The Crippen Diaries 2007 (Week 8)

Not quite Emergency Ward 10

Monday 19th February

Monday is always busy, and at the end of the morning surgery, there are a lot of phone calls. One of the phone calls was to Jim, and there was a warning note on the computer screen saying that he was angry. When I called, he was indeed angry. I dread to think what he was like with the receptionist because patients always tone it down a bit when they speak to the doctor.

Jim had phoned just after ten o’ clock, and wanted an appointment to see me this morning. By ten o’ clock, all my appointments had gone. It is Monday, and it is the busiest time of the year. It is like that.

I asked Jim what the problem was. He had developed a lump on his scalp, within the hair line, and he kept traumatising it with his comb. It had been there for a couple of months, and he thought it should be looked at. I offered to make him an appointment for tomorrow morning at 8.00 a.m. That was not convenient. Nor was Wednesday, Thursday or Friday, notwithstanding the fact that we have appointments available from 7.45 a.m. in the morning until 7.30 p.m. at night. Jim has to commute to work and leaves too early and returns too late to make any of the times we can offer.

“What made you phone today, when you have had the lump for two months?” The answer was simple. He had had the morning off work to go to the dentist, and once he had been there, he thought he would get the lump “sorted out” as well.

“Could you not just see me now?” he asked. I still had eight phone calls to make, several letters to dictate, a lot of other paperwork and two visits. There was nothing urgent about his problem in terms of a day or two. I said I could not see him “now”. Strictly, that was a lie. Of course I could have seen him now. But I cannot be in two places at the same time.

I know people will write in and say I was unreasonable, and why should people have to take time off work to go to the doctor, and we should offer “more convenient” opening times and so on and so forth. But they are wrong. It is this sort of demanding attitude to a service perceived to be free that is bringing the NHS to its knees.

Jim had had a problem for eight weeks. One morning, at a time dictated entirely by his convenience, he decides he should see a doctor, and expects to be seen immediately at a time of his choosing.

The NHS cannot provide a service like that. And why should it?

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Tuesday 20th February

A bad start to the morning.

I started EMIS on the computer and up came a message. Not the usual stuff warning me that "there are only 2 gigabytes of storage left" but an eerie message saying “You are now connected to the spine.”

I had to do some nifty option selections to disconnect. Whoever jumps through the “choose and book” hoops in the practice, it is not going to be me. The practice manager tells me that this may be the only way I can make referrals soon.

I really do not know how much longer I can cope with this.

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When I was a student they were called joints. They were rolled on LP covers. “Country Joe and the Fish” (give me an "F") or “Blows Against the Empire”. I think the magic powders were mainly Trill and Oxo Cube. Bill was around at the time. Maybe that was why he did not inhale. I only heard the rumours.

I saw Michelle today.

A teenage girl who has serious drug problems. She does not think they are serious because “I don’t inject and I don’t do coke”. I was trying to “relate” to her, I guess. It is not Trill and Oxo cubes now. It is serious. It is the slippery slope to schizophrenia and we have enough of that already.

I was feeling increasingly “old fartish” but managed to achieve eye contact and smiles. The scare stories do not work with Michelle. She is seeing the drug counsellors. “They have shown me all the videos. I believe them.” I think she does. But she does not understand that they apply to her.

I remember, as a junior hospital doctor, seeing my first patient with heart failure. He was so divorced from my experience that he could have been visiting from a different planet. Now, much older, when I see patients with heart failure, they are on my planet. Or maybe I am on theirs.

I don’t know how to get onto Michelle’s planet.

She is highly intelligent. Her school have told her she can get mainly “A stars” in her GCSEs next year. If she keeps going to school. Michelle says she wants to be a lawyer. I have a daughter of the same age. She wants to be a lawyer too. But she goes to school. And she does not do drugs. As far as I know. I don’t think she does.

