Human dissection - any volunteers?

When I went for my interview at Medical School, the Dean asked me how I would feel when I walked into the dissection room for the first time. I said I would be nervous, but I did not think I would faint. That probably sums up the feelings of most first year medical students on their way to be introduced to their first cadaver. One girl did faint. Most everyone else cracked macabre jokes and laughed loudly and inappropriately. So we started on the long path of learning how to deal with the unpalatable.

Dissection is one of the rites of passage for medical students, but it was not much fun. We had one body between four and, once the novelty wore off, it became boring. Dissecting a human body requires skill and knowledge which, by definition, you do not have in the early days of medical school. I could learn so much from dissection now, but I will not have the opportunity.

Who gives their body to medical science?

I am not sure. I have had perhaps three patients in twenty years who have made enquiries. The last one was fairly recently. I recounted in the diary how, having made the arrangements and done the paperwork, she came back to check that no one would come for her body until she had finished with it. She was genuinely worried that, if she became seriously ill, in its keenness to get their hands on her body, the Department of Health might not treat her as vigorously as she would wish. A delicious thought.

There is currently a shortage of donors. As seen here, The Department of Health is worried:

“Public misperception of the difference between anatomy and pathology partly explains some people’s reluctance to donate their bodies to medical science. For example, there was a clear reduction in the number of bodies donated, during 2000 and 2001, following the discovery that body parts had been retained without consent, by the Pathology department at Bristol’s Children’s Hospital and Alder Hay Hospital Liverpool.

There was another reduction in donations following the TV series “Anatomy for Beginners” which featured public anatomy demonstrations.On both occasions, some intending donors specifically withdrew citing these events as the reason for withdrawing.”

It is difficult to see how the government can address this issue in an acceptable manner. A television advertising campaign would not seem quite right, though New Labour may well think of something.

In years gone by, the medical profession relied on “informal arrangements” with graveyards and undertakers, and the activities of the resurrectionists who robbed the graveyards on their behalf.

Messrs Burke and Hare were more entrepreneurial than the resurrectionists. My elderly patient would have been rightly fearful of these two gentlemen. They did not wait until the “volunteers” had finished with their bodies before delivering them to the famous Scottish anatomist, Robert Knox. In what became known as the West Port murders they sold the corpses of at least sixteen of their victims.

William Burke was publicly hanged for his crimes. The Anatomy Museum of the Royal College of Surgeons of Edinburgh holds his death mask and a wallet allegedly made of his skin. Burke was only convicted on the evidenve of his erstwhile colleague William Hare. Hare confessed to the murders and gave evidence against Burke in return for his freedom.

Nowadays no payment is made to people wishing to leave their body to medical science. Anyone who is interested should contact:

Human Tissue Authority
Finlaison House
15-17 Furnival Street
London
EC4A

Or they can email the inspector of anatomy : details here

+++++++++++++++

People sometimes express concern that medical students do not treat the bodies they dissect with respect. My experience was that for the first few days of dissection there would be some jokes and banter to cover up the nervousness we all felt. But I never saw a body being treated with disrespect. The following comment has just arrived from a student still at medical school:

"I did a BSc in anatomy and physiology before I went to medical school. I absolutely loved the dissection in anatomy, it probably helped that we had more time to do it than the medical and dental students. It was an amazing experience, and one I would not swap for anything.

I got far more out of doing the dissection myself than using prosections. We were in small groups of either two or four per body, with really good backup from the lecturer and postgrad demonstrators. We also went around everybody else's bodies to see some of the normal differences in structure.

We were all so thankful to those people who donated their bodies. We got very attached to 'our' body, and they were always treated with the utmost respect. "Don't do anything around these bodies that you wouldn't do in front of your grandparents" the lecturers motto, and a very good one it was too. By the time it came to the memorial service where we had to go to the chaplaincy with the relatives of the donors everyone got really emotional, it was almost like a memorial service for someone in our own family."

Grand Rounds 2 (36)

Yet another edition of Grand Rounds has just been posted by KidneyNotes.com which is writteny by an American nephrologist

As bad as rape?

Caesarean Sections

Two weeks ago, Patricia Hewitt announced that doctors were to be instructed to offer pregnant women the choice of a home birth. I am implacably opposed to home births in the UK and I posted an article saying so. My reason for this opposition is straightforward. Safety. There are not adequate facilities to resuscitate a mother or baby in the home environment and it is not possible to predict who may need such resuscitation. Until such time as there are such facilitates, and this means country wide availability of Obstetric flying squads, able to respond within minutes, home births are not a sensible option.

Many disagree, and there have been nearly 300 comments to date, and they are still coming. (They can be read here) Passions have run high.

One comment in particular appeared that needs further discussion. On first reading I dismissed it as emotive nonsense. That comment was that a bad obstetric experience was like being raped.

Over the years, I have seen far too many women who have been raped. There will be others, patients of mine, who have not sought help from me and possibly, indeed, not sought help from anyone.

I have also seen some women who have had bad obstetric experiences. Sometimes not anyone’s fault. Sometimes, sadly, there have been problems with unsympathetic doctors or midwives. I have seen patients who, as a result of their bad experiences, have developed post-natal depression.

I have never had a patient compare their experience to rape.

Of course, I am being anecdotal. I have many years experience. I have seen a large number of patients, but I am only one doctor. It would be wrong to generalise on my individual experiences.

Nonetheless, and after much thought, I cannot accept the hypothesis that a bad obstetric experience is like rape.

I make no excuse for some of the appalling things that have been done to women in the name of good obstetric care, but this is not rape. The worst obstetrician, or the cruellest and most unsympathetic midwife, may mistreat their patients, but this is not rape. There are far too many Caesarean Sections, but they are not rape. Hospital deliveries may not be as enjoyable experience as home deliveries, but they are not rape.

Whatever I believe, some disagree. Read these two comments, taken from the original article.

“I was a victim of rape at 14years old, a virgin. I had a hospital delivery and specifically said no epidural for baby no.1. I had an epidural (against my wishes) during transition. When being on my back and numb from the waist down it gave me flashbacks to the rape.
They call it body memory. It was horrendous, so bad that my partner left me a month after my son was born. He couldn’t handle my PTSD.

I had no anger towards the doctor, only myself. Of course I was angry towards the perpetrator who raped me as a teenager but I just didn’t expect it to come flooding back to me when giving birth. I had no control over this. It just happened. Completely out of the blue.

I believe that many survivors of abuse and rape are reminded of it by feeling out of control. This is what labour can do. For me it was being numbed from the waist down and flat on my back (this is how as a child I disassociated myself from the experience, by numbing and removing myself from my body).”

And a second comment from an experienced doctor:

"I am repeatedly struck by the high level of self-reported childhood sexual abuse and rape in homebirth advocates. I put in the words "rape survivor homebirth" into Google and found 15 separate instance of phrases like "since I am a survivor of rape, I wanted a homebirth" or "as a survivor of rape I knew that the way my OB treated me what just like rape". There definitely seems to be a notable association of these phenomena: a history of previous sexual assault, a bad childbirth experience, and PTSD. Here's my question:

Why is there such a ferocious insistence that it was the childbirth experience that caused the PTSD and not the previous sexual assault?

There seems to be a large group of women who report being sexually assaulted in some way, and they are adamant in their insistence that the assault did not have serious psychological repercussions. They were fine until they had a baby. The psychological issues became apparent then and, therefore, it must have been the doctor's fault.

What is going on here? No matter what the doctor did, it could not begin to compare to the original assault. I am almost forcibly struck by the level of anger toward the doctors. Yet there is a curious lack of emotion toward the original assailant. The level of anger directed toward the doctor seems startlingly high, and the level of anger toward the assailant seems curiously low.

It feels like there is a psychological need to blame the doctor INSTEAD of the original attacker. Why should that be?" (Dr Amy Tuteur MD - homepage)

+++++++++++

Childbirth is a painful and dangerous business. It is more dangerous to a woman’s health than anything she will experience until she reaches old age. It can be traumatic and it can go wrong. We must do everything we can to make sure we minimise the disasters and provide support thereafter.

But rape? No, I do not accept that.

Introducing the concept of rape into a discussion on the merits of home births is an attempt, consciously or not, to hi-jack the argument. It reflects some deep primeval fear of childbirth and fear and resentment of doctors, particular male doctors. Worse, it demeans and trivialises the experience of women who have been raped.

The original two articles were:

Home birth lunacy – here
Home birth tragedy - here

The Crippen Diaries (Week 21)

Not quite Tannochbrae

Monday 22nd May

Family doctors are nervous about urgent phone calls early on Monday morning. They usually mean that someone has died unexpectedly over the weekend.

David was living on borrowed time.

He had his first heart attack twelve years ago aged 68. He was in chronic atrial fibrillation and, for the last two years, end-stage low-output heart failure. In simple terms, he had very little functional heart muscle left. Getting dressed was a trial. He managed but it was not easy.

He was a widower and lived alone, but was surrounded by a close and attentive family.

I saw him Friday lunchtime. He had been using his oxygen a bit more than normal. There were no new findings. His atrial fibrillation was well controlled, his blood pressure was low, and even talking made him a bit short of breath. He did not fancy hospital, and I did not push him.

He died in his sleep in the early hours of Sunday morning. His family had been with him on Saturday night and by all accounts he was in good spirits. They went round on Sunday morning to find he had died in his sleep. He was still propped up in bed. The duty doctor had seen him, and certified death.

David’s son phoned this morning. We had the usual difficult conversation. For the family, however old and however expected, it is still Dad. For the doctor, however old and however expected, there is always that pang of guilt, “Oh God, did I miss something, should I have sent him in, could I have done more….”

As another doctor had seen David, and as the death was expected and uncontroversial, I was able to issue the death certificate without seeing him. But he was for cremation. Cremation papers are different. Two doctors have to sign, and both must view the body and interview the family.

I hate going to the undertakers. We are paid £62 for inspecting the body and signing the cremation form. The job has to be done, but it is not one I like. I know all the local undertakers well. Part of my job. They are always preposterously cheerful when I arrive. Part of their job I suppose. I find it macabre.

I went into the back room, the fridge was opened, and they slid David out.

If a body is not moved for several hours after death, and this was the case with David, there will be a suffused bluish purple mottling of the skin in the dependant part of the body. That is gravity. If there is pressure on one part of the skin, for example from lying on the floor in an awkward position, the pressured skin will be white and the whiteness is highlighted by the surrounding purple-blue areas. It is gruesome. The fact that I have seen it many times does not make it any easier.

A forensic pathologist can work out from the distribution of the colour and mottling what position the body was lying in. Dr Crippen is not a forensic pathologist, but the distribution of the mottling on David’s skin was not compatible with dying on his back propped up on pillows. It was more compatible with being face down on the floor.

If you suffocate someone by putting a pillow over their face, there will be tell tale petechial haemorrhages around the eyelids. Do not get too excited. You can also get them from recurrent sneezing! David did not have any petechial haemorrhages.

I know this family well. I did not for one moment think there was any question of foul play. Nonetheless, particularly post-Shipman, we all have to be careful.

I had to phone the daughter back. A difficult call. She had gone in with her husband and discovered Dad. I asked what position they found him in. He usually slept propped up on half a dozen pillows. But when they went in and found him, he was slumped on his side, with a hand under his face. He was cold, and had been like that for some hours. They had lifted him up into a more comfortable position.

Looking at David’s body again, this story was entirely compatible with and explained the odd distribution of mottling on his face and, indeed, on one of his hands. The little frisson of excitement of an implausible forensic triumph disappeared. The relief was enormous.

I am glad I did not send him into hospital.

I did the paperwork and went for lunch. A hard earned £62.

++++++++++


Tuesday 23rd May

The second patient in has toothache.

This presentation is driving family doctors mad. The all caring Labour government has abolished NHS dentistry. People who cannot afford a private dentist do not go at all. When their teeth fall apart and become painful, they come to us.

Dr Crippen is not omni-competent. In particular, he is not a dentist.

This lady has poor dental hygiene, a rotten tooth, inflamed gums and a probable abscess. It seems cruel to turn her away. So I prescribe antibiotics and analgesia, and tell her that I should not really be treating her.

She promises she will go to the dentist, and I tell her that I will not treat her next time.

She will not and I will. That is how it is.

++++++++++

A 27 year old man who has just joined the practice. I do not know him. I do not have any old notes on him. He sits down and looks at the floor. He says “I am sorry to bother you, I just want a repeat prescription for antidepressants.”

I ask him why he is on antidepressants. He says, “because I am depressed.” I ask him how long he has been on them. “Years. I don’t want to talk about it.”

I say I cannot do the prescription unless we did talk about it. He bursts into tears, stands up and walks out. Not angry. Not slamming the door. Just sad.

Failure of consultation. I do not know what else I could have done. I will worry about it.


++++++++++

A grumpy attractive teenage girl with her mother. She is monosyllabic. She reminds me of my daughter. They went to a nurse-led walk in centre earlier in the day. They waited two hours to see the nurse who told her she has a left ear infection and should “go to your doctor and get some antibiotics.”

She has a temperature. Her left ear drum is a bit pink. So is her right. This happens to young people with temperatures. There is no indication for antibiotics. This does not go down well with mother or daughter.

++++++++++

I do a late night surgery on Tuesdays so that people can come after work. This means I have a two hour break in the afternoon, but eight at night is still eight at night and I am tired. The last patient in is an elderly lady accompanied by her sister. Her husband died three weeks ago. The sister wants me to “give her something to help her.”

The only thing I can give her is time, which I do, but it is hard work at the end of a long day.

+++++++++



Thursday 25th May

Doctors always say “there is a lot of this about” whether or not it is true. It seems to comfort some patients to feel that others have similar problems. There are a lot of coughs and colds about at the moment, and Dr Crippen has one. A dry, irritating, intrusive, noisy, tracheal cough. So I have been trying not to cough over the customers, and also trying to smile when they say, “You should see a doctor, doctor”. I do not know how to treat such coughs. Maybe I should look on the internet. All suggestions gratefully received.

++++++++++

I saw Julie this morning. She is fifteen and she came with a friend who is also fifteen. They were both chewing gum. Julie is six weeks pregnant and wants a termination. Into the moral maze again. She has not told her parents. She will not tell her parents. She will not tell anyone in her family. She is intelligent and frighteningly worldly-wise for one of her age. She intends to stay at school and hopes to go to university. A pregnancy would be a disaster. She has worked it all out. On the day of the termination, she is going to stay with her friend and tell her mother it is a “sleep-over”.

I know Julie’s parents well, particularly her mother. I know that mother would be devastated, not so much by the pregnancy, but by Julie’s inability to tell her. I also know, and Julie obviously does not, that mum had an abortion herself when she was a teenager. It is a shame there is no way to get these two together.

++++++++++

My partner throws one of the medical comics into my room with a felt tip high-lighter around a small article. This article says that treating patients who have heart failure with diuretics may improve them symptomatically but increases their mortality rate by thirty percent. We have hundreds of such patients on diuretics. Diuretics have been part of the standard treatment for heart-failure since Galen. Or before, probably. This is like being told that exercise is bad for you, or that chocolate helps you slim. I am going to have to read this up.

Sods law, of course, the very next patient is someone with well-controlled heart failure. Can I say “well controlled” anymore? Or should I say “well controlled but with a thirty per cent greater risk of death”? Thankfully, he has not read the same article yet. I check him over. All is well. I leave him on his diuretics.

++++++++++

The journalists have just discovered (see the BBC report here) that no one knows the optimum treatment for patients with early prostate cancer. Doctors have been saying this for years but have been ignored by the journalists who have campaigned to increase the demand for routine PSA screening. Trouble with journalists is that once they discover something they did not previously know, they assume that no one else knew either. Now they will be telling us we do too much screening.

++++++++++



Friday 26th May

Not duty doctor today, for once, and it is half-term. The pressure is off for a short while. I had three gaps in the morning surgery. Luxury.

My cough is much worse today and I have lost my voice so I can only talk in whispers. I thought of taking the day off. I often think of it, but never do. Mrs Crippen said, “Well, if you are having a day off, can you take the girls to school and can you pick up my dry cleaning as I have a meeting?” She does not get it. I need to stay in bed and be pampered. No sympathy there. Might as well go to work then.

I have not taken codeine as recommended. Angry Doc’s suggestion of a large dose of prednisolone (steroids) is tempting but seems dramatic. Don’t steroids have side effects? Olbas oil pastilles also suggested. Are you not supposed to inhale these? I am a pathetic patient. I found a very old Strepsil in my case so I sucked it.

Always liked Strepsils.

+++++++++

We had an argument at lunchtime about areas.

All GPs in the UK have to have defined practice areas. They must be available for patients who live within this area. This is particular relevant for visits. A registered patient is entitled to summon you to his house. So you do not want a patient who lives thirty miles away.

We are therefore meticulous about enforcing our area boundaries. If someone moves out of the area, they have to change doctors. It is logical. If we did not do this, we would be doing visits up and down the length of the M1.

No problem there, then.

