Friday, September 28, 2007

"The Pills"

Mrs Antrobus has the gout. She had it a few months ago and hobbled along to see Dr Neighbour. He, quite rightly, gave her Indocid (a shiny new Non-Steroidal Anti-inflammatory Drug – NSAID for short). Of course, by new here I mean invented during the latter half of the last century, but in overall terms that’s quite new really.

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

I read the news today.... oh boy!

A while ago Orchidea asked what it feels like being the harbinger of bad news. What follows is my best attempt at a succinct(ish) reply.

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

Party Time!

It had all but escaped my notice, but will come as no surprise to regular readers. This blog is now officially terrible.

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

Family Practice, a vignette.

Enter in procession Lilly (and teddy in pushchair), Elizabeth (mummy), Freddy (in pram, with attendant whirry jangly spidery mobile thingy) and, riding trail, Nigel (daddy).

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

Risk Management?

A couple of weeks ago Pat had some chest pain. It was unclear if her pain was indigestion, heartburn, or, perhaps, something more serious. But that’s o.k. In these enlightened times we have “pathways of care” to enable us to sift such problems.

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

Do I look like a Professor?

I'm thinking of taking the surgery out on the road, to perform under a red and white striped awning with a proper little replica prescenium theatre and some wooden puppets. And a swozzle. (I think that's what they're called, you know the things that make your voice go all "swozzley"...)

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

What we did on our holidays....

For one week the population of the tiny Cornish hamlet of St Veep has just been 15% Jests. The cottage was a sumptuous affair, spookily kitted out as an almost exact replica of our own dear Jest Acres, even down to the tea towels and crockery. Not that the tea towels are that surprising really, Cornwall being a much more appealing vista with which to bedeck domestic linens than grimy old Brum and environs…

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….