The Crippen Diaries (Week 13)
Monday 27th March
I lost my temper with a patient this morning. Unforgivable. One should not do it. But we are all human. I was running over an hour late. It happens. I had had a long consultation with a man whose wife is dying in the local hospital. He was worried about the care his wife was getting. For all the faults in the NHS, she is getting first rate care. Trouble is, she has end stage heart failure and, short of a heart transplant which she is not going to get because she is too old and too ill, she is going to die. And then a nineteen year old girl with an appendicitis. Well, it might be an appendicitis. Well, I could not say for sure it was not. Trouble with an appendicitis is that it is easy to diagnosis, but very difficult to exclude with confidence. And then a ten month baby with a slight temperature and nothing else. Happy, giggly, responsive, nothing to find apart from the temperature. But mum was worried about meningitis and wanted to know how I could be sure that her baby did not have meningitis. I cannot be sure. This is the ice across which I skate every day. No one can be sure that a patient does not have early meningitis. That is the trouble with this wretched condition. It often starts with utterly trivial symptoms and then a few hours later the patient is desperately ill. And I told her that. And we chatted. And I said meningitis is rare, it is not about at the moment, and there was no particular reason to worry about it, but she should bring the baby back later if she was worried. She left, much calmer.
I had hardly drawn breath as the man walked through the door. He did not look in the slightest bit unwell. “It is outrageous. Absolutely outrageous. I have been waiting an hour, and I am late for work. What sort of service do you call this?”
I said, “I am not prepared to be talked to like that. I am not prepared to see you. Please leave now.” And I stood up and opened the door.
He will complain. I shall answer the complaint by saying that medicine is unpredictable, that I cannot be in two places at once, and if he does not like the service he is getting from us, he can take his business elsewhere.
Stressed. And it is only Monday morning.
++++++++++
Tuesday 28th March
What are we doing to the English language?
I am often invited to medical meetings. Today, I received an invitation from the Cardiac Network Manager* to go to a cardiological meeting to discuss resource allocation for the management of cardiac arrhythmias in the county. Nothing wrong with that. Except she calls it the “Arrhythmia work stream” meeting.
What does she mean? Why is it a “stream”.
And then I have in my hand a letter from the nurse-specialists at the local hospice who are having a gynaecological cancer update. This meeting will:
And finally, this morning I had a letter from the orthopaedic oxymoron which made me angry. I had referred a patient with severe chronic sciatica to the orthopaedic surgeons. When he got to the clinic he was seen by the “consultant nurse”. She advised him that if the pain was severe he could “take paracetamol on a time-contingent basis.”
I think this means that if he is in pain, he can take two panadol every four hours as necessary. But I am not a linguist. I do not speak "nurse". I can manage a little French. But that is as far as it goes. Perhaps I should go on a course.
That is three months wasted, and I will have to send him back to see a surgeon.
(*another admin nurse-specialist tasked with pissing off doctors by telling them how to do their job. £30,000 a year plus pension. Cheap at half the price, whatever that means. What does it mean? Should it not be cheap at twice the price?)
+++++++++++
I checked my email, and cheered up immediately. A document from the DHSS sent in by one of my spies in the pharmacology department of a leading English Teaching Hospital. Thanks guys. Please keep it coming.
I think it important that I share this document with you in full.
_________________
More extended roles for nurses
Published:
Wednesday March 21st 2006
Reference number:
2006/0416
At a meeting of the Provisional Wing of the Nursing Confederation today, Health Minister Patricia Hewitt made the following statement:
“Following the resounding success of extending nurse prescribing powers to any drug for any patient, I am delighted to be able to announce two further extended roles for nurses. These were suggested by Sir Ronald Egg, the President of the Royal College of Physicians. When I told him about the extension of nurse prescribing, he said: “I am speechless. Why don’t you go the whole bloody hog and let them be brain surgeons and fighter pilots as well!”. I thought this was an exciting and innovative idea, and I asked our scientists to investigate."
Professor Gary Bonkers, Director of the Interventional Healthcare Policy Unit at Formerpoly University said:
“Patricia asked me to look into the possibility of nurses becoming brain surgeons and fighter pilots, so that’s exactly what I did. I organised an intensive two-hour focus group consisting entirely of nurses and sat them down with a flip chart and a few Bourbon biscuits. The verdict was unanimous – if they could prescribe every known drug to any patient without six years of formal medical training, why on Earth couldn’t they scoop out the odd brain tumour and whiz around in one of those jet thingies? We are all very excited about the prospect of this innovative extension of nurse practitioner capabilities, although I suspect that the brain surgeons and fighter pilots will be a bit miffed. Can I have my knighthood now?”
