The Crippen Diaries (Week 11)

Not quite Tannochbrae

Monday 13th March

A particularly bad, trying day at work. Arrived in at 7.50 a.m. feeling glum and chatted to two of my partners. We have all read the same articles in the newspaper over the weekend. The blessed Patricia is now saying that the problems in the NHS are due to the doctors.

Alright, she is only a politician. It is nonsense. But it is in the papers. People will believe it. It is deeply dispiriting, and our morale is already rock bottom.

And then on to the morning surgery from hell.

++++++++++

First patient is David. Elderly man. Charming. He was a tank commander during the war. He is in atrial fibrillation, he is not maintaining his blood pressure, he keeps flipping in and out of heart failure and is being admitted for pacing in two days. When Dr Crippen was a houseman, all patients such as this were “clerked in” by the houseman. That does not happen anymore. Nowadays, they are assessed by cardiac nurse specialist. She is much cleverer that Dr Crippen because she can do this assessment by telephone. David has had a letter saying that he should be at home by the phone this afternoon, waiting for her call. He is puzzled. “How can she assess my cardiac status over the phone?” Beats me. I have to use a stethoscope, but then I am only a doctor.

++++++++++

Mavis is a hugely efficient retired social worker. Her husband has Alzheimer’s disease, quite advanced now. There is a three year waiting list for in-patient care of Alzheimer patients and he has only just gone on it. Social services offer her two weeks respite care a year. She is not managing. She is on her knees. She has a bit of angina (stable) and needs full investigation but will not go for it at present.

Trouble is, she is looking after her husband really well. So when social services “assess” her, she is classified as low need. She knows the system. She worked in it herself. “The best thing I could do is have a heart attack, then we would be high need” she says.

She is right.

++++++++++


Tuesday 14th March

A calm routine morning. Lots of coughs and colds. I’m afraid I did not fight the antibiotic fight as well as usual. The first hay-fever sufferer of the year? I think the pollen count is zero and the weather is still artic. Maybe he is allergic to snow-drops.

++++++++++

Lunchtime meeting with most of the other partners. More QoF nonsense. Strangely, the stress of yesterday has made me less angry about it all. The district nurse says that the news is good from the hospital about the bed sores. Why do we have to wait for the crisis? And the QoF? Well, I suppose the government is trying its best, but it has just got it wrong.

We talk about how to solve the nursing crisis. It seems straightforward. A lot of girls who want to do nursing are kept out because the entrance criteria for nursing, certainly down in London, are much the same as they are for university. We need to reduce the academic requirements and allow young people with practical skills back in.

++++++++++

A much busier afternoon. You rarely get a day which is quiet through out. A home visit to see an elderly man who has tripped on his patio. He has a spectacular black eye and conjunctival haemorrhage. Conjunctival haemorrhages look scary and frighten people but are rarely serious. Otherwise, I think he is all right, but you have to give the usual head injury instructions and you always wander away thinking about sub-dural haemorrhages.

++++++++++

A two year old boy with a urinary tract infection. Mother is flabbergasted when I say that he will need to be investigated. Can’t you just give him some antibiotics? I can certainly do that, but he needs investigating to make sure that the urine in his bladder is not refluxing back to the kidneys. Mother does not seem to believe that we will have to order scans and involve paediatricians, but that is what has to be done.

What did my old Professor say? In the UK each year 2000 people go into end-stage renal failure and in at least half of the cases, the damage has been done before they are four. Snippets of medical school programming stick for life. I don’t know if it is still true, but it is built deep into my hardware and cannot now be eradicated. Whatever the current figures though, they all need investigation.

++++++++++



Thursday 16th March

Phyllis is a very valuable patient. She is 59. She is overweight. She smokes forty cigarettes a day and has done for years. She takes no exercise. Her cholesterol is 7.2 and her BP is 168/90 despite treatment, or perhaps because she does not take the treatment that we give her. She works in the local petrol filling station. She lives alone in a small council flat and she is terrified of doctors. One could earn a fistful of QoF points from here if one did all the nagging one is encouraged to do by the blessed Patricia. We do try. Gently. But Phyllis is frightened of doctors. She does not like taking tablets and she does not really understand the significance of high cholesterol. But we do out best.

A few weeks ago she made an appointment of her own volition rather than after being chased by the practice nurse. She had developed angina. It was not easy to get the history from her. There were no abnormal physical findings apart from the raised blood pressure but, on the history, it was unstable angina. It was coming on at random, often at rest.

