NHS Blog Doctor: The Crippen Diaries 2006 (Week 6)

Monday 6th February 2006

February/March is always the busiest time of year for us. There is a lot of viral illness about. At least half the morning is full of hot children with not too much wrong with them. Adults have an increasingly extravagant vocabulary with which to describe the common cold. Temperatures, for example, always “rage”. Think about it. How can a temperature “rage”? What does a “head cold” mean? As opposed to a “foot cold”? And two people said, “I wouldn’t have bothered you, but I am going skiing, and I wondered if you could give me something to throw it off. How exactly does one “throw off” a cold? I mentally imagine a cartoon of the Highland Games “cold throwing” competition.

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A elderly man with severe asthma and bronchiectasis. I saw him last week, nebulised him, put him on a broad spectrum antibiotic and high dose steroids. He did not respond so I sent him in. He spent four days on the “Medical Assessment Unit” (that is another word for part of the A & E department so that the hospital can keep its three stars for not having people in A & E for more than four hours) and then a young houseman who he had not met before came in and said “the chest ward is still full so you might as well go home.” He goes home on exactly the same treatment I sent him in on, has a dreadful two days and comes back to see me. I am therapeutically destitute. He is on everything already. Back into hospital. Maybe they will find him a proper bed today.

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Three visits, one very difficult. A delightful extended Pakistani family. Grandmamma is in her eighties. She weighs nearly twenty stone. She has ischaemic heart disease. She has COPD. She has maturity onset diabetes. She does not speak a word of English. Her children are out at work. Her grand-daughter, who has two small children of her own, looks after her. Grand-daughter is on her knees. It is too much. God knows how she manoeuvres her onto the commode.

Families from Pakistan and India do not “do” nursing homes. They look after their own. Grandmamma needs to be in a nursing home but is wonderfully well cared for by her grand-daughter and the family. Except they over feed her. Constantly. It plays havoc with her diabetes. I keep telling her. The nurse keeps telling her. She just smiles and cackles. She may be ill and old, but she is still the materfamilias. What she says, goes. When she wants food, she gets it.

Today Grandmamma has fallen off the commode and hurt her ribs. She may have a fracture. Not too serious but it has tipped over her respiratory problems. She is looking a bit blue. She is still smiling away but she is quite poorly. Into hospital with her. She is unhappy. She knows she will be kept on a strict diet in hospital. When I have gone she will give her grand-daughter a bad time.

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Tuesday 7th February 2006

First in is David, a business executive in his late forties. I cannot control his blood pressure, or not satisfactorily. It was picked up a year ago at one of the health checks that Dr Crippen does not believe in. It was a consistent 190/110 when we started. He was completely asymptomatic. Nothing to find on examination. All investigations normal. We excluded exotica like renal artery stenosis, coaractation and so on. Having done all that and got him on four different forms of medication and only got his blood pressure down to 160/96 (on average) I sent him off to the clinical pharmacologists. They had a fresh start, re-jigged his medication, so that he is still on four different drugs but two of them are different. His BP today was 158/98. The latest letter from the Prof says, “…I think we are going to have to accept that David runs a higher blood pressure than we would like.”

Just so. David has now had eighteen consultations with doctors of one sort or another, countless checks with the nurse, given more blood for tests than a blood donor, taken six different forms of medication and we still have not got it right. He did not feel ill when we started on him. On balance, he says, he does not feel too bad on the medication, but he does get light headed occasionally.

I wonder, sometimes, if it might be better if we just withdrew our services from asymptomatic patients like David. But I must not be a nihilist.

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A 71 year old lady with angina who had an arteriogram five days ago. Three coronary arteries badly blocked. She had been taken Rennies for the angina for six months, and only came because they were not working and she wanted something stronger. She is on the urgent CABG list and will have her surgery within two or three weeks. She really will, even in the creaky old NHS. I guess in the USA she would have it done within two or three seconds, but this is not bad. The NHS still delivers for serious problems and, when it does, it cheers me up enormously. This should give her another ten years of life with a bit of luck.

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A worried mother with a five year old boy, Timothy. Timothy always looks pale. He is not eating enough. “The neighbour said he should have a blood test.” Timothy is a happy looking lad. He does look a bit pale. A careful examination reveals nothing. Mum has brought his Red Book. His height and weight are on the right centiles. He enjoys school.

I take Timothy out to play with the receptionists for a while so that I can chat with mum. A cousin of hers died of leukaemia. This a common worry for parents. It is very unlikely that Timothy has leukaemia or anything else for that matter. But you cannot prove a negative. Always difficult this one. I shall talk to Flea about it. I do not know Timothy does not have leukaemia (I bet he doesn’t). I do not know I do not have leukaemia (I hope I haven’t).

A blood test would be helpful but blood tests are not fun for five year olds. Difficult. I always try to get the parents on-side on this sort of thing, in transactional terms talk with them on an "adult-adult" basis. Some times you can. Sometimes you cannot. With this mother you can. We discuss the pros and cons of blood tests on five year olds and the risks and benefits. We agree to see how Timothy goes over a month and, if mother is still worried, we will do the test.

It's a compromise, as is life.

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Thursday 9th February

I mentioned the new simplified system for providing oxygen for patients at home last week. We have been filling in HOOF forms all week as requested. Allied Respiratory (must check out who owns them – I wonder if they are friends of Tony’s?) cannot cope and so we are going back to the old system.

