Monday, December 31, 2007
It’s not been a specially great year here in Ambridge. A bit like the Nikkei, we’re closing the year a good few percentage points down. That said there have been highlights, both personal and professional along the way. It just seems they have been significantly outweighed by the lowlights this particular year. As a prime example, the year that began with exuberant chocolate fountains (yes I did mean plural) to a full house on New Year’s Day, goes out to a much more sedate chocolate fondue for five tonight, and for the first time ever we get two New Year celebrations exactly one hour apart, as one of our little flock will be celebrating Bonne Annee in mid exchange visit far away from the familial bosom.
(And if he doesn’t ring us close on the stroke of Minuit local time there’ll be ructions).
So all in all ’07 goes down in the Jest family annals as a bit of a damp squib.
We’re hoping for better in ’08, and despite the preceding misery (“the poor old lad’s come over all Seasonally Affective on us again” I hear you all shout, and you might have a point…) I would like to take the opportunity to wish all who tread here hereafter, the very best of years ahead.
And, of course, as much chocolate as you can comfortably accommodate ;-)
Tuesday, December 18, 2007
And then, last Friday she arrived back at surgery in grip of another nasty respiratory virus. It’s still not exactly clear how she made it this far, because she arrived in extremis. Indeed after one look at her I was afraid she was on the verge of a respiratory arrest. With judicious use of the nebulizer we managed to get her breathing rate down to below sixty a minute and removed the awful dusky blue tinge from her lips and tongue, but she was plainly still in a lot of trouble and needed to go in to hospital to get sorted out, or at least to be assessed for oxygen therapy.
Except that there was no way to persuade her to go into hospital.
“You see I’ve got to get home to look after Mr. Tiddles.”
No,Ivy’s surname doesn’t even approximate to Tiddles.
She was, of course, referring to her cat, Mr. Tiddles the little black and white bundle of fluff she calls family. It appears her nearest relative lives about as far away from Ambridge as is possible and still be technically resident in Blighty, and may not be in the best of health either. Her closest neighbour on whom she might call is a sprightly ninety five, but not steeped in the lore of feline husbandry, and anyway “it wouldn’t …be right…. to impose … she has ….problems …enough.” All this between gasps which just go to underscore the imperative of Ivy’s admission to Ambridge General.
And so it is that Mr. Tiddles now has a daily entry in our home visit book for the duration of Ivy’s stay on the wards at A.G.H.
Friday, November 30, 2007
In I went, full of trepidation. Two hours later I emerged triumphant. Horizons had been scanned, forward motion was observed and a jolly nice Macedoin de Fruits analogy slipped in under the wire. All told I had shoe-horned in a grand total of five reader submitted buzz words or phrases. And more importantly, my Double-O status is safe for another year. The denizens of Ambridge can sleep safe in their beds, knowing that Dr J is on watch.*
So thank you to all contributors for your sterling efforts in making this year’s appraisal more amusing. It is possible there will be concerns at NHS management level about my sanity after the report goes in, but there’s probably nothing new in that anyway. I now expect my call up to visit Q branch for some new goodies any day, so just one question remains.
Where do I sign to get my new Aston Martin?
*Although actually of course night work and weekends are no longer in my purview…
Friday, November 23, 2007
Not that I haven’t been thinking of you all you understand. And now I’m back and already I’m after a favour.
“Bloody typical…” I hear you all muttering, “It’s always Me-me-me with him. We don’t know why we bother… honestly… “ and so forth. And you’re probably quite right. Still you can’t blame a chap for asking, so here goes.
As last year, next Monday morning I am to be appraised. A colleague and mentor will be stopping by for a chat, to try to detect if I have developed any homicidal tendencies since last we spoke. I’m pretty sure I haven’t, so that should be ok, but the whole process can be a bit of a travail. To lighten the mood last year we tried a game of “buzzword bingo”, a little something I shamelessly plagiarized from Blogger par excellence, Greavsie.
So what I’m looking for are a few choice buzzwords for this year. All suggestions gratefully received. Of course if you felt you wanted to submit them wrapped in a ringing endorsement stating how the Caseblog has transformed your sex life, cured that embarrassing little crop of warts, given meaning to an otherwise drab and hopeless existence, or other such fitting tribute, then however much it might embarrass me, you should give free reign to those feelings.
Just don’t tell anyone I asked…..
*excuse supplied to Mrs Badcrumble for non-appearance of homework, circa 1969. (And no we never did have a dog).
Monday, November 05, 2007
Nelson has Type II diabetes. You know. The grown up sort. The kind that won’t put you into a coma in just a week or two, and, that seldom requires insulin at the start. One of the problems with this is that, in an effort to get his blood sugars to target, he has ended up on rather a lot of meds. And some of those meds can, paradoxically, cause weight gain. So he may just be experiencing a side effect.
“So,” say I, “what exactly have you tried?” A reasonable request I think you’ll agree. But Nelson’s body language comes over all discomfited.
“Well, I don’t have sugar in my tea anymore. And I’ve started using all those low fat thingies….” At this point his brow creases as he casts around for other lifestyle changes made in the three years or so he has been afflicted.
“So have you tried dieting at all?”
The stunned look in reply says it all. It appears he was hoping for a visit from the “Weight Loss Fairies” to magic the excess avoirdupoids away.
And so we agree to give it a go. In the end he is weighing in a good three kilo’s heavier than he was in the spring, and this tips him over into the dread “Obese” category, which, coupled with his diabetes is not the best news. He has a target to make in the next four weeks, and if he can hit or get close to the required 2.5kg weight loss we shall be in a position to start him on some meds that might help (yes yet more meds, Type II Diabetes Mellitus is not for the faint hearted—‘scuse the pun).
If not he gets to go to the endocrine clinic for further advice.
Or we could always send in the Weight Loss Fairies...
Monday, October 22, 2007
The first clue that things were going to be less than straightforward was Lynda’s admission right at the outset that she was “… in a bit of a mess.” Lynda is a woman of middle years, and not generally prone to euphemism. The second clue passed me by at first, but on the desk she had deposited her car keys—nothing unusual in that—hanging from a cutesy teddy bear key-ring.
It transpired that a few weeks ago Lynda had an intimate liaison with a “new partner”. Or a good old fashioned one night stand to be more accurate. Some weeks on she was left with a continuing reminder of the same, and requires investigation to rule out STI. We agreed that rather than refer her straight to the GU clinic, to spare her blushes we could initiate investigations here and only refer if we found a complicated case of infection. From her symptoms the most likely culprit remained candida and so the full rigours of the GU clinic might well be unnecessary.
So as I was completing the microbiology form to arrange the requisite swabs, I happened to glance over to where teddy lay resplendent on the desk. There he lay in all his glory. I can assert his masculine gender with some certainty, since there he was hung quite literally “like a bear” and with a “Prince Albert” to boot. Keeping a straight face through the remainder of the consultation was a real challenge I must say…
Monday, October 15, 2007
Now on with the motley….
I’ve seen some pretty odd indications for admissions to nursing homes in the past. On at least a couple of occasions we have had to admit patients to a local Home for healing of their pressure sores (it helped that the Home’s matron was at the time an internationally published authority on the subject and a true mistress of her craft, thus disproving the old axiom that “those that can’t teach”).
We have also felt in necessary, on more than one occasion, to admit frail patients to nursing homes rather than to hospital to keep them away from the Jabberwock strains of MRSA or C. Difficile (prn dif-ik-illy not dif-iss-eel it’s LATIN people!). There was even one occasion when I admitted a chap to get him away from the maggots (we are talking real live wigglies here, not the Lovecraftian imaginings of a diseased mind).
Still today’s notification takes things to a whole new level. I have a patient who was recently admitted to a nursing home for her own safety after a fist fight developed between her family and her carers.
From now on I’m thinking of changing the old monicker to Doc Holiday.
Wednesday, October 10, 2007
As a result, he is a bit put out to find his angina back again. It isn’t that severe. He can still manage hills and stairs pretty well. He just has to remember to pace himself a little better. And if he forgets (because inside he still feels closer to twenty eight than to his chronological “pushing eighty”) he gets a short sharp reminder. Given that he had been symptom free for much of the past three years this has come as a bit of an imposition, and he is keen to learn what I am going to do about it.
“These pills are no help at all!” he says, brandishing a green and white packet at me. It’s not one I immediately recognize, and with all the waving I can’t quite manage to read the tiny stick on pharmacy label that would inform me as to which precise anti-anginal medication has been letting him down. I take the packet off him, and call up his current meds on the screen. The box contains his statins (cholesterol meds useful for preventing further deterioration—but not for relieving the pain of angina when it hits). The screen shows he has no regular anti-anginal medication. But then, until the past few weeks he has not has regular angina either…
The screen shows his last script for any angina reliever medication was over two years ago, and this has long run out.