Well, there is, because we only pretend to enforce our boundaries. We all make exceptions. Mrs Bloggins has been a patient for twenty years. She is only moving half a mile away, so we keep her. I have a middle-aged patient who is bipolar and can be difficult. She was thrown out off her accommodation locally and has been put in temporary hostel accommodation five miles away.

I felt sorry for her. I told her (unofficially) that I would keep her on. Then she called out one of my partners on my afternoon off. My partner complained and told me I should throw her off. I countered by saying that she should throw of Mr & Mrs Jones who are her patients and who also live five miles away. She will not do that because Mr Jones is her builder and he is very good.

Lines are logical, but sometimes it is hard to draw lines through people’s lives.


++++++++++


I had an email from a colleague on the other side of London today. He has been asked to liaise with his PCT about a new innovation for the provision of care for people with “mild to moderate” mental health problems. In particular, and specifically, this new “service” (sic) is suggested as being appropriate for people who have been sexually abused.

My colleague cannot decide if this is a wonderful idea, or yet another strategy for limiting health care for people who cannot afford to go privately.

The presentation has a specious credibility. This sort of stuff always does. Dr Crippen thinks this is more cost-cutting codswallop, designed to fob off patients who cannot afford private therapists. It is not going to be "talking therapy" now, it is going to be "reading therapy". But this is Nu-Labour, we can make it sound better than that.

Bibliotherapy. Hmm...sounds good.

Last week I saw a girl in her late twenties who, as a teenager, had been serially raped by her stepfather. She was not mentally ill. So now I am supposed to write a chitty for her to take to the local library to get a self-help book. That is what all this pseudo-research and psychobabble means.

Maybe I am just too old and too cynical.

Any views?

(for those who cannot be bothered to wade through it all , I have put the Crippen four line summary at the bottom)



PILOT PROJECT PROPOSAL

A Books on Prescription Scheme for the local PCT

What is a “Books on Prescription” or “Bibliotherapy” Scheme?

• 1 in 6 people have a common mental health problems like depression at any one time (ONS, 2001)
• 90% of treatment is provided in the Primary Care setting (Frude, 2005)
• Counselling services are often very thinly spread and there is often limited psychological therapy available (Frude, 2005)
• Lengthy waiting lists for specialised psychological or psychotherapeutic services can cause frustration with both referrers and patient (Williams, 2001)
• Patients prefer psychological therapies to other treatments (Tylee, 2001)
  

There is currently a well recognised a gap in services for individuals with mild to moderate mental health problems. The Book Prescription Scheme allows self help material to be available to individuals with mild to moderate mental health problems, with or without a prescription from their GP or healthcare professional. Therefore, this scheme offers an additional mode of support for this group in an accessible and flexible manner.

The NICE Guidelines (2004) for depression and anxiety states that self help books, such as bibliotherapy (Book Prescription) are recommended as an intervention for anxiety and depression. NICE (2004) also suggested that ‘As a possible first step, patients with bulimia nervosa should be encouraged to follow an evidence based self-help programme’ (p.16).

This paper sets out the evidence base and proposed model in order to pilot implementing this NICE guidance within the PCT.

Background

In 2003 Frude et al. set up the first Book Prescription Scheme in Cardiff. This scheme was highly successful and as a result it was estimated that by August 2005 at least 40 schemes were up and running across the UK (Frude, 2005). The number of areas introducing the scheme is always increasing and the scheme has now been established in our neighbouring county.

Evidence for Books on Prescription

• Den Boer et al. (2005) found that patients using self-help book schemes showed a significant improvement in emotional disorders, versus the waiting list or the no treatment conditions.
• Cuijpers (1997) concentrated his meta-analysis focusing on depression, and results showed that self help materials show a significant effect
• Williams (2001) self-help treatments are most effective for the treatment of anxiety, depression and sexual dysfunction. Williams also found that non-supported self-help appears to show no difference in how effective the outcome is compared to supported self-help.
• Keeley et al. (2002) carried out a survey of 500 cognitive behaviour therapists attitudes towards bibliotherapy. It was shown that 90% of the therapists recommended self-help materials, usually as a supplement to individual therapy.

Neath Port Talbot (2005) surveyed individuals who had used the Book Prescription Service, and the individuals who had prescribed the books. From the individuals who took books out, it was found that:

• 82.2% recorded a rate of satisfaction for the benefit of the book to be over 5 out of 10.
• 81% of the respondents said that they were still using the books prescribed
• 95% would recommend this scheme to a friend or relative
• 37% have not gone to seek further help, assistance or support for their problems after reading the book recommended.
  

Comments include:

• ‘I have learned to look at life in a more positive light’
• ‘After reading the first chapter I thought about my problem and what I could do about it’
• ‘I found the scheme very helpful and beneficial and people should be encouraged to use the service’
• ‘I think it is very helpful especially to know that your symptoms are so common they actually wrote a book on it! Also, I felt it was similar to counselling but in my own home’

Williams (2001) states the benefits of the Book Prescription Scheme:

• An effective way of delivering treatment either as the main or a supportive component of treatment, which can be accessed with minimum delay
• Popular and acceptable with clients
• Avoids the potential embarrassment of having a psychiatric referral
• Patients take responsibility for self-management, may enhance their sense of control over their illness
• May reinforce and consolidate learning, and allows the patient to refer back to the material whenever it is needed
• Self-help material can help an individual identify early warning signs of a relapse and learn skills of how to cope with and deal with them
  

Beating the Blues-Computerised Cognitive Behaviour Therapy (CCBT)

• Beating the Blues is a computerised programme, which incorporates psychological therapies to help individuals suffering with depression and anxiety.
• NICE Guidelines for depression (2004) recommends that CCBT should be considered for patients with mild depression. The NICE guidelines (2006) recommend specifically the use of Beating the Blues package for mild to moderate depression and anxiety, this package has been purchased by the North Surrey PCT.
• Proudfoot et al. (2004) carried out a study looking at individuals who had used CCBT, and found that overall individual’s depression, negative attributional style, work and social adjustment had improved and there was a great satisfaction with the treatment.

How the Scheme will work

• The patient goes to the GP (or other health professional*)
• The patient is assessed and identified as having psychological issues or mild to moderate mental health problems that would benefit from the use of the self help materials on the list (including Beating the Blues).
• The GP (or other health professional) prescribes an appropriate book/CCBT for the clients needs
• The patient goes to the library to pick up the Book Prescription
• Or for CCBT - The patient goes to the library and books sessions to use the Beating the Blues package in the library
• The patient reads and carries out the exercises in the book/CCBT
• The patient borrows the book for the same amount of time as all library books
• Follow up to be agreed between the G.P. (referrer) and patient.

*As the scheme gets established, other professionals will start prescribing the Book Prescription Scheme too, such as CPNs, Graduate Mental Health Workers and Primary Care Counsellors for example.

There will be posters advertising that self-help books are available in the library, as well as a website and word of mouth, so individuals who have not been to a health professional, can also access this service.

Who is the Book Prescription aimed at?

• This scheme is aimed at individuals with mild to moderate mental health problems, the books cover common mild to moderate mental health problems (e.g. depression) and issues that often affect emotional well-being (e.g. sexual abuse)
• The patient will need to have good literacy levels, and show motivation to use the Book Prescription Scheme.
• The books are only available in printed form, and at present only in English.
• Books will be available at the library for individuals with or without a Book prescription from a health professional

The Crippen Four Line Summary

Patient: I feel really depressed, doctor.
Doctor: Do you have private health insurance?
Patient: No
Doctor: Bog off and buy a book

Starving to death

Can he save the NHS?

We need to call, once again, upon Sir Bob Geldoff to come to the aid of an underprivileged and neglected group of people who suffer from malnutrition, and some of whom are dying of starvation before our eyes.

Where is it happening now? Ethiopia? The Congo? Biafra? Not at all. This time it is happening in Britain. In the British National Health Service.

Let Dr Crippen state this clearly and unequivocally.

British citizens in British NHS Hospitals are suffering from malnutrition.

How can this be?

It is entirely the fault of the Labour Government. Its management of the problem had all the hall marks of Nu-Labour:

• Financial irresponsibility.
• Ham-fisted media mis-management.
• Dishonest cover-up
• Finally, as the ship sinks, a Panglossian statement that “all is well.”

First, the Labour Government poured money in. To be precise, £40 million of taxpayers’ money on a programme to improve hospital food. Next, the ham-fisted media mismanagement. Let’s front-end the programme with a celebrity. Food critic Loyd Grossman who, as we discovered here, gave his services for free agreed to endorse the initiative.

Grossman sauces

The programme failed, and was abandoned.

Why did it fail?

Andrew Burnham MP, a health minister said:

“The comments from patients who are admitted to the NHS highlight that this is a high-quality service, not a service in crisis. But we still have a lot of work to do to provide a truly patient-led system.”

The dishonest cover-up and the bland statement that it was a “high quality service.” Churchill might have called this a “terminological inexactitude”. Dr Crippen calls it brazen dishonesty.

And can anyone explain the last sentence to Dr Crippen? In the context of providing food for hospital in-patients, what is a “patient-led system”? What does it mean? Should it not be a “chef-led system”? Or a “caterer-led system?”

Patient-led system? Guff, Andrew. Nu-Labour, Hospital at Night, spin-doctored guff.

The problem is not the food, bad though it may be. It is the process of getting the food into the patient. A lot of people who go into hospital are ill, elderly and infirm. It is estimated that a third of all people admitted to hospital need help with eating. This is called nursing care. Remember, we used to have nurses in hospital who looked after patients.

There are very few left now. Nurses have now become “specialists” and spend their days annoying people by pretending to be doctors and getting a picture of the night with Sue & Dave.

The Government has admitted that:

• last year seventeen million hospital meals were thrown away untouched
• 40% of hospital patients have malnutrition.
• Over 50% of hospital inpatients lose weight or become undernourished.*

There is no more to be said.

Dr Crippen is ashamed.


*Reported in The Times here

Home birth tragedy

Prolapsed cord

Carrying on the debate about home births, Dr Crippen has his attention drawn to an article in the Daily Telegraph written by an experienced midwife, Traci Relph, who tragically lost a baby during a failed home delivery.

I do not normally comment on real cases. But this midwife has chosen to go public with her experience and to use it to justify her continuing belief in home births.

It is therefore fair to comment, and to put the other side of the argument.

In particular, Traci says her baby:

“…would not have been saved even if I had given birth in a hospital”

I know it may be a comfort to say that. I am sorry to cause upset. But this statement is made in a national newspaper to a wide and impressionable audience. It is not true. This baby was in grave danger but might well have been saved had the birth taken place in hospital.

Let us consider the facts.

“Two-o'clock in the morning, and I was in the late stages of labour with a midwife struggling to save the life of my baby boy as an ambulance rushed us through the deserted streets of south London to Lewisham Hospital.

I was seven centimetres dilated and she had pushed her hand right up into my vagina, trying in vain to keep his head from crushing the umbilical cord carrying oxygen to his brain.

She kept her hand there for 56 minutes, even as I was being wheeled at high speed along the corridor into theatre, and right up until the moment my baby was lifted up and delivered by Caesarean”

As I said in the original post, poor old Tom Reynolds has to try to pick up the pieces. I am sure the ambulance service did their best, but they do not have the equipment to deal with this sort of emergency. You need an operating theatre.

And you do not have 56 minutes to find one.

Traci continues:

“That was in June 2001 and I was 37 years old, a mother of three who was part-way through midwifery training. But nothing could have prepared me for the trauma of a home birth that went horribly wrong.

Earlier in the evening, as the first contractions had begun, I'd been laughing and joking with my in-laws and friends. Having had two home births already, I felt fairly laid back and comfortable in my own environment, and Simon, head of marketing in a graphic design division, was equally relaxed. We had no idea of the nightmare that would ensue in the early hours.”

This was a relatively elderly mother in her fourth pregnancy. Cord prolapses are rare, but they are 60% more likely to occur in multiparous women. Read about this in detail here.

Look at four of Traci’s comments:

• Earlier in the evening, as the first contractions had begun, I'd been laughing and joking with my in-laws and friends.
  
  
• Having had two home births already, I felt fairly laid back and comfortable in my own environment
  
  
• We had no idea of the nightmare that would ensue in the early hours.
  
  
• But nothing could have prepared me for the trauma of a home birth that went horribly wrong.

There are no guarantees in obstetrics. You can never predict what will happen, however experienced you are in obstetrics, and however many previously normal births a mother has had.

If you have a prolapsed cord, you do not have 56 minutes to spare.

This was a tragedy.

In my view, a tragedy that could have been avoided. It is proof positive of the dangers of home births.

The full article in the Daily Telegraph may be read here.

+++++++++++

Would anyone wishing to comment on this article, please do so under the original post, “Home delivery lunacy” which can be found here.

Home delivery lunacy

Neonatology

More dumbing down of health care, and more arrogance from Patricia Hewitt. God, who will rid me of this tiresome woman.

It is reported today that Patricia Hewitt is to “challenge the assumption” that the safest place to give birth is in hospital and that home births can be dangerous.”

It goes on: “…doctors will be told to offer all pregnant women the chance to deliver their baby at home with the help of a midwife and their own choice of pain relief.”

Told, note.

Dr Crippen will not be “told” to make this offer.

Dr Crippen would love to have a system of home deliveries but home deliveries are only safe if there is a fully equipped obstetric flying squad which can respond and arrive in a matter of minutes. An obstetric flying squad needs two doctors, one for the mother and one for the baby, an incubator and lots of other kit.

Obstetric flying squad

There are no obstetric flying squads where Dr Crippen works. There are very few in the country.

Home deliveries will be supervised by madwives, often the so called “independent” madwives. "Independent" madwives have "chosen to work outside the NHS" primarily because the NHS does not support their practices.

Some of the militant home-delivery brigade of madwives are the most arrogant and dangerous health care workers in the NHS. They do not understand that a catastrophic post-partum haemorrhage can result in the death of a mother within minutes, and that it cannot be predicted. They are not trained to resuscitate flat babies; they have neither the competence nor the equipment. And, as so often with specialist nurses, they do not know their own limitations, they do not know what they do not know, and they resent any attempt by the medical profession to try to educate them.

They want to jump into the birthing pool with the pregnant mother, the husband and the vicar, sing ten green bottles and then eat the placenta. They ignore the risks. And when disaster strikes, as it surely will, it will be Tom Reynolds who has to try to pick up the pieces.

There is much that is wrong with the hospital obstetric service in this country. That needs to be addressed.

A sudden unplanned switch to home deliveries managed by madwives is not the answer. Dr Crippen and his partners will have nothing to do with home deliveries. We will do everything within our power to persuade women not to have them. If they insist, we may have to remove them from our list.

Why has Hewitt done this? Two likely reasons. Her focus groups have told her that home deliveries are popular and home deliveries will take the strain off an overworked hospital system, thus saving money. More votes and less expenditure. Perfect.

Trouble is, babies cannot vote. Particularly not dead babies.

__________

An American neonatologist points out to me a recent discussion about a home birth catastrophe caused by an incompetent madwife going beyond the boundaries of her training; indeed going beyond the boundaries of common sense:

"The baby was full-term but he needed a ventilator to breathe. He had been deprived of oxygen during the birth process and suffered perinatal asphxia. He suffered it bad. His kidneys didn't work, his heart wasn't so good either, he had seizures until he became comatose, and eventually his brain got so bad that there were barely any brain waves. After discussing it with his parents, we removed the baby from the ventilator and he died.

This baby was the result of an attempted home delivery. An uncertified midwife kept the mother at home far too long, having mother push and push, trying to keep her from having to go to a hospital with it's too technical and "unnatural" approach to birth, where, heaven forbid, they might actually try to monitor the baby's condition during labor and intervene if it were necessary. By the time she did finally go to a hospital and deliver, the baby was a goner. He was a fine baby. If it hadn't been a screwed up delivery, he'd probably be playing ball with his dad now."

Read the full, horrifying article, and the 175 comments it attracted, here. I hope Patricia Hewitt catches up with it.

__________

A further article, "Home birth tragedy" , has been added above. A midwife tragically lost a baby during a home birth due to a cord prolapse. It took too long to get to the hospital. She still advocates home births. The article is here. Would anyone wishing to comment on the new article please do so here, so that the debate stays in one place.

How much is a doctor worth?

Wat Tyler has been spending his spare time attending the Public Accounts Committee at the House of Commons. It beats doing the Sudoku. I think.

He has written an article on the financial disaster of allowing doctors to contract out of out-of-hours (OOH) work for a mere £6000. Considering the amount of work we did, this was one of most staggering financial miscalculations the government has made since it came into office.

OOH work is now, for the first time since 1948, out in the market place. To get it done, the government has to pay a wage that will attract the workers. It is expensive. It would be. It is the real cost of health care.

How much should doctors be paid?

I have not got a clue. Doctors’ pay is currently better than it has been in 20 years, but it is cyclical. There have been bad times.

