The Crippen Diaries 2007 (16)

Not quite Emergency Ward 10

Monday 16th April

Back after a gap.

The break in the diaries was due to the MTAS and MMC furore, which has not yet abated. Then, a week’s holiday in the Lake District and back to all the patients who have waited "until you finished your holiday, doctor”.

The first patient of the morning was Jim, a fit 79 year old. He was distraught. His wife had been admitted to hospital just before Easter for a routine hip replacement. She was a year older than him, and had maturity onset diabetes and ischaemic heart disease. She had held out against surgery on her hip until the pain, particularly the rest pain at night, became intolerable. The operation went well. She was up and mobilising. Then, early on Good Friday, Jim was phoned to be told that she had had “a bad turn” and was very unwell. He went straight to the hospital. When he arrived, there was no nurse at the desk. He saw curtains around his wife’s bed. Thinking that maybe the nurses were with her, he went straight to the bed. Opening the curtains, there were no nurses there. His wife was dead.

Jim has no criticism of the care she received. It was excellent. It was just unfortunate that there was no one at the door of the ward to meet him. It happens. There had to be a post-mortem. His wife had had an embolus, he was told. Fat embolus? Pulmonary embolus? He does not know, and neither do I. I will get some information in a few days.

Jim and his wife knew the risks. He is not bitter, but he is bereaved and he had come to talk, which we did. And he brought a carrier bag full of her medication. I looked inside. There was a pair of glasses, her reading glasses, in the bag. I offered them back to him. He did not want them.

An awful way to start the week.

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The next patient was Eric a 27 year old fork-lift truck driver with hay fever. He was grumpy because I had kept him waiting twenty minutes. He was grumpy because he had paid a lot of money to the chemist for some anti-histamines which “don’t work”. He wanted to have “that injection” that gets rid of hay fever.

I don’t do “that injection” for hay fever. It is dangerous. And, to be perfectly frank, I was still thinking of Bill and looking at his wife’s glasses sitting on the desk. I suppose I should have thrown them away. I had thrown her drugs away. But glasses are so personal.

Eric seemed to think that I was not devoting all my attention to his hay fever. Eric was right. He left with some eye drops and a nose spray to complement his anti-histamines.

I threw the glasses in the bin.

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

David is 71 and lives alone. He is a widower. He has a daughter in Wales, to whom he is close. They see each other regularly. David is a retired quantity surveyor. He has, as he would be the first to admit, always been a worrier. He was very worried indeed today, visibly shaking. He said, “I think I have bowel cancer.”

The history was that, ten days ago, he suddenly found he had to strain to pass a large bowel motion. It hurt a little and then, when he looked down, there was blood in the bowl. The following day there was a little more blood but just on the paper. The next day he was back to normal. No blood. No change in bowel habit. Feeling well, apart from anxiety.

There was nothing to find on examination apart from a small pile. I bet that was the culprit.

He waited over a week for me to get back from holiday. He has not told his daughter as he does not want to worry her. I do not think this will turn out to be anything ominous but the one thing I cannot do, is the one thing David needs. A written guarantee that he does not have bowel cancer. I cannot give him that. They will see him quickly in the colo-rectal clinic. On this history, he will see the nurse rather than the doctor. Then he will have to wait several weeks for the follow up investigations.

Several weeks of worry.

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

Mrs Jones phoned. Her grumpy, elderly, independent mother, who lives nearby in sheltered accommodation is refusing to take her thyroid tablets. Mrs Jones wants me to sort this out. A classic general practice problem. I am not a health police officer. If someone does not want to take their medication, that is not my problem. Except it is, when it is an elderly patient. Or is that being ageist?

So I agree to meet the daughter at Mrs Jones’ flat.

Mrs Jones seems very well. She is not demented or dementing as far as I can tell. She does not wish to be examined and she is not prepared to have a blood test. The only abnormal behaviour is her refusal to take her medication. She has been on it for years. Why the sudden change of heart?