So he leaves with a script for a new spray, and my encouragement that he ought also to continue his statin and other meds as well. He’s also going to have a few follow on tests to make sure he hasn’t become worse, but all the evidence of his last investigations shows things were quite stable within the last three months.
I am a little troubled that both he and we have slightly lost the plot here. After all he did already have angina when he began attending the CHD clinic , and for all the preventives he is now receiving, it remains the case that his pre-existing ischaemia will, from time to time, make itself known, and when it does it is quite o.k. for him to react to this with reliever medication. It seems we both need to learn to see the wood again, as well as focusing on the trees...
Wednesday, October 03, 2007
Tony called yesterday to update me on his progress. He was effusive in his praise of the surgery, and of the hospital team he was referred to. In charming and measured tones he took me through his last few weeks, from my referral to the initial surgical outpatients appointment just a few days after. Thence to CT scanning and back to a different, oncology, outpatients appointment where they gave him the expected news, that he did indeed have a carcinoma, and that it was too invasive and widespread for surgery. He goes for palliative radiotherapy in the near future.
He appreciates that the prognosis is poor, and yet is quite unreasonably grateful to the team that have made the diagnosis and given him that information. It may sound surprising, but in my experience such innate nobility and generosity of spirit is not at all unusual. Indeed I would go so far as to say I often feel most appreciated* by those patients for whom I can do the least.
Annoyingly, the converse is also often true, and patients for whom one has attempted impossible feats of logistics, who have then accessed the specialist of their , often quite unreasonable, choice and undergone the high tech intervention for whatever problem they have presented, return to moan about delays in treatment, parking problems and the quality of the hospital food. After consultations like this you will find me tearing what little remains of my hair out, and wondering just why it is I heave myself out of bed each morning to come here...
And then Mrs Archer will wander in for a review of her Diabetes and High Cholesterol, and with a twinkle in her eye, and not a hint of irony, hand over a box of Clotted Cream Fantail Shortbread, “for you Doctor, from my holidays…”.
Well at least it helps explain her sugars and cholesterol!
*Such utterly unwarranted appreciation comes with a large slab of guilt on the side.
Friday, September 28, 2007
It worked like a charm for the gout. Only problem, it made poor Mrs A feel terrible: queasy, giddy, sore-tummied, tight-chested, in short pretty much all the listed side effects short of massive and life threatening gastrointestinal haemorrhage. She almost preferred having the gout.
This is a shame, because, and I can speak here from personal experience, when it works and is tolerated Indocid can be a great help. Still it appears Mrs A is particularly sensitive to the side effects of NSAIDs and so we perhaps should avoid them for the future. But Mrs A has the gout. Again. It’s time, to coin a phrase, to “get mediaeval on it’s a**e”. No more Dr Nice-Jest!
You see, for all our modern sophisticated scientific method, sometimes you just have to go the apothecary route. It’s time to wheel out the Autumn Crocus. More properly, time to wheel out that extract of the aforementioned known to our ancestors as colchicine. It’s a difficult drug to use because it can be quite toxic, causing vomiting and diarrhoea. Indeed the dosing instructions contain the comforting advice “take Ye until ye paine hath abayted or peradventure it happeneth that ye patient vomiteth or suffereth an flux of ye bowelf, prithee”, or words to that effect. It’s also a bit of a pain having to go back to prescribing in grains and drachms, but, for all that, it can and often does work every bit as well as the shiny new drugs, and is often better tolerated.
I have this mental image that the drug is prepared by tonsured and habited apothecary friars sequestered in sheds at the bottom of monastery gardens, dispensing antique wisdom and solving the odd ecclesiastical murder. Somehow I suspect this is no longer the case, but it suits my fancy to continue in my delusion, and to delight in turning the clock back a few centuries once in a while.
Wednesday, September 26, 2007
Students these days spend a lot of time learning about 'breaking BAD NEWS' along with other essential communication skills. We old sweats had to pick these things up the hard way. In reality I'm not so sure we didn't get the better deal though. The thing is, there ae just too many variables you need to factor in to being an effective harbinger. In my view it is damn near impossible to role play this particular scenario effectively, simply because none of the actors involved (one hopes) can truly have any concept of the stakes involved.
The dramatic conventions of stage and screen would dictate that each such occasion is played to the hilt, with everyone in the room wearing their heart on their sleeve and the whole spectrum of grief played out in a few short minutes. As with so much else in life, reality is somewhat at variance with high drama, or even with soap opera. Life, even the end of life, is a continuum. Our scene does not begin with the director shouting 'action'. Neither does it end with the close of the office, or house, front door.
Furthermore, a great many of those for whom the bad news is intended are merely having their own impressions confirmed. Granted this is not the case for all, but my own experience has it at a significant majority. Factors such as faith, ethnicity, family support, prior family history, and both the patient and their families past life experiences all need to go into the melting pot.
Next one has to consider the relationships already built up between doctor and patient (be they good or ill), their connection to the wider practice and community, and to their hospital consultants, teams and specialist units.
From all of the above, it should be pretty clear that there can never be a one size fits all approach to the harbinger business, and we risk confusing juniors, having them believe the whole 'Bad News' agenda has been dealt with in half a day of safe and cosy roleplay.
Now, returning to the question, I have two answers that at first blush may seem rather a cop out. I hope I can show you they are not.
The first and simplest answer is 'never good'. I am frequenly accused of having a penchant for stating the bleedin' obvious, but I fear it needs stating anyhow. With all the evidence presented, when faced with a life threatening diagnosis, it can feel rather as though you sit as judge, jury and executioner dishing out arbitrary and summary 'justice'. This feeling can be even worse if, with the 'benefit' of hindsight you feel the diagnosis was in any way delayed. And it can feel worse still if you have come to know the patient very well, or, ironically, not well enough.
Which brings me to the second and rather woolier answer. The act of delivering such a verdict, as previously aluded to, is interactive, with at least two participants. As a result the scene, though it shares a number of common threads, feels different every time.
For the majority of patients as I said before, you are simply confirming their own impression. It takes some pretty spectacular mental gymnastics to live for any length of time with a significant and potentially life threatening diagnosis, and not to at least guess that somthing is amiss. It can, and occasionally does happen, and when it does we can stray into the sphere of high drama.
But for most folk, with most significant diagnoses, you move speedily from 'what' it is to 'how' to make it go away / stop hurting / slow down. This is where one turns from simple messenger to true harbinger.
O.K. I'll admit, I had to go and look it up. I had always assumed the two terms were near interchangable, all be it that harbingers carried more portentous news, harbinging as they commonly do, Doom, or Spring or some other word requiring a capital letter. And so indeed they do, or did, but they do much more than simply foretell an arrival. They are the fore-runners, the attendants sent out ahead of notable personages to prepare the way. It is their job to see to it that shelter is arranged and that provisions will be on hand to sustain and refresh their charges.
So in the imparting of bad news it behoves us to think about the aftermath, and be ready to reach out and offer what shelter and sustenance we can. Where there is hope of recovery, however slight, we must be sure to offer that hope. And where there is none, we must make it plain that there is still much that can be done to offer comfort and support for as long as it will be needed.
And in doing this well, however painful the message can be both to give and, more particularly, to receive, by showing that we can and will always try to prepare the way, it is possible to take some pride in being an effective harbinger.
Monday, September 24, 2007
It has all the hallmarks, namely; frequent tantrums, regular spouting of meaningless drivel, and an unhealthy fascination with bodily functions. In fact it is just like any other two year old. Sadly though, it is not very likely that it will begin to develop signs of increasing maturity as it moves relentlessly from blog-toddlerhood to blog-kindergartendom.
It has been a fun couple of years on the whole, notwithstanding the attempts of Radio 4 to mess with my mind. I’ve met some lovely bloggy people (in a virtual sense that is) who are far saner and more mature than I can aspire to be, and they and this oeuvre have kept me as close to sane as I am ever likely to approach, so to all my many and varied therapists a big thank you is in order.
Sadly it’s too young for my favourite cake (a “bootlegger cake” made with tons of nuts, a modicum of rum, and a bourbon glaze for those who are interested) so I’ll just have to look after that for it myself, but there are party hats and hooters aplenty, and lots of crisps and e-number laden dainties to ensure another year of hyperactive misadventure for any who care to join in.
Oh, and a ball pool for us all to romp in, so don’t be shy, come and join the party!
Tuesday, September 18, 2007
The wagons circle and come to a halt in front of the desk. I half expect an influx of the whooping, bareback riding, arrow shooting Sioux Nation, all painted for war and sporting streaming feather bonnets.