Wat says:

"On PMQs today, some Labour plant asked whether the PM shouldn't get paid more than everyone else because...well, he runs the country. Out here, we all realise there's no answer to that. Wayne R couldn't do PMQs, but then again, Tony doesn't score that often. The only pay test that means anything is that of the market."

There are thousand of men and women in the City earning seven figure salaries. Men and women at the top of their profession. This year there were over three thousand city workers who were paid January bonuses of a million or more.

There is no market for health care.

Wat’s commentators do not understand that. If my daughter gets leukaemia, no one is going to make a profit out of treating her. The people who treat her will not be well paid considering the expertise they, to coin a phrase, “bring to market”.

Compare the City salaries with the salary paid to the head of paediatrics at Great Ormond Street.

£80,000 a year. And no bonuses.

Burning our Money is about saving tax-payers money. Since 1997 an implausible amount of money has been poured into the NHS with little improvement in health care. Much has gone on salaries. I am not going to enter into the debate on doctors’ pay rates personally, but I will yield to no one in my belief that nurses, by which I mean the nurses who stay in real nursing, are grotesquely underpaid. And the only way the hospitals can attract nursing staff is by employing WIMPEY** to trawl the Third World and steal their nurses, thus effectively exporting our health care problems.

The “market” does not work in health care.

But the “marketeers” rant on causing upset and offence to doctors. Have a look at Wat’s recent article here. In particular, have a look at the comments column here, and the remarks that are made about the value of doctors.

If the commentators are right I do not think I will bother to get up tomorrow.

So, a challenge.

People are forever saying doctors are paid too much (or sometimes too little). Put you money where your mouth is. Name a figure.

How much, precisely, should a full time doctor be paid each year?

What do YOU think they are worth?


**WIMPEY = We import millions of Phillipinoes every year.

Quacktitioner Alert (6)

Quacktitioner tales are flooding in. Do keep them coming. I shall continue to highlight the worst ones.

This from a NHS BLOG DOCTOR commentator:

"Whilst at a meeting yesterday, I got a phone call from my wife, who had been rushed to hospital by her optician. Over the last few weeks, she has been having problems with her eye - migraines and over sensitivity to light. She decided to have an eye test in the UK, as it is considerably easier than having one in French (we recently moved to parts foreign) and we have had this trip planned for some time. Her optician noticed some retinal damage that was serious enough to be immediately sent to an eye emergency department. Indeed, so urgent that she suggested my wife didn't go home first - but go straight to the hospital in a taxi.

Upon arriving at the hospital, she was told quite bluntly by a nurse quacktitioner that she should see her GP, it might not be very serious and even if she was referred to see an eye doctor, she would be waiting a long time.

The nurse's 'advice' was based on two tests - how my wife's pupil reacted to light and whether she could follow the nurse’s finger with her eyes.

• She did not look into my wife's eye to check the retina.
• She wouldn't arrange an appointment with a specialist,
• She would not refer my wife to a doctor of any kind, despite the optician advising my wife (who did look at her retina) it was the worst case she had seen and would probably result in an urgent operation.
  

Effectively, the nurse didn't know what the problem was, didn't know what caused it, didn't know what treatment she should have, didn't know how seriously it should be taken, whether any long-term irreparable damage was present or indeed whether anything could be done in the meantime to prevent any further damage.

Obviously, the quacktitioner didn't have 'retina damage' next to one of her check-boxes, or in her list of 'what tests to do given symptoms'. So we have paid for a private consultation to be carried out tomorrow, by the very same consultant that works in the department my wife was sent to, but was not allowed to see. I don't expect my wife to have an operation the next day. I also don't expect my wife to even see a consultant the next day. But I certainly don't expect my wife to be told to go home by an under-qualified quacktitioner who hasn't even examined her."

+++++++++++++++

Yes, I have had the same experience, as have many of my partners. The local eye department is front-ended by nurses. They do not have the training or the experience to examine the back of an eye. This examination is called fundoscopy. It takes years to become competent at it. Nurses cannot do it, so they do not think it is necessary. We send patients with urgent eye problems further afield now to ensure they see a doctor who is trained in ophthalmology.

What is this?

Opticians are good at fundoscopy. They do it a dozen times a day. It would be fair to say, and no disrespect to opticians, that sometimes they over-react to minor abnormailities, but nonetheless they perform a valuable screening service. They are, for example, perfectly capable of picking up detached retina. Early diagnosis of a detached retina means the eyesight can be saved. Look at the picture above. Did you spot that it is a retinal detachment? Why not? You have had as much training in retinal pathology as the average nurse

No doctor in his right mind ignores the worries of a experienced optician.

As always, nurse-specialists do not know what they do not know.

++++++++++

Original story from AJD - home page here

The Guardian reads Dr Crippen

An excerpt from the Crippen diaries in the Guardian today, and in the Guardian Unlimited. Sadly, I was extolling the virtues of the Spanish Health Service rather than the NHS.

It was not always like that.

Read the newspaper article here and the orginal diary entry here

The Quacktitioner Royal

Among our ancient mountains,
And from our lovely vales,
Oh! let the pray'r re-echo,
"God bless the Prince of Wales!"

(sing along here)

It is distressing to find the Prince of Wales has turned his attention from architecture to medicine. He has now had the temerity to address the World Health Organisation on the value of alternative medicine.

There is no such thing as alternative medicine. There is only medicine. There is good medicine and bad medicine. There are doctors and there are quacks.

All medical treatment that has a rational scientific basis is used by doctors. The rest is humbug.

Medical science is not omnipotent. There are illness, some life-threatening, that we cannot cure. There are many non-life threatening illnesses that we cannot help.

Ancient man invented God to fill in and explain the gaps in his knowledge. Why did the sun rise? Why does the moon go round the earth? And so on. As science advanced and the gaps became smaller, the need for God, or gods, diminished.

Two hundred years ago patients suffering from myxoedema died. There are graphic descriptions of the descent into myxoedematous madness and death. Then we synthesised thyroxine and a fatal condition became so easy to treat that it is now regarded as trivial. The advances in the treatment of leukaemia, particularly the childhood leukawmias, over the last fifty years, have been staggering. Antibiotics. Coronary artery replacement. Kidney dialysis and transplants. Science marches on. The remaining gaps are small but there has been a corresponding increase in expectation. As medicine has not been able to satisfy these expectations, people turn to quackery to fill the gaps.

If medical science cannot solve a problem, for the “alties” that is the fault of the blinkered and ignorant doctors who will not take the quackery on board. What is an "altie"?

Read ORACs many excellent posts on alternative medicine and, in particular, his entertaining article on “What is an ‘altie”

“That term is term is an "altie" and has a meaning similar to the term "woo-woo," in that it describes people who are so militantly pro-alternative medicine and so distrustful of conventional medicine that they will never admit when conventional medicine is effective and refuse ever to concede that any alternative medical practitioner might, just might, possibly be a quack. Part and parcel of being an altie is an anti-intellectual and antiscientific attitude that does not allow a little thing like evidence to sway one from one's belief in the power of alternative medicine."

The believers in "alternative medicine" never produce evidence. They produce anecdotes. They believe that the plural of "anecdote" is "evidence". It is not. It is "anecdotes".

Let us consider one common medical condition. Simple back strain. Every day in the UK thirty thousand family doctors have a heart sink experience as patients present with acute mechanical back pain. There is nothing you can offer except painkillers most of which could be bought over the counter. Ninety five percent of the suffers will be better in six weeks whatever they do, with or without treatment. This is not good enough. Patients demand more. Doctors are honest. They have nothing more to offer. So the “rubbing” therapists step in to offer a "solution". The private physiotherapists, the chiropractors, the osteopaths, the acupuncturists, the list is endless, will all take your money for their spurious treatment. And when, a few weeks later, you are better, they will take the credit, and you will want them to because they have your money.

Fraud and dishonesty abound in quack medicine. Ignore the Prince of Wales. You would be safer listening to his views on architecture and marriage guidance.

Considerations of space make it impossible to go through the whole lunatic fringe of quackery but Dr Crippen would like to mention a few that cause him particular concern.

Chinese Medicine : there is nothing wrong with Chinese medicine as practised by the many fine Chinese doctors in China. But the little old ladies who sell brown paper bags full of bird seed out of the back door of Chinese Restaurants have nothing to do with medicine.

The “rubbers” - osteopaths, chiropractors and private physiotherapists : they have little to offer suffers for mechanical back pain. Take some aspirin, have a long soak in a hot bath and save your money.

Homeopathy : much favoured by the Royal Family. Utter, incomprehensible nonsense. Dangerous if used as a substitute for medical treatment.

Herbal medicine: well, it depends what you mean. Some of the finest drugs known to medicine have “natural” origins. The Foxglove. Aspirin. Cyclosporin. But, as well as having “natural” origins, all these drugs have been extensively tested by scientists. Patients occasionally say to me when I prescripe something, “Is it natural?” My standard reply is, “You mean like cow-dung and Deadly Nightshade?” People want to take St John’s Wort, because it is “natural”. It contains hypericum, which is a chemical anti-depressant. Why not get a real anti-depessant, which has been tried and tested, from your doctor? The saddest thing about St John’s Wort is that it can interfere with the contraceptive pill. Unwanted pregnancies do not help depression.

Acupuncture: has a real role in providing pain relief provided the needles are sterile. Not much good for anything else. More Chinese hocus-pocus.

Reflexology : nonsense
Radionics : nonsense
Cranial osteopathy: nonsense
Watsu: these practitioners float their patients in water so that they can better relate to them. No, really, they do!

I leave until last the quacks I hate most. The “cancer” practitioners. They hold out the possibiltity of a “cure” when conventional medicine has failed. Sometimes they offer their treatment instead of conventional medicine. These people are criminals. They need locking up. They will sell you vitamins and things like laetrile. I am not going to refer to any of their sites.

As and when Dr Crippen gets an incurable cancer, he will research everything that is available, believe me. If if he finds anything that has a scientific evidence base, he will be after it. As yet, there is nothing with a scientific base that medicine cannot already provide.

Anyone who has cancer and is considering alternative therapy, should read Snake Oil by Jon Diamond, written whilst he was suffering from cancer, and also metastases, written by a breast cancer suffer.

And the Prince of Wales? I wish him well. I wish also he would stick to doing something he understands.

Whatever that maybe.

Patio Builders again

Mass graveyard

There is no let up.

They are after the patio builders again.

Once again, these wretched patio builders are back under the spot light. The public anger and fear surrounding the Fred West case continues and has yet to be assuaged despite the efforts of the very lovely Dame Janet Smith.

Dame Janet believes that there are many other murderers lurking in the patio building industry, and they may be poised to strike.

An elderly woman

In her lengthy enquiry, she concluded such putative murderers can be identified by assessing the building skills of the patio builders.

Remember Freddie? He was a mass murderer and patio builder. He abused his professional position as a patio builder by using said patio building and sundry other artisan-like skills to conceal the dead bodies of his victims.

Fred West

Dr Crippen has already looked at the action the Patio Builders Association has taken to assess their members for murderous qualities.

Dame Janet now wants to take it further. She believes that a hidden iceberg of murderous patio builders can be identified by compelling the whole industry to submit to annual assessments of their brick laying skills.

Dame Janet says that good brick layers would never murder their clients. But bad brick layers? Oh dear me! They must all be villains. So all we have to do is subject them to an annual test of their brick laying skills. Easy.

Fred West Inquiry chairman Dame Janet Smith, keynote speaker at the meeting, held at the Royal Society of Patio Builders, criticised the Government for failing to implement her recommendations three years after they were made.

'There are many patio builders who are determined to ensure high quality of their brick work " Dame Janet said.

"But there are others, and their numbers are substantial, who think everything is fine and that Fred West was a one-off villain. I try not to despair about such people."

A leading London Patio builder, Ian Heath said:

“…too much scrutiny of patio builders would damage trust between them and their clients. Stopping a murderer is different from dealing with people's brick laying abilities.” (Full report here)

Thank God for Dame Janet. Someone has to bring these wretched patio builders to heel before we are all murdered in our sleep.

But just a minute.

No one ever criticised Fred’s building skills. He was much in demand.

As was Dr Harold Shipman.

The Crippen Diaries (Week 20)

Not quite Tannochbrae

Monday 15th May

There is a large comprehensive school close to the practice. At least half the children who are registered with us attend it. The headmaster has just written to all parents saying that any child who is off school with illness must have a doctor’s note confirming the illness.

This policy will mean a lot of extra work, mostly unnecessary. But that is not what makes me cross. This is an insult to parents. These decisions are a matter for parents. They should be the judge of when their children are fit to go to school. If my children have so much time off that their education is suffering, I expect the school will contact me, if I have not already contacted them. Doctors are not truant officers. It is not for us to disempower parents.

We draft a letter to the headmaster stating that we will not be issuing certificates for children who are off school. We state that if he has concerns about a child’s poor attendance due to illness, he may write to us for a medical report. Provided we have the parent’s consent, we will provide the report and we will charge a professional fee for its preparation.

I do not think this is going to be a major income stream.

Silly man.

++++++++++

Andrew is a retired architect. Used to be a great rugby player. Like so many ex-rugby players his joints are a mess. When he retired ten years ago, he and his wife bought a small house in Spain. Initially they went out just for the winter, but now they are out there for nine months a year.

He needs a hip replacement. It has been playing up for some years but he kept putting it off. He is getting rest pain, and his exercise tolerance is severely limited. Just before Christmas he gave in. He is on the waiting list to have it done.

He was all smiles today. He is going to have the operation in three weeks time. In Spain. And he is not going privately. He will have it done on the Spanish Health Service. The large British ex-pat community where he lives now have most of their medical care in Spain.

When I started, all the ex-pats came home for their medical care. Now most of them go out to Spain for it. The waiting lists are shorter. The nursing care is better. The hospitals are cleaner.

So they tell me.

It is all anecdotal, but it depresses me.


++++++++++

I saw two women with breast lumps this morning. Angela and Christine. Both in their late forties, a dangerous age for breast cancer. Angela has a family history of breast cancer. Christine has not.

Clinically, Christine’s lump is ominous. I fear it will be malignant. Angela’s is almost certainly benign. Both must be referred to the breast clinic, and both under the two week rule (TWR).

I tell Christine that I was worried about her lump, that I fear it might be malignant and that I will be getting her an urgent TWR appointment. She has a few questions, we talk it through and she is grateful for the speedy availability of the appointment.

I tell Angela that I am as sure as I can be that her lump is benign but that we have to be certain, and so I will get her an urgent appointment within two weeks. She asks if I can get her an appointment quicker than that. I cannot. She asks if I could phone the consultant’s secretary and get her squeezed in more quickly. I could make the phone call but I am not going to. It is unfair to pressurise them like that. They are already providing an excellent service.

She asks if it would be “worth going privately”. She does not have private health insurance. She might get a private appointment a day or two sooner, though that is not certain. I explain that it would not be just the cost of the consultation. There would be the mammogram. And, as it felt cystic, probably an ultrasound, and then possibly an FNA. You are up to a thousand pounds before you can say BUPA. She decided to wait for the appointment, but clearly felt it “was not good enough.”

Expectations. Expectations. Expectations.

This keeps happening. I sympathise. It is awful waiting for appointments, waiting for tests, worrying about cancer. But the NHS really delivers here, and still it is not good enough.

++++++++++


Tuesday 16th May

I have not seen Trevor for several months but he was the first patient in today. When I last saw him here in January, I wrote:

The second patient of the morning was Trevor. 32 years old. Hopeless alcoholic. Disturbed childhood. Physically and sexually abused.

He is dishevelled. He stinks of yesterday’s alcohol. He is shaking. Not yet had the first drink of the day. During the consultation he vomits and, before I can get a bowl in front of him, he catches it is cap.

He refuses admission to hospital.

“They aren’t interested, they just want to get you out as quickly as possible.”

I don’t say anything. It’s true. Most of the medical profession avert their eyes, literally and metaphorically, when an alcoholic turns up. The local psychiatrists are not much help. They will not take a direct referral. Instead, they write to the patient telling them that if they want to be seen, they must contact the department themselves. A test of “commitment” they call it. It’s a hurdle. A lot fall at it. Trevor always has.

I cannot not believe it. Trevor looks well. He is coherent. He is reasonably clean. As he chats I flick through the computer screen. Three weeks ago he presented to one of my partners, desperately ill, dehydrated, vomiting and shaking. My partner sent him in. He was so ill that they had to keep him. Drips, antibiotics, vitamins, food and nursing care. Despite his history, the psychiatrist did not see him.

A member of the CMHT did.

“Not depressed. Can go home. Refer back to GP.”

Great. I need to stop getting angry about this but I keep thinking, “What do you have to do, how ill do you have to be, for the psychiatrist to see you?”

Trevor has been out of hospital for nine days and he has not had a drink. He has not gone as long as this ever before. He has split up with his long-standing partner. She is also an alcoholic and is still drinking heavily. Vodka for breakfast. They are good and bad for each other in equal measures. They fight like cat and dog half the time and prop each other up, literally and metaphorically, the other half.

