Further Confessions of a GP (The Confessions Series)

by Benjamin Daniels

  In a speech given in March 2013, the then Health Secretary accused nurses of ‘coasting’, and stated that too much of the NHS is focused on reaching minimum targets, ‘at any cost’. He suggested that NHS staff were striving only to not come last, rather than achieving world class levels of excellence – the gold medals of health care. As the UK still basked in the proud glow that followed the 2012 Olympics, a comparison between athletes and nurses seems an effective way to suggest that hospital medics should strive to achieve better.

  Perhaps the most obvious difference between the 2012 Olympians and NHS hospital staff is the funding the government provided for them. When the London 2012 bid was announced as successful, the government provided careful planning, support and money to our athletes, and in the summer of 2012 the results were there for all to see. The vast majority of nurses and doctors actually do start their training aspiring to achieve ‘world class levels of excellence’, in much the same way that an athlete might in the early stages of his or her career. For medics, though, the ability to achieve these goals is often then compromised when we are told that we need to care for more patients with less staff. We are also expected to complete increasing piles of paperwork, which keep us away from our patients.

  When this causes standards of patient care to slip, we are vilified for lacking in compassion. It’s the equivalent of criticising an Olympic rowing team for not winning gold even though their boat was broken and two out of four rowers had been replaced with extra coxes shouting opposing instructions. It’s no surprise really that nurses and doctors are too often simply relieved to reach the finish line intact, rather than struggling on to win the gold medals that would give the Health Secretary his glory.

  I do agree with the Olympian/nurse analogy on one level. You could throw as much money, coaching and facilities at me and I could never become an Olympic athlete. However hard I trained and ‘strived for excellence’, I would never win an 800-metre Olympic gold medal. I’m just not designed for it, in much the same way that Mo Farah might make an awful nurse. Health care is not the career for everyone; there are doctors and nurses who perform poorly not because of facilities or funding but because they are in the wrong profession. I think we need to accept this early on in the training stage of medical careers and make sure we don’t let people work in the NHS who will never be able to offer patients the compassion and expertise they deserve.

  Thankfully, despite these poor performers often being the headline grabbers, there are thousands of nurses with the same compassion and dedication Sian has. Her Olympic moment for me was won when she missed her daughter’s 10th birthday in order to sit with a grieving relative. She won’t be offered an OBE or a lucrative sponsorship deal, but in my opinion she is just as deserving of a gold medal.

  Paradise

  It was absolutely pouring with rain, but it was our wedding anniversary and we had promised ourselves a rare midweek night out. After we’d made a mad dash from the car to the local Indian restaurant, a waiter opened the door for us and showed us to our table. As we took off our sodden coats, we watched as the drains on the street outside overflowed and an impressive stream of surface water ran down the road. We were the only ones who had ventured out on such a wretched evening.

  ‘Miserable out there, isn’t it? Like a bloody flood,’ I commented to the waiter as he came to take our drinks order.

  ‘No, sir. This isn’t a flood. I am from Bangladesh and we have real floods there. Many people die.’

  ‘Oh, well, yes, of course. Erm … I just sort of meant it as a turn of phrase.’

  As if I didn’t feel humbled enough, the waiter continued, ‘Every day I am thankful to live in this paradise here in the UK.’

  Looking out at the dark grey empty high street with the rain bucketing down, it was hard to try to picture this as paradise. There were no golden beaches or palm trees, but I knew what the waiter meant. Simply living in the UK makes us among the luckiest people on the planet. Regardless of the constant talk of economic downturns and double-dip recessions, we still live in a time and place in which the vast majority of us have food, shelter and safety almost guaranteed. I must admit that I felt slightly taken aback by the waiter’s comments, but I can understand how it might feel to listen to English people complaining about the weather as they leave unwanted food on their plates and then return to their warm dry houses.

  During a short stint working in Africa, I witnessed some dreadful things, which put my life into perspective. On the day I returned home I promised myself never to take anything for granted ever again. Under no circumstances would I complain or moan or whinge, and I would absolutely never ever say ‘I’m starving.’ Of course, I broke my promise and I do all of those things. Sometimes it requires a little reminder like this that really I shouldn’t.

  At work there are days when the majority of what I see is unhappiness. In the context of the ‘paradise’ our waiter saw in our homeland, it does seem a little obtuse. Of course, unhappiness and depression are complicated, and just because we don’t live in a war zone, or suffer famine or natural disaster, it doesn’t mean that there aren’t some fairly horrendous things happening within my patients’ lives that cause them great distress. Some patients tell me they feel guilty for how low they feel because they know objectively how lucky they are. Depression is a disease and for some of my patients it is a matter of trying to adjust brain chemicals or using therapy to deal with past traumas. But for people like me, who sometimes just get a bit grumpy about the minor inconveniences of life, I wonder if simply watching the news and gaining a bit of perspective might be more in order.

  Yes/No

  Often when my patients ask me for my advice it is with the expectation that I will be able to give them a quick Yes or No answer. I frequently disappoint them; the great majority of decisions made in general practice are a shade of grey as opposed to black and white.

