The last time I witnessed someone die of AIDS was 2002. He was a young man, barely out of his teens, and he was lying helplessly in filthy sheets in a Mozambique hospital. I can still picture the painful-looking sores eating into his lips and the skin cancers that had spread all over his body. Pneumonia was taking over his lungs, meaning he was gasping for breath. His broad shoulders showed how muscular he had once been, but now he was hunched over with his muscles all but completely wasted away. We gave him antibiotics to try to fight the infection but the HIV virus had completely destroyed his immune system. Each day on the ward round I saw him fade further away until he was almost a skeleton. Everyone was surprised how long he lasted. Finally, during my last week there, he gasped his last breath in front of my eyes.
Times have changed and now HIV is brilliantly managed by our local clinic. People living with HIV today can look forward to a normal life expectancy on treatment. Without treatment the condition is unpredictable and dangerous. I feel woefully out of my depth with Tarig, but while he continues to refuse to take treatment or be seen by the specialist, he is stuck with me, and I with him.
‘Look, Tarig, let me at least treat the thrush on your tongue. I can give you some drops that will clear it. And can you let me do some blood tests so that we know at what stage your disease is?’
Tarig reluctantly agreed.
I documented again very carefully Tarig’s decision to decline a referral to the HIV team and that he was of sound enough mind to make this choice. If he was genuinely going to die of this disease, I needed to make sure that I was able to protect myself medico-legally from any potential fallout.
Is the quality of NHS care really declining?
Late one evening 30 years ago, the senior partner at my surgery visited a six-year-old boy at home with a fever. He diagnosed a viral illness and advised paracetamol. By the next morning, the young lad was dead from meningitis. Mortified to hear of his mistake he visited the grieving family to apologise, but rather than being met with anger and legal proceedings, he was thanked by the tearful parents for his help and efforts the previous night – and he continued to be the family’s GP for years to come.
The diagnosis of early meningitis is as difficult to make now as it ever was and it is still missed by doctors today, as it was 30 years ago. Losing a child to the disease is as horrendous as it always has been. The difference appears to be that expectations have changed. We don’t yet have lawyers loitering around A&E waiting rooms or chasing ambulances, but there definitely appears to be an increased awareness that medical errors can lead to financial compensation and claims continue to increase year on year.
Annual NHS compensation payouts grew from £277 million in 2000/01 to almost £1 billion in 2010/11. This is partly related to the increase in the number of claims but also to the increased cost of the individual claims, which can be up to £10 million each. Ironically, this increase is in part due to improved NHS care rather than an increase in errors. The young boy with the missed meningitis 30 years ago may well have survived today. The diagnosis may have still been missed early on, but improved intensive care facilities could have resulted in him surviving, albeit with severe brain damage and physical disabilities. The biggest compensation payouts are made to help financially support severely disabled children who may now live for several decades but remain in need of long-term expensive care packages.
So in these times of desperately low NHS resources, what can we do about expensive compensation payouts? The obvious answer is to reduce the number of cock-ups. This may seem simple enough, but unfortunately mistakes and errors will always happen. The causes are multiple and I am not trying to brush over or dismiss them. I am also not trying to excuse them or suggest that the NHS and its staff shouldn’t be held accountable; I am simply stating that as long as health care is delivered by humans, errors will be made.
Every day the tabloid media offer terrifying tales of health-care blunders. It feels like a continuous drip-feeding of the idea that the NHS is broken and doomed to collapse. These stories feed fears that every operation will be botched and every medical decision made will be the wrong one. I don’t begrudge compensation payouts when genuine mistakes have been made and I’m sure the families involved would rather have the good health of their loved one than a damages payment. However, it is important to recognise that the rise in the number of claims isn’t due to standards of care in the NHS falling. We still have a long way to go, but here on the coalface, I genuinely think that overall the quality of care is improving.
As doctors, it is our job to learn from our mistakes, share them, be honest and open about them, and most importantly make sure they don’t happen again. As patients, I would advise that you ask questions, share medical decisions with your doctor and educate yourselves about your own health and illnesses. Medical mistakes have been, are and will always be made, but fortunately genuine cases of medical negligence are still rare. The cynic in me wonders if the constant drip-feeding of medical error stories is an attempt to convince the public that the NHS is failing and therefore dampen down any opposition as widescale privatisation of the health-care system is sneaked in through the back door.
Jimmy Savile
The exposure of child abuse allegedly perpetrated by Sir Jimmy Savile was a massive shock to me. As a kid in the 1980s, I used to love Jim’ll Fix It and was once greatly envious of those children who got to sit on his knee. Not any more. Although never my greatest hero (Daley Thompson wins that award), Savile was nonetheless an integral part of my childhood. A part that has now been completely tarnished.