Sadly this is not Blazing Saddles and no Sioux arrive. Neither does the revennant divine Madeleine Khan. Disappointed I slog on with the consultation(s).
On this occasion we have a family affair with both Nigel and Elizabeth requiring attention. Lilly spends her time lining up the trucks and passing daddy all the teddies in the room, one at a time whilst he tries to look masculine under a rising tide of faux fur. Freddie lies there, whirring and jangling in a miasma of frequent heroic farts a prop forward would own with some pride, to Elizabeth’s evident and rising embarrassment.
The consultation(s) ended, we begin the process of restoring teddies and trucks to their rightful places, and guiding the fartmobile through a series of complicated manoeuvres that would tax an HGV driver to the utmost. In a few short minutes (well ten to fifteen) the whole family is ready for the road, and off they go, as the sound of galloping palomino stallions draws ever closer.
Tuesday, September 11, 2007
So Pat found herself shunted off down the Yellow Brick Road to Oz… er, the Rapid Access Chest Pain clinic. They did a battery of tests, including and exercise EKG*. All were inconclusive.
In case you were wondering, that means that the RACPC has not been able to show that Pat has heart disease. But, in these enlightened times, this does not mean Pat is out of the woods. You see, the way the pathway works, if you have conclusive tests, i.e. proven heart disease, then to get whisked straight from clinic to Cardiology Out Patients to having a stent put in (where possible) before you can say “myocardial ischaemia”. And you get put on lots of drugs to “save” your life.
But if, as with Pat, the tests do not prove you have heart disease, well you still might have it anyhow, so instead of all the tedious mucking about actually making sure one way or the other, you just get put on lots of drugs anyway, “just in case”. Pat has been told she must come and see us to start her meds A.S.A.P. These are to include a beta blocker (recent headlines reporting these drugs are less good at preventing heart disease and so should not be used without a compelling reason) and a statin (to lower cholesterol- can lead to deranged liver function and rarely to muscle wasting).
Now, call me old fashioned, but before I start a patient on long term medication with a significant side effect profile, I would at least like a clear indication, and in the case of the statin a baseline blood test to monitor her liver function BEFORE she starts, so that when her liver function is abnormal on the statin (as it will inevitably be) I can be sure it was in fact normal before the treatment began. The only problem is, poor Pat is now scared she may drop down dead of a heart attack before she gets to start her treatment.
Unfortunately, the RACPC neglected to tell her that though we feel statins are an important part of the preventive treatment for patients with established heart disease risk, even where this is the case (which we as yet have no reason to suspect is so for her) we have to treat eighty patients to prevent one cardiac death.
Somehow we seem to have lost all sense of proportion in managing medical risk. Intriguingly this is happening as we see the drug companies more and more involved in training the Nurse Practitioners who run a lot of the “Rapid Access” diagnostic facilities.
* yes you read it right. I’m actually with the Americans on his one (actually of course it ought to be “epsilon kappa gamma” but EKG has to suffice to save all the mucking about with fonts etc.).
Friday, September 07, 2007
Then I could re-enact last night's little closing scene for you.
In they came . Lets call them, for the sake of argument (and yes I really do mean argument here), Mr Punch and his lovely wife Judy.
I should have guessed there was trouble brewing,. After all Mr P was late for his appointment. A mind boggling twenty four hours late for it! Now even my regulars don't expect me to be running that far behind, and Mr P isn't one of them anyway so his tardiness was quite spectacular. Still the receptionists were quite insistent that he really needed to be seen (a bad sign in itself) and so I invited him in.
Now in hindsight, Judy frog-marching him in, he with pained expression, she holding his right arm pinioned half way up his back, might also have been a bit of a "non-verbal cue" as we are trained to call them.
As they sat down I opened with a non-comm ital and cheery "What can we do for you?"
What follows requires the above puppets and swozzle to recount...
Judy-- He's been a very bad Mr Punch. He's not very well at all and he won't come to see you so I've had to bring him....
Mr P (swozzle)-- Oh no I'm not!
Judy-- Don't listen to him, I know all about it. He's been off at the naughty pub drinking lots of naughty beer.
Mr P (swozzle)-- Oh no I haven't!
Judy-- Oooh! He has too, and I need you to tell him to stop it.
Mr P (swozzle)-- Oh no you don't!
And so we went on. Round and round in ever decreasing circles. In the end it became apparent that their relationship (if such it can be called) was a relentless cycle of recrimination and reprisal and had been so for years. She thinks he drinks too much. He thinks she doesn't drink enough. Both may have a point. What they really seemed to need was a referee. I even had the temerity to suggest they see a counsellor about their relationship. As they were leaving, he turned to offer a parting remark.
"We tried that three years ago. they suggested we divorce!"
Now, at the risk of coining a phrase here...
Dr J (swozzle)-- That's the way to do it!
Thursday, September 06, 2007
The parish church was also built in the hamlet even though there are other somewhat larger settlements in the vicinity. At some point in decades past the church yard appears to have been renovated and a number of memorial stones discarded. Some wily former owner of the cottage we rented saw an opportunity there and so the path that leads from the gate to the front door saw us treading over elaborate 1830s copper plate inscriptions remembering Eliza, wife of Joshua of this parifh and the like. Somehow I suspect this simple act of thrift means the worthies so recorded come to more peoples attention now than they would have done remaining in the churchyard. They may also be remembered more widely since the visitors book suggests our recent predecessors in the cottage hale from several different flavours of abroad.
One of the delights of staying in such a small settlement is that for the sake of a five minute drive along one of the narrower Cornish lanes, you get to feel all the advantages of remoteness, without the attendant trekking and so forth. The traffic past our window was more hoofed than wheeled all week .
If you ever find yourselves in this neck of the woods, we can recommend the food at the Ship Inn in Lerryn, though the service is a little idiosyncratic. Still the salad tastes as good off the table top as it would have done on the plate, and the young waiter was ever so willing, if a tad dyspraxic…. The kids would also give the ice creams from the Lerryn village shop an honourable mention.
On the drive down the aforementioned lane from the cottage to the pub we discovered a new sport, Squirrel Racing. Three times during the week as we trundled our nervous way along one of the more single-tracky bits in the Famille Jeste Tour Bus, out from the hedge popped a squirrel. (We think it was the same one, but they may have a relay team in training….) Said squirrel then pelted along the lane alongside us for twenty metres or so before popping back into the hedge. The honours ended 2-1 in favour of the squirrel(s), though one of those was because the cheating little blighter kept weaving in front of us, plainly out of his own lane.
But the uncontested highlight of the week was a magic fifteen minutes on a small boat in Fowey harbour-mouth in the exultant company of a bottle nosed dolphin.
Sadly, already, just four days back in good old Ambridge, the hol’s seem a million miles away and half a lifetime ago. It’s been a bit of a week, But perhaps more of that anon….
Friday, August 24, 2007
So this morning, in anticipation of this fact, I have been to the train station in Borchester to book my train ticket for tomorrow morning. You see our travels are to be a two stage process this year through the vagaries of cat care. The advance party leaves by car, well our Big Red Bus actually, this afternoon whilst I am still slaving over a hot surgery. I shall return to an empty nest tonight, ready to crate up our two untamed panthers (well they think they are, and who am I to disabuse them…) ready for their hol’s at the cattery, and having deposited them at same first thing tomorrow morning,* I shall be making my way south to join the remainder of the family on the train.
This weekend, as well as being the first truly sunny weekend in living memory, is a Bank Holiday weekend here, and the last gasp of the school summer holidays, so all of England will be on the move. Indeed form the look of the station first thing, the diaspora has already begun. I pulled up on the concourse to be greeted by a scene from the “Golden Age”. Long-nosed Tourers with vast sweeping wheel arches and running boards a yard wide were dropping off ladies in billowy dresses and improbable hats. Small boys in sailor suits, and girls in pinafores darted up and down the platforms to a clatter of marbles falling from pockets and hoops being batted along with sticks. Blue uniformed porters huffed along behind two wheeled trolleys piled high with hampers and trunks. Then I realized I had turned up at the Severn Valley Railway station by mistake and went next door to the “proper” one.
I even managed to book a ticket on the train I wanted, at the time I wanted, and be in and out of the station inside five minutes (leaving plenty of time to sit and ramble before surgery gets going as you can see). So whilst I am away for the week, once again I donate this space to you gentle readers to comment as you will, and also, this year, to set a hare running.
In a comment on the previous post the charming Orchidea has asked me to write on how it feels being a “Harbinger” where there is bad news to be imparted. I intend to give this some thought over the week and to post a reply soon after. So is there anything else you “always wanted to know about GPs but were too afraid to ask” ? **
Oh, and whilst I'm away would you all mind keeping an eye on Jest Acres for me, the Green Recycling Bin needs to go out on Thursday if it's not too much trouble, and there's a wee bit of milk left in the fridge if you want a coffee or anything...