She will not come to any harm without thyroxine for a few days or even a few weeks, but it will catch up with her in the end. Maybe she has not been taking it for a while. There is no sign of a stockpile in the house. Her last blood test – about ten months ago, she is due another – was normal.

What do you do?

I have asked one of the district nurses to pop in next week and see if her persuasive powers are better than mine; and to try to get a blood specimen. Yes, I know, a bit of a buck pass, but I am not sure what else to do.

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Tuesday 17th April

Alice is 56 and is widowed. She does not have any children. She works as a clerical officer for a large freight-forwarding company. I had seen little of her until she presented a few weeks ago with an ominous breast lump. All that needed to be done has been done except for the post-operative radiotherapy which starts next week.

She came in looking embarrassed and tearful.

She cannot afford the transport to the radiotherapy centre. It is a thirteen mile journey. A bus and a train and a walk. The cost to her is just over £10 a day. That is five days a week, for several weeks. She has been off work for a while and is now down to SSP (statutory sick pay) which is about £70 a week. She does not have much in the way of savings and does have all the normal household outgoings.

The NHS ambulance service used to provide transport but that has now been restricted to patients who are physically unable to use public transport. Alice is perfectly capable of getting on buses and trains.

Strangely, she is not angry about the situation. She is ashamed. She has applied for a grant for transport. I do not know anything about this, but it involved sending letters and reports to Preston in Lancashire. Alice gives me the name of a civil servant there who has told Alice that they have not given her the grant as they “have not received a report from your doctor.” That is me.

I have not sent a report because they have not asked me to. So I phone up said civil servant in Preston and, having spend several minutes negotiating the phone options, (“If you are really cross, press the hash key…) fail to get hold of anyone who knows anything about Alice.

At this stage, I call in one of the office staff and delegate what is rapidly becoming the task from hell.

The NHS is free at the point of entry, but you have to get there under your own steam.

There must be a better way.

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My secretary informs me that, whilst I was away, further diktats have arrived from the local mental health service, and hands me the following letter and document. Another form to be filled in before a referral can me made.

Both the covering letter and form make me fulminate with anger. Let us look at the letter first.

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It is not a letter at all. It is a circular. And it is anonymous.

Note the passive tense. “We are now required…”.

By whom?

Why?

The ethnic origin and marital status of patients with psychiatric problems are usually but not always relevant, but why is yet another data collecting task being imposed upon us. Why is the government collecting these data? Do they want to be able to tell the Daily Mail that West Indians are madder than the Irish?

Why is this relevant? Why has there been no discussion? What happens if a patient does not wish this data to be collected. It is one thing to put in a psychiatric history something like “Mrs Heaney was born in southern Ireland…”. That information is not easily extractable by the commissars. Now it has to be on the computer analysable tick-sheet on the front of the notes.

I hate it.

Next, look at the form that we are supposed to get the patients to fill in.

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It starts with a characteristic bit of dishonesty, so typical of this government.

“To help us make sure that the services we provide are unbiased and equally accessible to everyone, we wish to record the ethnic group and marital status of the people who use our services.”

Codswallop. Sounds good, maybe, but it is codswallop. Recording this data has no relevance to helping to provide an “unbiased and equally accessible” service. The psychiatric services are dire beyond belief, but are equally unavailable to all, without regard to race and marital status.

It is well known that immigrants and, in particular people of African and West Indian origin, get a raw deal from the psychiatric services. They do not have difficulty accessing it, but they often get second-rate care once they are in the system.

You will not solve that problem by counting numbers. You need to look at quality of care. And racial prejudice within the service.

What they might like to record is the number of patients who manage to see an NHS psychiatrist. Very few indeed. Most are fobbed of with a “risk assessment” by some over-promoted amateur whose skills start and end with their ability to tick boxes.

The only way to guarantee a psychiatric assessment where I work is to go privately. They will not be recording that though.

Then look at the categories.

