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転がるイシあたま
中山間地・島・三角州……様々な田舎や町や街を転々として様々な経験をしてきた１９５０年代生まれの内科医の呟きです（最近はリハ科も兼任しています）。昔の思い出・今の思いなどを、アトランダムに語ります。「次に一体何が出てくるか」と楽しみにしてもらえるようなブログを目指します。
「偉い医師」は存在するが「医師だからエライ」ではない、がモットーの一つです。「先生様」でも「患者様」でもなく、お互いに「さん」で呼び合えるような世の中に、が秘かな望みです（書いちゃいましたけど）。
タイトル履歴
2008年４月に「医師アタマ」という本の存在を知り、あまりに似ているので本ブログのタイトルを「いしあたま（医師頭）」から「転がるイシは苔むさず」に変更しました。ただ、前のタイトルへの愛着捨てがたく、同年５月31日に「転がるイシあたま」に再変更しています。
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厚労省にはタイムマシンがあるらしい
野球の長嶋茂雄さんの映像や免疫学者の多田富雄さんの「日数制限反対」の訴えによって「回復期リハビリテーション」というものが世間に広く知られるようになったと私は感じています。ただ、「リハビリテーション ＝ 脳卒中」という図式が広く知られただけで、リハビリテーションが他にもいろいろな病気を担当していることは意外に知られていません。たとえば急性心筋梗塞、整形外科的疾患（大腿骨骨折など）でも回復期リハビリテーションを行なうことが保険上可能です。それともう一つ重要な分野があります。「臥床廃用症候群」です。
１）むかしむかしあるところにおじいさんとおばあさんが二人仲良く暮らしていました。二人とも身体は弱ってきていましたが、それでもなんとか日常のことはしていました。
２）ところがある日、おじいさんは高熱を発して倒れてしまいました。担ぎ込まれた病院では「重症の肺炎です」との見立てで、おじいさんは数日間生死の境をさまよいました。
３）治療が良かったのかおじいさんの体力があったからか、幸いなことにおじいさんの肺炎は勢いを失いました。集中治療室からは数日で出られ、一般病室で１０日くらい寝たまま点滴を受けていたら、肺炎の所見は消えてくれたのです。ところが、病気は治ったのにおじいさんの体力は弱ってしまい、ベッドでやっと寝返りを打てる程度になってしまいました。
４）「これは、長く寝ていたせいでしょう。たとえ数日でも使わないと筋肉は細くなりますから」と主治医は言いました。「回復期リハビリテーションが必要です。理学療法や作業療法で、体力をつけ、日常生活の活動の練習をしてもらいましょう」。
これが「臥床廃用症候群」（この場合には「肺炎後臥床廃用症候群」）の流れです。
ところが、あまり上等ではないリハビリテーション病院では、これを“悪用”する場合があるのだそうです。それほど重病ではない病気でも「寝ていたら弱った。これは臥床廃用症候群だ」とこじつけてせっせと回復期リハビリテーションを行なう、と。
そこでこの４月から厚労省は新しい「廃用症候群に係る評価表」の提出を病院に義務づけました。「どうして廃用になったのか」「廃用の内容」「改善の可能性」「改善の見込み期間」などを毎月書いて提出しろ、というのですが、そこで笑っちゃうのが「廃用に陥る前のＡＤＬ（Activities of Daily Living)」の項目です。
廃用に陥る前の「Ｂ．I（Barthel Index）」や「ＦＩＭ（Functional Independence Measure）」の合計点数を記載せよ、とあるのですが……これは無茶苦茶な要求です。
ちょっと考えてみて下さい。上の「例」で「廃用に陥る前のＡＤＬ」とはつまりはどこのことでしょう。２）の担ぎ込まれた病院では「枕も上がらぬ重態」なのですが、もしもこれを「廃用に陥る前」にしてしまうとこのおじいさんは「廃用に陥る前は寝たきり」「廃用に陥ったら寝返りができるようになった」になってしまいます。「廃用になったらＡＤＬが上がる」だなんて、そんな馬鹿な話はありません。ということは、３）の「廃用ＡＤＬ」が比較するべき「廃用前」は１）です。で、皆さん、ご自分の（病気で倒れる前の）「Ｂ．I」や「ＦＩＭ」の正確な合計点数を把握しておられます？ それと、その証拠も。
（単に「本人の証言」だけだと弱いのです。たとえば私の経験でも、ある人に「この病気になる前は、どのくらいの運動ができていました？」と尋ねると、本人は「ときどきテニスをしていました」。けっこうなお歳の方だったので「ほう」と素直に感心しているとあとで息子さんが「あれ、30年前の話です。最近は時々散歩するのがやっとでした」と教えてくれたことが）
もちろん、１）のレベルでのかかりつけ医や２）のレベルの急性期病院でも、「Ｂ．I」や「ＦＩＭ」を駆使していることも前提条件として必要ですが。でもそんな病院や診療所が日本中にごろごろ転がっているとは私には思えませんし、そこが「Ｂ．I」や「ＦＩＭ」を使えたとしても、そこに通院している人すべてをそれできちんと評価しているとは私には思えません。
ともかく「今目の前に現われた“この人”の一ヶ月とか二ヶ月前のＡＤＬを即座に点数化すること」が可能であると厚労省は考えているようです。
ということで１）のＡＤＬを評価するためには「タイムマシン」が必要なのですよ。過去を覗いて患者さんの「以前の生活ぶり」を正確に評価するために。
書類にきちんと正確に書き込もうとするまっとうな回復期リハビリテーション病院の場合、厚労省のどこに申し込んだらタイムマシンを貸してもらえるのかな？
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