NHS Blog Doctor

Comment spammers

2008-05-26T11:07:00.002+01:00

Like many other bloggers, I am currently suffering from a deluge of comment spam and so, for the first time ever, I have turned on comment moderation. All genuine comments, however critical or outspoken will, as always, be published.

The humour of Nadine Dorries

2008-05-26T10:20:00.004+01:00

Richard and Nadine

I used to advise any word-weary blogger in need of some light relief to pop in to the Center for Nursing Advocacy, consistently the best source of unintentional humour on the internet. They are currently campaigning against this:

April 1, 2008 -- Recent reports say a clinic in Spain has told its nurses they will be docked pay if they fail to dress in miniskirts.

I am proud to say that the Center for Nursing Advocacy has now been knocked of the top spot of unintentional humour by none other than Nadine Dorries. Nadine has been causing apoplexy amongst the swear bloggers. Since the defeat of her none too hidden hidden agenda amendment to reduce the upper age limit for abortion, she has completely lost the plot. Her pseudo-blog posts (switch the comments back on, Nadine) have become increasingly bizarre. Yesterday she was seeming to portray herself as Julia “whore with a heart of gold” Roberts in Pretty Woman. Big mistake, Nadine, big mistake

Then there was this distasteful piece from the previous day:

The ridged look on Jacqui Smiths face gives me huge pleasure.She is possibly the most arrogant and least pleasant of all the Labour women. There will be no seat turning from red to blue which will give me as much pleasure as that one. The Sky News prediction for a general election makes me giddy! I have to go and lie down.

PS I haven’t been triumphant or complacent in this blog have I?

Turn the comments back on, Nadine, and we will tell you. She won’t though. If she did, she would not be able to fantasise:

When the Speaker called my name, I was lifted to my feet by the cheers and support of my colleagues, and an overwhelming feeling of good will, which sustained me throughout. I work with lovely people. The Times described them today as my personal ‘marem’, the male version of a harem. I wish! More later. Nadine Dorries

The only time she is not funny, is when she is trying to be:

Who is this Alchi Ida that Gordon Brown talks about so much?   Is she a pensioner who drinks too much mother's ruin?   Answers on a postcard please! Nadine Dorries

Those whom the Gods wish to destroy, they first make mad. Poor old Nadine.

The Madwives of New Zealand - another baby dies

2008-05-25T11:11:00.006+01:00

Home birth

When I was studying law, Patrick Atiyah was Professor of Law in Australia. Within legal circles he was best known as a proponent of “no fault” compensation for personal injuries. There is much to be said for it particularly when we consider the fate of a foetus, severly injured during labour. In England, a birth-damaged child’s chance of compensation depends solely on his lawyer’s skills in proving fault on behalf of the doctors and midwives. Did Mr Jordan pull too hard and too often on the forceps when trying to deliver Mrs Whitehouse’s baby?

"The recent decision of the House of Lords in Whitehouse v Jordan brings to an end a sorry tale of protracted litigation surrounding this case of alleged medical negligence….the importance of the Whitehouse case lies not so much in its clarification of the relationship between medical negligence and the concept of “error of judgement”, but rather in its underlying indictment of the present system of compensating victims of medical accidents.” (Whitehouse v Jordan)

It is a complex and fascinating area of law. In Britain, and particularly in the USA, the ever present risk of a negligence claim makes it essential for all doctors and midwives to have proper professional insurance. For the US obstetrician this is becoming prohibitively expensive. For the British “independent midwife” (many of them madwives), who insist on working outside the NHS, professional insurance is no longer available. No commercial insurance company is prepared to underwrite their idiosyncratic professional behaviour.

It is different down under in New Zealand. Professor Atiyah’s dream of “no fault” compensation has come true. A reader from New Zealand writes in to say:

In keeping with your previous posts on birthing outside of hospital (in a seemingly bizarre place run by a company known as 'Birthing Units Ltd') & more insight into the international madness of midwives, I can recommend a recently published report by the Health & Disability Commissioner here in New Zealand (basically a government appointed commissioner who investigates complaints against anyone in the health sector) into an appalling catalogue of cock-ups that led to a neonatal death.

Midwife, Ms D
Midwife, Ms E
Obstetric Nurse, Ms F
A Birthing Unit

A Report by the
Health and Disability Commissioner

Case 05HDC01760

It's fairly long & detailed but deals with similar themes to those you raised - what happens when private companies or individuals are allowed to run midwifery services. Over here everyone is covered by ACC (Accident & Compensation Claims), essentially a national insurance policy, so the midwives are allowed to roam free without fear of tort. The upside is that no-one can sue for damages which makes for a refreshingly open & honest healthcare system with no-one practising defensive medicine; the downside is as previously described - midwives roam free, unfettered by self-awareness.

It is indeed a detailed report. It contains a catalogue of errors, incompetence, indifference, and attempted cover-up, at the end of which there is a dead foetus. What happened to the independent midwife?

The Tribunal found these actions amounted to such a significant departure from the accepted standards that discipline was warranted, it upheld the charge of professional misconduct. Penalties included
supervision/monitoring of the midwife for a period of two years
a limit of no more than four midwifery cases per month for a year
a recertification audit by the Midwifery Council
a New Zealand College of Midwives Midwifery Standards review
a fine of $2,080.00
a penalty of censure.

Is that enough? In England, this midwife would probably have been prosecuted for manslaughter. This report makes me shiver. Be warned. If the government gives in to the independent midwives and provides them with state (aka taxpayer) underwritten indemnity insurance, there will be no controlling them. Tragedies like this will become common place in the UK.