For the last nine days, Trevor has been living in his car. He parks it on some rough land near the canal. He has been to social services and they have given him an information pack and sent him to the housing department. The housing department referred him to social services. The housing department say there is no one in our precious home county who needs housing. And, anyway, he is an alcoholic.

I spend a long time talking with Trevor. Sober Trevor is intelligent and articulate. Bleeding heart liberals would say his problems are all due to his bad childhood. Wat Tyler would say “pull your socks up or I will put you on a bonfire”. I think it is his bad childhood.

I will start badgering social services and housing. There is an excellent CPN locally who helps alcoholics. She will see him.

If the housing department and social services would do something immediately, Trevor might survive. I fear they will not. He will return to his partner and the cycle will start again.

It is frustrating.

++++++++++

Yesterday, I had to order some domicillary oxygen for a patient. I have mentioned this before. In the old days, I wrote a prescription and the local chemist fixed it up within 24 hours. It took five minutes to arrange. Then the goverment took control of the system, centralised it and "simplified it." Now we cannot issue a prescription. Instead we have HOOF. We have talked about this before.

I feel a slogan coming on. This is no longer about ordering oxygen. It is about “Working for healthier lungs.”

Hmmm… I like that.

The business of supplying oxygen has generated so much new work that there is now a HOC newsletter which I found here. Sadly, that site is being re-designed, so I referred to and re-read the updated protocol here and having done that was able to fill in the HOOF form (as seen here ) . I faxed it through yesterday afternoon and went home.

The patient had about six hours oxygen left which I knew would last twenty four hours. I told her I would phone today and if here was no oxygen, I would get her into hospital. I phoned her with no expectations. Joy. She had the oxygen. It arrived yesterday. It arrived four hours after I sent the fax.

What can I say?

Clearly, all my critical remarks about Patricia Hewitt and protocols are unfounded. The system has worked.

Good old Patricia.

Good old new Labour.


++++++++++


Thursday 18th March

British Rail announced in December 2005 that they were going to stop running trains for four months whilst they reviewed the service. You may have missed the announcement. Fortunately the service started again today. From now on, applications for train tickets will only be accepted from people who want to travel. Putative passengers who had tickets in December will be offered a restricted service of short journeys to destinations not of their choosing. Those who bought tickets after December will have to buy another one.

Too silly for words. Of course it is.

Today I received a letter from Debbie, the specialist nurse for children with learning disabilities.

Anytown Park Health Centre
Coventry Road
Anytown

14 May 2006

Dear Colleague,

Re : Community Nursing Team for Children with Learning Disabilities

As you are aware, a decision was taken to freeze our waiting list in December 2005, to enable a review of the Learning Disability service to be carried out.

This has now taken place and as a result, the revised criteria for accessing the service is as follows:

Referrals

Referrals to the service will be accepted directly from Consultant Paediatricians and GPs, or from other healthcare professionals, with the GPs support for the referral. This is in line with practice based commissioning.

Criteria

1. Under Fives

• The child must have a learning disability
  
• A specific reason for referral must be given.

2. Over Fives

• The child must have a learning disability
  
• A specific reason for referral must be given.

The revised criteria will apply to all new referrals to the team from 15th May when the list is reopened.

Children already on the waiting list, who are no longer eligible for a service, will be offered short-term support.

Referrals sent to the team during the period of time the list was closed, will need to re-refer, via the appropriate referral pathway.

Please find enclosed the new referral form together with a copy of the new referral pathway. Please note this team will no longer accept old referral forms.

A further review of the service will take place in November 2006. In the meantime, if you have any queries, please do not hesitate to contact me.

Yours sincerely,




Debbie Jones
Specialist Nurse for Children with Learning Disabilities

Enc: the referral pathway


I think I have got that. They stopped taking referrals for five months whilst they thought about the kind of service they wanted to offer. They concluded that the learning disabilities service would in future only accept children with learning disabilities.

Well done, girls.

Now there is a five month back log. But at least we have a referral “pathway”.

What does this mean?

Why is working in a nationalised industry jeopardising my sanity?

++++++++++

What happens to children with learning difficulties? They become adults with learning difficulties. Because they are grown up, people do not realise and are less tolerant.

Patrick is 42 and has learning difficulties. I met him for the first time today. Patrick has worked as a shelf-stacker and a lorry driver’s mate, and as a labourer. At the moment he is not working at all. He came today because he is feeling tired all the time. TATT as it is called in the trade. This is a heartsink symptom. If you are feeling TATT, find some different words or the doctor’s eyes will glaze over.

Patrick was theoretically on lofepramine and olanzepine. Because he keeps losing his temper, he was put on olanzepine by the locum psychiatrist for people with learning disabilities. When Patrick gets cross he hits people. Usually his long suffering girl friend. He was put on lofepramine, an anti-depressant, by the CMHT who were seeing him until someone noticed the expression “learning difficulties” in his notes and turfed him out. Ordinary psychiatrists do not see people with learning difficulties.

He is not depressed and does not need lofepramine. He is not psychotic and is unlikely to benefit from olanzepine. Both these prescriptions were “get you out of the door” prescriptions. He realised that too. He threw them away.

The learning difficulty locum psychiatrist thinks Patrick may be a BPD. This is a non-diagnosis for difficult patients they do not want to see anymore. It means "I can't help you and I don't like you." Patrick says he would like some counselling but there is no one who will provide it. He asks me if I have some tablets to stop him feeling TATT. I do not.

Patrick is a big man. I am glad he is not cross with me. I chat with him for half an hour. He has a remarkably good sense of humour. He says he is bouncing around the system like a pin ball.

He is.

When he goes I write a letter to all the psychiatrists and CMHT team members who have seen him saying “you are all playing pass the parcel with this man. I think there is a grave danger that one day he will kill someone. Can no one take ownership of the problem?”

In a different life, when I was a lawyer, I went into Strangeways prison in Manchester.

There were a lot of Patricks in there. It is cheaper than a psychiatric ward.

Half an hour behind. Again. And stressed. Again.

+++++++++++



Friday 19th May

Duty day today, and it is busy, but everything is eclipsed by Andrea.

Andrea is 24 and is South African. She finished her degree there and is doing the “world tour” before she returns home to settle down to work, career, life and all those things. She has been in the UK for eight months. She is working as a sailing instructor in a local inland reservoir. I met her for the first time this morning.

She sat down, glanced at me, looked at the floor and said, “I’m not coping.” She sat silently for a long time. Then she said “It’s not worth it.”

She came over to the UK with her boyfriend, but they split up three months ago. After another long pause I asked her when she had last been happy. She laughed and said about three years ago. I have bulimia. I am on these – she took out a packet of Paroxetine and put them on the table. They don’t help. She is not vomiting anymore, but she still does laxatives. Lots of them. All her family are in South Africa. We talk a little more. She is not sleeping well. She never cries. Never. She says she is not suicidal.

Another long silence. Then, “I was raped on New Years Eve.”

Another long silence. I ask if she went to the police. She did. He was arrested and prosecuted. It went to the Crown Court, but then the CPS decided to offer no evidence and the case was dropped. “I was drunk at the time” she said. They told me they would never get a conviction. “I kept saying no, but I was drunk.”

I ask, “What brings you today, rather than in January, or next week or next month?”

She says that yesterday she stood in the supermarket holding a packet of paracetamol in her hand for so long that someone came over and asked if she was all right.

“Do you want to harm yourself?”

She shakes her head. Then she rolls up her sleeves and without a word shows me superficial lacerations on both forearms.

I ask if she has told anyone. Everyone at work knows. He used to work there as well but they sacked him. They are supportive and protective. I ask if she has told her parents. She looks at me for a long time and shakes her head.

++++++++++

Jobbing general practice.

I fantasize.

After Andrea goes, I wander down the corridor and grab our onsite counsellor. She agrees to see Andrea on Monday. I pick up the phone and track down Tessa, the local consultant psychiatrist. She is always supportive. We have a natter. Then she says, OK, what have you got? A disturbed, self-harming, socially isolated bulimic with low self-esteem who has been raped. Right, I’d better see her. Is she all right for the weekend? Yes, she is, and I have fixed up support for the rape, but I need help juggling the bulimia, the paroxetine and the possible depression. Tessa agrees to send her an early appointment and she will liaise with me and our counsellor.

Back to reality, Crippen.

The only think I have got is the CMHT.

I could phone them. But I am not prepared to discuss this girl with a “senior” mental health worker or the like. I have tried it before. I know what they will say.

First, the fob off. “Ah, she has an eating disorder so she should go to the eating disorder unit.” Our eating disorder “unit” is run by nurses and dieticians.

Then the self-help groups. They will offer to fax me a list of the various organisations who “help” women who have been raped. I have the list myself and I am a dab hand with Google. There is nothing wrong with these organisations but they tend to be (oh! dear, I feel the flak approaching) a bit “right on” for Andrea. Andrea is not “right on.” She needs a hug. I cannot provide that. She needs her mother. I cannot provide that either. She will not tell her mother what has happened over the phone. She probably will not tell her mother at all.

Finally, if I say it is urgent, they will offer a “risk assessment” by the protocol laden nurse specialist. I have already done a risk assessment, and a lot more than that. But I am not in the CMHT. I do not have a protocol. I have not ticked any boxes. So that does not count. Urgent referrals to the CMHT automatically generate a “risk assessment”. This is nothing to do with a psychiatric assessment or a diagnosis.

Patricia Hewitt says I am clogging up the system with unnecessary referrals.

The referral “pathway” to the CMHT is a protocol based form that has to be faxed through. I have to grade the seriousness of the problem. Does she need to be seen “same day” or within “two working days”, or within “five working days”? The CMHT does not work weekends.

I hate writing words like “raped” on forms to be faxed off into the ether. But that is what I do. I go for “two working days”. Four would do. Anything reasonable would do if I could discuss it with a sentient human being.

She will be seen by someone next week. They will refer her to the eating disorder unit. And that will be it. I know. Been there before.

Andrea is a highly intelligent university graduate with low-self esteem and bulimia who is self-harming and has been raped. She is not potty. I do not thing she is suicidal. She needs help. She needs sympathy. She needs support. She will get none of it.

Give me an hour a week for six months and I could provide most of what she needs. I do not have that time.

Part of my problem is that I am a relatively high-emotive doctor. This is not a good thing.

Patricia Hewitt and "Talking Therapy"

Talking therapy

Patricia Hewitt has done it again.

She has opened her mouth and inserted her foot.

Last month she perpetrated the biggest PR gaffe of this Labour administration when she said that the NHS was having its “best year ever.” She was lucky to come out alive from addressing the Royal College of Nursing, and there was surprise that she survived the Cabinet reshuffle.

Now she is attacking GPs. Again. This time it is our fault that the NHS cannot deal with depression. Back into the coconut shy.

A letter to Hilary Benn is reported in PULSE magazine:

Health Secretary Patricia Hewitt has claimed GPs are at least partly to blame for the crisis in access to depression services.

In a letter to fellow minister Hilary Benn about Pulse's campaign on depression care, she said GPs were clogging up the system by making inappropriate referrals.

Mrs Hewitt admitted access to psychological therapies could be 'problematic', but added: 'In addition, referrers sometimes lack knowledge about which treatments are appropriate.'

Strong stuff, Patricia. Where is your data?

"The Department of Health was unable to provide evidence of inappropriate GP referrals to back up Mrs Hewitt's assertion."

I see.

Let me tell you what is happening on the front line.

A large number of patients presenting to GPs are unhappy.

These people are not psychiatrically ill. They are not potty. Fifty years ago, they would not have come at all. They would have spoken to grandma. Or an aunt. Or any member of the extended family. Or their priest. They do not do that anymore. They come to their secular priest, in other words, their doctor.

When I started in my current practice, we had one and a half counselling psychologists on the premises. They were readily available to see patients at our request, and were able to see them within a week or two. Teenage girls who have split up with their boyfriend; the recently bereaved; unhappy marriages; stress at work. This is day to day general practice.

We must not medicalise these patients. They do not need medication. They do not need CBT. They need a little support. But, whilst they should not be medicalised, they must not be ignored. Teenage girls who have split up with their boyfriends take “trivial” paracetamol (Tylenol) overdoses. You can call it para-suicide if you like, but sometimes they miscalculate. They do not know the dangers of paracetamol. The para-suicide becomes a real one.

Most of these patients can be helped by three of four sessions with a sympathetic counsellor. And they used to be.

The Labour government took our counsellors away. There is now a centralised system for counselling off site. It is under funded and cannot cope. As the system is not coping, entry has to be restricted. Hewitt is doing that by saying that many referrals to the system are “inappropriate”. She is getting GP referrals “screened” by the CMHT.

We have met the CMHT before here.

A middle aged woman comes to see me because her son has been killed in a road traffic accident. I am now deemed not competent to decide what sort of help she needs. This bereaved mother has to be “screened” by someone with no medical training to see if the referral is “appropriate”. This screening is not done face to face. She is sent a questionnaire which contains questions which ask her to grade her level of distress. Is has to be done like this so that the non-trained CMHT worker can tick boxes, count numbers, refer to the protocol and measure the amount of grief.

How distressed were you by the death of your son

1. hardly distressed at all
2. mildy distressed
3. moderately distressed
4. moderately to severely distressed
5. severely distressed

Most patients fall at this hurdle and tear the questionnaire up. Two weeks later they will get a letter noting that they have not returned the questionnaire and ending “we assume that you no longer require help, and have discharged you from the system.”

That saves some money.

Meanwhile, I will do my best to put some time aside for the patient and help her myself. I have no problem doing this. It is an area of interest. But I cannot provide this service for all my patients. The demand is too great. A few go privately. One of our counsellors who was sacked provides an excellent service privately, but not many can afford £70 an hour. And that is the cheaper end of the spectrum.

PULSE reports:

Dr Nigel Watson, chief executive of Wessex LMCs and a GP in New Forest, Hampshire, said:

"It is not that we are referring to the wrong people ¬- for most people there is nothing to refer to."

Grand Rounds Vol. 2, No. 34

Grand Rounds

Grand Rounds is this week hosted by Dr ibear at Doc around the Clock, here

A summary of the best of medical and other blogging from the USA and around the world.

An interview with Dr ibear can be found on Medscape:

Dr. ibear: I was trained in Family Medicine and I did a residency at a hospital that was a level 1 trauma center. We Family Medicine residents were the only residency program in the hospital. Therefore, we spent an extensive amount of time in the emergency department. I did countless intubations, central lines, chest tubes, spinal taps, code blues, etc. By the time I finished my Family Medicine residency, I found that I liked Emergency Medicine much better than working in a clinic. After graduation I spent about 5 years traveling around the Midwest working in mostly rural, small-to-moderate-sized ERs honing my skills. Now I have settled down in an ER group that feels quite comfortable with my experience and skills. So although I'm not formally trained in Emergency Medicine, this is what I do now, and all I do now.

Read the full interview here.

What is an alcoholic?

It may seem strange for an experienced doctor to say what I am about to say, but here goes anyway.

I do not know what the word “alcoholic” means.

I used to know before I was a doctor. It meant someone who was addicted to alcohol. Someone who had a physical craving so great that he started drinking as soon as he got out of his bed and continued until he collapsed back into it. It meant a dirty unshaven man lying in the gutter clutching a brown paper bag with a bottle inside it, singing, swearing and vomiting. It meant that sad man who, many years ago when I was a student, grabbed me outside the chemist and asked if I would go in and buy him some methylated spirits.

I suppose all these people are stereotypical alcoholics. I do not see patients like that.

The problem about the word “alcoholic” is that people assume that if they do not fit into this stereotypical image, there cannot be problem.

“Alcoholic” does not encompass the housewives whom I stand behind in the supermarket. Three bottles of the cheapest white wine and a tin of cat food.

“Alcoholic” does not encompass that eminent QC who drinks two or three bottles of claret every night. Only first growths, don’t you know.

Some years ago a 48 year old police officer, a chief superintendent no less, came to see me.

“When I was shaving this morning, I noticed the whites of my eyes were yellow.”

They were too. He did not feel ill. Going through his history, we came to alcohol. He drank three quarters of a bottle of whiskey every night. He had done that for twenty five years. He never got drunk. He had never had a day off work. He was in liver failure.

“Could you stop drinking?” I asked.

Yes. No problem, doc. And he did. Immediately. Without difficulty. His liver still failed. He had a transplant. He is back at work. He has not drunk since.

Was he an alcoholic? Is the QC an alcoholic? Are all the housewives drinking cheap supermarket wine alcoholics?

I do not think it is a helpful word. I have stopped using it in a medical context. “Excessive drinking.” “Alcohol related problem”. Whatever. This is easier. And less pejorative.

Doctors switch off if they smell alcohol. Literally or metaphorically. Whatever you do, never go to a doctor smelling of booze. Even if you are having a heart attack. Drink some water. Clean your teeth. Suck a mint. Do whatever it takes to get rid of the smell. If you do not, your notes will contain a remark like “Smelt of alcohol at 2.45 p.m.” This remark will follow you around for the rest of your medical life. It will be on your notes. It will be on your computer records, and very soon it will be on your identity card.

