The Crippen Diaries 2007 (3)

Not quite Emergency Ward 10

Monday 15th January

The first patient of the day was an elderly lady with a painful foot. She took off her left shoe and stocking to reveal an inflamed bunion, and an infected in growing toe nail. I asked her to slip off the other shoe and stocking so that I could check the right foot. She hesitated. “Do I have to, doctor”. I said it was helpful to compare the two, and I needed to check the state of her other toes and toe nails. Clearly reluctantly, she took off the right shoe and stocking. Her right foot was filthy. Very smelly. Dirt under all the toes nails. Her left foot was spotlessly clean. She had washed one, but not the other. I pretended not to notice, but she put her hand on my arm and looked at me. “It’s not easy. I am alone.”

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Reg, an 82 year old man brought in by his daughter. She phoned me about him at the end of last week. She is worried because he lives alone and, although he normally copes well, he had seemed frail over the last couple of weeks and his flat was smelling of urine. Reg was unaware of the smell but on questioning admitted that for the last week or two he had had difficulty passing urine. Examining him he had a huge but soft, benign feeling prostate and his rectum was impacted with faeces.

It needs checking out. I can arrange for the nurses to sort out his bowels for the time being. I dipped his urine and it was a full house on the dipstick apart from the sugar which was negative. Probably he has become constipated, then impacted and that, together with the large prostate gland, has caused the UTI. I put him on some antibiotics and arranged some tests including, rather reluctantly, a PSA. It has to be done and with a prostate that size is almost bound to be elevated. If it is, I have to decide whether to refer him to the urologists. It is hard not too, but that will generate a prostate biopsy, which is not much fun.

In many ways, if sorting out the urine and infection and the constipation gets him back to normal, he would probably be best left alone.

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The receptionist puts through a phone call from a patient who has told her she is in severe pain. She is indeed. It is toothache. I suggest that she goes to her dentist. She says she has tried that, and they cannot see her until next week. This may be true – it sometimes is - but there is a fair chance that she really means that she is not prepared to pay to see a dentist and has not even tried to make an appointment. I do not know this patient but, looking at her address, I bet that is the likely explanation. So I say that the only thing she can do is find a hospital with an emergency dental service and try them. She says she is phoning from the Casualty department of the local hospital, but has been waiting there over an hour and wonders if I could see her more quickly.

I do not “do” teeth.

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A long practice meeting to talk about QoF data and targets. We have to hit the targets by the end of the financial year or we lose the money. We are a bit behind schedule this year, largely because the partner who is responsible for the analysis of mental health, depression and dementia has not done the work yet. He never does until the last minute which annoys the partners who are efficient about this sort of thing. He has not done it because, even though he is interested in these areas of health care, he finds data analysis intensely boring particularly as this data is of little or no value to the patients. It is like this every year with him. Or with me, as I should say, for of course it is me.

So I will sit down for a couple of hours a day for the rest of this week and get it sorted. Dreary, dreary work. I have much better things to do with my time. But six to eight hours work will get it sorted, and will earn the practice just over £23,000.

Seriously. I am not exaggerating. The figures are in front of me. It is too silly for words. It is a waste of taxpayers’ money. It is not all profit because a fair proportion is swallowed up in computer and staff costs but I reckon at least two thirds of it is.

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Tuesday 16 January

I do not like watching people chewing chewing-gum. The first patient today, a middle aged woman, was chewing gum. A small piece. With her mouth slightly open. She moved it around and sometimes it appeared momentarily on her tongue. This is the third time I have seen her over the last ten days and each time she has been chewing gum. Maybe it is the same piece. Maybe she really does stick it on the bedpost overnight. I watch, fascinated and revolted, and it makes it difficult for me to concentrate on the history she is giving. I am very close to asking her to take it out and put it in the bin. If she was a child, I would. Is it acceptable to ask an adult to do the same? I do not know. But it is discourteous to chew gum when you go to the doctor.

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A sixty seven year old man comes in. He has developed a collection of seborrhoeic warts on his back. With each year, more appear. Some people get them. Some do not. But they are a common feature of the “maturing” skin.

