Monday, October 22, 2007

If you go down to the wood today...

The ghost of Monty Python is apparently abroad. Or to put it another way I’ve just had another of those completely surreal consultations that leave me marveling on the vagaries of the human character and chortling quietly to myself.

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

Welcome to Tombstone!

First a small matter of house keeping. It appears that after fifteen years the domain that also supplied my email address has been withdrawn. My very kind ISP have supplied me with a shiny new domain of my own and a new mail account to go along with it, so for those who feel the need to know, I can now be reached at “the-doctor-is-in(AT)doctorjest(DOT)co(DOT)uk”

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

Gosh, look at all these trees!

Bert’s angina has been playing him up. Over the past few years he has been a diligent attender at the CHD clinic, and his blood pressure, cholesterol, glucose et al are all perfectly managed. He takes his allotted and guideline mandated handfuls of pills as required. In short, Bert is a model patient, and he is managed to the last scintilla exactly to protocol.

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

In which Dr J has a bit of a moan...

This post has been quite hard to write and might be equally so to read. I’m afraid you’ll have to take my word for it that in no way is it intended as a whinge, however it turns out…

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.