Friday, May 30, 2008

Through the looking glass. (II)*

I dunno, what with all these Bank Holidays we have nowadays it seems we get paradoxically busier. I suppose it might also have to do with having two docs off for half term, and despairing parents looking for things to occupy the kids during the same…

Anyhow, it seems we have survived and so normaller service might soon be possible. Maybe. And after my more recent flights of fancy the weather has gone back to doing what it does best (being horrid) and it’s back down to earth with a bump for poor old Dr J.

Still, it gives me pause to consider another similarity I share with Mr. H. Dumpty, in that, when I use a word it “means just what I want it to mean”. Two instances today serve to highlight this fact.

The first relates to a blood test on a lady who feared she had rheumatism. In the event her blood tests have all returned “negative” meaning of course that they show now evidence of rheumatic disease, so in this sense a “negative” result is a “positive” message to be able to impart.

(Did that last bit sound a bit like that time honoured definition of cricket so beloved of northern tea-towel manufacturers at all? You know, the one that begins “You have two sides, one out in the field and one in. Each man that's in the side that's in goes out, and when he's out he comes in…”)

The second instance came in Asthma clinic. Sebastian is a runner. He also happens to have late onset asthma, and since a flu like illness in November he has had increasing trouble with his wheeze. Annoyingly this has been worse when he runs. We’ve tried a few different changes in meds along the way and the last one has restored his lung function to is previous excellent form. In effect he has lung function readings at 120% predicted, i.e. 20% better than normal. “That’s brilliant” say I, in all sincerity. “No it’s not” he retorts, “ my 100m time is still three tenths off what it was last season.”

Apparently it’s all about perspective.

* See I'm being green and recycling titles now.

Wednesday, May 21, 2008

In which I kid myself I am Mr D'Arcy.

We do love talking about the weather here in dear old Blighty. Well after all we seem to have so much of it and it’s so much safer than talking about politics, religion, or that other thing…

Here in Borchester it’s not at all uncommon to experience “four seasons in one day”, especially at this time of year. So to have five consecutive days of sunshine and actual warmth last week came as a bit of a surprise. Of course we are now back to “changeable” with “sunny spells” and “showers”, but it was nice while it lasted. Or at least it was for most of us. For one small group of our regular customers it has proved to be a bit of a challenge though.

To explain why, I need to take us back a couple of years. Around that time we got a brand shiny new test to play with here in GP land, the eGFR. It is a whizzy test to be sure. It tells us, by some clever sciency technique too complex for my little grey cells, how well a punter’s kidneys are filtering. This is a pretty useful piece of information, believe it or not. It is especially useful where a customer already has diseases known to muck up kidney function, like diabetes and some sorts or hypertension to name just a couple. And better yet, we have an evidence base of drugs to use to help improve renal function once it is shown to be “failing” as charted by a decline in eGFR.

The only thing is, in screening for other conditions, as we will often do in the elderly, we will ask to look at their blood chemistry (measuring other vitally important chemicals like sodium, potassium, urea and creatinine) and the lab now takes all that chemical soup and uses it to generate an eGFR result, even where that’s not what we were looking for. This in turn has revealed what we have actually known for a long time, but not previously quantified, which is that older folks' kidneys do not filter efficiently. This means that in the absence of any of the scary conditions alluded to above it is still quite possible to have a low eGFR and hence “renal disease” purely as a function of being older. And since we have a lovely evidence base for medicines that will help preserve renal function many of them are ending up medicated.

Now I know you all though sunshine was only medically important in things like rickets (good) and skin cancers and such (bad), but it seems also to have been having an effect on such medicated older patients. The class of drug most widely used in renal protection is the ACE (angiotensin converting enzyme inhibitors). And ACE drugs are known to lower blood pressure, and to do so disproportionately well in the elderly. Taking a little old lady, with “renal disease” (that’s little old kidneys to you and me) and bunging her on an ACE will likely improve her renal function a bit, and could drop her blood pressure a bit more than a bit. Now add in unseasonably warm weather (and them “not casting a clout”, May not yet being out and all) and a sort of "pressure cooker in reverse" effect takes place. So in this past week the surgery has seen a handful of little old ladies having a fit of the vapours as their blood pressure falls to “fainty” levels.

It’s called the law of unintended consequences. Still it’s kind of nice to think I can still cause ladies to swoon at my age….

Thursday, May 08, 2008

Wherefore art thou?