How do you know if you have an alcohol problem? If you are asking yourself that question, you probably do have one. But, if in doubt, ask yourself the four CAGE questions.

1. Have you ever felt you needed to Cut down on your drinking?
2. Have people Annoyed you by criticizing your drinking?
3. Have you ever felt Guilty about drinking?
4. Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?

Two positives and you are in trouble.

If you cannot face your doctor, have a look at Dryblog, the best and least threatening internet resource for heavy drinkers.

Highly recommended.

Quality outcomes

Dr Crippen has referred many times to the government’s obsession with measuring performance in the NHS.

I draw your attention to the latest method of auditing patient satisfaction.

An NHS trust in Cornwall has been criticised for telling nurses to record the number of boxes of chocolates left for staff by grateful patients.

Managers at the Royal Cornwall Hospital NHS Trust said they used the procedure, dubbed by staff as a "chocolate audit", to assess patient satisfaction.

Figures for the trust, which is responsible for hospital sites at Treliske, Penzance and Hayle, showed that in 2005 there were 8,000 gestures of gratitude, including boxes of chocolates and thank-you cards and letters, compared with 316 letters of complaint for the year.

Jono Broad, of the North Devon Patient and Public Involvement Forum, said: "It's sheer lunacy - management madness in the extreme.

"It's all because the rules say nurses cannot accept gifts from patients - even if it is just a box of Quality Street.

"They have to record how much the gift is worth and who it came from. Then the sweets are shoved into a cupboard."

What a joy.


Reported by the BBC

Dinosaurs of medicine

Two family doctors meet for lunch

For a variety of reasons, I had a shitty day at work today and last week was pretty trying as well. Morale in general practice is low at present. Because we are on the front line of the NHS, we carry the can for most of the problems. So often we are little more than a coconut shy.

I would not mind taking the flak for earning a quarter of million pounds a year if I was earning it. I am not.

I get home and an email points me at an article in The Times on Line. There has been a discussion recently about so called “cyberchondriacs” - patients who go out on the internet and research their own medical problems. Nothing wrong with that. I would do exactly the same thing if I were not a doctor.

Let me quote from the article:

The average GP once went to college, long ago and often far away, and learnt to become a more or less competent jack of all trades; it is inconceivable that he can be up to speed with every detail of every medical advance in every malady that comes before him.

Either he simply hasn’t the time or — more frequently in personal experience — he hasn’t the inclination. Round our way the job involves just 27 surgery hours a week, tops (no house calls, lunchtimes, evenings or weekends), a cosily undemanding sinecure for which you trouser six figures as long as you can continue to mystify the customer with a few words in Latin.

Hard as it is to break up their party, GPs need to understand that their future function lies solely in providing referrals to the waiting lists of decent specialists who are properly on top of their subject, or in signing prescriptions for drugs that they’ve never heard of but their patient has.

They will, of course, still have the last laugh by insisting that they cannot manage to do either until their next free appointment, three weeks from Friday, by which time you will be already cured. Or dead. (“Just keep taking the Googles” by Carol Sarler)

Read the full article here

It is easy to understand why patients do not mind the traditional doctor’s role being taken over by non-medically qualified "health care workers". Family doctors have become the dinosaurs of the NHS. Continuity of care? Forget it. Patients want instant access to a “health care worker” for their minor medical problems, and access to a secretary to write a letter to someone about their major problems.

What would Dr Cameron and Dr Finlay have said?

The writing is on the wall. We will soon be gone.

Quacktitioner Alert (5)

A reader points out to me that home obstetric deliveries will soon be as safe as hospital deliveries.

Has Patricia Hewitt secretly funded obstetric flying squads for the whole country?

Sadly not.

This is another Quacktitioner Alert.

“Scotland on Sunday” reports:

SCOTTISH midwives are being trained to perform potentially dangerous forceps deliveries in a bid to tackle a chronic shortage of specialist doctors. Health bosses in Aberdeen are creating a new type of medical staff called "assisted birth practitioners" in an attempt to reduce the lengthy waits mothers can face before being seen by obstetricians during labour. The Scottish Executive last night confirmed the pilot could be rolled out across Scotland. But according to managers behind the project, the move has met with resistance from midwives.

The new practitioners will be trained to use forceps and carry out ventouse procedures to deliver babies, procedures previously only carried out by highly trained doctors. The move has been heavily criticised by maternity campaigners who fear it is an attempt to deliver specialist maternity cover on the cheap and could see the number of forceps deliveries, a risky and potentially traumatic procedure, soar in Scotland.

Forceps deliveries can often lead to injuries including cuts and bruises to both the baby and mother. If used wrongly, babies can be left with broken bones and even brain damage. Currently there are five midwives in Elgin, four in Aberdeen and two in Orkney taking the two-year course in a joint venture with Bradford University to take up the new assisted birth practitioner role. On top of assisting delivery they will also be taught how to take foetal blood samples from the baby to monitor during labour. Organisers behind the scheme claim the new practitioners will provide an invaluable service in remote areas where obstetricians are in short supply.

"In the right hands, these procedures are perfectly safe," said Jean McConville, clinical midwifery manager at Aberdeen Maternity Unit, who is leading the project. "We have midwives with more than 20 years of experience and have witnessed dozens of forceps deliveries who are now being trained to carry them out."

Read the whole, horrifying article here. It demonstrates all the characteristic Crippen hall marks of “dumbing down”.

"...it is an attempt to deliver specialist maternity cover on the cheap."

It saves money.

Madwives are not competent to carry out these procedures. So we had better rebadge them so that no one notices. They are going to be called “Assisted Birth Practitioners.” That’s all right then. Sounds good. The title does not mean anything, but it sounds important. We know about this. Once again it is Hospital at Night with Sue and Dave. Jean McConville, the head honcho madwife says:

"We have midwives with more than 20 years of experience and have witnessed dozens of forceps deliveries who are now being trained to carry them out."

Quite so.

She has read and is quoting from Dr Crippen’s comment on the plan to allow air hostesses to fly aeroplanes:

"There is a critical shortage of qualified pilots. It takes many years to train a pilot to fly a modern jumbo jet and the expense of this training is enormous. We have a body of young men and women, all keen to help out and fill the gaps. These young people have been serving food and drinks to the passengers for many years, and are valuable members of the Air Crew Team. Given their years of experience it is only economic sense to make more use of them on the flight deck. They have been watching the pilots fly the planes for years, and will have no difficulty in taking over from them in certain controlled circumstances."

Tracey Smith, an air hostess for nine years said, "I am very excited about this move and look forward to working with my pilot colleagues." (Full article here)

Soon it will not be just over-promoted trolley-dollies. Dr Crippen revealed here that nurses are to have an important role to play in the front line of the RAF.

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”.

When is this going to stop?

A lamb to the slaughter?

Spring Lambs

It is Spring again and a fascinating new blog appears. The Hippocratic Oaf is in his second pre-clinical year at Oxford University. He intends to document his progress through medical school and into medicine. If he keeps it up, it will be fascinating.

He writes well.

“I also regularly read blogs and columns written by British hospital doctors. From these groups of people I notice two common trends: A burning hatred for the management of the NHS and a general tendency towards clinical depression. Medical training and hospital careers run people into the ground. It's painful, gritty and unrewarding. Avoid it at all costs. It will consume your very soul. These are the messages I get from the people who actually know what they're talking about, yet I merrily ignore them. I'm still in the aforementioned stage of childlike bliss.

I have yet to enter the awkward and angst-ridden teenage years of adjusting to a hospital routine. It's possible that I'll hate it and will drop out as soon as I get a real taste of hard work. It's possible that everyone exaggerates to liven up their prose; who'd want to read about a well-contented doctor cheerfully going about a pleasant day at work? Maybe I'll hate it but feel obliged to continue anyway out of some misguided sense of duty, working every waking hour until I'm eventually anaesthetised to all that is worthy in life.”

So young. So enthusiastic. As were we all. And yet, do I detect a trace of cynicism already? Surely not!

Which reminds me, I have not taken my medication yet today.

Grumpy old man denied medical care

No medical treatment for him

Dr Crippen’s attention is drawn to an article in the Times on Line written by Mick Hume.

An elderly man has been refused medical treatment by the Queen Elizabeth Hospital in King’s Lynn, Norfolk because they do not like his political views. Specifically, they have cancelled his hip operation.

Would they have cancelled his operation if it had been to remove a cancer?

I do not like the views of the BNP but I would not refuse them medical treatment. For that matter, I do not much like the political views of Tony Blair. I could go on.

Dr Crippen is not sure that the nature of his political views are relevant but, for the record, what are these views that caused so much offence? He is against abortion. Nothing wrong with that. An honourable position. In pursuit of his views, he sent photographs of aborted foetuses to some members of staff at the local hospital. These caused upset. He was prosecuted, found guilty and sent to jail for 28 days.

"Ruth May, the hospital’s chief executive, claims that the ban is justified because the “offensive” publications he mailed caused “great distress” to her and her staff and thus contravened the NHS policy of “zero tolerance”.

Have hospital authorities been granted the power to turn away anybody who upsets them? It may come as a shock to delicate souls in the upper echelons of the NHS, but some elderly people can be cantankerous, obnoxious and express unfashionable opinions in an uninhibited way. So what? Should the NHS introduce a policy of euthanasia for offensive old gits? "(Mick Hume)

Once again, it is not clear if the doctors seem were involved in this decision.

If they were, I feel ashamed. This is not the way doctors should behave. It reminds me of the touching story of Ronald Reagan being admitted to hospital after he had been shot. When the surgeon arrived, the President said, “I hope you are a Republican.” The surgeon replied, “We are all Republicans today, Mr President.”

And that is how it should be.

Read the full Times article here.

Where have the psychiatrists gone?

Occupational therapy on psychiatric ward

I can think of no better example of what is going on in British psychiatry than today’s report from the BBC of the use of illegal drugs on hospital wards.

There is grave concern amongst the medical profession, and particularly amongst GPs, about the damaging psychiatric effects of so called “recreational” drugs. Cannabis still has a reputation for being harmless and the Government compounded this by downgrading its legal categorisation. There must be evidence that dope smokers vote New Labour. And as seen here the new Conservative leader is not able to account for his activities whilst he was a student. Maybe he kept sneezing because of hay fever.

British prisons have long been a haven for drugs. Now it seems that psychiatric wards are as well.

The head of a psychiatric hospital admits more than one in seven patients takes illegal drugs on the wards.

Oliver Treacy, borough director for mental health services for Barnet, Enfield and Haringey Mental Health Trust, admitted: "It is quite common that patients will use drugs on wards. It can make patients worse and it can actually introduce a sense of desperation and violence."

He estimated that up to 14% of patients in some wards at Chase Farm were currently taking drugs on the premises.

Drugs workers helping in-patients at the hospital said one patient recently took crack cocaine on the ward.

One nurse said it was difficult to stop all illegal drugs entering the hospital. Samuel Ankara said: "One patient was using a bed sheet to drop out of his window to pick up drugs from a dealer below, then another one tried to bring in drugs hidden inside a kebab."

Experts say the problem is not helped by the fact that different NHS trusts have different policies on dealing with the issue.

The most striking thing about this report is not the drug problem. It is the fact that there are no doctors involved. We hear from Oliver the hospital administrator, and from some nurses.

Where are the psychiatrists?

How extraordinary that this report, referring to a specific hospital, contains no reference to a psychiatrist. Do they not care? Do they know what is going on?

Whoever is in charge here, it is not the doctors.

GPs are bombarded with “newsletters” from hospitals telling them how well everything is going. These are always on the Soviet model of “Good news, comrades, tractor production has improved.” It was not difficult to find the relevant document from Oliver. True to form, it is an orgy of self-congratulatory bureaucrats and middle-managers awarding each other prizes:

Staff Awards for Excellence 2005
The Staff Awards for Excellence Scheme prompted over 60 nominations this year from staff, service users and partner organisations. The Awards Ceremony was held on 7 December 2005 at The Oasis Restaurant, St Ann’s Hospital. 5 overall winners were chosen, plus a number of runners-up received recognition. The winners are:

• John Carolan, Ward Manager, Barnet
• Richard Perry, Patient Advice and Liaison Officer, Enfield
• Michela Del Guercio (Del), Domestic Assistant, Haringey
• Claire Wells, Service Administration Manager, North London Forensic Service
• Shaun Collins, Assistant Director: Haringey Child & Adolescent Mental Health Services



Congratulations!
Andrew Smith, Trustwide Mental Health Act Co-ordinator has attained his LL.M (Master of Laws) in Mental Health Law, Policy and Practice from Northumbria University. He would like to say a big ‘Thank You’ to all the staff at BEHMHT who agreed to fund and support his studies - well done Andrew!

Well done, indeed, Andrew. And Del. Well done all. Sad that none of the psychiatrists achieved a degree of excellence.

Read Oliver's full document, in all its soviet splendour, here.

Meanwhile, Oliver is not sitting on the drug problem. He is taking action. He is going to employ a nurse therapist/drug advisor. It is all here.

Where are the doctors? Why is this initiative not being led by the senior consultant psychiatrtist? Maybe there is not one.

Is Dr Crippen being unfair? I am told that the Bible does not mention trousers and that if one were to take a true fundamentalist approach one should not wear them. Lots of people do, though. Just because these documents do not mention psychiartists, it does not mean that there are none.

But where are they?

What are they doing?

Hitting the targets

Hitting the targets

It is not just in archery that hitting targets is important. Unfortunately, in the NHS it is not "fun", no matter who wins, or how "they" handle it. Do patients "win" if doctors hit all the targets? The Secretary of State thinks so.

Pravda reports that Patricia Hewitt is encouraging hospitals to meet targets to attract more patients.

In a report on the British NHS, Pravda reports (seriously, it is in Pravda – here):

“The health secretary, Patricia Hewitt, today signalled that NHS hospitals face the possibility of closure if they fail to attract sufficient numbers of patients.

Speaking at the International Convention Centre in Birmingham in her first public address as the newly appointed health secretary, Ms Hewitt echoed her predecessor, John Reid, by saying it was possible that some services could close if patients deserted them.”

Hospitals will soon be reporting their overall mortality rates and the individual mortality rates of the consultants working within the hospitals. In this age of consumerism, it seems reasonable that the public should be able to access these figures so that they can best judge which hospital to choose.

We have lots of targets in schools now. SATS, GCSE’s, AS levels, and “A” levels. All the national newspapers publish annual league tables showing the “best” schools in the country. The tables report only on exam results. There is no effective way to measure what is called "value added".

Some schools fiddle the exam results by only allowing pupils to sit exams in their best subjects.

Thank goodness that sort of thing could not happen in hospitals.

Or could it?

A hospital doctor asks a colleague in a different speciality to perform an urgent investigation on a patient who is critically ill. The reply he gets is:

"If he is going to die of cancer anyway in a week we don't really want to do the test; if there are complications it will put our mortality figures up and it isn't worth the risk. First I would like you to do some more tests to find out if he does have cancer so we can think again."

Read the full story here.

Consumers – that is, the patients – will wish to stay away from doctors and hospitals with high mortality rates.

Who, then, will look after the critically ill?

The Terminal Care Industry

Fawlty Medicine

Crippen: Good morning, Mrs Davies, and how are you today?

Mrs Davies: Not at all well, I’m afraid, Doctor. Would you mind killing me?

Crippen: Certainly, Mrs Davies. I have a slot free at 2.30 pm this afternoon. Would you like to be despatched here in the health centre or at home?

Mrs Davies: The health centre would be fine, doctor.

Crippen: Excellent! See you this afternoon.

________

Doctors have a variety of coping strategies. Many of these strategies seem psychopathological to the lay man. Some of them, such as heavy drinking, which is rife in the medical profession, are. Humour, perhaps, is not.

The business of being asked to kill patients is to me so bizarre, so macabre, that I cannot take it seriously. I lapse into a John Cleese/Basil Fawlty voice and go through silly imaginary conversations.

The wretched Joffe Bill is still alive and well in the House of Lords. The twittering middle classes will be in full flow this weekend. We move ever closer to Oregon and Holland.

If doctors are to start killing patients deliberately as opposed to accidentally, there are some challenging moral and practical issues to be discussed. Dr Crippen will be returning to those issues over the next few weeks. First, though, why is there currently so much demand, amongst the twittering middle classes at least, for doctors to be allowed to kill selected patients?

I believe this demand is a result of the terminal care industry and the hospices. They are responsibly for the greatest medical fraud of modern times. They have repackaged dying and death as a process and event that we may enjoy and from which we may learn. When a patient is dying, and the reality strikes home, so great is the fraud and consequently so great the disappointment, that patients seek an early way out.

I shall not be killing terminally ill patients. If you want to kill yourself, as far as I am concerned, that is a matter for you. I will do everything in my power to dissuade you but, ultimately, it is your right.

Just do not ask me to get involved.