Were I not a doctor, these allegations of abuse might have felt like a watershed moment for me. They might have ended a certain naivety bestowed upon me by the good fortune of a sheltered, happy and abuse-free childhood. As a medic, that innocence ended when I first set foot on a psychiatric ward a decade or so earlier. I was astounded at how many of the inpatients of both sexes had been abused as children or young adults. In medical school I had learned that mental illness was something that randomly afflicted people due to a combination of genetics and miss-firing neurotransmitters. I had been taught that in mental illness brain chemicals go wrong in the same way that chromosomes go wrong in Down’s syndrome, or blood clotting doesn’t work in haemophiliacs. Reading through the medical records of the female patients on the acute psychiatric ward, there was not a single one who had not suffered some sort of trauma as a child or young adult. Stories of sexual abuse, physical abuse, neglect and usually a combination of all three jumped out from almost every set of notes.
The psychiatrist in charge of the ward told me that she would be out of a job if she could somehow prevent anyone from ever being abused as a child. The psychiatric wards would be empty, she told me. Those wards weren’t empty. They were in fact full to bursting with desperate, damaged, unhappy people and the constant pressure of more people needing to be admitted was always there. Now clearly not everyone abused ends up with a mental illness and not everyone with a mental illness was abused. I’m sure genetics and brain chemicals also play their part, but the association between childhood trauma and mental illness in adulthood is well documented. I wonder if those adults who do the abusing even consider just how much pain and torment they cause and just how long it lasts.
Most A&E departments have regular self-harmers who repeatedly present to the department with cuts on their arms that need stitching up. In A&E, we only asked for the details of what had happened that day and would often feel frustrated spending time mending what appeared to be self-inflicted injuries. Here in general practice, we get the whole life story and soon learn that although the cuts on the arms are self-inflicted, the underlying damage was probably meted out by an adult abuser some years earlier. As a doctor it doesn’t necessarily make self-harm any easier a problem to manage, but at least it goes some way towards helping me understand it.
Of course, everyone’s aim is to prevent children being abused. As with Jimmy Savile’s victims, it
has taken until adulthood before many of my patients have opened up to me about the abuse they suffered as children. My constant anxiety is about how many of my young patients are suffering abuse right now. Statistics would suggest at least one or two, which is a sobering thought and enough to persuade me to keep asking questions and stay vigilant.
There aren’t many positives to take from the allegations that flooded the media following the exposure of Savile, but I hope that the current publicity might encourage us adults to remember how common child abuse is and to always bear it in mind when working with children and young people. Even more importantly, perhaps it will inspire one or two children to feel empowered enough to step forward and speak up about abuse they are suffering from right now. Many of us are wondering about the adults who were around during the 1970s, and asking how did they let it happen? Wouldn’t it be a great shame if in 40 years from now people look back on this generation and ask the same thing?
Nathan
‘I reckon I’ve got AIDS, Doctor.’
‘Right, okay, erm … what makes you think that?’
‘Well, I think that I might have caught it the other night.’
‘Did you sleep with someone you think might be at risk?’
‘Well, up until last week I’d never had sex before, but I think something might have happened on Friday night.’
‘Right, so what happened?’
‘Well, I got really drunk. I remember being in a club and then my friends say they lost me for about half an hour until they found me asleep in the kebab shop with sick down me and took me home.’
‘And are you worried you caught HIV that night?’
‘Well, I don’t remember you see, so I could have done. Anything could have happened in that half an hour.’
‘Well, yes, in theory, I guess, but do you really think you might have slept with someone when you were in that state?’
‘Might have done.’
I looked up at Nathan and wondered how I might put this without sounding mean.
‘I guess what I’m trying to say, Nathan, is that isn’t it a bit unlikely that you had sex in the half an hour between vomiting over yourself in a nightclub and then being found asleep in the kebab shop next door?’
Nathan looked at me blankly, as if this didn’t seem very unlikely at all. I would never claim to understand the inner workings of the female mind, but I can’t believe that any girl would consider a drunken, barely conscious Nathan covered in vomit to be sexually irresistible. I was really going to have to spell this out.
‘I guess what I’m just trying to say is that isn’t it a little bit improbable that you were able to meet a girl, chat her up, take her somewhere quiet and persuade her to have unprotected sex with you, while then managing to get back into the town centre and falling asleep in the kebab shop where your friends found you just 30 minutes later. All this while being so drunk that you could barely walk and were covered in vomit.’
Nathan did look a bit crushed. Perhaps I had overdone it a bit, although I did refrain from mentioning that in that sort of drunken stupor he was unlikely to have been able to get an erection. I really had pulled his story apart like a top lawyer laying into the defendant. Surely faced with such damning evidence, Nathan would crumble and accept that he probably didn’t catch HIV that night.
‘I still think I should have a test just to be sure. It would make me feel better.’
Under normal circumstances regular HIV tests are to be commended, but in Nathan’s case I was worried that by giving him a test I was colluding with his health anxieties. Nathan’s irrational fears about his health weren’t new. A few months earlier he’d been convinced that his very benign looking mole was skin cancer and wouldn’t be reassured until I sent him to see a dermatologist. He had also recently convinced himself he had a heart problem because he was sometimes aware of his heartbeat and so kept coming to see the nurse and demanding an ECG. In fact looking through the notes, Nathan was in the surgery almost every week.