President of the Royal College of Nursing, Dame Megan O’Maniac, said:
“This is another important development for nursing practice in the UK. It will be an enormous boost to patients, the medical profession and the Royal Air Force but, much more importantly, will challenge professional barriers and be great fun for nurses. It should bump their salaries up nicely too. There is nothing that my girls cannot do provided they have a two-week skills acquisition course, an impressive-looking certificate, a long-winded and badly written protocol and a good idea of who to blame if it all goes tits up. UK nursing graduates have no desire to practise actual nursing; we import thousands of Philippino nurses to do this sort of work so that my girls can do much more exciting and innovative things that don’t involve other people’s poo”.
Charge Nurse Shane Trumpett, Team Leader of the Hartlepool Walk-in, Walk-out Neurosurgical ISTC, said:
“We have pioneered a state-of-the-art pilot site in Hartlepool to benchmark the potential advantages of nurse-led neurosurgery. The operations are performed by a Surgical Nurse Practitioner and the anaesthetics are given by an Anaesthetic Care Practitioner. It’s wonderful, there isn’t a doctor in sight! Our preliminary study clearly shows that our results are no worse than the neurosurgeons’ success rates, although we have decided to rename the unit ‘The Hartlepool Walk-in, Wheel-out Neurosurgical ISTC’. It really is exciting and innovative!”
Supreme Commander of the Allied Tactical Air Unit, Staff Nurse Mandy Watkins, said:
“Nurses truly have an important, exciting and innovative role to play in modern air warfare. We have introduced a holistic approach to the carpet bombing of civilians, and we have highlighted the fact that the opinions of the bombees, or ‘clients’ as we call them, and their families are vital in the planning of an effective integrated bombing pathway”.
At the end of the press briefing, Health Minister Patricia Hewitt was asked: “Could you envisage nurses extending their role to providing good quality basic nursing care to ward patients at any point in the future?” In reply, she said:
“Don’t be ridiculous.”
Press release ends
(Members of the Centre for Nursing Advocacy who would like their own copy of the document should send an s.a.e. to Dr Crippen at NHS BLOG DOCTOR)
++++++++++
Thursday 30 March
A 56 year old man who a few weeks ago had an odd, transient disturbance of consciousness whilst sitting on a train. For about thirty minutes he was unsure where he was, where he was going, and what his name was. He was taken to the local hospital. He has had a CT scan, a neurological assessment, and several other investigations. Everything was normal. The neurologist has told him it might have been a TIA but was probably transient global amnesia and discharged him. He he entirely back to normal.
Except the protocol says he has to be seen by the nurse-specialist in the Community Rehabilitation Team. But I do not need "re-habilitating" he says, and I had to take the afternoon off work.
She has written a letter to me. Except it is not a letter, it is some protocol driven boiler-plate text from the word processor with spaces for the nurse-specialist to fill in. Her neurons have fused because she does not know about transient global amnesia.
It is not.
He came to see me as the “advice” the nurse-specialist had given him was different to the advice the consultant neurologist had given him and he was confused.
The nurse-specialist will probably be earning £30,000 a year plus pension. Why is she not looking after bed sores?
++++++++++
Timothy and his estate agent father are back. They have read David Atherton’s excellent book on childhood eczema.
They still think Timothy has food intolerance and are now wondering if he might have “intestinal thrush.”
They have decided to take themselves to York, where there is a company called Yorktest, which advertises widely on the internet.
I did not cover this at medical school and so I could not possibly comment.
The CEO of Yorktest is John Graham. The company must be excellent, and must be doing very well for he has a big smile.
There are five other directors who have big smiles too. I shall be fascinated to see how Timothy gets on. Full information about all the services Yorktest have to offer can be found here
Not quite TannochbraeI lost my temper with a patient this morning. Unforgivable. One should not do it. But we are all human. I was running over an hour late. It happens. I had had a long consultation with a man whose wife is dying in the local hospital. He was worried about the care his wife was getting. For all the faults in the NHS, she is getting first rate care. Trouble is, she has end stage heart failure and, short of a heart transplant which she is not going to get because she is too old and too ill, she is going to die. And then a nineteen year old girl with an appendicitis. Well, it might be an appendicitis. Well, I could not say for sure it was not. Trouble with an appendicitis is that it is easy to diagnosis, but very difficult to exclude with confidence. And then a ten month baby with a slight temperature and nothing else. Happy, giggly, responsive, nothing to find apart from the temperature. But mum was worried about meningitis and wanted to know how I could be sure that her baby did not have meningitis. I cannot be sure. This is the ice across which I skate every day. No one can be sure that a patient does not have early meningitis. That is the trouble with this wretched condition. It often starts with utterly trivial symptoms and then a few hours later the patient is desperately ill. And I told her that. And we chatted. And I said meningitis is rare, it is not about at the moment, and there was no particular reason to worry about it, but she should bring the baby back later if she was worried. She left, much calmer.
