People feel low for all sorts of reasons and whatever they are they should still come and see their GP for support. The point I’m trying to make is that one size doesn’t fit all. Maybe we should try harder to look for alternative ways of helping people rather than always simply trying to make all the bad stuff disappear with a happy pill. Some people benefit from counselling or other forms of talking therapy, although, unfortunately, these are generally very oversubscribed and underresourced. Some people don’t actually want counselling or antidepressants but simply feel a bit better by coming to see me and telling me that they are feeling a bit sad. It can feel odd as a doctor not to then prescribe something or make a referral. It feels like I’m not doing anything at all but I’ve learnt not to underestimate the healing power of simply listening.
Top 1 per cent of the population
These are apparently genuine excerpts from medical school entrance exams.
Three kinds of blood vessels are arteries, vanes and cater-pillers.
Blood flows down one leg and up the other.
The hookworm larvae enters the human body through the soul.
For fainting: rub the person’s chest or, if a lady, rub her arm above the hand instead.
For fractures: to see if the limb is broken, wiggle it back and forth.
For dog bite: put the dog away for several days. If he has not recovered, then kill it.
For nosebleed: put the nose much lower than the body.
For drowning: climb on top of the person and move up and down to make artificial perspiration.
To remove dust from the eye, pull the eye down over the nose.
For head colds: use an agoniser to spray the nose until it drops in your throat.
For snakebites: bleed the wound and rape the victim in a blanket for shock.
For asphyxiation: apply artificial respiration until the patient is dead.
Before giving a blood transfusion, find out if the blood is affirmative or negative.
If the lady is sexually activated, you must do a pregnancy test.
Computers
I was on holiday in Namibia. I was sitting around a fire in one of the most remote deserts on earth, yet simply by using my mobile phone, I could instantly view photos of my cousin’s new boyfriend in Australia and read a full and detailed report on how my Sunday league football team had lost again in my absence. Once back home in NHS land if my patient goes to see a consultant at the hospital two miles down the road, I have to wait several weeks for his letter to be typed, posted, arrive at my surgery and then be filed by my secretary. It seems crazy to me that we are so backwards when it comes to something as essential as sharing important information about patients.
In general practice our failure to have embraced technology is usually nothing more than an annoyance, but in hospitals it can be more than that. Currently, if an unconscious patient is admitted to A&E in the middle of the night, the doctors will often have very limited medical information about them. The patient might have some paper notes in a file sitting in a secretary’s office somewhere, but unfortunately, there is no way that the A&E doctor can access the GP’s computer records, which might have lots of very useful information that could potentially help save the patient’s life.
If A&E had access to the medical records, we might have information that s/he was a diabetic or a heroin addict or even that s/he had advanced cancer and didn’t want to be resuscitated. As you can imagine at 3 a.m. on a Sunday, this information could be very useful and greatly increase the speed with which we could make a diagnosis. The records might also give us a relative’s telephone number and a list of the person’s normal medication.
There are obviously big benefits of having all our medical records on a computer system to which all healthcare professionals can have access. The area that many people are concerned about is maintaining confidentiality. There are so many people working for the NHS and in social care that sensitive personal information about us all could be available to a huge number of people. For example, if my sister up in Newcastle started seeing a new bloke, might it be tempting for me to look up his healthcare records? Unethical as it would be, I could find out if he had ever had genital warts or been arrested for hitting his ex-wife. These are the sorts of personal details that are often on our medical records and access is currently only available to the staff at your current practice.
Presently, the government is investing billions into a new integrated computer system for the NHS. The plan is that we will be able to store patients’ records centrally and also send referral letters and book appointments online. We are nowhere near having the system fully in place yet, but there have already been the usual grumbles of discontent. This has partly been because of criticisms about the quality of the technology and also opposition from patients and doctors. Personally, I do think that we do need to update the way in which we work. The technology would be a huge time-saver and, in some cases, a life-saver. Somehow we need to maintain patients’ trust and perhaps do this by allowing them to keep certain parts of their records excluded from the national database. The worst possible outcome of a national computer system would be that patients no longer felt safe disclosing personal information to their doctors.
Kieran
Perhaps the most influential thing that happened to me at medical school was the death of a close friend. Kieran and I did our A levels together and as I went off to medical school, he had gone off to Leeds to start a psychology degree. Towards the end of my first year, I got a phone call from Kieran saying that he was in the hospital attached to my medical school. He had discovered a lump in his armpit some time ago, but full of the excitement of his first year at university, it had taken him a while to get round to seeing his GP. He was quickly diagnosed with a type of cancer called non-Hodgkin’s lymphoma.
Over the next two and a half years, Kieran proceeded to have several courses of radiotherapy and chemotherapy for his cancer. He had periods of remission but, unfortunately, they were always followed by a relapse. Our worlds had always been very similar, but now they seemed far apart. I would sit in lectures learning about the side effects of chemotherapy and just a few floors above me Kieran was lying in a hospital bed losing his hair and vomiting his guts up. I used to pop in to see him between lectures and even wheeled him, drip in tow, into our student union bar to watch a few of the big England games during the 1998 World Cup.