* I should probably have pointed out that I won’t be crating them up until it is time to go to the cattery, and not leaving them boxed up all night as my appalling sentence construction might have implied.
** with an affectionate (as in please don’t sue me) nod to the genius of Woody Allen.
Tuesday, August 21, 2007
You learn that “infarction” means death of tissue deprived of oxygen and is not just a posh way of saying “infection”. And you learn to call anything from a pimple to a tumour a “lesion”, ( rhymes with legion, from Latin laesio “hurting”). It’s a useful word, lacking all precision as it does, thus allowing us to talk about any variation in appearance or texture of skin in erudite fashion without revealing to the punter whether they should be terrified or relieved about the particular “bit” under discussion. It stops callow juniors from blurting out the word “tumour” inappropriately when discussing minor blemishes, or too soon when discussing major ones.
So far this week I have seen one lesion from either end of the spectrum. First came Tony. Tony has been getting steadily worse over the past month or so. He has lost weight, had frequent bouts of diarrhoea and increasing problems with control of same. He looks and feels wretched. Examination sadly confirms a large “lesion” per rectum. It is a tumour, and I have to tell him so. He is expecting the news and takes it phlegmatically. After all he has already had one brush with malignant disease and seen it off. He has also lost one child to another form of malignancy, and, after the awfulness of this, nothing much even comes close. His principal concern is if any proposed investigation and treatment can be out of the way before next years holiday, planned to celebrate a significant anniversary. I do hope it will be.
After Tony came Jennifer, husband Brian in tow. Brian is a bit cross. It seems Dr Neighbour treated Jennifer last week for a “lesion” on her shin. The blemish in question was a small area of non-malignant sun damaged skin or a keratosis. Dr N zapped it with our favourite toy, the liquid nitrogen gun, last week. The thing, far from dropping off in four to five days as she had hoped, has blistered rather alarmingly (as they often do). It needs no further treatment since as the blister separates it will take the keratosis with it naturally. It is best left to do this on its own, but Brian is not at all happy. He wants it out of the way before their holiday in two weeks.
I toy briefly with the idea of introducing him to Tony.
*Paronomasia being after all an aquired taste, even in the playgrounds of the wild westcountry.
Tuesday, August 14, 2007
Most of the partners at the Ambridge Surgery have school age kids still, and so tend to need to take some time off through July and August for child care / family holidays, which leaves us short handed pretty much all through this month and in to September. Then again, much of Ambridge itself, and indeed its environs, is also on holiday, so the workload also tends to go down. Particularly when our little corner of the midlands can’t compete with the likes of Stratford upon Avon (home of the Immortal Bard) or “Historic Warwick” (their own self appointed soubriquet), for the lucrative UK tourist market.
All in all, two days back from another week at home with the kids, I feel very much becalmed. Which is not so bad, giving as it does, valuable time for catching up on paperwork and preparation for appraisal and so forth.
The only slight problem, stranded as we are in these medical Horse Latitudes, is that we are hosting a new medical student this next few weeks, and there’s so far been nothing very interesting for him to see.
He’s quite an engaging lad really. A bit northern, but none the worse for that, and at least he’s not, as so many seem to be these days, (pause for dramatic effect) a Brummie…
So if any of you happen to be in the area, or are even thinking about passing trough, and could muster up an interesting symptom or two to offer the poor chap, I’d be eternally in your debt. And for once it appears you won’t have to worry about waiting for an appointment.
Wednesday, August 01, 2007
It’s so warm I’m sitting here in the lunch hour with BOTH consulting room windows open listening to the pulsing chink-chink of a reggae rhythm wafting in from the car park. There must be some law of nature that brings the reggae into full bloom as soon as there are more than four hours of uninterrupted sunshine and twenty-something temperatures if you ask me. In short, barring the absence of a suitably exotic cocktail, and the small matter of an afternoon surgery to be survived (chiz, moan, groan) all’s right with the world.
Which is good, because in the past few days much of the world has been calling in to visit us. So far this week, in no particular order I have seen Black South-Africans, White Zimbabweans, a Kiwi, a few Poles, a Russian, a guy from one of the Baltic nations (sorry can’t now call to mind which), an Uzbek, numerous Pakistanis and Bangladeshis, more than a few Jamaicans (one of whom regales me with a tale of woe about his erstwhile tenants, whom he took to be Chinese when they were in fact illegal Vietnamese immigrants) and even taken delivery of a box of Mangoes from a very kind and appreciative patient who imports them specially for me once a year.
Even ten years ago it would have been hard to imagine such a widespread mix of peoples visiting a sleepy suburban surgery in the heart of England, but nowadays such consultations are increasingly routine. The only thing missing from our little League of Nations is a coach load of Japanese tourists. Oh , no, hold on a minute, first appointment this afternoon, Mr Harunobu, bus driver….
* O.K so I made up the penguins.
Friday, July 27, 2007
Today he has been sent by the nurse for an overhaul of his treatment. His consultant endocrinologist has also sent us a letter advising he start medication to assist with his weight loss. He tried the same medication a few years ago, without success, but this time he feels he is better motivated to make a go of it. The reason…
Nurse has told him that if he can shift some weight she is more likely to fancy him!
Needless to say, this has got me thinking about the behavioural standards we observe as professionals. I am quite sure that the remark reported above was made in all innocence and in good humour. I also suspect it came at the end of what was probably a challenging consultation where he was again being confronted with a compelling need to loose some weight to improve his health and thereby his chances of longer term survival without complications.
Now, stop to consider how this scenario might have played if the patient were female and it had been a male clinician making the remark. I cannot imagine a situation where this might happen in todays litigious climate. And I find that a rather sad proposition. As many regular readers will know I am a firm believer in allowing humour in to the consulting room whenever possible, and yet I would involuntarily shrink from making such a suggestion, however well I felt I knew my patient. This may speak more to my grammar school educated, male only, formative years, but I suspect not.
Tuesday, July 24, 2007
Dr J (for it is he): So Mrs. A. what can we* do for you today?
Mrs A (with furrowed browed daughter hovering in the background adding emphasis in the proper places by mime every bit as artistic and expressive as the great Marcel Marceau): Well Doc, I come over all queer** at the weekend didn’t I.
Dr J: “?” (return of the inquisitorial eyebrow)
Mrs A: You know, proper poorly. (From the contortions and grimaces going on in the background I take it either that she has taken up Sumo as a new hobby, or had some sort of loin pain.)
Dr J: So what exactly do we mean by “Poorly” here Mrs A?
Mrs A: Oh you know. All “unnecessary” like. I was really breathless you know. I’m sure it’s the tablets. (At this stage my “Interpreter for the deaf” has gone into some sort of paroxysm, perhaps a scene from Psycho, but she didn’t do the “Film / Book / Play / Song” thing at the beginning, so I must admit to being a bit stumped).
I’m not sure if we were going round the houses or just the mulberry bush, but you get the picture. After a bit more verbal sparring and inspired modern dance interpretation in the background, we got to the gist of the consultation. Mrs A did indeed have a urinary infection at the weekend. That made her feel physically wretched, as anyone who has ever been so afflicted will attest it might, and that in turn brought on a series of panic attacks with hyperventilation.
Given that she already has the necessary antibiotics she left armed with and advice sheet and a brown paper bag.
I suspect I shall be seeing her daughter soon with a sprain or two judging by the way the poor lady limped out of the consulting room.
Still, the Royal College would be proud of me, picking up on all those “non-verbal” cues and all…
*You can argue that talking about oneself in the first person plural smacks of delusions of grandeur. I prefer to think of it as implying that I am putting the entire facility of the Ambridge Surgery, smoothly oiled diagnostic and therapeutic machine that it is, at this one patient’s disposal for the duration of our shared consultation. Then again, you might just be on to something….
** Mrs A is of that generation still able to use words like queer and gay without any connotation.
Monday, July 23, 2007
Fortunately not so at Jest Acres. It pays to live at the top rather than the bottom of the hill you see. Although even we were not immune to the effects of a vast tonnage of wet stuff invading the local electricity substation and making for a brief though undoubtedly lively firework display before plunging half the county into stygian gloom, in our case for about seven hours, on Friday night.
All weekend we have been hearing of friends and acquaintances who have been much less fortunate, forced as they were to spend a night in a local community centre, or in a couple of cases stranded roadside in a coach. There was news on the radio this morning of one poor lady who ended up giving birth in a caravan on the Motorway, with the help of the woman from the car behind who happened to be a midwife.