Michelle is being bounced around the NHS at the moment. She has a drug counsellor from a charitable organisation. Her drug counsellor is “right on” and young and knows all the current vocabulary. He probably knows how to roll a joint on a CD. He has advised Michelle to roll her “joints” or “spliffs” or what ever they are now called an inch shorter every week.

Maybe that is the best way.

I asked Michelle if she wants to stop smoking cannabis. She does not.

I do not have the answers, but I do not think that serially circumcising the joint will work. I told Michelle that if there was anything I could do she could come back at any time.

I hope she does, but I am not holding my breath.

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Thursday 22nd February


It is very busy at the moment. February & March are always the busiest times of year. And it is half-term. We have two doctors away on holiday and, unusually, one ill. We get locums, and some of them are good, but it is never the same. Patients tend to come back for a second opinion or hang on for one of the doctors they are used to. Better the devil…

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An endless stream of children with temperatures, coughs and colds. Each one has to be examined properly. Toddlers take ages to undress and dress again. Most parents accept the advice that “it’s a virus” and “there is a lot of it about”. It is almost always “a virus” and there is a lot of it about. But when you say something a dozen times a day, it begins to sound like a cliché. What we can never do is guarantee that the apparently minor virus illness will not, by tomorrow, be something else; an ear infection, tonsillitis, meningitis, encephalitis or whatever. We have had one encephalitis so far. It is even more important not to prescribe antibiotics inappropriately and yet day in, day out we are put under pressure, sometimes intolerable pressure, to prescribe.

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Friday 23 February

Duty doctor today. Started early, just before 8.00 a.m.

The appointments ran out at 11.15 am (later than some days) and so my list of phone calls started to mount. By the time I had finished the morning surgery, there were eighteen patients to call.

Five “hot” children – I told them to come straight down

Six requests for repeat prescriptions. We do not take requests for repeat prescriptions over the telephone. For a hundred and one reasons, but mainly safety and also to stop the phones being blocked. Of the six, I had no alternative but to do four of them – whatever “rules” you have, you cannot leave an asthmatic without inhalers. Two I refused. Both were patients phoning from work who are “too busy to come in to be seen” and both had not been seen for several months. I made them both an appointment for next week. They were not very happy.

The other seven genuinely needed advice. “Can I take paracetamol with my new medication?” (Yes) “I am getting hot flushes since I stopped HRT and my friend has recommended Black Kohosh. Is it safe? (I haven’t a clue). “I still have not had an appointment from the hospital. Did you do the referral letter." (Yes). “When will Dr James be back from holiday?” (Next week.) And so on and so forth. Time consuming. Trivial. I wonder what would happen if there were a token £5 charge for telephone advice?

I saw the five hot children. One of them was very hot and poorly and had signs of pneumonia. I sent her into hospital.

Zoom upstairs for a coffee and a piece of cake. One of the receptionists is sixty today. Gossip with three medical students who have been with various partners this morning. They were asking questions about the biochemisty of obstructive jaundice. We let our new young partner deal with those.

Back downstairs. Three visits had come in. Went straight out to do them. Two of them were patients who had been sent home the day after surgery. This happens. Particularly on Fridays when the big pre-weekend hospital "clear out" takes place. Not much wrong with them. They were both nervous and on edge having left the cocoon of the hospital. Their husband’s both felt that they should be “checked over.” I duly “checked them over”. I am never quite sure what this entails, but they seemed all right. When I was a hospital doctor they would have been kept in hospital longer. The third visit was to one of our patients who is terminally ill. He needed some reassurance and an adjustment of his syringe driver medication. I stayed for a coffee. Putting off going back to the health centre.

When I got back there was another batch of phones calls. I asked nine patients to come down but was able to advise the others by telephone. The patients who came down had no serious illnesses, but all needed checking over.

Another couple of phone calls and finally a visit on the way home. My wife is on call this week and so often gets home late.

Greeted by two grumpy teenagers asking “What’s for supper?”