The Crippen Diaries 2007 (17)

Not quite Emergency Ward 10

Monday 23thApril

The first patient in came to discuss her newly diagnosed ENT condition. She developed chronic recurrent dizziness after a prolonged fairground ride. It was not helped by any treatment we could give her, and the first ENT specialist was not able to help her either. All scans were normal. The second ENT specialist told her she has “mal de barque” syndrome.

In days gone by, I might have flannelled a little. I am old enough now not to be ashamed of ignorance. I told her I had never heard of it, and said “Lets ask Dr Google.”

Most of the stuff that came up was in French. Phobic postural vertigo was one definition. This lady exhibits no signs of phobias and she is most certainly not mad. More research needed her, and probably a chat with the ENT specialist.

+++++++++++

A charming 19 year old girl who has just been bounced by the blood transfusion service because she is anaemic. She brought the information with her. Her haemoglobin is 11.9 and should be 12 or more. She is entirely well though her periods are a little heavy. She is also O Rhesus negative, so the blood transfusion service do not want to lose her.

The difference between 11.9 and 12 is within experimental error. She will take some iron for three or four weeks, and I am sure they will be able to have her back then.

Brilliant that a teenager will do this in return for a luke-warm cup of tea and two of those oddly named “Nice” biscuits.

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

Bill presented just before Easter, on the afternoon of Thursday 5th April, to be precise. The previous day he had noticed that his urine had been red on two occasions. Not unwell. No prostatic symptoms and, considering he is nearly seventy, that is pretty good. On direct questioning, he said that his urine stung a little as he passed it. This needed checking out. You cannot get urine microscopy over a Bank Holiday. I arranged for two urine specimens and some blood tests for the following week. The blood tests were normal. In particular, the PSA was normal. Both urine specimens showed a lot of red blood cells but no evidence of infection. His blood pressure is normal and his prostate does not feel enlarged.

He needs further investigation.

On Monday 16th April I referred him to the haematuria clinic. We have excellent urologists locally. They have always provided a good service, even before the two week rule nonesense. Bill has an appointment with one of the consultants a week tomorrow, Tuesday 1st May. Eight days away.

Bill is not happy. He has not had anymore blood in the urine, but he has been reading up about “microscopic haematuria” on the internet and is frightened that he has bladder cancer. He wants me to get onto the hospital and bring his appointment forward. He has indeed phoned the urology department secretary who told him, as they always do, that his appointment can only be brought forward if he gets “a letter from your doctor.”

Bill may have bladder cancer. I understand his concern. But he will have gone from presenting in primary care to sitting in front of the specialist within a little over three weeks, and that three weeks included the long Easter Bank holiday.

It is not in my gift to “bring his appointment forward”. I could write to the urologist but I am not going to. His clinics are all ready full, and he is doing the best he can. I sympathise with Bill. Blood in the urine is frightening. (If you doubt that, put half a dozen drops of red ink into a lavatory bowl – it does not take much to look dramatic). But on any criteria, he is being sorted out as fast as anyone could expect.

This is more than anxiety. It is the unrealistic expectations generated by a system perceived to be “free” at the point of entry.

Tuesday 24 April

I have a degree of sympathy with the local “housing needs commissariat”. It must be very difficult when you only have a handful of house to share between hundreds of disadvantaged unmarried mothers. I have no sympathy, however, with the strategy they use to get people out of their office. “You need more points. Get your doctor to write a medical report”.

All well and good.

“Mr Jones is a bilateral amputee currently living in a bed-sit on the third floor with no lift…”

I wish it was like that. Usually, however, it is a sad and see-through attempt to connect a small patch of damp in the bed-sit to that vague history of asthma that some one once mentioned to Samantha when she was a child.

When the housing department used to write to us for medical reports, we used to charge for them. They wised up to that. Now they tell the patient to “ask your doctor for a report.” They do not pay. We still do them. What else can you do? Today’s Samantha is at her wit’s end. She has three children and lives with them in a wholly inadequate one bed-roomed maisonette. She wants a three bed-roomed council house with a garden.

Samantha probably was a bit asthmatic as a child, and one of her three children coughs a bit more than he should, and there is a damp patch, and there is not a garden, and there is an alcoholic living next door and I cobble a few words together and send it off to the council and nothing will happen.

It is a game we all play. The “letter to the housing department” game.

++++++++++

“I’m not a tablet person, doctor.”

This opening gambit (yes, it is a gambit in the real sense of the word if you say it to a doctor) always makes my heart sink.

“But I have not been sleeping well, so I have been taking Valerian Root. Is that all right?”.

“Thought you weren’t a tablet person, Mrs Davies.”

Mrs Davies does not understand. I run through the history. There is no obvious reason why she is not sleeping. I have not got a clue about Valerian Root, so I consult Dr Google who soon takes me to Homeherbs.com which tell me that:

Valerian is well known for its sedative qualities and its ability to relax the central nervous system and the smooth muscle groups. It has been used as a sleeping aid for hundreds of years and has also been indicated for anxiety, confusion, cramp, depression with anxiety, dysmenorrhoea, hives, hypochondriasis, hysteria, improving circulation, intestinal colic, lack of concentration, menopausal dysfunction, retarded and scanty menstruation, migraines, nervous excitability, palpitations, PMS, rheumatic fever and pain, stress, tension and tranquiliser withdrawal.

Valeriana officinalis

God, that is brilliant. Why did they not tell me about it at medical school? It cures nearly everything including hypochondriasis, hysteria, the menopause and rheumatic fever. I think I will leave a large vat of it outside the health centre and go home. And it is only £10.95 for a hundred capsules.

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What’s a STEMI?