What has been really interesting in all the attendant chaos and disruption, has been the tone and content of the reportage. We are constantly reminded by reporters, none of whom are old enough, of the evocation present rescue activities raise of the "Dunkirk Spirit", almost as though the present act of a very Old Testament Vengeful God can be likened to the tramping through Europe of the Feldgrau clad hordes of a malignant, and arguably clinically insane, megalomaniac.
I freely admit to having been very fortunate in that I was not called on to travel to or from work last Friday, and so was spared the indignity of having to abandon the car and wade through sludge. But for those that were, and for those still unable to return home as a result either of flooded roads or houses, the threat posed by the current unseasonal monsoon and it's aftermath, is in no sense as real or as enduring as that posed to the entire nation and its way of life over sixty years ago. To continue to use such lazy journalistic hyperbole dishonours the memory of the generation that endured Dunkirk and the long grey years of fear and terror that followed.
This is in no way intended to belittle the impact of what are fast emerging to be the worst floods in living memory, on the communities worst affected. They are entirely desrving of recognition for their present day fortitude and forebearance. Likewise the emeregency services and their armed forces colleagues who have stepped up to offer vital support to those most in need of rescue in such trying circumstances deserve a more relevant and more contemporary recognition than to hark back more than sixty years for our exemplars.
Also, it would really help if the Beardy Man Upstairs would turn the taps off now.
Friday, July 13, 2007
Dr J: “?”
She: “I found it when I was in the shower a couple of days ago, an’ it’s still there, an’ I don’t like the look of it.”
He: Looks up at the ceiling in exasperation.
Dr J: After a few questions to elaborate that the rash is painless and has no association with bleeding or ulceration “Right, perhaps we’d better take a quick look.”
Round we go to nursies room for a quick look.
She: getting up to go through to be examined “Can he come in too.”
He: Another flash of eyes ceilingward.
Nursie: “Yes of course, in you come.”
So in we go. She scales the couch and reveals the offending area. He remains outside the curtain. I’m beginning to think he must be “something in ceilings”, or perhaps a modern Michelangelo Buonarotte.
And there they are. A little cluster of warty lesions.
Dr J: “Righto, what say you pop your togs back on and come back through to the consulting room and we’ll talk.”
And we do.
Yes, they do look like warts. Yes they might be sexually transmitted, but he has no such rash and is quite certain he has not been “playing away”. To sort things out she’s going to need to visit the GUM clinic where more precise diagnostics might be available.
The only thing is, from the looks on both their faces, the fall out from this little outcrop of warts looks likely to be pretty devastating.
Wednesday, July 11, 2007
"Hold up Dr J" I hear you cry, "just what the hell are you talking about?"
In truth I almost fear to utter it's name, for like the soon to be very topical once again Dark-Lord-Voldemort, it is a name of dread import, not to spoken lightly. It is.....
"Oh do get on with it you fool!"
Well alright, but don't say I didn't warn you. It's Hand-Foot-and-Mouth time again. Since last we spoke about this dread affliction the guidance issued by UK health authority the National Electronic Librray for Health has become even more reassuring. It has been said that HFMD (there, now it's even got a proper acronym and everything) might be implicated in early miscarriage if contracted when pregnant, but the latest NELH article makes no mention of this, because the risk is vanishingly small. And yet, once a tot gets the trademark red spotty hands and feet and is noted to have the same at any pre-school gathering, out come the black bordered plague notifications to be distributed to every parent of every tiny potential vector in the place.
The upshot is a week or two of exclusions of kids from their child-care, and a glut of tinies, spotted or not, through the duty surgery for scrutiny to see if they have "The Black Spot".
All I can say is heaven help the Pugh twins, and little Jack Silver.
Monday, July 09, 2007
Then there’s the awkward “You tell ‘im..”
“ No, you tell him…”
“No-no-no, you tell ‘im….”
By this stage you know something’s seriously amiss. Having sat there like a Centre Court spectator at a tie break, swiveling your gaze first one way then the other as the points alternate to around 9-8 in mum’s favour you finally feel obliged to interject just to get the consultation moving. You just know mum’s going to make junior do all the talking (whereas the “Pioneer Battalion” mums hit you with both barrels before Junior’s bum has hit the seat).
Then there’s the reveal:
“I’m gay and my boyfriend just died from Aids…”
“I’ve got a five bag a day Heroin habit…”
“I’m really Fifi not Freddy….”
“What do you have to do to be a sex addict? ….”
“I know you’re all in league with the Martians…”
You blink twice and pray the poker face has held (sometimes more difficult than others), and then you start to earn your keep.
“Right,” you say, “here’s what we’re going to do…..”
Tuesday, July 03, 2007
In no other mainstream occupation is it reasonable to expect and proper to ask clients to undress and expose their most intimate areas for inspection, or to expect them to do the psychological equivalent and bare their souls, thoughts and inner beings for scrutiny. This trust has to be earned by a proper respect for the sanctity of the person and the privacy of the confessional.
Doctors who abuse this trust by violating their patients physically or abusing or manipulating them emotionally do us all a great disservice. They erode faith in the profession, and they place unnecessary barriers between doctor and patient in the consulting room if patients are left in fear that their most private thoughts and feelings will be broadcast to all and sundry, or the doctor is left holding back on potentially life improving remedies because he fears a patient or a relative might misconstrue the intent of the treatment on offer.
How much worse then is the position currently emerging that suggests doctors are implicated in plans to commit mass murder. If this turns out to be the case then their status as doctors must be irrevocably stripped and as much distance as possible placed between their warped ideology and their bogus claim to be healers. Doctoring is not an exercise in academic excellence, as our universities seem determined to try to make it. Neither is it a badge to be picked up and put down, by day white coated healer, by night agent of a misguided holy war in the name of whatever ideology. Real doctors could never find any justification for such courses of action, however oppressed they might feel personally or as a member of a race, caste or creed.
So if the charges against the so called doctors who are alleged to have planned to carry out bombings prove to be correct, it behoves the profession as a whole, as it does in the case of the war that spawned such hatred, to state firmly and on the record, “Not in my name!”.
And as our exemplars we should rather turn to those presently charged with caring for one of the bombers presently hospitalized through his injuries, for though by their actions they might forfeit the right to practice their medical skills, no action can be allowed to stand between a patient in need and the skills and dedication of true healers.
Monday, July 02, 2007
It was a truly marvelous contraption. In the eighties it wouldn’t have been surprising to see such a machine festooned with wing mirrors and its owner in the very latest fur trimmed parka. The only problem was its wheelbase being a good six inches too long to safely negotiate the Ambridge Surgery hair-pin.
Regardless of this fact, and in the dogged determination typical of the generation that survived Dunkirk and the Blitz, the operator of this magnificent conveyance had been battering it back and forth against the apex of the corner in the hope of forcing a passage. And behind him was a queue of vaguely amused looking patients politely waiting for him to get out of the way, rather than offering to lend him a hand!
In the end we had to back him up into main reception whilst we cleared a more accessible room for his consultation. At which point he stood up, gathered his stick from the back of the contraption, and walked apparently unimpeded into the newly cleared consultation room for his encounter with Dr Neighbour, who being a little further down the corridor, and perhaps a little deafer, had missed all of the intervening excitement and was a little surprised to be called into a different consulting room to see his patient.
Monday, June 25, 2007
We somewhat more shabby looking and infinitely more sleep deprived juniors huddle round the hapless punter’s bedside, gazing at our shoes and wishing that Dr Bloggs hadn’t blurted out the first test that came into his head when the Prof quizzed the assembled company as to what was to be done to our victim next. After the round we would all shamble off to the mess and commiserate with poor old Bloggs, whilst secretly congratulating ourselves that for this round at least we had evaded the basilisk’s gaze.
Then we would have a group chunter about the arrogance of old age and professed professorial omniscience. How could we be expected to diagnose and treat without the freedom to do tests. After all we had sweated and strained for years to train to this point, finally to be given the run of the toy-box that was the path lab, only for our elders and betters to now repeatedly nag at us not to use it.
I’ll warrant that there isn’t a houseman / intern trained in the past four decades for whom the above scenario doesn’t ring true. And yet as I sit here in what I take to be the mid-point of my career, I find myself more and more on the side of the fossils. Perhaps this ossification is just a part of the natural conservatism (very small c for this writer) of advancing age and experience, but it comes more form the increasing realization that the more tests you put otherwise healthy folk through, the more anomalous results you find, and the less you have a clue what to do with them.
As a case in point I offer the following. Our local path lab has recently “enhanced” its level of service by including for free in all liver function tests an assay of an enzyme called (in short hand) Gamma GT. This enzyme is well recognized as a marker for excessive alcohol intake, but sadly it is not at all specific as other forms of chemical challenge to the liver (including many prescription medications) will also provoke a rise in levels.