Seborrhoeic Warts

This man is physically active, he goes swimming a lot, and they embarrass him. He would like to have them removed. Rightly or wrongly, this can no longer be done on the NHS and he cannot afford to have them removed privately. He gets cross with me when I tell him this. I suspect he thinks I am being awkward. I am not. If I refer him, the referral will be returned.

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Patricia Hewitt has instructed hospitals not to follow-up patients in the hospital clinics unless it is absolutely essential. So there is a big turf-out going on at the moment, just as they turfed out all the chronically mentally ill from the long stay mental hospitals twenty years ago. Peter is 47. He was turfed out of the diabetic clinic last week and told to “see your own doctor”. Peter has had insulin dependent diabetes since he was a teenager and has always been under the hospital. He is in early chronic renal failure and attends the renal clinic who have not turfed him out. He has (currently well controlled) hypertension, but is on four different ant-hypertensive agents. He has angina, or used to have, but since his stent has been symptom free. He is obese and has hyperlipidaemia and raised triglycerides. He is on 18 different drugs.

I check his blood pressure, his long term diabetic control, his recent bloods and all does indeed seem well. I press the button to print out his prescriptions. The chemist must smile when he walks into the shop.

Diabetes is not one of my major interests, but two of my partners are very interested and, along with two nurses trained in diabetes, run an excellent clinic at the Health Centre and so will take him over. And he will be fine, I suppose.

But I start to wonder. If a consultant diabetologist is not going to keep on a patient like this, who is he going to keep on? What are consultant diabetologists for? I think they are for people like Peter, and that this is gratuitous cost cutting, but maybe that is old fashioned.

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Thursday 18th January

Another moral conundrum.

We have good sheltered accommodation in my area. A lot of purpose built one bedroom bungalows. Ground floor. Wide doors, bathrooms and kitchens designed with the older, frailer patient in mind. Mrs Dawson has lived in one of these for some years. Her daughter, Rose, lives in Cornwall, or used to until a few weeks ago when she fled from her violent, abusive drunken husband. She is now sleeping on mother’s sofa.

Rose was distressed after her experience with her husband but has calmed down considerably since she has been back with mother. She intends to stay in our area and get a job. But she cannot get a job until she finds accommodation of her own. As a single person who has no children and who has a roof over her head, albeit not an ideal one, the council are not going to produce accommodation for a long time.

If you live in council sheltered accommodation, you are not allowed to have a guest staying. Well, that is not quite true. The actual position is that if you have a guest staying who is earning, then they are deemed to be paying rent, even it they are not, and your benefit is reduced. In other words, if Rose gets a job, Mrs Dawson’s benefit will be reduced.

So Rose has been to the Citizen’s Advice Bureau who have told her to 'go to your doctor and get him to sign you off work for “stress”.' Rose was stressed, and I did sign her off work for two weeks, but two weeks has turned into four, she still has nothing from the council, and she wants me to do another certificate for her. For a month this time, she suggests.

She is not ill. She is in a desperate situation. This is yet another example of the multi-faceted poverty traps in our creaking Welfare State.

What do you do?


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I saw Chloe, a seventeen year old girl, last week who is seven weeks pregnant. She is in the middle of her A levels at a local posh private school. Both her parents are professionals. I talked with her a long time. She does not want a termination. She does not believe in them. If necessary she will take a year off. She had discussed it with her parents who had been though shock and anger, and were supportive. She might think of adoption but either way she does not want a termination. We talked for a long time and I made all the usual arrangements for ante-natal care.

She came back today with her mother. I have decided to have a termination, she said, and burst into tears. “It’s what she wants, doctor, it’s for the best.”

There was no subtle way of stage-managing this. I told mother that I would arrange a termination for Chloe if that was her decision, but said I wanted to talk to her by herself about it. Mother looked uncomfortable.

Chloe is coming back tomorrow. We shall see.

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We had the “choose and book” (CAB) commissariat down today. For the security checks. They have taken a mug shot of all the staff. I had to produce a document with my photo on, and two utility bills to prove that I am who I say I am. So be it. Never mind how long I have been working for the NHS, this is how it is to be done.