You will note that I do not use the word “euthanasia”. “Euthanasia” is one of these dreadful euphemisms that we employ to make the unacceptable acceptable. We indulge in semantic gymnastics to make killing palatable. Animals are not killed, they are “put down”. Criminals are not killed, we execute them. Soldiers are not killed in war; they “lay down their lives.”

I digress. Back to killing patients.

I have looked after more terminally ill patients than I care to think about and, as I get older, it gets more and more difficult. I have never killed a patient. I have never been asked to kill a patient. I have never done anything to a patient with the intention of accelerating death.

Contrary to popular believe, good symptom control does not accelerate death. I believe it may prolong life, and a reasonable quality of life too. When, finally, a patient becomes weak, is unable to eat and drink, and is lapsing in and out of consciousness, I will put up a syringe driver with sedative medication in it, and the patient may be on this for a day or two. When, finally, they die, it is not due to the medication.

I do not accept, and I have never accepted, that a medical condition can become so intolerable, so painful, that the only sensible option is to kill the patient. The work done by the late Dame Cicely Saunders made it clear that it is always possible to provide acceptable symptom control. “Palliative care” as it is called by the terminal illness industry, is not rocket science. It would be an over-simplification to say it was just about giving an adequate dose of pain killers on a pre-emptive basis. But there is not much more to the medical side than that.

Cicely Saunders' great contribution to medicine was showing that it could be done. That it was reasonable that it should be done. If you like, she gave doctors and nurses permission to treat symptoms.

I put her in my personal top ten of the greatest 20th Century doctors.

The message has got through to most doctors and some nurses. Nurses, sadly, are still trained to believe that analgesia is a reward for pain, not a preventative. Midwives, in particular, are from that school of thought. Try asking for an epidural if the gas and air on your “birthing plan” is not enough for you.

Whilst the hospice movement has been immensely valuable, it has caused problems. Two problems in particular. It has fraudulently promoted the image that dying need not be unpleasant. That dying can be some sort of clap-happy learning experience. Worse, it has encouraged people to believe that it is best to die in a hospice rather than at home surrounded by their family.

I have in front of me a circular from our local hospice, inviting our nurses to one of their courses. It says:

“The Colorectal Cancer update study day will enable the student to identify the journey that the colorectal 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. Group discussion will be encouraged to enhance learning and create a relaxed environment.”

It is twaddle like this, fuelled by the media, that leads people to believe that it is their right to enjoy dying. When the reality of death approaches and they realise that dying is not a pleasant experience, that so much of the public face of "palliative care" is fraudulent, they seek a quick way out.

A patient of mine was admitted to the local hospice. The care he had there was faultless. I have no criticism of them of any sort. After three days he took his own discharge. I asked him why.

It was the first week in January. He was on a four bedded ward. The patient who was in the next bed died. There is a lot of that in a hospice. The priest came to do the business. The three other patients heard every word. When the priest had finished, he drew the curtains, smiled at them and said “Happy New Year.” My patient got an uncontrollable fit of the giggles.

He came home.

Let me spell out a few, simple home truths. Not currently politically correct. Not what the documentary makers would have you belief, not what Esther Rantzen would say.

Dying is a bugger.

It is unpleasant. It often involves discomfort. It is the loneliest experience you will ever go through. It is heart-breaking for you and your family.

It is a real bugger.

But let us not sweep it under the carpet and rush you off to the hospice where death can be processed and packaged. Out of sight. Out of mind.

Hospices remove death from life. They sanitise it. We have already removed birth from life in the UK. Obstetric medical services are currently set up so that no one in their right mind has a home delivery. It does not have to be like that. Now the same is happening to death.

Be realistic about dying. It is not pleasurable. It is not fun. There may be some physically painful times, though these can nearly always be controlled medically. There will be some emotionally painful times. These can not be controlled so easily. You will be sad. You will be lonely. Ideally, you will be at home, surrounded by your family, supported by the family doctor, the district nurses, the Marie Curie nurses and the local vicar or priest. If that is not possible, you will be in the hospice.

There will be some bad times. Times of deep sadness and despair. There will also be some good times, some quality times. Not in any transcendental and philosophical way, but in terms of precious time spent with family and friends.

Whatever else is going on, that is too good to miss. Do not throw it away. And do not ask me to help you throw it away.

__________________________

Listen to this moving interview on the BBC Radio 4 Today programme with a former nurse, Sally McIntosh, who is in her mid fifties and has incurable cancer. She has weeks to live. She gives her views on assisted dying. (You will need Real Player)

The Crippen Diaries (Week 19)

Not quite Tannochbrae

Monday 8th May

A very worried 16 year old boy comes alone. At 16 he is entitled to come alone but most teenagers of this age usually drag a parent along. I ask him what the problem is. He blushes and bumbles and mumbles about having some spots on his penis. He is not really sexually active. He says he has had intercourse once. “Sort of”. I do not ask him what “sort of” means. In any case the spots predate the “sort of” episode by some months.

On examination he does indeed have little white spots spread over the shaft of his penis. A couple have been traumatised. He admits that he has been pricking them with a pin, and trying to squeeze them out.

These are PPPs. Pearly penile papules. They are extremely common. Normal really. Leave them alone. They are harmless. Strangely, few teenage boys have heard of them. They ought to be warned about them routinely. It would save a lot of anxiety. This lad had been worrying about them for months before he summoned up the courage to come. I will not traumatise you by showing a picture of PPPs, but those who wish to see them in all their glory (if they do not have some of their own) can look here.

++++++++++


I used to believe that old age was an excuse for unpleasantness and that it was unfair to call any old person “unpleasant”. I have changed my mind. Age does not make you unpleasant. Unpleasant middle-aged people become unpleasant elderly people.

Mrs Jones is 79 and is unpleasant. I do not like her. Doctors are not supposed to say that, are they? Sorry. Nonetheless, we all have patients we dislike and Mrs Jones is one of mine.

I looked after her husband when he was dying of heart failure. He wanted to move his bed downstairs. Mrs Jones would not let him. She is too house-proud to clutter up her sitting room with ill husbands. He used to go upstairs on his hands and knees. Her house is always immaculate. It looks as though it has not been used. She has a south facing sitting room. She keeps her curtains closed during the day to stop the sun fading her carpet. A bit like her attitude to life, really.

Because I do not like Mrs Jones, I always go out of my way to be particularly pleasant and accommodating to her. I am meticulous about her medical care. Well, thinking about it, I hope I am meticulous about everyone’s medical care. So I am probably over-solicitous with her.

She has come today to complain that she is not sleeping. A young couple have moved into the house next door. They play loud music late into the night. She wants something to help her sleep. I am sympathetic but this is not a medical problem. I explain in detail why sleeping tablets would not be appropriate. I suggest she talks to the neighbours. She says she never talks to them as she does not like them. I resist the temptation to ask how she knows she does not like them if she has never talked to them.

She goes when she realises I am not going to give her a prescription. She is not happy but then I do not think she does “happy”.

++++++++++


Tuesday 9th May

A letter arrives about Marion, a 42 year old who has recently been diagnosed with myxoedma. She is on the right treatment now and feeling a lot better. She has also been suffering from headaches, sweats and is stressed at work.

She has taken herself to an Autogenic Consultant. I have never heard of Autogenics. My mental Quackometer is beeping loudly. The Autogenic Consultant says:

“I gather she has a stressful job and would like to undertake Autogenics to help her cope with her symptoms and her job.

Autogenics is suitable for people who want to reduce the effects of stress. However, as some health conditions need careful monitoring I would be grateful if you could let me know if she has any other medical conditions of which I should be aware.

I enclose a leaflet on Autogenics, and the patients signed consent to divulge her medical details.”

I have never heard of Autogenics, so I check it out on Google and read the leaflet. On the worst analysis, the treatment seems harmless and, as it is relaxation based, and Marion is stressed, it may be helpful. And the letter is both sensible and professional

So I turn off my Quackometer. Quacks do not liaise sensibly with conventional physicians. I shall read up on Autogenics. Maybe there is something in it.

++++++++++

I have a patient dying of disseminated carcinoma of the colon. Both he and his family are fully aware of the diagnosis. Like an increasing number of patients nowadays, he has what is called a "Living Will" deposited in his notes. When he was well, and he brought it to me, he was vociferous about what he would and would not want if, as and when he was terminally ill. Now that he is, he does not mention it.

I have never had a patient mention a Living Will when they are terminally ill.

He has not had much pain. Contrary to popular belief, severe pain is not a common feature of widespread cancer. He is on oral slow relief morphine, steroids and an anti-emetic drug.

I had a long talk with him today. He is fed up. That sounds as though I am trivialising. I am not. They were his words, “God, I’m fed up, doc”. He is not depressed. He is angry about it all. He is only sixty three. His daughter is six months pregnant.

Dying is a bugger.

I hate the clap-happy way the hospice “movement” and the media leads us to belief that dying can be a “learning" experience, a "sharing" experience. It is not.

It is a bugger.

When I was younger and knew everything, managing terminal illness was difficult medically but easier emotionally. Now the medical side is easy, but the emotional side is difficult.

++++++++++




Thursday 11th May

First patient is Dorothy. She is a fit 66 year old on no medication. She presented two weeks ago with jaw pain. She had already been to the dentist who found nothing and rightly referred her to the doctor. The jaw pain was intermittent. Never at rest. Brought on by exercise. Walking up stairs. When she made the bed. Sometimes her left shoulder hurt as well as her jaw. It had not worried her too much as the pain always went off in less than half a minute.

This is a classical history of angina. We have open access to exercise tests and she had one done within a week. She walked for five minutes on the Bruce Protocol, stopping because of tiredness rather than jaw ache. There were ischaemic changes on the ECG both on exercise and in the recovery period.

This is now proven classical angina. It is stable. She is now on aspirin, a statin and a small dose of a beta blocker. She still gets occasional jaw ache but it is much better. Much better. She came today to discuss this letter:

St Elsewhere's Hospital

Mrs Dorothy Jones

27 Coventry Road
Anytown.

11th May 2006

Dear Mrs Jones

We have recently received a referral from your cardiologist for you to have a procedure (1) in the angiography suite. Your name has been placed on the waiting list. (2)

In accordance with the current government guidelines, from April 2004 the maximum wait time for cardiac procedures will be six months. (3)

The Trust endeavours to ensure that all patients are admitted as soon as possible and in order of clinical need. We will contact you again approximately eight weeks prior to (4) your procedure to organise a date that is convenient to you. (5)

If your symptoms increase in frequency or come on more easily during this time please contact your GP. If you are an angina sufferer and you experience chest pain/tightness that continues for more than fifteen minutes (6) and is not relieved by rest or GTN spay, please call 999 for an ambulance.

Yours sincerely,



The Angiography Suite Team (7)

__________

Mrs Jones is broadly reassured by this letter. Everything is in hand. No sense of urgency is conveyed so the problem cannot be urgent. The hospital know best.


Let’s go through the letter:

(1) No one bothered to explain to her what the procedure was. Arteriography has both a morbidity and a mortality rate, and she needs to be advised about that. Someone in the clinic may have briefly discussed the test, but she was probably in a bit of a tizzy and forgot most of what she was told. Fair enough. I talk her through it.

(2) Dorothy is now walking through a cardiological minefield though she does not know it. The longer she is left, the more likely she is to step on something nasty. Yes, her angina is stable and she is not in the high risk category but she IS at risk. This is why I have private health insurance. Of course, no one has told her she it at risk. And because she has a letter from a hospital, from an angiography suite no less, she assumes that there is no problem and that waiting is all right. I have had patients die on this waiting list. I do not tell her any of this either. I am a coward, I suppose, but what is the point? It will not bring her appointment forward and the stress may aggravate her angina. I wonder if Tony Blair would have to wait six months for an arteriogram on the NHS. He uses the NHS, just like you and just like Dorothy. Of course he does. He said so. (See "I'm all right, Jack" here)

(3) The government has “decreed” what the maximum waiting list should be. It does not work like that. The waiting list is the waiting list. If Dorothy does not get her angiogram within six months, the hospital will lose some points. So what? She still will not have had the test.

(4) “Prior to” – “before” as we lovers of the English language prefer.

(5) They will not “organise a date that is convenient” to Dorothy. They will, without discussion, send her a date. If she cannot make it, if her son is getting married on that day, she can turn it down. She will be sent another date some weeks ahead and she will have let the hospital off the hook in terms of government targets. Not their fault if she cancelled.

(6) Pain lasting more than fifteen minutes. Hmm…does that mean pain lasting ten minutes is OK? And they have missed out the single most important warning sign. She needs to get immediate help if the pain starts coming on at random, at rest. Stable angina comes on with exercise. Unstable angina comes on at any old time and is a dangerous symptom requiring immediate medial intervention. I warn her about this, but it should be on the protocol.

(7) Why can a cardiologist not put his name at the bottom of the letter?


I shall see her at frequent intervals and question her about her angina and I will alter and increase her medication if and as necessary. She will probably be all right. Most patients in her position survive.

Dorothy is not as stressed by this letter as her doctor. If patinets do not realise there is a degree of urgnecy about a problem they do not worry. Best not tell them then.

I must check my private health insurance is up to date.

++++++++++

Friday 12th May

This is a relaxed Friday because, for once, I am not duty doctor. And Spring is well-established. We have moved from the busiest to the quietest part of the year. Lots of hay fever, but that is straightforward.

++++++++++

First patient in today is Ralph, a 61 year old retired electrician. He comes to the doctor about once every five years. He complains he is getting a recurrent metallic taste in his mouth. He has been to the dentist who says there are no problems and that he has excellent dental hygiene. As the problem is intermittent, I ask him if he knows what brings it on. He does. It comes on when he eats broccoli and drinks white wine at the same time.

Family doctors come across little nuggets like this all the time. Broccoli and white wine causing a metallic taste in the mouth. Why should this be? I have not got a clue. More interestingly, why has he come about this problem? Devotees of Balint (I am a devotee) would say this is just his subterfuge, the cloak he wears, to get himself to the doctor. The real problem is his poor sex life. Or something.

I give him plenty of opportunity to bring up "or something". He sticks resolutely to Broccoli and white wine.

I suggest that perhaps he should avoid the combination. He obviously thinks I am trivialising the problem. “That’s not the point, doc. I want to know why it is happening.”

So do I Ralph, so do I.

++++++++++

A very hot ten month baby. I saw her yesterday. There was nothing to find apart from the temperature. Nothing at all. Mum has been trying to get a urine specimen. Sadly, she has not succeeded. She was convinced she would manage by holding the baby over a potty after feeds, but it has not worked. I have given her a paediatric urobag (basically a polythene bag with a sticky top surface that you put over the baby’s front end). It came off, and the urine spilt, and we did not get any. This baby is very hot indeed. Temperature 40.2 C. There is still nothing to find. We have to exclude a urine infection. It is Friday. It will not keep until next week and the hospital labs are closed over the weekend, so I send this baby up to the paediatricians.

I hate thermometers. We do not have one at home. A hand on the forehead suffices there. Doctors are renowned for ignoring their own children’s medical problems. But I am not a real doctor at home, I am a parent. In my role as a real doctor, I have to take temperatures. It is expected. Flea wrote about this recently. I still sometimes think the world would be a better place without thermometers. Am I becoming a nihilist?

++++++++++

Quacktitioner Alert (4)

Dr Crippen has already described the difficulty he has in getting psychiatric patients assessed by doctors.

"A seventeen year old boy with a long psychiatric history took a paracetamol overdose a few days ago. This is his second serious suicide attempt. He was kept in hospital for nearly two days whilst the physicians sorted him out from the physical point of view. The psychiatrist did not bother to go to see him. He was “assessed” (sic) by a mental health nurse who told him to go home and make an appointment to see his GP. No appointment made to see a psychiatrist. No hospital follow up at all. Difficult to know how good the “assessment” was as the nurse did not even bother to do a letter.

What are we supposed to do now? We are worried about this boy. We are more worried about the local psychiatric department, which is dreadful beyond words. As soon as commissioning is introduced we will be removing all the psychiatric care from this hospital. We have told them this. They do not care. We did this when we were fund-holders and found excellent psychiatric services elsewhere. The Blair government abolished fund holding in 1997 for doctrinal and political reasons even though it was working well. It is now re-introducing it under a different name."

The GPs in my area believe that we have some of the worst psychiatric services in the country. The local consultant psychiatrist lost interest long ago, if indeed he ever had any.

It is difficult enough to get hold of a psychiatrist during the day and impossible at night. There are no psychiatrists in the local hospitals at night, as described here.

We described here how the government has “dealt” with the crisis by re-badging.

This is not “Oh Christ, I’m bleeding and there are no doctors available.” This is “Hospital at Night”.

Sue and Dave paper over the cracks with some psychobabble entitled “Getting a picture of the hospital at night”. They are “teambuilding.” Not just an ordinary team. They are building:

"...a multidisciplinary night team which has the competencies to cover a wide range of interventions and the capacity to call in specialist expertise when necessary."

