herring, making their presence felt only occasionally by some comment that would flare briefly on the ward round, reminding us of our mutual humanity. But mostly they were cases: mitral stenosis, a third nerve palsy, and we pursued their physical signs like vultures, perched on the end of their beds with our stethoscopes.

    And then gradually through time, like some animated Kaplan Meier survival graph, your family, friends, and colleagues slipped off the 100% line, and became part of the shoal. Suddenly the blue, panting old woman in the corner of the ward, with cor pulmonale and the loud second heart sound, is your mother. The man in intensive care with the subarachnoid is your colleague and friend. And the fretful, uncertain parent is you. Uncertain because you are no longer sure that fate will always deal you the best hand in the way that it did when you were immortal.

    Before I did medicine I did a degree in physics. I think that medical students should learn more physics. The three laws of thermodynamics are particularly important:

    You can't win.

    You can't break even.

    And you can't even get out of the race.

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