  For example, one patient might ask me if she should take a cholesterol-lowering drug, or another might ask me whether he should have an operation on his knee. The patient hopes I’ll simply say yay or nay, but in both cases I’ll actually drone on endlessly about the pros and cons. I’ll recite boring facts, such as risk statistics, drug side effects and surgical complications. Eventually, after imparting my wisdom, I’ll turn the question back to the patient and explain that it is their body and their decision.

  However, just occasionally, I do have the very satisfying opportunity to respond to an enquiry with a definitive answer.

  One such question is: ‘Am I going to die, Doctor?’ This is one of the rare questions to which I can be 100 per cent sure of giving the correct answer: ‘Yes, you are definitely going to die. We are all going to die.’ I appreciate that the patient is usually asking whether they are going to die in the immediate future, but the reality is that as soon as we try adding that sort of clarity to the answer, we start moving back into that very unsatisfactory grey area again.

  ‘Is there a bug going around, Doctor?’ is perhaps the only other question I am commonly asked that I can always answer yes to. Unfortunately there is always a bug going around. It’s how bugs roll. If they stopped going around they’d die out, which sounds appealing, but according to microbiologists would result in disaster. I’ll take their word on that.

  A less common question asked by a patient recently was whether it was okay for him to have sex with his partner via her colostomy. Now, I really don’t consider myself to be particularly prudish – patients tell me about all sorts of slightly alternative sexual behaviours and I rarely raise an eyebrow. Even if I wouldn’t necessarily choose to partake in all of the said activities, anything that takes place between two consenting adults in the privacy of their own home is okay with me. Not colostomy sex, though. That’s a straightforward no.

  David

  I don’t think it will be a great surprise to any of you to hear that a reasonably high number of the patients who come in to see me leave my room without receiving a definite or immedi
ate diagnosis from me. The great advantage I have in general practice is that time is by and large on my side. The patient in front of me is usually not severely unwell. They may well be in discomfort, worried and upset, but they are very rarely just about to expire before my eyes. This means that there is a bit more time for me to work out what is causing the aching legs, funny rash or tiredness that my poor patient might be suffering from.

  However, working in the emergency department, time is often at more of a premium.

  When the paramedics brought in David, barely conscious and with slow breathing, I really needed to work out quite quickly what was going on. I couldn’t rouse him enough for him to tell me anything, so I was left with the tricky task of trying to deduce the cause of his comatose state from hundreds of possible causes.

  The best place to start was with the information that the paramedics already had at hand. They told me that David was 31 years old with no past medical history of note. He had been looking after his two-year-old daughter while his wife was working her shift as a nurse. He was absolutely fine when she left for work, but when she arrived home she found David lying unconscious on the sofa. Fortunately their daughter was unharmed and happily watching CBeebies, apparently unaware of her father’s poor health.

  Why had a young, previously healthy man suddenly gone into a stupor? I started trying to work through some of the more common causes. I began with diabetes, but his blood sugar was normal. There were no signs of infection and no signs of a head injury that might have knocked him unconscious. His breathing was slow, but his lungs seemed clear. I was hedging my bets that something was going on in his brain and so was sure that the CT head scan I had just ordered was going to throw up some answers. Top of my list of suspicions was that an aneurysm in his brain had popped, causing a type of stroke. We managed to get the CT scan done pretty quickly, but to my surprise it came back completely normal.

  Nearly 45 minutes had now passed and I still had absolutely no idea why David was unconscious. He was stable, but although he wasn’t getting any worse, he definitely wasn’t waking up. His wife had managed to find someone to look after their daughter, so was at his side, looking understandably upset and worried. I felt under huge pressure to work out what was going on. What was I missing? Barry the charge nurse wandered back from his break and took a glance at David. ‘Sure he’s not overdosed on something?’ he asked.

  ‘He doesn’t look like a drug user,’ I responded.

  Barry gave me a sideways look. ‘Come on, Ben, you’ve been doing this job long enough to know that doesn’t mean a thing. He’s a youngish bloke, unconscious with slow breathing. We both know the most common cause of that.’

  Because David didn’t fit my stereotype of a drug addict, I hadn’t even considered drug overdose as a possibility. Whereas, even before my other patient Kenny introduced himself as Crackhead Kenny, it wouldn’t have taken a genius to suspect that he might be a user: his clothes, his hair, his tattoos and even his smell … everything fitted the stereotype of the archetypal drug addict. David had a young daughter and a wife who was a nurse working at this very hospital. He lived in one of the nicer parts of town, and this was a Tuesday afternoon, not a Saturday night. He couldn’t have been taking drugs, could he?

  Barry was never one to turn down the opportunity to get one over on me. He grabbed a pen torch and shone it into David’s eyes. Both pupils were tiny. Next he grabbed David’s left arm and pointed out to me the needle prick mark on his forearm. We had taken blood and put in a cannula in his right arm, so the needle prick must have already been there when David arrived at hospital. Without saying a word, Barry went to the cupboard, pulled out some naloxone and injected it into David’s cannula. Naloxone is an antidote to morphine and heroin. It reverses the effects almost instantly. Within a minute David was awake, pulling off his oxygen mask and asking where he was.