I had hardly drawn breath as the man walked through the door. He did not look in the slightest bit unwell. “It is outrageous. Absolutely outrageous. I have been waiting an hour, and I am late for work. What sort of service do you call this?”
I said, “I am not prepared to be talked to like that. I am not prepared to see you. Please leave now.” And I stood up and opened the door.
He will complain. I shall answer the complaint by saying that medicine is unpredictable, that I cannot be in two places at once, and if he does not like the service he is getting from us, he can take his business elsewhere.
Stressed. And it is only Monday morning.
++++++++++
Tuesday 28th March
What are we doing to the English language?
I am often invited to medical meetings. Today, I received an invitation from the Cardiac Network Manager* to go to a cardiological meeting to discuss resource allocation for the management of cardiac arrhythmias in the county. Nothing wrong with that. Except she calls it the “Arrhythmia work stream” meeting.
What does she mean? Why is it a “stream”.
And then I have in my hand a letter from the nurse-specialists at the local hospice who are having a gynaecological cancer update. This meeting will:
“Identify the journey that the colorectal cancer patient has undertaken through their disease trajectory. The day will explore how a diagnosis is made and the effect that this has on the patient and their significant others.”Strewth! Disease trajectory? Significant others? Do they mean family and friends? What are they doing to the English language? And since when was colorectal cancer a gynaecological problem?
And finally, this morning I had a letter from the orthopaedic oxymoron which made me angry. I had referred a patient with severe chronic sciatica to the orthopaedic surgeons. When he got to the clinic he was seen by the “consultant nurse”. She advised him that if the pain was severe he could “take paracetamol on a time-contingent basis.”
I think this means that if he is in pain, he can take two panadol every four hours as necessary. But I am not a linguist. I do not speak "nurse". I can manage a little French. But that is as far as it goes. Perhaps I should go on a course.
That is three months wasted, and I will have to send him back to see a surgeon.
(*another admin nurse-specialist tasked with pissing off doctors by telling them how to do their job. £30,000 a year plus pension. Cheap at half the price, whatever that means. What does it mean? Should it not be cheap at twice the price?)
+++++++++++
I checked my email, and cheered up immediately. A document from the DHSS sent in by one of my spies in the pharmacology department of a leading English Teaching Hospital. Thanks guys. Please keep it coming.
I think it important that I share this document with you in full.
_________________
More extended roles for nurses
Published:
Wednesday March 21st 2006
Reference number:
2006/0416
At a meeting of the Provisional Wing of the Nursing Confederation today, Health Minister Patricia Hewitt made the following statement:
“Following the resounding success of extending nurse prescribing powers to any drug for any patient, I am delighted to be able to announce two further extended roles for nurses. These were suggested by Sir Ronald Egg, the President of the Royal College of Physicians. When I told him about the extension of nurse prescribing, he said: “I am speechless. Why don’t you go the whole bloody hog and let them be brain surgeons and fighter pilots as well!”. I thought this was an exciting and innovative idea, and I asked our scientists to investigate."
Professor Gary Bonkers, Director of the Interventional Healthcare Policy Unit at Formerpoly University said:
“Patricia asked me to look into the possibility of nurses becoming brain surgeons and fighter pilots, so that’s exactly what I did. I organised an intensive two-hour focus group consisting entirely of nurses and sat them down with a flip chart and a few Bourbon biscuits. The verdict was unanimous – if they could prescribe every known drug to any patient without six years of formal medical training, why on Earth couldn’t they scoop out the odd brain tumour and whiz around in one of those jet thingies? We are all very excited about the prospect of this innovative extension of nurse practitioner capabilities, although I suspect that the brain surgeons and fighter pilots will be a bit miffed. Can I have my knighthood now?”
President of the Royal College of Nursing, Dame Megan O’Maniac, said:
“This is another important development for nursing practice in the UK. It will be an enormous boost to patients, the medical profession and the Royal Air Force but, much more importantly, will challenge professional barriers and be great fun for nurses. It should bump their salaries up nicely too. There is nothing that my girls cannot do provided they have a two-week skills acquisition course, an impressive-looking certificate, a long-winded and badly written protocol and a good idea of who to blame if it all goes tits up. UK nursing graduates have no desire to practise actual nursing; we import thousands of Philippino nurses to do this sort of work so that my girls can do much more exciting and innovative things that don’t involve other people’s poo”.
Charge Nurse Shane Trumpett, Team Leader of the Hartlepool Walk-in, Walk-out Neurosurgical ISTC, said:
“We have pioneered a state-of-the-art pilot site in Hartlepool to benchmark the potential advantages of nurse-led neurosurgery. The operations are performed by a Surgical Nurse Practitioner and the anaesthetics are given by an Anaesthetic Care Practitioner. It’s wonderful, there isn’t a doctor in sight! Our preliminary study clearly shows that our results are no worse than the neurosurgeons’ success rates, although we have decided to rename the unit ‘The Hartlepool Walk-in, Wheel-out Neurosurgical ISTC’. It really is exciting and innovative!”