Kieran came from a big Irish family. During my teenage years, I had spent a lot of time at his house and I knew his parents well. There was no one medical in his family and during Kieran’s treatment his parents clung to me as a source of medical knowledge and as someone to translate the jargon into real English. I didn’t really want this role. I was only a couple of years into medical school and hadn’t even heard of non-Hodgkin’s lymphoma when Kieran told me he had it. I wanted to be there simply as Kieran’s friend and wasn’t ready to play the role of doctor during this awful illness.
As I progressed through medical school, Kieran’s cancer spread and worsened. I learnt more medicine and did begin to gain a limited understanding about some of the medical components of his illness and treatment. Eventually, the cancer spread to his brain and although Kieran and the rest of the family seemed to view this as only a minor setback, my basic medical knowledge was sufficient to know that the prognosis was now very poor. Just after Christmas 1999, Kieran declared that he had been given the all clear. He hired out a bar and threw a big party to celebrate. Kieran still looked terrible but told everyone it was simply the aftereffects of his chemotherapy. Deep down I knew that something wasn’t right but I so wanted him to be cured that I let myself believe that he was. While his friends got drunk and partied, Kieran sneaked off home and took a massive overdose. He had been told earlier that week that his cancer was now untreatable but he clearly didn’t feel able to tell us this. He wanted to have a big party and then go out with a bang. I guess he needed to take back some control over his life that had been ruled by the
cancer for so long.
Kieran’s overdose was unsuccessful and he had two more precious weeks before he died peacefully at home. He had the opportunity to say goodbye to family and friends, plan his funeral and decide where he wanted his ashes to be scattered. We were all grateful for those last weeks and I hope Kieran was, too. At his funeral I remember his mum hugging me and, as we both wept she said to me, ‘This will make you a better doctor.’ An amazing thing to be said by a woman who had just lost her 22-year-old son. I just hope she was right.
Peter
‘’Allo, Doc. We’ve got a right one for you’ere. Mad as a box of frogs. We found ’im running down the middle of the dual carriageway completely starkers and shouting in gobbledygook.’
It was 3 a.m. on a cold February night and I was on call for psychiatry. The police had picked up my latest patient and, after diagnosing him with being ‘as mad as a box of frogs’, a common police diagnosis, they kindly dropped him off at the psychiatric ward for me to assess. The man, who we later found out was called Peter, was in his early twenties and looked fairly frightened. He was shouting in an unfamiliar language and was miming being attacked and chased. He gave the policemen each a hug (very much unappreciated) and they left him in my less than capable hands. Peter was wrapped in a blanket kindly donated by the local constabulary and given how cold it was outside, I wondered quite how he had survived any length of time being completely nude out on the dual carriageway in the middle of nowhere.
The most likely diagnoses going through my mind were some form of paranoid psychosis, possibly drug induced or maybe schizophrenia. He may have been having some form of manic episode but without him seeming to understand a word of English, the assessment was very difficult. We sat in a quiet room and I tried in vain to communicate, as did he, but we got nowhere. He had no clothes, no wallet and absolutely nothing to identify himself with. I admitted him to the psychiatric ward. What else could I do?
The next morning, I took my consultant to see him. Peter was a bit calmer, but still gesticulating and shouting. My consultant tried speaking to him in French, which gave me the giggles as it just made an odd consultation even more ridiculous, especially as my consultant’s French was terrible and the patient was clearly from Eastern Europe somewhere. We do have interpreters available but we had no idea where this guy was from so didn’t know where to start. After nearly an hour of getting nowhere, Ludmila, the ward’s Polish cleaner, came into the room to empty the bin. The patient took one look at Ludmila and then said a few words to her and gave her a smile and a wink. Despite the language barrier, it was obvious to us that Peter was speaking the international language of leering and bad pick-up lines. Ludmila gave him an icy look and turned to us. ‘He is of Belarus. He is not mad, just drinking too much wodka. Always the same is man from Belarus. Too much drinking, gambling and chasing of womans. Not enough working. They have bad reputation in my country.’
My consultant looked annoyed. ‘Ludmila, do you actually speak his language?’
‘No, just recognise he is of Belarus. All men from there are the same. Not mad, just drunk.’
‘Thank you, Ludmila, but perhaps it might be best to leave the psychiatric diagnosis to me.’
Ludmila shrugged, gave Peter another icy stare that made the whole room shiver and left. We phoned up the interpreting service and found out that it was going to be five days before a Belarusian translator would be available. We still weren’t sure if he was having paranoid delusions and needed some form of psychiatric medication. He had no money and didn’t seem to know anyone here so we kept him on the acute psychiatric ward. Most of our young male psychiatric patients spent their time on the ward sleeping, eating, watching TV and occasionally masturbating. Peter was like a breath of fresh air. He enthusiastically joined in the ward’s activities, going to the cooking morning, creative-painting day and Sunday morning yoga class. He also didn’t let his failure to be understood prevent him from trying all his favourite Belarusian chat-up lines on the female patients, staff and visitors.