Do we really need this kind of detail? Am I alone in finding it offensive? And if it is relevant, for example, to record details of British and Irish origin, why not Welsh and Scottish origin? Yes, I know about the definition of the UK and Great Britain and Eire and so on, but is this really relevant to a psychiatric history? If Irish origin is important, then so is Scottish and Welsh.

And just a minute. “Black background”? People born in Britain are British. Is this really about the colour of the patient’s skin?

And would someone tell Dr Crippen why it is that we are not collecting this sort of data on patients with asthma, or arthritis, or inguinal hernias? Why are we only collecting it on the mentally ill?

What is the real agenda?

Maybe I should move to Tunbridge Wells and start writing letters to the Daily Telegraph, but I hate and resent this. Data for data’s sake. Control freakery. Intrusion into the private lives of the mentally ill.

I hate it.


+++++++++++

Thursday 19th April

A desperately frustrating morning trying to get some help for David and Mary, his long-suffering partner. David is a Welshman. He works, when he does work, as a bricklayer and thus can earn good money. He is a keen snooker player and, in a different life when he was in Wales, had ambitions to play professionally. It did not work out.

His marriage broke down. He moved to England several years ago and now lives with Mary, who is a hotel receptionist. They have no children, but David has a ten year old son in Wales, whom he sees occasionally.

David suffers from anxiety and depression. To allay the anxiety, he drinks. To bury the depression, he drinks. The drinking makes the anxiety and depression worse, so he drinks more. You can argue about the definition of “alcoholic”. David qualifies on any definition you care to advance. He drinks gargantuan amounts. Sober he is delightful. Drunk he is foul tempered and frightening. He has never hit anyone. He never gets violent. He does not smash things. But who knows what will happen tomorrow.

The psychiatric services are playing pass the parcel with him. He has been under the care of the CMHT for over a year. They tell him not to drink. He is under the care of the alcohol team and they tell him that he drinks so much it would be dangerous to stop abruptly. They have suggested he changes from vodka to beer. They have offered him group therapy, but he cannot manage that. He is too anxious to do “groups”. He was about to have a ten week out patient supervised “de-tox” course, but when he turned up for the first session, they breathalysed him. He had not had anything that day, but the previous day’s intake was still showing. You have to turn up to “de-tox” sober so they would not let him in. He had breached his contract.

David wants and needs in-patient de-tox. There is no NHS facility that provides that in my area. Because David always smells of booze, the medical doctors are not interested. The psychiatrists are not interested either. David has never seen a psychiatrist, even though he is has been under the care of the CMHT for a year or more.

Two weeks ago, he took another overdose. We are not talking the teenage girl’s three paracetamol and an Alcopop. We are talking forty to fifty 40mg Citalopram tablets and seventy 50mg Campral tablets, all washed down with two litres (yes, two litres) of vodka.

He was taken to hospital by Mary and a mutual friend. He was not seen by a consultant psychiatrist. He was not seen by any of the psychiatrists. He had a “risk assessment” done by a nurse.

Take a look at it. Apologies for the quality of the scanning

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What can one say?

Mood : low. (really?)

Regrets his actions and believes he would not repeat od/self-harm. (Really? Why should he stop now? How many tablets does he have to take for someone to respond to his cry for help?)

PLAN

Discharge ( ? plan)
Refer to CMHT for early appointment. (He is already under the CMHT)

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I have printed the letter in case you did not believe it.

The NHS is free at the point of entry. I heard that somewhere. Can’t remember where. Maybe I read it on the back of a match-box. David cannot find the door.

David needs psychiatric help and in-patient treatment and de-toxification. He needs help with his anxiety and depression. He is not going to get it unless he goes privately. He is not even going to see a psychiatrist unless he goes privately.

Make no mistake, David is a difficult patient. I spoke to someone about him today. They said, “Oh God, he is impossible; he will not co-operate; he won’t stop drinking”.

So, bog off David, you are a pain in the ass.


PLAN?

Nothing.