  Barry was trying to catch my eye so that I would notice his smug smirk, but I was too preoccupied with David and his wife. Her relief at his recovery was very quickly replaced with tears of hurt and anger. As a nurse she knew the significance of his sudden improvement following the naloxone. Through her tears she kept asking him why. David only seemed to be able to answer, ‘I don’t know.’ It turned out that he had spent a period of time injecting heroin regularly in his early 20s but had kept away from it for years. For some reason, today his previous addiction had got the better of him and he’d tried to inject himself with the quantity of heroin that he used to take as a regular user. After such a long break, his body was naive to the drug and he accidentally overdosed.

  Russell Brand talks very eloquently about the power drugs have over an addict even after years of staying clean. For some people the pull of that ‘high’ is something that hangs over them for ever, however settled and happy their drug-free life might seem on the outside. I learned that day that I had to leave my stupid stereotypes behind. Clearly, anyone can suffer from drug addiction.

  The hardest part of the day was telling them that I was going to have to contact social services. I’m sure David was a great dad, but he had taken drugs when he was responsible for looking after his young daughter. Despite David’s pleas, I just couldn’t ignore that. I spent a lot of time with David and his wife, and we talked about getting help and support for them both. David had beaten drugs before, and there was no reason why he couldn’t again. He had so much to stay clean for.

  Hospital deaths

  There have been a fair few doctors and nurses over the years who haven’t exactly covered our profession in glory. It’s understandable that medics who have either deliberately or accidentally killed their patients make headline news. However, just occasionally, there are hospital deaths that aren’t solely the fault of the medical staff.

  One medical team in a hospital in South Africa started noticing that each Saturday morning a patient who occupied a certain bed on the intensive care ward would be found dead with no apparent cause. Initially it was considered a morose coincidence, but soon staff realised that there must be some reason for the patients in this specific bed to all die within a week of arrival on the ward. The doctors feared the bed was contaminated with some sort of killer bug that was infecting the patients. Appropriate investigations were undertaken, but no bug was found. Presumably because of a lack of beds, or an unwillingness to give in to superstition, the killer bed was always refilled with a new patient each week, but the mysterious deaths continued.

  Until, one day, somebody took notice of the cleaning lady as she did her weekly Friday-evening deep clean. The cleaner entered the ward, unplugged the life-support system beside the bed, and plugged in her floor polisher, before spending half an hour cleaning the ward. The staff finally realised what had been happening. Over the noise of her polishing machine, no one would have heard the gasps for breath and the death rattle from the desperate inhabitant of the ‘killer bed’. The cleaner would then plug back in the life-support, leaving a lovely clean floor and a dead patient. Labelled in the press as the ‘South African Floor Polisher Massacre’, the exact numbers of people who died still isn’t known!

  (Disclaimer: I have absolutely no evidence that this actually happened, but I read it on the internet so it must be true?!)

  Sinbad

  As soon as I had rung the doorbell my heart sank. High-pitched yapping of a small dog was followed by the scraping of paws against the front door – always a foreboding start to a home visit.

  ‘Sinbad, shuddup! Stop that noise!’ I heard, as my patient Mrs Briggs shuffled slowly up to the door and grappled clumsily with the handle.

  When the front door finally opened, Sinbad didn’t allow his advancing years or excessive weight to prevent him from jumping up at my legs and excitedly sniffing around my groin. Sinbad was a fat Jack Russell with a tuft of white hair on his chin that uncannily matched the sprouting white hairs on the chin of his owner.

  Mrs Briggs was a kindly lady in her 70s. She was large all over, but most notable was the size of he
r legs. Years of fluid retention meant that her legs had steadily expanded to the size of small tree trunks. The circumference of her thighs looked barely different from that of her ankles, with only a few creases of her tightly stretched skin to suggest where her feet joined her lower legs. Her bloated feet were completely solid, and poking out were 10 spherical toes with brittle yellow toenails nestled on top. The soles of her feet were made up of a white crust of rock-hard skin with a flaky surface and some cracked scaly patches around the heel. The only footwear that she could now fit into were some old frayed slippers that had had the back cut away.

  ‘Do you want me to lock Sinbad in the backroom, Doctor? I know not everyone’s a dog lover.’

  Every part of my being wanted to say ‘Yes, please’, but for some reason I politely agreed to allow Sinbad to accompany us. After Mrs Briggs had sat down on the sofa, Sinbad curled up contentedly at her feet and for just a short moment I felt something close to affection towards them both.

  ‘Thank you so much for coming out and visiting me, Dr Daniels. I’ve got some biscuits out specially.’ With that Mrs Briggs reached over and passed me a cracked china saucer holding a number of shortcake fingers. ‘Do take one,’ she said.

  Over the years I have had all sorts of refreshments offered to me by patients during home visits – cups of milky tea and custard creams are the norm, although I have been offered more than one gin and tonic, and on one occasion an old Rastafarian gent tried very hard to persuade me to share with him the enormous spliff he was smoking. As a general rule, I always decline the food or drink (or marijuana) offered by patients, but I’m rather partial to shortbread and I hadn’t yet had a chance to grab my lunch.