Eventually, the translator arrived and we crowded into the interview room to finally conduct a proper consultation. Peter launched into a long monologue in Belarusian and, with the help of the interpreter, we were finally able to find out a bit more about how Peter had ended up on our ward.
It turned out that Peter had arrived in England the previous week to find work and make some money. He met some Lithuanians at the coach station and they said that they could find him some work on a farm picking cabbages. To celebrate his first night, they played cards and drank vodka. He got very drunk and remembers losing his money and then his clothes in the game. He didn’t remember much else but thinks he then got into a fight with one of the Lithuanians and they chased him naked from the farm. He was a bit cold but he assured us it was nothing compared to Belarusian winters. The police picked him up after an hour or so and he was very impressed that they were kind and didn’t beat him. He also thanked us explicitly for our kind hospitality during his stay. He found that English people were very nice but some of the residents here were a little strange. He had decided to return to Belarus, as travelling wasn’t really his thing. He then invited us all to stay at his home at any time and told us that we would all be made very welcome. Apparently, his mother made the best goulash in the whole village. Peter gave us each a kiss on both cheeks and left. I dread to think how much it cost the NHS to keep him on an acute psychiatric ward for five days but probably more than Peter could earn in a year back home. Ludmila was very smug. ‘Like I am saying, all Belarus man the same. Lithuanians man even worse.’
Granny dumping
Granny dumping is the act of getting your elderly relative admitted to hospital in the build-up to Christmas so that the rest of the family can have a less stressful holiday period. I remember the more senior doctors moaning about granny dumping in the build-up to my first Christmas after I qualified. I didn’t believe that it could actually happen, but every year before Christmas there is an influx of elderly patients whose families can’t cope with them any more or who are jetting off to a converted farmhouse in Tuscany that doesn’t have a stairlift.
Granny dumping is a very harsh expression and the actual individual cases are more complex. Being a full-time carer for a family member is an immensely difficult and often thankless task, but crises always seem to occur at Christmas and all too often lead to an unnecessary hospital admission. This is exactly what happened to one of my elderly patients one Christmas Eve. I was covering the afternoon session at a small surgery where I didn’t know the patients. It was nearly 6 p.m. and I was looking forward to getting home to start celebrating Christmas with my family.
The phone rang as I was just seeing my last patient of the day. A distraught daughter was crying down the phone: ‘It’s my father. We can’t cope any more. He’s got Alzheimer’s and he’s getting frailer. My mother had a stroke two years ago and can barely look after herself. We need some help.’
‘It’s 6 p.m. on Christmas Eve,’ I unhelpfully pointed out.
‘I know!’ wailed the daughter. ‘I’ve got my own family to look after and my sister is away skiing. Dad gets confused during the night and wanders around the house. He just needs someone to sit with him overnight. Someone to make sure he doesn’t fall. My mother can’t be expected to do it, she’s too frail. I’ve got my daughter and her young family staying at ours so I can’t do it myself. If you can’t arrange something, he’ll have to go into hospital.’
I hate these situations. I was being made to feel responsible for this person’s difficult situation. It wasn’t fair to admit him to hospital when he wasn’t actually unwell; however, I could see the daughter’s viewpoint. She had her own family to look after and didn’t want to spend Christmas Eve chasing her confused father around his house. What I couldn’t understand is why this always seems to happen just before the holidays start. Couldn’t something have been organised weeks ago?
This was a social problem rather than a med
ical one. Other than take him back to my house and have him spend Christmas with me, I didn’t really know what I could do. I ‘Googled’ the telephone number for the local emergency social services and gave it to the daughter. I told her that they might be able to organise some sort of emergency care overnight. Her dad didn’t need a qualified nurse, just a caring person to sit with him and guide him back to bed when he got up and started wandering. There were enough carers in this town who would probably appreciate the money and plenty who weren’t Christian and would happily work on Christmas Eve.
Half an hour later I phoned the daughter back to see how she had got on. She told me that she had dialled the number I had given her but no one had answered. After ten minutes she called 999. The ambulance had just taken her dad to A&E. Another Christmas granny dump delivered to the NHS. Once in A&E on Christmas Eve, there was no way that he would get home. The cost of the ambulance, A&E treatment and ward admission would be thousands of pounds and I just hoped he didn’t get a bout of MRSA with his hospital mince pies. Someone sitting with him overnight would have not cost more than £100. What a waste.
Some areas have wonderful emergency social services with a team of physios, carers and social workers on call to provide urgent assessments and vital care to people who desperately need it. They keep people out of hospital, saving money and preventing people from catching MRSA and other hospital bugs. Unfortunately, most emergency social services teams are terribly underfunded, understaffed and suffer from low morale. They might not have a flashing blue light on their cars but they are desperately needed and would pay for themselves many times over by preventing unnecessary hospital admissions, especially at Christmas.
Confessions of a GP Page 16