Patents with unstable angina need immediate hospitalisation. I arranged for an ambulance to take her in. She was both horrified and terrified.

The NHS is good at this sort of emergency. She was assessed in the local hospital, had an arteriogram, and was then transferred to the regional cardiac centre for a CABG.

On arrival there, someone noticed that there was a shadow on her CXR which looked ominous. She had a bronchoscopy the following day and the biopsy confirmed a lung cancer. Not surprising with her history. She was asymptomatic from the lung point of view and in a back to front way was probably lucky that she had developed the angina as it enabled us to discover the tumour earlier than we might have done. And it is operable. All the screening investigations were normal.

There was one thing outstanding. “I have to go to another hospital for a PAT scan.” She meant a PET scan. The first hospital had made the appointment for the scan. Then she had received a phone call from the second hospital saying the scan was cancelled as they did not have the funding as they were in a different Primary Care Trust area. Could she phone her doctor to get him to make sure that the PCT funding for the PET scan was in place, and then could she phone the hospital back to arrange another date.

Phyllis is frightened of doctors. Phyllis is frightened of lung cancer. Phyllis is frightened of operations. Phyllis is mystified by arcane three letter acronyms and, it transpires, Phyllis is a bit frightened of using the telephone. Phyllis was in tears. Not because of the cancer. Not because of the angina. But because she was not able to cope with having to arrange a scan herself.

So we did it all for her. It took awhile but it is sorted. Whilst the receptionist was attacking the bureaucracy, I checked her BP and reviewed her medication. She is on the full whack of anti-anginal, anti-hypertensive medication and the angina is controlled for the present. She still needs surgery. She asked me if they could do the operation on the lung at the same time as the CABG. She had been too frightened to ask at the hospital. Ashamed to say I was not certain. I suspect you have to go in a different way for a pneumonectomy or lobectomy so it may mean two goes. I will have to find out.

She will have the PET scan in a few days and, I hope, will have the surgery. Then her angina will be sorted out. And, staggeringly, she has stopped smoking. She must be frightened.

The best and the worst of the current NHS, all in one patient. Phyllis will get all the treatment she needs. But she was left having to negotiate two hospital switch boards to try to arrange a specialised scan that she did not understand. Not the end of the world but, for someone like Phyllis, it was all too threatening. It should not happen.

++++++++++


Friday 17th March

Some years ago I have a brief relationship with a woman who we shall call Mavis. It lasted two or three months. Brief snatched meetings, half an hour here, half an hour there. Eventually, I got bored and my wife was not, to say the least, best pleased with it all. So after a short but meaningful relationship, Mavis had to go.

Touch typing is an important skill for doctors. Now that we all use computers, if you do not touch type, you lose eye contact with the patient as you laboriously enter the history. It has another advantage. One of the trials of family medicine can be patients who chatter endlessly. What I do now is take down the consultation verbatim, without interruption. It is often a stream of consciousness that would grace an existentialist novel. Or Finnegan’s Wake.

Ralph is an 82 year old long-divorced retired baker from Wales. He is not demented. He has well controlled hypertension. I see him twice a year. The nurse sees him twice a year. He talks endlessly, without interruption. He used to get me stressed. Now I look forward to seeing him. He sat down today. I took his blood pressure. It was was normal, as always. The bloods done by the nurse last time were excellent. I asked him how he was. This is what he said (and I quote verbatim, honest!):

“I could see Aneurin Bevan was in when he was dead and gone. What’s the point? You can moan and groan. Japanese, Chinese, you name them. How are you keeping doc? The arm, it was the car accident we had in India with wonder girl, the ex, I was pushing the children round the Taj Mahal if you know that area and he was born in the barracks in Cairo, anyway, my brother was in a nursing home for thirty years in Devizes and he said he should not have the knife so I just left it. We cannot see ahead of us. Look at all those women who were paid less than men. My brother, and I was best man, married in 1940 but never had kids as he was hypochondriacal and is now in a nursing home and is well, well over ninety now. Alice was in a nursing home for thirty years and she would not let him have the knife either. We cannot see ahead. Alice married a Swedish man who qualified in Dundee. I should have stayed in Dundee. So thank you for the prescription I will go to the chemist now and see you anon, we have had such a hard winter, so I am going to the foot people now, you take care.”

And off he went. Quite happy. What a joy. But what does it all mean?


++++++++++