In bloody Ambridge, that’s where! He’s been here for a week and he feels rotten. Julie’ has chucked him out, and the prospects for a rapprochement seem pretty slight given that she’s about as far away from here as it’s possible to be and still be in Blighty. Nothing about this oft repeated scene should be that surprising. After all we live in the age of the disposable relationship, so it hardly matters how long they’ve been “stepping out together”. And anyway we’ve all been there at one time or another. It’s a developmental stage entirely normal in adolescence. Even couples we know damn well are going to get back together inside a fortnight have to have the plate flinging, hair tearing, I-never-want-to-see-him/her-again split if their relationship is to be taken at all seriously.

Except that today our Romeo is the far side of seventy and, being male and a bit unrecontructed, to make it to this age he has ended up on a regime of anti-hypertensive and anti-diabetic meds that would stun an average sized elephant (and an African Elephant at that). Of course he still feels sixteen on the inside, and for at least the last week has been getting by on caffeine and adrenaline in pretty much equal quantities without the balancing effects of sleep or a decent meal.

The final upshot of all these shenanigans sees Romeo come within an hairs breadth of a close encounter with the frayed and aging Ambridge Surgery Carpet. You see, not actually being an average sized African Elephant, the combination of anxiety, heartache, anti-hypertensives et al, has left him feeling a bit odd, and in mid consult he comes over all wibbly and threatens to faint.

Twenty minutes later after fifteen of those with his feet up higher than his head, and following a NAAFI strength tea with half a bag of sugar (yes, I know his blood sugar will go up a bit more that would be healthy in the long term, but we're talking emergency resuscitation here-- ask your granny, she'll tell you all about it...), he is restored to something approaching equilibrium. He’s gone off home now for a bit of a rest, a decent feed and the company of a mate. And without most of his anti-hypertensives.

If this story has a moral at all, I guess that it’s this; eighteen or eighty, male or female, if you absolutely have to chuck your significant other, spare a thought for the other poor souls in their GP’s waiting room and let them down gently. It takes a bit more than ten minutes for us to mend a broken heart, and the rest of the queue aren’t always that understanding. *

Thank you all for listening.

* though it is noteworthy that despite all having to tell me about how busy they were and how inconvenient the tardiness of the morning surgery was, not one of them elected to rebook for another occasion. Perhaps they think poor old Romeo will be back….

Tuesday, May 06, 2008

Off to see the Wizard...

Just as our Colonial Cousins love their Latin we properly educated Englishmen love our Greek, but however your opt to derive it Oedema* / Edema is a serious pain in the arse* / ass. Not literally of course as that would be proctalgia* (sorry, don’t know the proper American term for this though it might contain a G and a W), but I digress comme d’habitude. For those not aware of this beastly complaint, it involves the infiltration of soft tissues with fluid. The precise mechanisms that cause this can be complex, but generally relate to advancing age and failing circulation or to severe inflammation. (Yes it can also be a direct pressure effect on the lymphatic system caused by other nastier diseases or their treatments too, but far more commonly it is just part of getting older.)

At its mildest we see it as a bit of puffiness round the ankles, late on a hot day, and especially after sitting down for a long time (typically on coach trips to “attractions” so beloved of the pre-war generation). From here though it often progresses to a worsening sense of puffiness then tightness then pain and at some point along this continuum there is the awful sensation of squishiness when you walk, and unsteadiness as a result. Add in to this the failing of other senses, that can make tripping all the easier and balancing all the more difficult and oedema can become a thoroughly miserable experience.

Such is the case for Dorothy, who this past four months has been tipped up by the whirlwind described above three or four times. Far from ending up in Oz the first episode put her in the Hospital with rib injuries and a dislocated shoulder. From that time she has become quite reclusive and thoroughly miserable and all through the simple but inevitable process of the accumulation of a half pint or so of water in her feet. Our therapeutic solution to this is to dry poor Dorothy out to reduce the swelling using diuretics. These make her need to pass more water and often with greater urgency, which is itself not great when you fear falling with every step. The problem is the other common “solution” is to apply compression with thick and heavy elastic stockings, which though effective are almost as painful as the swelling, nigh impossible to apply unaided, and Toto aside, poor Dorothy lives alone. So today we have stepped up to a stronger diuretic in the hope that we can get her back into her ruby slippers. We need this to work to restore her confidence and to quite literally put her back on her feet.

* All underlined in wriggly red lines by my rotten American spellchecker.