Supreme Commander of the Allied Tactical Air Unit, Staff Nurse Mandy Watkins, said:
“Nurses truly have an important, exciting and innovative role to play in modern air warfare. We have introduced a holistic approach to the carpet bombing of civilians, and we have highlighted the fact that the opinions of the bombees, or ‘clients’ as we call them, and their families are vital in the planning of an effective integrated bombing pathway”.
At the end of the press briefing, Health Minister Patricia Hewitt was asked: “Could you envisage nurses extending their role to providing good quality basic nursing care to ward patients at any point in the future?” In reply, she said:
“Don’t be ridiculous.”
Press release ends
(Members of the Centre for Nursing Advocacy who would like their own copy of the document should send an s.a.e. to Dr Crippen at NHS BLOG DOCTOR)
++++++++++
Thursday 30 March
A 56 year old man who a few weeks ago had an odd, transient disturbance of consciousness whilst sitting on a train. For about thirty minutes he was unsure where he was, where he was going, and what his name was. He was taken to the local hospital. He has had a CT scan, a neurological assessment, and several other investigations. Everything was normal. The neurologist has told him it might have been a TIA but was probably transient global amnesia and discharged him. He he entirely back to normal.
Except the protocol says he has to be seen by the nurse-specialist in the Community Rehabilitation Team. But I do not need "re-habilitating" he says, and I had to take the afternoon off work.
She has written a letter to me. Except it is not a letter, it is some protocol driven boiler-plate text from the word processor with spaces for the nurse-specialist to fill in. Her neurons have fused because she does not know about transient global amnesia.
Dear Dr Crippen,Mr Smith has had a copy of this letter too. He tells me that he was baffled to be called to the clinic as he was not expecting it. He said that he told the nurse that both the neurologist and I had talked to him about transient global amnesia. She advised him that was a sort of stroke.
Mr Smith was seen in the nurse-led stroke risk clinic.
This appointment was an opportunity for the patient to discuss their risk factors for stoke and to understand any medication changes made as part of their stroke. The principal risk factor was:
TIA (not proven)
Hypertension (code G2) – BP normal
Hypercholesterolemia (code 44P) – cholesterol normal
He was given advice concerning the above risks.
I have given him my number so he can contact me for follow up in three months if he feels it is useful.
It is not.
He came to see me as the “advice” the nurse-specialist had given him was different to the advice the consultant neurologist had given him and he was confused.
The nurse-specialist will probably be earning £30,000 a year plus pension. Why is she not looking after bed sores?
++++++++++
Timothy and his estate agent father are back. They have read David Atherton’s excellent book on childhood eczema.
They still think Timothy has food intolerance and are now wondering if he might have “intestinal thrush.”
They have decided to take themselves to York, where there is a company called Yorktest, which advertises widely on the internet.
Here at YORKTEST, we’re specialists in food intolerance testing. With over 20 years experience, our food intolerance testing service provides you with all the information and support you’ll need to be able to make changes to your diet.
A whole variety of health problems have been linked to food intolerance – symptoms such as Irritable Bowel Syndrome, migraine, eczema, asthma, being tired all the time and others. Our job is to identify which foods are triggering these symptoms by analysing a small sample of your blood against up to 113 different foods.
We have already helped thousands of people find relief from their symptoms, and from our in-house customer research, 82% of customers say they would recommend YORKTEST to others. Let us help you identify your food intolerances so you can get the best out of your health!
For many people, health dictates the way they live their life. How can you go round to a friend’s house if you think an attack of IBS might strike? You might have to cancel a night out because your migraine means you need to be in bed. Not being able to wear that new top because you’ve had an eczema flare up. Worrying about going on holiday and being ill. All of these are everyday considerations for a large number of people.
As food intolerance becomes more widely accepted and understood, lots of people are beginning to associate poor health with what they are eating. However, just because some foods affect one person, this doesn’t mean that it will be the same for everyone, and trying to find out which other foods trigger your symptoms can be like finding a needle in a haystack!
This is where YORKTEST may be able to help you. Our foodSCAN food intolerance tests can identify which foods your body is and isn’t coping with properly from just a small pin-prick sample of blood.
I did not cover this at medical school and so I could not possibly comment.
The CEO of Yorktest is John Graham. The company must be excellent, and must be doing very well for he has a big smile.
CEO of YorktestThere are five other directors who have big smiles too. I shall be fascinated to see how Timothy gets on. Full information about all the services Yorktest have to offer can be found here
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