We all worry about our health sometimes, but most of us have a sensible threshold as to when we need to seek medical help for our ailments. We are able to look rationally at our symptoms and decide how potentially serious they might be, and can usually reassure ourselves when they are obviously benign. Nathan doesn’t seem to possess this ability. He could be called a hypochondriac, although this seems a slightly crude, old-fashioned description. I would say he has health phobias. He has an irrational fixed fear about his health that often takes over his life and is very debilitating. When Nathan presents with yet another ailment, my gut reaction is to attempt to reassure him. He knows that he worries excessively, but his overwhelming health fears trigger a niggling doubt in me. Like the boy who cried wolf, perhaps at one point Nathan will genuinely have something wrong that needs treating and I’ll be the one that misses it.
Nathan and I became trapped in a folie à deux, in which he came to see me for reassurance and I encouraged his behaviour by offering him a test that gave him a brief respite from his fears when the result come back as normal. Round and round we went, but I decided it was going to stop today.
‘Nathan, you don’t need an HIV test because you don’t have HIV. You’re a healthy 17-year-old lad and you need to stop worrying about your health.’
‘I reckon I’d just stop worrying if you gave me an HIV test.’
‘I’m going to refer you to a therapist. To address your excessive health concerns. You need help to find ways to stop worrying about your health so much.’
Nathan looked at me blankly and then quietly left my room. He didn’t ever go to see the therapist I referred him to, but instead went and got an HIV test from the walk-in sexual health clinic. I guess that I ultimately failed in my plan to break the cycle, but on a more positive note Nathan does seem to be coming in to see me less frequently. Perhaps he’s better at dealing with his health phobias. Or perhaps he’s just given up on me and is sitting at home terrified that he is about to die from the latest of his perceived ailments.
Army medical II
It was a year after I had completed the army medical for Lee. He still looked like a young boy, but something had changed in him.
‘I’m due to go back for my second tour in Helmand, Dr Daniels, but I don’t want to go. Can you write something to say I can’t go back?’
‘I guess I can try. Was it really bad out there?’
‘It was terrible. All my friends back here keep asking me is if I killed anyone. I don’t even think I ever saw a Taliban to shoot at, let alone kill. All I saw on patrol were kids and women and old people, but every step you’re wondering if a sniper is going to get you. Every time you see a kid you wonder if they’re going to blow themselves up. They look at you like you’re scum and the women shout at us in their language and spit at us. Being in the vehicles was even worse. Imagine being in a vehicle that gets blown up by an IED [improvised explosive device] and catches fire. You either stay inside and burn or you try to get out and a sniper shoots you.’
He went on: ‘My mates think it sounds exciting, but I was scared the whole time even though most of the time nothing happens at all. Even during down time I couldn’t relax. All the worrying made me ill. My bowels were all over the place and I barely slept. Some of the other guys in the battalion took the piss out of me, but I know they were scared as well. I just can’t go back there. Since I’ve been back I’m just angry all the time. Please don’t make me go back.’
‘Lee, I can try writing something, but ultimately it’s the army doctors who get to decide, not me.’
I wrote a long letter stating that I believed Lee had post-traumatic stress disorder. They might dismiss it outright given that Lee hadn’t really even seen much action, but he did have all the symptoms. He couldn’t sleep, was having flashbacks and experiencing continually high levels of anxiety.
Lee was worried that I would think him a coward, but the thought didn’t cross my mind. I’ve never been in the situation where my levels
of bravery have been tested. Who knows how I’d cope in the environment of frontline Afghanistan, never being able to close your eyes and go to sleep without a little part of your brain knowing that a rocket could come flying through the window or a Taliban disguised as a police officer could shoot you while you slept. Why some people cope in that situation and others don’t, I’m not sure, but Lee was my patient and he wasn’t faring well. My letter concluded with the statement that I thought Lee was not safe for frontline duties and could be a danger to himself and his battalion. I hoped the army might believe me and give Lee a medical discharge.
Lee didn’t have to wait to find out if the army would discharge him on medical grounds. He got into a fight with some local lads in the town centre and his punch put a 16-year-old boy in intensive care. He is on remand and looking at a likely one-year stretch in prison. I haven’t seen him since, but his mum’s optimism about him going into the army to keep him out of trouble seems a sad irony now.
Betty Ferrari
I was working in A&E again. As I arrived for my shift my heart sank as I spotted the queue of ambulances sat at the entrance. Each paramedic crew was patiently waiting to offload their patient into a department that was already completely full. Barry was in charge today, and he was looking very flustered as he tried to move trolleys in and out of cubicles in a gallant attempt to make space when there was none. The phones were all ringing at once and it felt like a scene from a disaster movie.
Further Confessions of a GP (The Confessions Series) Page 6