In these days of health promotion and disease prevention we have a lot of patients on med’s (especially statins) that require regular monitoring of their liver function. In the past six months, since the path lab’s generous “upgrade”, many of them have had their liver function tests reported as “abnormal” as a result of higher than expected Gamma GT levels. Doubtless a number of these patients will have taken our advice about a glass of red wine a day being good for the heart a little too literally, but the majority (we are a sober society here in Ambridge—Eddy and Lillian notably excepted perhaps…) will not. And now they have “abnormal” Gamma GT’s what are we to do with this unasked for knowledge.
We have invited a professor to comment.
An eminent professor from the centre of excellence.
I’ll leave you to guess what his reply was….
Friday, June 15, 2007
The rain lashes the windows of the car before being unceremoniously shoved aside by wipers on their highest speed setting. The rain suddenly stops. The wipers flick little steams of sparkling diamonds over already drenched peasantry as they wave their, now extinuished, steaming firebrands at me. The wipers yowl in pain across the now dry screen then degenerate into desultory fart noises till I can flick them back to off.
On the whole I'm rather glad I only had one home visit to make today.
Monday, June 11, 2007
Exchanges have changed a bit since my day when you were farmed off to a family somewhere in the "near abroad" (France in my case, since there was no possibility of a latin or ancient greek exchange-- chiz chiz*) still in short trousies, and left to fend for yourself. These days the poor kids seem to have some cultural thingumy laid on every day and just use their host's places to crash in, except at the weekend.
So this past Saturday saw the gates of Jest Acres thrown open to around a dozen of our visitors and a similar number of their hosts. We were all on our very bestest best behaviour. No Basil Fawltys, no mentions of Minehead**, no "Two world Wars and One World Cup"s. Not that I think the kids would have known or cared what the hell the fuss was all about.
As a baby of a baby boomer, the last great european unpleasentness, and indeed the one before, cast a very long shadow. Not so for this generation. It was wonderful to see them all lounging about on the beatifully manicured lawns (did I mention I'd mown them myself-- no?-- really?) chatting about football, Schumaker and Hamilton, swapping Ipods and generally getting on with being teenagers.
Being parents of a lad, we had not, so far encountered many of his female contemporaries, so those he had invited to our little barbie were as new to us as their German guests. Indeed we had to spend a moment or two sizing each little girlie huddle up come feeding time before knowing whether to speak normally (assuming they were Brits) or slowly and loudly in time honoured tradition (if not). I have to admit to getting it wrong at least once.
And during all this whatever the correct german term for "entente" building, there was I manfully flipping burgers and sizzling bangers on the barbie, wreathed in the heady smoke of carnivore heaven. There can be few jobs more satisfying than hunter gathering a shedload of meat patties, scorching them to an even charcoal black, then watching the resulting mound of meat products disappear. And such caveman cooking needs no language, but crosses all supposed cultural boundaries, taking us all back to simpler times.
And this was when I stumbled across a dichotomy. As recreation there is nothing finer than setting to, firing up a griddle and providing for your tribe and their guests. Yet as an occupation it has become something to look down on.
Sorry, but that was it really. No great revelations or damascene experiences, but a thoroughly pleasant weekend in the company of a bunch of charming teenagers who despite their differing languages had more in common with one another through their use of Ipods, MSN, email the ubiquitous mobile phone et al, than with their wrinkly parents. Somehow I find this massively reassuring. However screwed up the world we have made for them I've got a feeling this next generation are globalized enough to start to put aside our traditional tribalism and get on with the job of sorting it out, or at least of going down in style to some bangin' tunes as the flashes from their camera phones light up the night sky.
* and ** attract the usual cyber-hobnobs for correct provenance.
Friday, June 01, 2007
Some things have undoubtedly changed, gone, for example, are the old “Nightingale Wards” of my medical youth. It’s all four bed bays now, and almost all single sex as well, and not before time either. Though it does rather deprive current inmates of those all too precious “Carry On” moments of yesteryear.
Thanks to the working time directive, perhaps helped along by decades of deficit and finally entrenched by the recent MTAS debacle, Doctors, even callow “Juniors” are now invisible. In two weeks of visits I think I saw a “Housemonkey” once, but it might just have been another visitor with lots of pens in his top pocket…
It seems in Patsy’s modern dependable NHS all the work of the ward is done by super-nursies instead. Not that there’s anything wrong with that per se, but I do rather wonder what has happened to the doctorin’ we used to be allowed to get up to between clinics and theatre lists.
On the other hand there is much that remains the same, and somehow, probably, always will. Rubbish gowns that show your bum to the whole wide world, horrid foam mattresses and pillows seemingly guaranteed to deprive even the soundest snoozer of the last vestiges of a restful kip, shabby flowers in greenish ooze in manky vases….
But the main thing I couldn’t help but notice is just how infantilizing the whole business is. From first thing in the morning to last thing at night the day is regulated and governed just like the Victorian nursery. You are woken at a set time. Breakfast follows. All the food, all day is nursery food, Cauliflower Cheese, Sponge and Custard and so on. And sometimes Nanny is “nice” and sometimes Nanny is “nasty”, but never Mary Poppins. The inmates are almost all and almost always talked to like three year olds by everyone from the Cleaner to the Modern Matron. Visitors command scarcely more respect. And despite the best efforts of Medical and Nursing Schools up and down the land the fine art of communication is abandoned in favour of the tone and ethos of the workhouse that once stood on the same site as the shiny new PFI hospital.
In such a regime the poor benighted inmates shrink visibly day by day, both bodily and emotionally to the same level. No wonder they are all so desperate to get out and reclaim their stolen adulthood.
Wednesday, May 23, 2007
The only thing is, the word means different things to different people. Some have given it a language all its own, with carefree talk about skinny this, grande that, latte the other thing, till no sane person under the age of thirty knows what the heck they are talking about. Some folk will accept anything wet and brown as the genuine article, others (present company not necessarily excepted) get all snobby and want to know what kind of beans it was made from and have a certain qualifying threshold of taste to be worthy of the exalted name.
In the final analysis, if it’s made from beans and not leaves, and isn’t chocolate, then it’s probably coffee.
By now most of you will have glazed over completely and will be left wondering what the hell I’m talking about. Or you’ll have gone to put the kettle on….
Oh, right, that’s Java for me then, and perchance a hob nob or two?
Ok this next bit requires a bit of a stretch, but stick with it if you can…
Right at the moment my caseload is suddenly overrun with patients with end-of-life disease. Most of my visits this past fortnight have been to administer palliative care or to help with bereavement. And most of the folk I visit would claim C of E as their religious denomination. And just like their coffee their C-of-E comes in all shades and flavours from the happy-clappy-evangelical skinny lattes through the christenings-weddings-and-funerals freeze dried instants to the high-church-latin-mass bean snobbery.
I could now descend into the depths of silliness and start assigning other choices of beverage to other faiths or denominations, (for some reason I’m getting Dandelion and Burdock for Wiccans about now….) but my point is (oh yes, there actually is one folks), we routinely ask for peoples denomination when we check them in for any variety of health service pretty much, and we take their professed C-of-E-ness at face value, but unless and until we ask what that really means (as I am having to do quite a lot at the moment) it is all too easy to lump them all in as freeze dried instants, when they might be looking for a whole lot more.
Brothers and Sisters, bless you all for listening. Here endeth the lesson. Now, where’s that Java…
Tuesday, May 15, 2007
And so without further ado, on with the motley.
Any GP will tell you, a request for a home visit to a patient in their eighties or beyond, where the notes are a slim folder, or latterly a near blank computer printout, with no clinical entry in over a decade, almost invariably spells bad news. Indeed generally the worst possible news.
At the other end of this domiciliary consultation there is almost always a large tumour of the breast, bowel, ovary or similar “occult” malignancy. Or rather, a patient afflicted with one of the above. A patient who has been enduring the onset of whichever it might be, silently, and for some time.
Often, though not invariably they have been living alone and untroubled by the world at large, with neighbours or other acquaintances seeing to their shopping. Being of a “self sufficient” generation they have tended to see to the cutting of their own hair, the mending of their clothes, and have their bills paid either by the same neighbours at the post office, or the bank by direct debit. Then, one day somebody turns up out of the blue, spots and odd contour in the clothing and decides it’s time to “get the doctor in”.
Of course it’s long past that time already, though there will still be things that can be done, and in the succeeding weeks a new relationship can be formed twixt doctor and patient as a package of care is built around their new found need. Almost always the patients are wholly undemanding, and would often rather have just been let alone in the first place, but again almost without exception they accept our “too little, too late” ministrations with good grace and a polite appreciation.