We received this email today from the new “Prescribing Support Team”:

To: All General Practitioners
All Practice Managers
Community Nurses

7 February 2006

Dear Colleague,

Re: HOME OXYGEN SERVICE IMPORTANT INFORMATION FOR DOCTORS/NURSES

Due to the current problems the new supplier ‘Allied Respiratory’ is having with the demand for delivering oxygen supplies and the consistent problems patients and doctors are experiencing with the phone lines, we have been advised of the following arrangement that will assist with the supply of URGENT OXYGEN.

FP10’s can be written for patients requiring urgent oxygen - they will be valid, honoured and reimbursed. This arrangement can be used if needed until 31st March 2006.

Thank goodness we have the newly funded “prescribing support team”. This was formed to deal with the complications caused by the simplifications that have been introduced. I am sure the pharmacists and four nurse “specialists” on the “team” will all be justifying their salaries.

This is a microcosm of the way the whole NHS functions under this government.

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Sybil, the lady with the headaches and the daughter in America, came back today. The 4head has stopped working. I still have not had a letter from the neurologist, and her daughter is still wondering why she has not had a scan. He has told her they are tension headaches. I am sure that is right. Should he have done a scan “just to be sure”?

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A diabetic patient came in for several things. Eye check. BP check. He needed a lorry load of prescriptions including some Viagra. He is getting through a lot. That is his business of course. I am treating his wife for depression. He knows that. What he does not know is that one of her complaints is that her husband has lost interest in sex. The joys of general practice. More Chinese walls.

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Friday 10th February 2006

A long and frustrating day.

The third patient in is a sensible lady who I see rarely. She has been having panic attacks, or that is what she calls them. She has difficulty getting on a plane and more recently is finding she cannot go into lifts. She is getting nervous about going to the local shopping centre. What is going on? There is no evidence that she is depressed.

She is having problems with her seven year old son. He is developmentally and intellectually normal, but has large, tense muscles which tend to twitch. It makes him unable to take part in sports days at school and he tends to school-refuse on those days. He was assessed by the local paediatricians over a year ago. They referred him to a tertiary centre of excellence down in London. He has had a detailed assessment by the paediatric neurologist who has told mum that he probably has myotonia congenita, also known as Thomsen’s Disease.

Dr Crippen learnt about this at medical school. He has seen one case in the whole of his medical career. He is not able to advise this lady in the detail he would like because, even when he has read it up (he had just done that) he does not have a “hands on” feeling for it.

A blood test has been sent off for a DNA analysis. It has to go to a specialised centre as it is a rare and expensive test. They say it will take six months to get the result. I do not believe that. This is the NHS at its worst. Worried parents find it hard to wait six days never mind six months.

In the meantime, the paediatric nurse specialist, who usually sees them at the clinic, and who has never seen the condition herself, has advised mum to go home and put “muscular dystrophy” into Google and read it up. She and her husband have been doing that for a month.

I think we have something to work on now with mum’s panic attacks. What is going on in the NHS? How long to we have to put up with these well meaning idiots on the front end?

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I am now an hour behind. The next patient in is Kylie. She is in her mid-thirties. She lives with my alcoholic patient Trevor. Ten years ago, Kylie was a senior sales executive with a household-name British retailer. Company car, secretary, executive loo, the works. Then her mother developed a disseminated melanoma and after an horrific eighteen months, died. Six weeks later her father died of a sudden heart attack. Kylie is an only child. She went off the rails. Alcohol, cocaine, cannabis, cocaine and more alcohol. She lost everything. She now lives with Trevor in a squat. They do not have hot water. They have a weird psycho-pathological dependence. She has been dreadfully down for several years. Four days ago she had had enough. At five o’clock in the morning, she took all her clothes off, walked along the banks of the Grand Union Canal and jumped in by a lock. The cold water semi-sobered her up, she screamed and screamed and, fortunately for her, two police officers heard her. One jumped in, held her up until the other could get a rope. They pulled her out and took her to hospital.

After the physicians has sorted out the hypothermia, a member of the CMHT came to see her, decided that it was not a “real” suicide attempt that she was “acting out”. He told her to go home and make an appointment to see her family doctor to “talk about anti-depressants”. She was sent home with no discharge letter, no note as to the findings and no follow up appointment.

I spend an hour with Kylie. It is a complex problem. Jumping into the canal in the early hours of a February morning is more than "acting out" and whatever label you put on it, it is dangerous. Jumping into a bottle of Prozac is not the answer. She has no money and, as usual these days, thousands outstanding on her credit cards. She is not even making the monthly interest payments. The credit card companies are sending in the bailiffs next week to remove the few possessions she has.

There is no counselling easily available on the NHS in my area, let alone proper therapy.

Somewhere in the mess that is Trevor and Kylie are two decent, intelligent people. What can you do? No one gives a toss. They are on track to join the tramps and bag ladies of years to come.

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I am now two hours behind which is amazingly stressful.

So the receptionist goes out to the waiting room, explains there has been a hold up, says that all will be seen today but if anyone would like to rebook for next week, they may. No one does. They wait. It is strange. If you are fifteen minutes behind, patients get grumpy. If you are two hours behind and apologise, they are much more tolerant, indeed sympathetic. They get a kind of Dunkirk spirit.

It is still a hard day.

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