Andrea is 72 and, on Easter Sunday was gardening when she developed “a very odd indigestion which made me sweat” and fell to her knees in the garden. He husband dialled 999. She was admitted to hospital and, it is quite clear, had superlative treatment. Same day angiogram. All that should have been was done. She was discharged on day five, feeling well and entirely asymptomatic apart from a sore, bruised groin.

The only thing that had been missed was an explanation.

STEMIs had not been invented when Dr Crippen was a hospital doctor. I told her what it stood for and that it meant a “small heart attack”. Is the word “small” justified? Well, in my book, anyone who walks out of hospital after a heart attack feeling well, with no angina, and no heart failure justifies the use of the word “small”.

We talked about what she could and could not do. Pretty much anything, really, including being Vice President of the United States! Andrea has never smoked and has always been fit and active. She is a keen walker and a regular swimmer.

“So why have I had a heart attack, then?”

The answer is age. When she was born, life expectancy for a woman was about sixty-four. She has won. When I was a child, people of 72 were old.

They are not any more.

++++++++++


Thursday 26 April

David, the alcoholic who needs in patient detoxification, and who me met last week turned up this morning. I was fully booked so he saw one of my partners. He was appallingly drunk.

“Smells of alcohol at 11.00 a.m.” the note started. And there, let me digress for a friendly warning. Never, never go to your doctor when you have just had a drink. You may only have one unit of alcohol a year, but if your doctor smells it, he will note it physically in writing, and mentally as well. For ever after he will wonder about your “real” drinking habits.

David gave my partner a bad time. He was not violent but he was abusive and demanded some Librium. My partner refused to prescribe for him at which stage David started swearing.

Finally, my partner asked him to leave.

We had a long discussion over coffee about the best strategy to adopt to deal with drunks. My partner was not very sympathetic.

There are big issues underlying.

Can a person’s behaviour become so unacceptable that they forfeit their right to medical treatment? Alcoholism may be an illness, but some alcoholics are near to unmanageable. It is easy if they are physically abusive but supposing the problem is solely that they will not take advice. That they keep turning up drunk?

Where does one draw the line?

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Friday 27th April

More news of David. He saw my partner yesterday. (see above)

Regular readers will remember David, the snooker-playing Welsh alcoholic, who lives locally with his partner, and has a son in Wales. David needs in-patient detoxification; he needs help with his underlying chronic depression; he needs help with his chronic anxiety problems; he needs help with his alcoholism; he needs to be assessed and followed up by a trained psychiatrist.

Dr Crippen has not been able to help him with many of these needs. Last week, as you will recall, he took a gargantuan overdose of medication. Re-read what happened to him in last week's diary, here.

The hospital were no help, and the alcohol team were reluctant to see him as he keeps drinking. Bit like the diabetologists not seeing people who have high blood sugars, but I digress.

So I took him on. I saw him with his partner. I agreed to de-tox him on an outpatient basis provided his partner kept the medication, and provided he did not drink. I started him on a high dose of chlordiazepoxide (Librium) to cover the withdrawal, and I saw him every day, with his partner. It all went brilliantly for four days. On day five, however, when we were due to start reducing the medication, he turned up an hour late. He turned up drunk. His partner was at her wits end. I spent a long time with him. He asked me to prescribe Librium, Valium anything, but I did not dare do it in view of what happened. I offered to continue seeing him daily, and made him an appointment for the following day. He did not come.

I have not seen him since. But, as I say, he saw my partner yesterday, and stormed out of the consultation. What happened to him next?

During the morning, my secretary brought in a fax.

click to enlarge

click to enlarge

Please make no mistake. David is not an easy patient. He is, in fact, a pain in the ass. No one would dispute that. But he is ill. And his illness manifests itself with "bad behaviour". If David does not get want he wants, he drinks. He takes overdoses. He falls, or jumps, into the river. For all that, I feel ashamed to be working in the British National Health Service.

Take a look at the letter in more detail.

"...he had been found the previous day in the river by the police"

There must be more to it than that. You do not "find" people in the river. Someone dialled 999. Someone pulled David out. Or did he just say, "Good afternoon, officer, I am having a swim"?

MSE (mental state assessment)

Appetite - "not bad
Sleep - doesn't sleep
Alcohol - large amounts, but dry some days.
Illicit drugs - see history : but the history is an equivocal one line.
Mood - flat of affect.Tearful at times.
Communication - good account of history. Articulate. Good eye contact.

This might pass for a mental state assessment for nursy, but a medical student offering this up in finals would be failed. "Flat of affect"? More normally we would say "Flat affect". This is a history taken by someone who does not use language well.

"currently off sick with an ankle injury"

David is "currently of sick" because he is pissed all the time.

"Last incidence of overdose Friday 20th"

Correct. But nursy does not seem to be worried by that.

"Does't want to die and just wants help"

Why not give him some help, then, before he accidentally kills himself. What more does he have to do to make you show some concern?

"David presented as a pleasant man, who is aware of his problem, but lacks the ability to do this. The above incident, hopefully proved to be a "wake up call". And he did appear genuinely shocked at how close he came to death. However, given all his additional support, I did not feel he warranted admission at this time."

Strewth!

OK, nursy, maybe English is your second language, but what does the first sentence mean? And do you not read your letters before you sign them?

A "wake-up call"? It has not woken the psychiatric department up.

Would someone out there tell me what exactly David has to do to "warrant" admission? Would someone out there tell me what David has to do to see a consultant psychiatrist? The only strategy I can think of is to go privately. Sadly, incapacity benefit will not cover that.

This is why Dr Crippen is so fed up with the lack of resources, and the dumbing down of the service to well meaning amateurs like this.

And finally, David did not turn up for his appointment this morning.