We tend to regard such patients as living in “denial” of their illness. I am increasingly coming round to the view that they are doing nothing of the sort. True, for some the diagnosis and prognosis come as a complete shock. But not many. Most have been well aware that “the game’s afoot” for months, if not years before coming to or attention. They have calmly taken the view that rather than be “prodded and poked” they will allow nature to take its course. Far from living in denial, they have been living in “acceptance”.
There is an art in caring for such cases that lies in laying out options, allowing fully informed choices to be made and then in stepping back and doing “just enough” to allow things to play out as they will. Caring need not always be synonymous with curing, and indeed in such cases seldom could it even if we wished it so.
Wednesday, May 02, 2007
Labour Day. Tanks rolling through Red Square in a show of might only the most organized form of labour can deliver...
...or May Day. Mrs Snell fretting as the Loxley Barrat infants tie one another totemlike to the Ambridge maypole with pretty coloured ribbons....
...or then again M'aidez the desperate gallic imperative that signals distress to the whole world, in the desperate hope that someone, anyone, might be listening and disposed to lend a hand....
It would be all too easy to take this post as an irrelevant whinge redolent of both self importance and self pity. I only hope you will all take my word for it that such was not my intent. After all we've known one another long enough for you all to know that's not my style.
In general I would far rather laugh off the stresses of the day, lurch with all the grace of an inebriate if stately W.C.Fields from one crisis to the next and keep on gigging. Indeed after this post I intend to return to doing just that, but not today.
So, why the long face I hear you ask in your best bartender voice. Well I'll tell you.
It all started on Friday. I was at a weekend conference of GPs and other interested parties. You know the sort of thing; a short talk before a long dinner day one, full on lectures breakfast to teatime day two, lots of small group work within the sessions, lots of networking between, and, trust me on this, nobody can set the world to rights like a gathering of gps. You see, we all know we're right about everything, all the time, and even when we are patently wrong. It's one of our most endearing traits. If you don't believe me, ask the wife.
So all in all these affairs tend to be pretty jolly, where all the afflictions that assail the human frame are sqaurely batted into touch by mid morning and we are just gearing up to take on the eternal verities over the lunchtime Pinot Grigio.
Except that for some reason this time the old GP magic just wasn't working. It turned out that we weren't even on steady ground with the afflictions bit anymore, hemmed in as we were by unprecedented levels of administrative interference in our working lives. Where before we had mostly felt free to examine the evidence for or against given remedies and interventions before offering them up for the adulation of the grateful masses, we were suddenly waking up to find the administrators had parked their tanks on our lawns and hemmed us in with Nice Guidelines, backed by the financial muscle of our immediate paymasters in the PCTs who keep muttering archly about with-holding funding from us if we don't prescribe in exactly the approved* manner.
Out on the village geen the strident Mrs Hewitt has managed to strap all the fledgling doctors of tomorrow to the MTAS maypole in miles of red ribbon and by the time she has funished untying them it will be a minor miracle if at least half of them haven't fled to Canada, Australia or New Zealand just to get away from her and her barmy schemes for their career development. Ironic when you think she's an ocker sheila herself....
All in all most of us are left with the impression that the NHS we all trained to serve, and had each commited decades of our working lives to, exists no longer, save as a convenient 'Golden Arch' style logo to be appended to all the little franchises that are setting up in business to replace it. The old public service ethos has finally given up the ghost. Our clinical independence has been frittered away on a 'pocket full of mumbles' in the form of our increasingly tarnished new contract.
And if you think all that sounds gloomy, I have to tell you I was one of the more optimistic members of our gathering.
* O.K. hands up who thought I was going to say "prescribed" again, eh?
Tuesday, April 24, 2007
I dunno where they went I’m sure. Ok at some point in those days yours truly got “another year older and deeper in debt” as the songsmith might have it, but the boat wasn’t actually pushed out that much so there’s no excuse there. It must be one of those Agatha Christie type lost week thingies, only without the mysterious hotel in Harrogate or wherever it was supposed to have been. Who knows. Perhaps in years to come there will be a great “Dr J’s Lost April” urban myth. Or perhaps not.
Moving on, we have noticed, here at the Ambridge Surgery, that there was a definite upsurge in “The Madnesses” over the past couple of weeks. Literally two of our long term but stable psychotic patients chose this past hot spell to drop a few of their collective marbles of their respective trays, to end up in need of hospitalizing. And there’s a whole couple of others who are simmering under.
Suddenly Ambridge begins to feel like New York (only with fewer bagels and homicides). Temperatures soaring into the thirties and all at once the entire population gets the seven year itch, cracks up or otherwise goes to pot, and we poor soles, we few, we happy few, we band of brothers, and, increasingly, sisters, are here manning the barricades and manfully (er – and womanfully) picking up the pieces.
Thank heaven for the past day’s rains. Perhaps that will help dampen their ardour and we can get back to proper General Practice*. In the meantime I’m off to buy an almanack just in case. After all it might pay me to know when the next full moon is due. And whilst I’m at it I think I might invest in some garlic and silver bullets.
* you know the sort of thing, peering into sore throats, doling out verruca creams and prying into peoples sex lives….
Thursday, April 12, 2007
Permit me to ellucidate.
The lanes leading to Ambridge are now firmly in the grip of Persephone. Hedges hitherto brown and stick-y have burst into a varihued emerald filligree. Trees of the proper sort (note botany is not one of Dr J's strong suits here) are busy wrapping themselves in pink or white candyfloss. Bluebells tinkle in the woods and Daffodils and Tulips nod their stately heads in the gentle morning breeze.
Indeed, since HMG so callously nicked an hours kip from us a week or two back, the usual morning drive has taken place to a backdrop of golden skies tastefully underlit by the newrisen sun. God is in his (or her) heaven, and all's very right with the increasingly warmer world. This also appears to be having an effect on the behavior of Borsetshire's avian inhabitants. At least on the basis of this morning's events.
And no I don't mean that behaviour, this isn't that sort of blog you know.
Scene 1 (a lane on the outskirts of Ambridge- a quaint English village. 08.03. In dappled sunshine) The big red bus sweeps gracefully round a languid left bend to be confronted by a cock pheasant. The aforesaid pheaseant is standing tall, owning the left hand side of the road. Stood in profile its black beady eye, surrounded by a piratical flash of red, fixes our hero with a look redolent of Saturday Night Chucking Out Time. "Come and have a go if you think you're hard enough" it declaims to the world at large and our protagonist in particular.
Ungentlemanly language can be heard as the big red bus swerves sharply to the right and away from the Pheasant's revolt.
Scene 2 ( the same lane, a little further on, past the crossroads and just along from the pub. 08.11. More dappled sunshine) the big red bus negotiates the crossroads with unaccustomed grace and elegance, instead of the normal ten minutes queueing and chuntering- Ambridge School is closed for the Easter Hol's- and glides on down the hill to the hollow, slowing and dropping in to third for the tight right hander at the botom of the dip. Taking the corner with the applomb of a rally driver at the height of his powers our hero is again confronted by an aggressive avian encounter.
This time he is mooned by a lady mallard.
Fade out to the sound of near hysterical laughter from within the big red bus....
Tuesday, April 10, 2007
Since not much has happened in my own little version of Ambridge lately, (unlike the "real" thing-- regular listeners will know what I mean and the rest of you really don't need to know, at least not for the purpose of this post...) I have been musing on a subject close to my heart, and thought this might be a good time to share the result of my deliberations.
Oh yes, the subject: Chocolate.
More specifically the purported healing properties thereof.
When I was a lad chocolate was indisputably bad for you. Even BAD for you according to some of the more virulent anti-choc' propagandists. It made you fat*, gave you spots and rotted your teeth.
Happily we now live in more enlightened times. Divers authorities would now have us believe chocolate is beneficial in all kinds of ways, reducing the risks of both cancer and heart disease, supplying vital minerals, elevating mood, even, they aver in hushed tones, enhancing the sex lives of women**-- and thereby presumably also of their companions...
It has even been shown to contain an ingredient (theobromine for those of technical bent) better at relieving cough than most commercially available remedies (though cramming it down so fast you choke is less likely to help that particular syptom-- Jesterly offspring please note!).
Given our posession of all these incontravertible scientific facts I now believe there is an unarguable case for putting liberal ammounts of chocolate on the NHS drug tarrif, to be delivered "free at the point of delivery" for the alleviation of all ills. To that end I am now shamelessly soliciting comments in support of my case for submission to the relevant authorities.
* An argument I believe I disproved in an earlier post-- neither will chocolate cause spottiness or tooth decay if used responsibly. So there.
