Friday, September 26, 2008

Old head, young shoulders...

Freddy had an asthma attack two weeks ago. He had had a bit of a cold in the morning, but not enough to keep him off school. By mid afternoon school were worried and called Mum to come and get him, and when they arrived at the surgery the poor lad was really gasping for air.

For those to whom this means something he was managing a couple of words between breaths, chugging along at around 50 breaths a minute, using all his accessory muscles, and visibly tiring. For those to whom none of that is especially significant, suffice it to say he was pretty damned breathless.

We whacked him straight on a nebulizer (an air compressor through which we can, and did, aerosolize asthma meds—easier to use and more penetrating than an inhaler for a patient in crisis) which soon sorted out his breathlessness, and packed him off home some forty minutes later with an armful of inhalers, a spacer device (a chamber thingy to put the inhalers into) and some steroid pills, plus all the nebulizer tubing and mask he had just been using for him to play spacemen with when he got home (and to help the Out of Hours docs should they need to get him back on a nebulizer at any point that night).

Mum also went away with clear instructions to look out for a flare of wheeze or breathlessness around four hours later as the nebulizer would be wearing off about then, and if the inhalers didn’t quickly turn him around she knew to call for help straight away. Happily that advice was not needed and, as I discovered today, he was pretty much all better after 48 hours of more intensive medication. All through the consultation though, Freddy looked exactly as you might expect, a pretty scared, rather tiny six year old boy, in need of his Mum.

Not so today.

Today he comes for his review and to plan his treatment from here on. He pulls up his chair, alogside but some distance from his Mum. Today he is immaculately turned out in his school uniform, and not disheveled as when we last met. He has not a hair out of place, and is the living example of calm, composed self assurance.

We agree to try and monitor his asthma with a peak flow meter, and he masters the technique in a couple of puffs with aplomb. Then we need to measure him to see how his result matches with the predicted value for his age and height— “Though I’m not very tall for a six year old you know.” And neither he is, though still tall enough not to present any concerns about arrested development. We also agree he should have a spacer for home and a separate spacer and inhaler combination to keep at school and a peak flow meter for home monitoring.

“You should personalize them with your favourite stickers.” I sagely advise.

“Ooh yes,” says Mum “you could do that in your craft lesson this afternoon.”

Well,” Freddy draws the word out for emphasis “I suppose I might, but I will have some work to do this afternoon too you know.”

I’m left reflecting that this is a young man who will go far, and also struck by the difference two short weeks and a proper asthma management plan can make.

Friday, September 12, 2008

The N'octor* will see you now...

Last night I was at a meeting where the new GP Out of Hours Provider company were making their pitch. They have been awarded a contract to offer night and weekend GP services to the citizens of Borsetshire starting this October, and so are in the final run up to their takeover.

The mouthpiece for their organization is a tall, chiseled type, with blond and elegantly coiffed locks, in a shiny suit with a lavender shirt and tie. He just oozes “Used Car Salesman”-ness. And his pitch is flawlessly reassuring. Patients making contact out of hours will first be answered by expert call handlers who will speedily ascertain the patients ID and contact details before passing them on to a clinician. If all clinicians are busy and they do not have an over-ridingly urgent problem, then their details will be held until the first such clinician is available to call them back, and their target will be to return these calls within x minutes, where x is a vanishingly small number. Once they have spoken to a clinican, those that need to be seen will be offered a speedy appointment at the nearest centre, or visited at home if housebound.

The new providers are committed to training, and to staff development. They will even help little old ladies to cross the road, pop in at night to fix them their tea and biccies, and tuck them in and read them a story before bye-byes. (Well o.k. I might have slightly embellished the last few points.)

Over all though, an impressive performance by a polished (almost literally so) performer. That is, until we get the specimen rota for the service they are offering. In retrospect (having had the chance to sleep on it I suppose) it should have been obvious from Mr Smooth’s choice of words. Like Humpty Dumpty before him (and I believe as I have also said previously like myself in my turn) Mr S’s words mean what he chooses them to mean. To you and I, hitherto, I suspect the word clinician would have conjured up the image of a proper professional. Probably a Doctor, or, at the very least, a Nurse Practitioner with a higher level of expertise that the standard nursing qualification. It appears to this hallowed band of guardians of the common health and wellbeing we must now also admit the ECP.

“?” you ask, as well you might, and as we all did…

“ECP” says our lad, undaunted. “That’s Emergency Care Practitioner”.

“??” we chorus.

This brave new breed will be at the forefront of our overhauled out of hours services. Without wishing to in any way denigrate this noble calling, the ECP job description is essentially written for a paramedic with a bit of extra training in emergency care—perhaps 2-3 years training after school / college as a minimum, compared to the eight years required of GPs in training.

So, the best advice I can offer the citizens of Ambridge, is to try not to get ill out of hours anytime this winter, as instead of a guaranteed encounter with a GP as we used to offer they are now faced with a one in three chance of being left in the, doubtless entirely capable, hands of an ECP n’octor.

*N'octor-- increasingly accepted contraction for the phrase "Not-a-doctor"

Tuesday, September 02, 2008

"Tell me why...."

….. “I don’t like Mondays!”

So go the words of the song. And this was the refrain in my head for much of yesterday morning. Churlish of me I know, but there it is.

“But why,” I hear you ask “so irascible this particular Monday?”

I’ll endeavour to tell you, but in doing so I fear I will alienate you, gentle reader, so I ask you not to judge too harshly. The real problem is of course, not Mondays, or even this last Monday in and of itself. It’s what I was doing this particular Monday, in comparison with the preceding couple of weeks.

Regular readers will know that the past fortnight saw the Jest family annual peregrination to the sun (on this occasion on a floating palace around the Adriatic). In essence we have been pampered almost beyond endurance, whilst soaking up the finest sights that the central portion of the Med has to offer. We have braved “La Serenissima” by gondola after hauling ourselves out of bed at Day-Break to witness our arrival in this fairest of cities at a stately pace from thirteen stories up—and if anyone ever offers you the chance to do the same, don’t think twice. We have witnessed the miracle of reconstruction that is the pristine Old Town of Dubrovnik. Our pallid English bodies have braved 36 degree heat in Corfu…. I could rave on at greater length, but even I am coming to hate myself as I do, so I’ll leave it there, but you get the picture.

Mid way through our trip the eldest learned he has aced his GCSEs (the first set of really BIG exams in Blighty for our readers from other jurisdictions) so all is most definitely right with the world. (A “proud Dad” moment for you all there—I’m hoping it will ingratiate me a bit after the alienation possibly engendered by the paragraph above…)

Then we come back to dear old Blighty. It’s cold and it’s raining and it feels like it’s been that way all the time we’ve been away, and will be so all the time until we can somehow get away again. And on Monday morning the surgery goes hopelessly awry as every single patient asks me how the holiday went, just to heighten the juxtaposition.

Still if it keeps up this way we’ll soon be able to get around Ambridge by gondola too, so maybe it will all work out right in the end. Just keep me away from the gun cabinet, that’s all….