This team is going to be so skilled that is has the "capacity" to call in a doctor. (What does "capacity" mean in this context? Why do they not write in English?) In other words, it is able to use a telephone. Count how many times the word “doctor” appears in their extraordinary protocol which, as always, can be found here.

It is not just at night. It is not, apparently, just in my part of the country. The author of “Trick cycling for Beginners”, a doctor doing post-graduate training in psychiatry, draws my attention to the state of affairs during the day as well.

How does her psychiatric hospital deal with psychotic in-patients?

Written by a nurse in the psychiatric day hospital:

"Norman stated that he had auditory hallucinations - the voices were too loud for him to concentrate. Again he was advised to inform his GP of his symptoms."

You do not believe it do you?

Read the full story here.

One of Dr Crippen’s patients, who was an in-patient on the psychiatric ward, had a relapse of his depression. He was frightened and distressed. He called one of the psychiatric nurses. She gave him 10p and advised him to call the Samaritans. On the ward phone. Who needs psychiatrists?

You probably do not believe that either.

It is true.

This is the CMHT in full flight. This is how NHS psychiatric patients are treated. This is dumbing down.

Welcome back to the wonderful world of the Quacktitioners.

++++++++++

I add on an elegant description of the realities of Hospital at Night written by an experienced hospital doctor who is about to be replaced by a quacktitioner.

Why does no one believe that this is happening?

This is not about attacking nurses. It is about trying to save the Health Service.

Read this doctor's full account here

Grand Rounds 2 (33)

Yet another edition of Grand Rounds has just been posted by Dr Tara Smith who writes Aetiology.

Tara C. Smith is an Assistant Professor of Epidemiology. Her research involves a number of pathogens at the animal-human nexus. Additionally, she is the founder of Iowa Citizens for Science and also writes for The Panda's Thumb.

Aetiology is a web log discussing a wide variety of issues pertaining to the science of biology. While much of the focus is on the epidemiology of infectious disease or general microbiology, these are fields that lend themselves to discussion of a much wider range of topics: general epidemiology, vaccines, medicine, public health, pseudoscience, and politics, just to name a handful. A discussion of the microbial world reaches into many facets of our everyday lives.

Tara C. Smith is currently an assistant professor of Epidemiology in Iowa. Born and raised in Findlay, Ohio, Tara received her B.S. in Biology from Yale University in 1998. A "temporary" stint as a technician led to a Ph.D. in microbial pathogenesis and virulence factor regulation in Streptococcus pyogenes (group A streptococcus) at the Medical College of Ohio in Toledo. She completed post-doctoral training in molecular epidemiology at the University of Michigan. Her current research centers on investigation of hypervariable proteins in the group B streptococcus, S. agalactiae. Other current projects involve studying the epidemiology and molecular biology of E. coli, Streptococcus suis, and influenza. Additional interests include microbial ecology, emerging diseases, zoonoses, and infectious causes of chronic disease.

Tara is interviewed on Medscape by Nick Genes, the originator of Grand Rounds, and the writer of Blogborygmi. Read the full interview here

You can't even give it away...

Free Health Care

When I went for coffee this lunchtime, one of my partners was fuming. He only had one visit this morning. Mrs Allsop. An elderly lady with a painful leg. She lives alone. She has a daughter who lives a few miles away. Possibly, from the message she left, a superficial thrombophlebitis. She needs to be seen.

When he arrived at the house, there was no one in. He telephoned her in case the door bell was not working. No reply. This is always a quandary. Has she succumbed to a more serious illness? Was it a deep vein thrombosis and a pulmonary embolus? Is she lying unconscious on the bathroom floor? Should he get the police to break in? We have all done it. It is embarrassing if you do that and find the patient has just nipped out to the supermarket.

He came back to the health centre for coffee. A receptionist came in. Mrs Allsop had just phoned. She was apologetic. She had forgotten it was the morning her daughter takes her for monthly trip to the hairdressers. She has arrived back home. Could the doctor pop round now to look at her leg?

++++++++++

The Times this morning reports that the number of missed hospital appointments is rising.

“Appointments missed by patients in England in 2005 – 2006 are estimated at 6.8 million, up from 5.7 million last year."

In other words, about 11.00% of all hospital appointments are missed.

The annual cost is estimated at £614 million pounds.

++++++++++

In my practice, when we had a system of booking in advance, between 20 and 25% of patients did not attend. (DNA)

We have now switched to so-called Advanced Access. This means that most patients can only book on the day. Without going into the merits and demerits of the system in detail, it has at least significantly reduced the DNAs. The figures have come down from over 20% to about 5%. That saves the equivalent of a full time doctor.

But, note, the DNA rate is still 5%.

In other words, even for appointments booked on the same day, one in twenty does not attend. Think about it. The patient phones at 8.30 a.m. and is given an appointment for, say, 11.15 a.m. and does not turn up.

Why not?

++++++++++

This is abuse of the health service. There is no mechanism for charging patients for this abuse.

And for the GP, fuming that his patient can be taken to the hairdressers but not to the doctors, not only does he have no sanction, he is still obliged to visit the lady if it is medically appropriate.

Why can the daughter not bring her down? Because she has gone back to work.

++++++++++

Something wrong here.


____________________

Readers in the USA wishing to take advantage of a healthcare system but who are unwilling to emigrate to the UK should read Matthew Lesko's book, "Free Health Care". Matthew says:.

"Yes, whether you have lots of money or no money at all. the government has programs and freebies for you. There are over 400 sources of free care and treatment, including how to take advantage of free clinical studies at the National Institutes of Health and at other health facilities all over the country; how to locate low-cost and free clinics in your neighbourhood; and how to find local doctors and hospitals that are willing to treat you for free."

That's the spirit, Matthew.

Out of Hours work - a personal view

Family doctor on-call

There has been a lot of comment in the press recently about the deterioration of “out of hours” (OOH) medical cover since GPs went onto the new contract. Over 90% of the profession accepted the government’s offer to opt out of providing this cover. GPs have had significant pay rises over the last two years. Not as high as the media would have you believe, but nonetheless significant. For the large part these pay rises have been achieved by chasing government designed health care targets which, though not totally without merit, have not impacted on the day to day health care received by patients.

Most patients would prefer to be able to see their own doctor on a Saturday afternoon than know that he has entered their height, weight and cholesterol levels onto his computer. So the deterioration in OOH service has not been mitigated by successful target chasing.

I want to give a personal account of what my partners and I have done with OOH care over the last twenty years. I will describe as best I can what has happened, and why it has happened.

I will describe honestly how we feel about it. I make no judgement as to rights and wrongs. That is for others.

I did five years of hospital medicine before becoming a family doctor. During those five years I worked 1 in 2s, 1 in 3s and, for one job, a luxurious 1 in 4. Working a “1 in 2” means that, as well as the ordinary working week, you work every other night and every other weekend. During those years, I saw little of friends in other careers and, indeed, lost touch with some of them. On nights off I was too tired to do much. I usually ended up drinking too much beer and falling asleep in an arm chair. My partner was also a doctor. If we got onto rotas that did not fit properly, we might go a month without seeing each other.

The general practice I joined, and am still in, had seven partners (now nine) but five of them were over sixty and two of them were over seventy. They did not do OOH work themselves. They farmed it out to a commercial deputising service, commonly known in the trade as the “dangerous doctor service”. I was committed to family medicine, and to providing a personal service to patients, as was the other young partner.

We started doing our own on call. As the older partners retired, the whole practice followed suit. We put a clause in the partnership agreement banning the use of deputising services. We were on a mission. We hated deputising services. We were totally committed to personal availability.

The on-call commitment was one weekday night a week, and one weekend in six. I usually did Tuesday night. From seven in the evening, when the practice closed until eight in the morning when it opened, I was available for the patients. At the weekend, we would be on call from eight o’ clock on Saturday morning through until Monday at 8.00 a.m. There was no time off in lieu. I worked solidly from Tuesday morning through until Wednesday evening. It was hard.

The weekends were worse.

I felt strongly that a family doctor should be available for his patients. That is why I went into the job. I did not fall off a hospital ladder. I was always going to be a GP.

I did not resent being called out for medical emergencies. I remember going to see an old lady in LVF at four o’ clock in the morning. Neither she nor her husband wanted hospital. So I gave her a small dose of morphine and a large dose of frusemide and went back to see her at half seven on the way into work. And she was better. Treating LVF – when it works – is gratifying. I remember nebulising the asthmatics. I remember the pneumonias, the chest pains, and the serious problems.

How often was I called out at night? We kept figures. It was not that often at first. On average, I would expect two visits before midnight and one after. Occasionally, they could be dealt with on the phone, but I was never very good at telephone advice, particularly for hot children. I never got back to sleep. Less stressful to go to see them.

It was always stressful. The stress was not doing the visits. It was waiting for them. The only time you relaxed slightly was when you were actually doing the visit. Even if you had a lucky night with no calls, you rarely slept.

Weekends were worse, particularly Sundays. The house-calls would start coming in at about seven o’clock in the morning, and the whole of Sunday would be spent driving from house to house. And always the frustrations: a couple of calls, drive home, and the phone goes again just as you got out of the car.

Telephone medicine is bad medicine as the failure of NHS DIRECT shows. For a conscientious doctor, a child with a temperature is always a possible meningitis. As a doctor, once you have spoken to the parent, the medico-legal responsibility shifts onto you. It may be reasonable to say "give her some paracetamol and phone back if there are problems" - indeed it is reasonable but when, three hours later, the child gets meningitis and Dad rushes her off to hospital, the story he will give is "...and the effing doctor refused to come and see her" and probably also the inexperienced A/E doctor or, more likely these days, the nurse specialist will raise eyebrows and say, "Didn't the doctor come out? Oh! Dear."

So, if you are a worrier like me, you always get up and go and see hot children. It is less stressful than lying awake thinking about it.

I did this for twelve years.

Things evolve with time. Things change. I got older. I had been doing OOH on-call work of one sort or another for seventeen years. I still did not resent the calls to urgent medical problems. That is the job. But the nature of the calls changed too. People no longer viewed the OOH service as something for emergencies. They started using it for routine medical problems.

I really was called out on a Sunday to look at a verucca. I had a call at 3.00 am for a couple who had just had intercourse and burst a condom. Could I bring them the morning after pill? Parents were no longer prepared to deal with minor childhood illness. I had to visit children with coughs, colds and sneezes at all times of the day and night. For some reason, OOH problems are always regarded as more urgent. A parent who phones at 8.00 am for an appointment on a Monday seems happy when given a slot at 2.00 p.m. At the weekend, however, there is an expectation, fuelled by the government, that such visits should be done within two hours. Why?

Some patients give less thought to calling out the doctor than they would to ordering a late-night take-away pizza.

I used to dread the 11.15 pm peak of visits. Kylie, aged 8, has a temperature and is lying on the sofa. Mum is coping with this, and not worried. Dad gets home from the pub, worse for wear, and says to his dear lady, "What do you mean, she has a temperature...get the effing doctor out" and then he phones and tells you that "I want the doctor out, I pay your effing salary"

In the late nineties, when the strain of providing this OOH service was becoming too much, I co-founded a doctors' co-operative with fifty colleagues in the area. This grew very quickly and within two years was one of the largest co-operatives in the country. We still did the OOH work ourselves, but we shared it. We set up OOH visiting centres so that patients could come in during the evening and the weekend.

We were a victim of our own success. Co-operatives did take the strain off but, by providing walk-in centres, fuelled the demand and the expectation for routine medical care at any time of the day or night.

Co-operatives sprung up all over the country. The government saw them as a mechanism for centralising and controlling OOH services and, with the new contract, took most of them over.

They made one mistake. They had not realised that the co-operatives only survived financially because the doctors worked either for free or for a token payment only.

The government underestimated the amount of work that GPs were doing out-of-hours. They offered to allow GPs to contract out of the work in return for a pay cut of £6000 per year. They thought there would be few takers. In fact, the whole profession took the option.

So now the government had to run the co-operatives themselves and had to pay an economic rate to attract doctors to the job. The source of free labour dried up. The co-operatives began to fail. A great shame. They had been an excellent compromise. Now it was back to our friends The Dangerous Doctor Service. This is an example of “the market place” in medicine. Much lauded by the right wingers as the answer to all the problems of the NHS. In reality, the market place serves only to demonstrate the real cost of medical care.

Dangerous Doctor Service

Neither I nor my partners work for the PCT out of hours service. Nor will we. There is no amount of money that could realistically be paid that would make any of us go back to this work. It is too onerous. It is too stressful.

The crowning irony of all this controversy is that, for the most part, the OOH service the government is attempting to provide is completely unnecessary. Most people who call a doctor out do so for reasons of their own convenience and could perfectly well come in to a call centre. NHS Direct tries to deal with it with a user friendly website and telephone advice, but it does not work. Nearly seventy per cent of calls to NHS Direct are passed on to the doctors. The aptly renamed NHS Redirect costs £70 million a year.

The cost of providing this unnecessary OOH service is enormous. It is a luxury we can ill afford.

I lost many years of my young adult life to OOH work. I could not cope with the strain of it anymore. I have to work a full day, 8.00 a.m. to 7.00 p.m.. There is no realistic amount of money that would make me go back to doing OOH work. If the government legislates to put the responsibility for modern OOH work back onto GPs I shall resign, as will thousands of other GPs. I could not do it anymore. It is not meanness or laziness. I could not do it.

This is why the government is in trouble with OOH services. They cannot find experienced family doctors prepared to do it. Some but not all of the doctors they do find are er...of a certain sort.

The most irritating thing about the demand for OOH routine medical services is that it is driven by the twittering middle classes who ought to know better. They ramble on about how hard they work, and the hours they do in their jobs, and therefore they think it reasonable that they should be able to see a doctor at the weekend. They do not expect to see their accountant or their stock-broker at the weekend, but that is different. What they do not realise is that having seen the doctor, there will be investigations and treatment. They will want to have their X-Rays and their blood tests and their physiotherapy and their out-patient appointments at weekends as well. And so it goes on. Unreasonable demand predicated by naivety and selfishness.

As Wat Tyler has demonstrated in Sex, Violence and Healthcare, the cost of health care is on track to consume the whole of the British GDP. We need to cut back on expenditure. We should concentrate on having a good service for medical emergencies at all times. We are failing in that area at the moment. It is not safe to be in hospital out side the ordinary working week as we saw in Hospital at Night with Sue & Dave and their protocol to cover up for the absence of OOH within hospitals.

Resources are thus being diverted from real medical care so that we can pander to Sebastian and Samantha who want their in-growing toe-nail cut on Sunday afternoon.

On a personal level, I regret that I will no longer be available to see the old lady in LVF. Now she will be sent straight into hospital. But I cannot provide a round the clock service for Sebastian and Samantha, however much money you offer me. I did it for seventeen years, and I have had enough. Someone else will have to cut their toenails.



Lazy Cat (and other) Tee shirts available from Teeze.co.uk

The Crippen Diaries (Week 18)

Not quite Tannochbrae

Thursday 4th May

With the bank holiday and the day off, it is going to be a short week. But patients often save it all up, so it was a busy morning.

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Three patients into the morning list and the receptionist puts an urgent phone call through. It is Mrs Barnes. She cares for her 79 year old husband who has an unusual form of epilepsy.

He has been extensively and appropriately investigated at Queen's Square. His epilepsy is “interesting” so he has seen the great and the good of British neurology who, great and good though they may be, have not been able to control his fits. However, he has been on a new-ish drug, Keppra for the last three months and it looks promising. He has only had two fits since he started it, which is an improvement.

These last two fits resulted in a trip to A & E. On both occasions by the time he had got through the paperwork and the triage nurse and the doctor had arrived, the fitting had stopped. So he was sent home, without a letter, with the advice to “get your doctor to bring your neurology appointment forward.”

This sort of thing infuriates family doctors. The hospital doctors are better placed than I to bring forward hospital appointments, and just as capable of writing a letter. I think. Maybe not.

Mrs Barnes does not fuss. If she calls urgently, it’s urgent. This time, Mr Barnes has been fitting on and off for four hours. I tell her should have phoned earlier, but she does not like to make a fuss. She thought it would probably stop spontaneously. It usually does. And she does not want him to go to hospital again.

I can count on the fingers of one hand the number of times I have been called to someone fitting. I described the last one a few weeks ago. Statistically, I have now seen more acute epilepsy than I would expect. So there should not be another one before I retire. I wish it worked like that.

I go straight round. Always a nightmare in terms of the working day. My partners will cover all my urgent patients, but most will rebook for tomorrow, which merely moves today’s work forward twenty-four hours.

When I get to the house, the home help has arrived. Mr Barnes has stopped fitting. The home help and Mrs Barnes have just got him onto the commode. He is in the middle of opening his bowels. He is conscious and reasonable coherent. I hate interviewing people sitting on commodes. They do not like it much either. So I go downstairs to wait. He starts fitting again. Back upstairs and the three of us manoeuvre him onto the bed. He is a big man. I administer some rectal diazepam which usually works for him. Five minutes later he is snoring.