** Could this be the origin of the mythic "Easter Bunny" of song and fable?
Wednesday, April 04, 2007
Today I have to tell you about one of those weird juxtapositions that throws the absurdity of what I do every day into stark relief. Please forgive me in advance if parts of this narrative come across a little more jaundiced than intended, as I said earlier it’s been a tough couple of weeks….
Just over a week ago Mrs. Snell arrived in surgery. She is a regular attender, sadly all the more so in recent months. Around a year ago she developed an annoying symptom. Neuralgia. Several times a day she is gripped by a sharp but enduring pain in her jaw, akin to the “mother-of-all-toothache”. This pain will last for minutes at a time, sometimes hours, and has no reliable preventative remedy. Capricious pains of this nature are also hard to manage with painkillers since the pills will take anything up to thirty minutes to kick in unless taken all the time, and in this time the pain will often have abated anyway. Medically the problem has a considerable nuisance value, and to Mrs Snell it is a torment that is slowly but surely driving her crazy. However it remians essentially trvial.
In the past six months she has seen a variety of dental, anaesthetic and alternative practitioners, taken their conflicting advice to heart, juggled with a complex regime of analgesics (up to and including Morphine), anti-epileptics and anti depressants, all of which form a part of the standard armamentarium of neuralgia treatment, and none of which are affording her lasting relief. At this consultation, as at several in the past I have had to advise her she might need to withdraw one of her several medications since it seems the side effects are outweighing any slight benefit it initially seemed to offer.
And every time we have to do this she gives me “The Look”. You know the one. It’s the look that says “I know what you’re really doing is trying to kill me”.
On any other day this would have been part of the normal cut and thrust. Sadly not on this last occasion. That same day was the day that Grace had died.
Grace came to see me around sixteen years ago, not that long after I had arrived at the surgery. She had gone through menopause six or seven years before that, and was a little put out to find she was bleeding again. One urgent referral, an admission and a lot of tests later she emerged from hospital with an inoperable gynaecological cancer. Undaunted she allowed herself to be put through the rigours of radio and chemotherapy, lost all her hair, but was put into remission. (And yes her hair did then grow back again).
As with all cancer diagnoses, especially when inoperable, she was then watched by her oncologist, initially every three to six months, then, after five years or so, annually, for evidence of recurrent disease. Sure enough, eventually, around eighteen months ago it happened. Despite poor odds, and the threat of repeated hair loss (no small thing for a lady at any age), Grace cheerily submitted to one more pulse of radiation and several courses of chemo, but by New Year it was apparent the treatment was no longer helping. She began to experience significant and increasing pain. In the end she bowed to the inevitable and accepted that paracetamol on its own was not going to see her through, and a couple on months ago she finally accepted a tiny dose of opiate analgesia, and we made one small increase in her dose a couple of weeks after. From that time on she told us she was pain free (though I have my doubts). She remained alert and coherent to the day she died, and only took to her bed in her final few days. Her outlook throughout was as positive as poor Mrs. Snell’s has been negative, and she achieved the best ending possible for herself and her family.
I know full well that knowledge of this would help Mrs. Snell not at all with her current problem, and am left fervently hoping that she will never be tested as Grace was.
Friday, March 16, 2007
Jack is in his mid seventies and had his first stroke a decade or so back. Strokes are weird things. the mechanisms are clear, either a blood vessel wears thin and bursts, nuking the surrounding brain tissue, or a clot forms within or lodges in an artery depriving a region of the brain of oxygen long enough to kill it off. In either event a bit of brain stops working.
The thing is, depending on the bit of brain affected you can get weakness or paralysis in muscles (because of the way we are wired up the muscles affected will be on the opposite side of the body to the hemisphere of brain containing the injured bit). This can result in weakness or full blown paralysis, and in either event this might or might not improve over the next few days to weeks. Additionally, again depending on where the vessel was and how much damage was done, sensations can be affected, speech and thought processes can be affected, fits can be caused.
Poor old Jack had quite a bad one, and got a lot of these effects. His right arm and leg didn't work properly, and at times his brain even forgot they were there (a phenomenon known as "sensory inattention"), he struggled to find words and had bouts of quite severe agitation often lasting several hours.
It was clear even early on that he was hallucinated when he became agitated. Eventually he got enough words back to tell his family what he was seeing. And what he was seeing was a swarm of moggies, who had, quite uninvited, invaded the house and were roaming at will. He really couldn't understand why his family were letting them in to torment him like this, and so he got quite cross and began to lash out. Whether this was directed at the cats or the family who were around at the time was not clear. What was, was that he was really quite distressed and unsettled by his hallucinations. And quite unaware that is what they were.
In the end it became clear that these hallucinatory episodes were part of the aura of a variety of epilepsy triggered by the brain injury of the stroke. Treatment with anti-epileptic drugs has really helped reduce the frequency and severity of his attacks and they are now much more manageable, to everyone's relief. However, in the interim the family hit on a novel solution to his distress. They bought him a dog. A big, fluffy cuddly toy English Shepherd. The brute is near life size and holds pride of place on the sofa beside him.
And he helps scare away the cats.
Wednesday, March 14, 2007
The Today programme are at it again. Or rather the Audit Commission as reported by the Today programme I suppose. Now it's the changes in Out of Hours arrangements that "have benefited no-one except the doctors".
Well, in purely financial terms this might well be so. You see, up until 2004 GP out of Hours care was provided to the NHS for free.
No really, it was.
Under the terms of the old GP contract individual docs had responsibility for their patients needs 24/7. To be sure right from the '60s the actual work was done by either co-ops of GPs working together or by commercial deputising services, but the responsibility for these arrangements was left with the patient's own doc, and it was that doc who paid for whatever out of hours arrangement he or she chose to use.
By the end of the 90's out of hours services had reached overstretch and were increasingly looked on not as an exceptional service there for genuine urgent need, but as an extension of normal services for anyone who chose not to make use of their own GP service in hours. Demand was steadily, even exponentially, rising, individual GPs morale was at rock bottom and there were even mumblings of mass resignations or industrial action if the spiralling demand was not better managed. In brief, the demands of the public at large, fuelled by the wholly unrealistic expectations of our political paymasters, had torpedoed and sunk the goodwill that had kept out of hours services going for four decades.
In the new GP contract responsibility for providing out of hours services was passed to the NHS management in the form of the Primary Care Trusts. GPs could still offer to be a part of the service provision, or could take a 6% pay CUT to no longer offer out of hours services. At the same time some of the process requirements made by the NHS for out of hours services (mainly to do with how fast the phones were answered) made it impossible for all but the largest GP run Co-ops to comply. In short we were shouldered out of being allowed to provide the service in a way we would wish, and obliged to pay for the privilege.
Granted, under the terms of the new GP contract our pay increased in a number of other areas, notably in the arena of performance related payments, but it remains the case that we continue to pay for the out of hours opt out to this day. And it should tell you something that the vast majority of us are happy to continue to do so.
For the following other lesser known facts of GP service provision in the UK I am indebted to the Avon LMC. Everything that follows hereafter is their work and was intended for wider dissemination, so do please tell all your friends.
There are approximately 36,000 GPs in the UK
It takes 6 years to train as a doctor and then a further 3 years to train to become a GP.
Each patient on average sees their GP 4 times per year – this means, there are over 250,000,000 GP/patient consultations per year; 15% of the entire population see a GP in a two week period.
The average practice in the UK has about 6,000 registered patients and 3 - 4 GPs. The average full time GP looks after 1,700 – 1,800 patients.
The average face to face contact with a GP costs £20, compared to £24 in a Walk in Centre, £27 for a telephone contact with NHS Direct, £75 for an attendance at A&E and between £100 – 300 for each attendance at a hospital Out Patient Department.
GPs are paid LESS than 20 pence per patient per day to provide all the day to day care that is required. This is less than the cost of a daily newspaper.
Surgeries are open from 8 am to 6.30 pm Monday to Friday.
Some GPs additionally provide care outside these times, via locally based out of hours services.
GPs refer about 10% of patients seen to hospital specialities, which means that nearly 90% of all health needs of the British population are managed entirely in general practice.
In a recent Government survey it was found that patients were more satisfied with their GPs than they were with the hospital service. General Practice in the NHS was the most popular of all public services.
In a recent Government White Paper, they stated that “by international standards general practice in England is efficient and of high quality. Indeed many countries view with envy our system of list based general practice”.
GPs are now paid differently in that nearly 50% of their income is via quality performance-related pay.
The performance-related pay is based on achievements made in the Quality and Outcome Framework (QOF). This consists of over 100 targets of which 76 cover 10 important disease areas, measuring performance against proven standards. This has contributed to the largest and most admired clinical database in the world.
The Government has transferred all its responsibility for funding part of GPs’ pensions to the GPs and then claimed this was a part of a pay rise.