The doctors are going to do CAB themselves. It will be done by some of the receptionists, and it will be a nightmare. CAB gives hospitals the chance to say “we are full, please try the next hospital on the list”. When you have worked through all three, and they are all full, I suppose you start again at the beginning.

Very few patients want CAB. What they want is an early appointment at the hospital they know and trust which, for over ninety percent of them, is the local hospital. This is purely a PR exercise which neither the doctor nor the patient needs. It is going to be time consuming and expensive and, mark my words, will be abolished within a couple of years.

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The Criminal Injuries Compensation Board are trying to pull the usual fast one on one of my partners. They want a full and detailed medical report from the notes on a patient who sustained some serious injuries during the commission of a crime. He has, quite literally, over a kilogram of notes. Several hundred pages, letters, X-Ray reports and so on. The CICB have offered to pay my partner £38 to prepare the report. There is four or five hours work involved here and my partner, quite reasonably, has said she will not do it for £38. They are refusing to pay more. If she does not do it, the patient's compensation will be further delayed.

What do you do?

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Friday 19th January

Another demoralising start to the day. The dulcet tones of the Secretary of State for Health on Radio Four, accusing family doctors of dishonesty; of swindling the NHS, and thereby the patients, of money that was meant for health care.

We really could not win on this. If we had not hit the targets (thereby increasing our income) we would have been branded as lazy. Of that I have no doubt. So we hit the targets. Now we are greedy and dishonest.

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Chloe came back this morning. Alone. She seemed together and organised. She has decided to have a termination.

It is not for me to talk someone out of a termination but I must say she made me uneasy. I probed gently about who had really made the decision. I asked her, in so many words, if it was her or her parents. She was resolute.

So I have made the arrangements.

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John, a 67 year old man with arthritis of the neck. He used to be a county standard rugby player and I am sure that twenty-five years of scrums has contributed to his condition. He has a soft collar, and has had NSAIDs and I referred him to the physiotherapists last autumn. He still has not heard from them. He last came about this in November. I copied the original referral letter to the Superintendent Physiotherapist in case it had gone astray. Nothing happened. So yesterday he phoned the department. They told him that they had had both my letters but that the waiting list for “non-acute” problems is sixteen to eighteen weeks. They also told him they might be able to bring his appointment forward if I wrote to them saying it was “urgent”. Is this urgent? I don’t know. I know he is in pain, and has been waiting over three months, and he is not sleeping well. So I wrote a third letter saying that the problem has now become urgent.

I have also suggested that the physiotherapy department responds to referral letters by writing to the patient by return giving them some idea as to when the appointment will arrive.

Frustrating. But I cannot get too excited. I have never been over impressed with physiotherapy as a treatment modality for age-related wear and tear conditions such as this. But it is a ritual that patients expect to go through.

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Heart failure is a wretched bloody condition. It can be far worse than cancer particularly as so many people are slightly gung-ho about heart attacks, and expect to make a complete recovery. David is in his early seventies and, in his time, was in the British National Swimming team. Until two years ago, he was swimming a mile every morning. Then, at the age of seventy, he had a heart attack. He never really came to terms with it. It was an insult. He was always so fit. He never smoked. He looked after himself. Sadly, a heart attack at seventy is part of the deal. He was not a high risk candidate, but it still happens. And he did not make a complete recovery. His left ventricular function is compromised. Now he can only manage one flight of stairs. He could go swimming, but not on his terms, so he does not go at all. He is on lots of drugs; ACE and diuretics including spironolactone and, as he has been in and out of atrial fibrillation, he is currently on amidoarone, which has affected his thyroid and so it goes on. He attends a regional cardiological centre and I see him regularly to check his failure, and his chemistry and, most important of all, his psyche.

The physical medical side is difficult enough. The psychological side is worse. Pottering around is not for David. He hates it. Worst of all, he knows there is no answer. He has never asked me what the prognosis is in terms of time. People with heart problems rarely ask. The media is interested in heart attack survivors, and CABGs and heart transplants. It is not interested in chronic, end-stage heart disease. So people do not realise how serious it can be.