I discuss the pros and cons of admission. Mrs Barnes and I agree it would serve no purpose. I say I will come back and check him at lunchtime. I am just getting into the car when the home help opens the upstairs bedroom window and shouts. He is fitting. Again.

Another dose of diazepam. Again, it works. Now he is very soundly asleep. His observations are stable. Mrs Barnes does not want him in hospital. I overrule her. I cannot carry on sedating him at home without nursing support.

I have the usual silly conversation with Ambulance Control. In the old days, I would describe the degree of urgency to them. Not any more. They now work to complex protocols. There is no room for discretion. I want Mr Barnes in hospital. I do not want or need a flashing-blue light ambulance to appear within seconds. I do want one within an hour or two. I give all the patient details and the address.

Once I mention fitting, “computer says no” to coin a phrase. It has to be a 999 crew.

“You have come through on the wrong line for that”
“But I did not want an emergency ambulance”
“Yes, but he is fitting.”
“Not at the moment, he isn’t.”
“He might start again.”
“Possibly. That is why I am calling you.”

I agree to a 999 ambulance. The controller has to go to a different screen for that. The patient details do not transfer from screen to screen. So I give all the details again. The final question is, “Is there a medical need for an ambulance”. I get a bit grumpy now. “Of course there is. That’s why I am bloody well phoning you.”

“No need to be like that, doctor, some people like to make their own way to hospital.”

No point in arguing. I apologise.

I worry sometimes that I may die before I get to the end of conversations like this.

The paramedics arrive. They are delightful. Mr Barnes is no longer fitting. He is snoring a bit. Off he goes.

He will sleep off his diazepam in A & E. They will not admit him, even though it was a prolonged fit. They never do now. Mrs Barnes will have to pay for a taxi to bring him home. There will be a recommendation again that he should see the neurologist sooner than planned.

I get back to the health centre and am an hour behind.

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Friday 5th May

Duty day and once again the day’s main task is to assess all patients who feel they have to be seen today as they have problems so serious that it would not be reasonable to wait until Monday.

There is always a group of hot children who probably have nothing more serious than minor viral illnesses. They are easy to deal with. I offer them all an afternoon appointment and see them.

++++++++++

A man phones just after lunch. He is in the City where he works. He has been getting intermittent chest pains all morning. From what I can tell on the telephone, it does not sound cardiac, but I know he is a little overweight and is battling with high-ish cholesterol. He wants an evening appointment which I could give him. But I am not prepared to take responsibility for his sitting on a train for an hour, so I advice him to go to Bart’s A & E department. If it is still open.

++++++++++

It is nearly two o’clock. I am out visiting a post-natal lady with mastitis who is too ill to come to the surgery. I have another couple of visits to do. I have already been phoned by one of them to ask “Are you coming, doctor?”

The phone goes. Mrs Jones, an 83 year old lady, had a fall in the bath just over a week ago. She hit her ribs. They are painful. Her niece has arrived for the weekend and is worried about the ribs. So, without phoning for an appointment, she has put Auntie in the car and brought her straight down to the health centre outside which she is now sitting.

This is one of the little challenges of general practice. We are not a walk in traumatology centre. I am twenty minutes away from the health centre and have two more visits to do. Even I cannot be in two places at once. But I do have appointment slots free later on in the afternoon and tell the receptionist to give her one.

“She is 83, doctor” says the receptionist. She emphasises the "is" to show that she does not approve. Our receptionists are a good lot. It is difficult for them. They are between a rock and a hard place.

The niece does not want to come back three hours later and feels she is speaking from the moral high ground as she has gone to the trouble of bringing auntie down.

I say I cannot see her earlier than the time of the booked appointment. I feel mean for the rest of the afternoon. When I do see her, the niece is grumpy. Mrs Jones is not. She never is. And she is wise enough to know about the treatment of bruised ribs. Not much, really.

A tiny, trivial example of the ups and downs of general practice. A patient has had rib pain for nearly a week. At a random point in time a relative decides she should see a doctor. Having made that decision, she expects an immediate response from the doctor and an immediate appointment at a time of her choosing.

Rationally, I think that giving someone a booked appointment on a Friday evening within three hours of the request for a non urgent problem that has been going on for a week is not only acceptable but, in fact, excellent service.

The niece does not. Nor does the Daily Mail.

And I still feel mean.

Homeopathy, bird flu and ducks.

Royal London Homeopathic Hospital

A few days ago we talked here about the over-reaction to the perceived threat of avian flu and the under-reaction to the death rate from malaria.

A public health doc writes in to draw my attention to the role of homeopathy in the treatment of bird-flu.

There is a connection between avian flu and homeopathy. Avian flu is transmitted by birds. Homeopathy is quackery.

There may be a Royal London Homeopathic Hospital. The Royal Family in general and Prince Charles in particular may be devotees. It is still quackery. Probably harmless provided always it is not used as a substitute for real treatment.

Public Health doc says:

“Thought you might like this article on bird flu and homeopathy. I normally have a lot of time for alternative therapy (in a sort of just-keep-taking-the-western-medicine-too kind of way), but this article made my blood boil. I liked the cited differences in survival between traditional and homeopathic treatments during the 1918 outbreak, with no sources.

I am about to email them to complain. I need a laugh.”

He refers to an article in the Sunday Herald which is, I understand, a Scottish Newspaper.

“During the 1918 pandemic, the average death rate was more than 30% for those treated with conventional medicine, but less than 1% for those treated with homeopathic medicine. Normally, each person visiting a homeopath is given a tailored homeopathic remedy targeting their symptoms – otherwise known as constitutional prescribing. However, during a pandemic, people exhibit such similar symptoms that a genus epidemicus can be developed. With adequate precautions and a dose of realism, not hysteria, you’ll stand a better chance against the onslaught of bird flu.”

Read the full article here.

Oh dear. Does anyone believe this sort of nonsense?

What does Dr Crippen advise in the event of an outbreak of bird flu? As soon as you start to feel beaky, take two aspirin, go to bed and keep your fingers crossed.

Grand Grounds 2 (32)

Grand Rounds is taking place again, this time hosted by Polite Dissent from the USA.

Scott, at Polite Dissent, takes a consistently hilarious look at medical matters in their widest context. Always worth a visit.

Nick Genes, from Blogborygmi, who dreamed it all up, talks to Scott about medicine and humour in a Medscape interveiw here

They do it better in Zaire

Marshal Mobutu Sese Seko

There has been much talk over the last few months about the huge salaries that doctors in the UK are being paid. Dr Crippen can now reveal that it is no accident. It is indeed the front end of a well-thought out but secret government policy.

My colleague, the well known medical writer Theodore Dalrymple, reveals all in an article for the Social Affairs Unit.

Patricia Hewitt has long considered the advantages of health care models in the USA, in France, in Germany and in Spain. Undoubtedly, she has read James Bartholomew’s iconoclastic book “The Welfare State We’re In” in which he challenges the ethos of the NHS in particular and the Welfare State in general.

Hewitt is not sufficiently courageous to dismantle the NHS. Instead it is to be remodelled on the system introduced in Zaire by the late Marshal Mobutu Sese Seko

New Labour will continue to increase doctors’ salaries to such a level that they are priced out of the market. When the NHS can no longer afford doctors, the “health care professionals”** will take over.

Dalrymple states:

“…when the Marshal had a toothache, he got in a Boeing 747 and flew to Paris; when an ordinary Zairean fell ill with a life-threatening disease, he went (if he still could) to a nurse in a clinic and got an aspirin, if there was one.

The Zairean model is very economical. Its costliness at its summit is more than compensated for by its cheapness at its base. The cost per person of a few flights of a Boeing 747 spread over 30,000,000 people is very little. And it is very egalitarian (and therefore, by definition, just), since the vast majority of the population gets more or less the same attention, i.e. very little.”

So, the great and the good will fly off on Blair Force One to find a physician and the rest of us can...eat cake, I suppose.

Read the whole of Theodore's excellent article here.



** "Health care professional" = I am sorry, doctor is not here today

A note from our Washington correspondent

Get Me Out Alive

"As a Nurse, She Knew the System. Then She Became a Patient"

An NHS BLOG DOCTOR reader in Washington draws my attention to an article in yesterday's Washington Post.

The problem with lack of basic nursing care is not just a UK phenomenon. It is worldwide.

Rosalind Feldman is a registered nurse in the USA. She has a doctorate in nursing science. She may therefore be, probably is, a nurse-specialist, or a nurse practitioner.

She fell and broke her leg.

As an experienced nurse, she formulated her own medical mission statement:

"My initial aims were simple: to fix my femur and end the stabbing pain I felt whenever I tried to move my leg."

Sadly, with modern hi-tech nursing care, it was not like that.

"Two days into my 10-day hospital stay -- five in acute care, five in rehab -- I revised my goals. I emerged from surgery wanting something more basic: to survive the microbes and risks of deep vein thrombosis, the ineptitude of some staff and the malice of others."

You can dismiss this as an anecdote if you like. But remember, it is written by a patient who is herself a nurse-specialist. Dr Crippen hears stories like this every day at work. And now, when he gets home, the emails are waiting as well.

Read the full article from the Washington Post here.

Something has to be done.

We have to get the nurses back to nursing.

Meanwhile, on a serious note...

I am grateful to a Consultant Pathologist from Brighton for sending me the above postcard.

New Labour is like cannabis:

• Both induce mild euphoria and a distorted sense of reality
  
  
• Both induce a tendency to talk rubbish in a meaningful way
  
  
• With both everything takes on added significance despite the fact that nothing is happening

Regular use of cannabis may be harmful. The long term effects of New Labour are as yet unknown.

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The New Labour Postcard and many others are available from Gathered Images, here.

Quacktitioner Alert (3)

Quacktitioners

I adore my old corduroy jacket. Its a bit tatty now, and so I only wear it for gardening. Mrs Crippen hates it. We went to a “Bring and Buy” sale. She calls them “Bring and Bugger-offs” but I stayed and bought it. She maintains it is no way to equip one’s wardrobe. I disagree.

I could however be persuaded that it is not the way to equip a national acute-response traumatology service.

What traumatology service, you may say. Quite! Comparisons with North America are an embarrassment. To the extent it exists at all, the standard of on-site traumatology in this country is appalling. If the public knew what was going on, there would be an outcry.

The inability of the overwhelming majority of hospital doctors, both junior and senior, to perform any basic resuscitation techniques is notorious and frequently written up in the journals. It would not be safe to let them loose at a major road traffic accident. If they cannot do it, who can?

Ignored by government and hospital doctors, the problem of the lack of an on-site traumatology service has been addressed by a number of enthusiastic GP’s. They have formed an organisation called BASICS. It's upaid. It's voluntary.

Many of the GP members are frustrated hospital doctors. They are bored with the hum-drum, day-to-day general practice for which they trained when they fell off the hospital ladder. They organise raffles and the aforementioned “Bring-and-Buy” sales to finance the purchase of VHF radios, flashing green lights and a pot-pourri of traumatological equipment. They tune in to the emergency service radio frequencies and at the first hint of blood, they are off.

They drive a certain sort of car; the younger ones, a Gti; the older ones, a Ford Capri. They all have Swiss Army Penknives. Dressed like ageing Power-Rangers, their cars plastered with day-glo decals, they arrive at major road-traffic accidents with a screech of brakes and a crate of the currently trendy colloid drips.

UK on-site traumatologists

They are all surgeons manqué; or maybe their odd behaviour is a reflection of the fact that GP’s will do anything to escape from their afternoon surgery. Whatever their rationale, it is not intuitively obvious that this is the best way to provide an acute-response traumatology service.

The government pretends we don’t need a service at all. Given that it is unnecessary, it does not matter that the doctors who provide it are, for the most part, the ones least qualified and least suitable to do it. So far. The psychiatrists and community physicians have yet to show interest. But who knows? The basic qualifications required to get involved in this volunteer service are… er… pretty basic.

As the government has decided we don’t need the service, it does not fund it. So it has immediate appeal to the highest principles of modern general practice. It is unpaid. The reductio ad absurdum from a cash-strapped government (and take this slowly because it’s complicated) is that they do not provide such a service because it is not necessary, but if, which is not accepted, we did need such a service, well, in fact it is all right because we already have one. Not the GP’s, though; they are tolerated with embarrassed amusement. No, it’s the paramedics. They are wonderful. They can do anything. And paramedics are not just ambulance men. No, absolutely not. They are ambulance men in green jump-suits. They are important. Men from the media in eiderdown-jackets make documentaries about them. They have cult status.

When the protocol-bound paramedic ends up arguing with the day-glo GP about who is best at putting up drips, we have the boy-scouts meeting Abbot and Costello. Police and fire-brigade officers can only look on in amazement.

It could only happen in England.

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A version of this article was posted in early December just after NHS BLOG DOCTOR started. Since then we have clocked up an amazing 100,000 visits. Thanks to all for your interest. But in the early days, there was only a small audience. I re-publish this article at the request of some nurses, to show that the problem of dumbing-down in the NHS is not confined to the nursing profession. Far from it. On site traumatology in the UK is, with one or two notable exceptions, inadequate and underfunded. There is a separate argument as to whether it is best to treat the critically ill on site, or get them to hospital as soon as possible. Princess Diana's tragic death might have been avoided if she had been taken straight to hospital. Whichever way that argument goes, there is no doubt that if you are going to have on-site interventional traumatology going beyond stabilisation, it has to be run by highly trained traumatologists and not by well-meaning amateurs.

LSSO at the Barbican

Béla just had his 125th birthday. It was on 25 March. You may have missed it. But it is still not too late to celebrate.

BÉLA BARTÓK 1881-1945

At the Barbican on Tuesday, 2nd May at 7.30 pm the LSSO, conducted by Peter Ash, its American artistic director, presents a concert performance of “Bluebeard’s Castle” with Andrea Meláth and Mihály Kálmándi from the Hungarian State Opera.

The following from concert-diary.com:

In a brave piece of programming - and to celebrate 125 years since the birth of Béla Bartók - the London Schools Symphony Orchestra (LSSO), is taking on the performance of his masterpiece Duke Bluebeard's Castle. This is a major collaboration with the Royal Opera House which will be staging its own performance of Duke Bluebeard's Castle this year. The Royal Opera House will be lending the orchestra its surtitles for the production at the Barbican and, as a mark of this collaboration, they have arranged for one hundred free tickets for the young players of the LSSO to attend the fully staged dress rehearsal of the opera on May 23rd of the Opera House.

This is also a collaboration with the Hungarian Cultural Centre in London and the Embassy of the Republic of Hungary. To assist in this celebration of the life of their countryman they are bringing over two luminaries of the Hungarian State Opera: Andrea Meláth and Mihály Kálmándi to sing the opera at the Barbican.

A few tickets are still available from the Barbican Box Office here.

Dr Crippen is an opera and music lover, and a particular fan of Bartók. I shall be taking Tuesday off to see this production so, with the Bank Holiday, next week’s diary will be shorter than usual. I must also, as a matter of integrity and probity, declare an interest. This is shameless self-promotion for one of the teenage Crippens who is a principal in the orchestra. You will be able to hear her, and meet the extended Crippen family, on Tuesday evening.

Quacktitioner Alert (2)

Quacktitioners

The governement media-manipulators often try to slip devasting and unpopular policy changes through at times when they think that the public will not notice. A quiet early May Bank Holiday is a good time. A quiet early May Bank Holiday when the Daily Mail and its reader are revelling in the Clintonesque sexual escapades of the Deputy Prime Minister is ideal.

And so, ever so quietly, it has been announced that nurses and pharmacists are to have virtually unrestricted prescribing rights. The British Medical Association has described this as "irresponsilbe", but no one is going to notice. Except the doctors, and no one listens to us.

We do not have a monopoly of Quacktitioners in the UK. The phenomenon is world wide. Dr Crippen has just had his attention drawn to a Quacktitioner "down under."

When Dr Crippen was a house officer on the Professorial surgical unit, one of his jobs was to make sure that the punters coming in for elective surgery, or relatively elective surgery, were fit to have it. This involved "clerking" the patient in, and getting a base line of a few standard investigations. If Dr Crippen had allowed a patient with, for example, undiagnosed severe anaemia, or an undiagnosed lung cancer, or whatever, to appear in theatres, he would have been dead. Dr Crippen that is. Possibly the patient too. So Dr Crippen used to do a meticulous work up on these patients, and that work-up would often involve a routine chest X-Ray (CXR).

Surgeons liked that sort of thing. Oddly enough, they still do. Barbados Butterfly, who is an experienced surgical registrar (resident) "down under", is now finding that Quacktitioners are obstructing sugical work-ups because they do not appear to fit in with their arcane Quacktitioner protocols.

Read all about it here

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There is currently a discussion going on in the on-line Observer/Guardian about the issues surrounding nursing care, or the lack of same.

My attention was drawn to this by a comment on this post.

Theses two articles can be found here and here, and are essential reading. Dr Crippen is not alone.

It is time to start a national campaign called:

“Let’s get the nurses back to nursing”