How NOT to stop smoking

2008-05-24T21:21:00.008+01:00

As readers of NHS BLOG DOCTOR will be only too well aware, I am a curmudgeonly, cantankerous old bugger at times. There is nothing more likely to reduce me to rage than a patient leaving a chitty from a “health care professional” instructing me to prescribe nicotine substitutes. Lots of reasons for my anger. First and foremost, I am not going to be told what to do by an unqualified HCP. Secondly, most HCPs are not allowed to prescribe, and for good reason, and the ones who are so allowed are dangerous. The way things are going soon they will all be allowed to prescribe independently. So be it. I will not be responsible for their actions - and don’t say I didn’t warn you about the dangers. Thirdly, I object to the taxpayer having to underwrite the substantial cost of nicotine substitutes. I think it is an outrage that they are available on prescription.

Fourthly, I used to smoke. It’s a long time ago now, but I still remember it, occasionally fondly. Life long non-smokers do not understand the pleasures of smoking. To them it is a filthy habit with no mitigating features. We ex-smokers know better. It is a filthy habit but, boy, the pleasure of that cigarette at the end of the meal... but enough of that! Suffice it to say that I know what smokers who genuinely want to give up are going through. I also know that no smoker will give up until they decide they want to. All the nicotine substitutes are presented by Big Pharma as an instant, magic answer. Pop a piece of Nicorette in your mouth and you will never want a cigarette again. It is not like that. You have to genuinely want to stop.

I formulated my own psychological strategy to stop smoking, and I use it regularly to help patients. I will not go through it again now, but may I humbly suggest that any smoker who really wants to stop should try:

The Crippen Stop Smoking in 28 days Plan.

It works and it is free.

But back to the nurses, pharmacists and HCPs who give patients chitties telling me to prescribe various nicotine substitutes. I tear the chitties up and throw them away. If patients want a prescription from me, they have to see me. That makes them cross. Tough. if they won't see me, they can buy their own substitutes and save the taxpayer some money. When they do see me, if they are amenable, I take them through the Stop Smoking in 28 days Plan. If they do not want to do it that way, but have their own plan, that is fine. I will do my best to help them. But if they have no plan and think they can solve the problem by slapping on a nicotine patch, I do not prescribe. They can buy them themselves. Most of these people will end up with the patch or the gum and continue smoking as well.

I have never prescribed Zyban or Champix and I never will. Using this sort of medication is not the right way to stop smoking. Even if it worked, and it does not, I have always worried about dangerous side effects, particularly with Champix. I was therefore pleased to find that the Drugs and Therapeutics Bulletin (a non-promotional, no-advertising-accepted pharmacology journal) has grave reservations about Champix. The article is still in copyright so, sorry, you will have to pay to look. Fortunately, there is an excellent review of the problems with Champix at Pharmalot

It it not just the Drugs and Therapeutics Bulletin that has reservations. It gets worse:

First, we’re told we can’t fly our planes if we’re also using Champix to quit smoking. Now, we can’t drive our rigs, either. The Federal Motor Carrier Safety Administration has issued a warning that advises medical examiners “to not qualify anyone currently using this medication for commercial motor vehicle licenses,” according to The Wall Street Journal. The move follows a study by the Institute of Safe Medication Practices that found a host of side effects linked to Pfizer’s quit-smoking pill
serious accidents and falls
potentially lethal cardiac rhythm disturbances
severe skin reactions
acute myocardial infarction
seizures
diabetes
psychosis
aggression
suicide.
In all the study, linked Champix to nearly 1,000 serious adverse events. Just hours after the study was released two days ago, the Federal Aviation Administration banned the drug for pilots and air traffic controllers. So far, though, the FDA, which previously issued health advisories about psychiatric side effects, such as suicide, hasn’t taken any additional action. (full report here)

So ask yourself this. Do you want to take a drug that the Federal Aviation Administration has deemed to be too dangerous for pilots and air traffic controllers?

Desperation in the American election : political assassination

2008-05-23T22:32:00.010+01:00

A sense of desperation is slipping into the American election campaign. Hillary Clinton plumbs new depths of cynicism and vulgarity. Why is she staying in the campaign? In case Barack Obama is assassinated.

Senator Hillary Clinton referred to the assassination of Robert Kennedy in 1968 as a reason she should continue her battle with Senator Barack Obama for the Democratic nomination. My husband did not wrap up the nomination in 1992 until he won the California primary somewhere in the middle of June, right? We all remember Bobby Kennedy was assassinated in June in California. I don’t understand it,” Mrs. Clinton said, dismissing the idea of dropping out. (New York Times)

Whilst Bill and Hillary consider hiring a hitman, John McCain is worrying that he may die of natural causes and so has decided to release his medical records to prove that he is immortal. Studying the records, the first thing we conclude is that the man is a heart-sink patient. What is the easiest test you can perform to check if a patient is a hypochondriac? Weigh the notes.

the details of McCain's health are contained in 1,173 pages of medical documents

1173 pages? Clearly a hypochonriac. But just a minute

The details of McCain's health are contained in 1,173 pages of medical documents spanning 2000 to 2008 (source)

That is only 8 years. What about the other 62? This man is not a hypochondriac. He is a galloping hypochondriac. And note that he has not really released his records. He has only allowed journalists a glimpse. A glimpse on the following terms:

The newer batch of records has strict security guidelines attached. Only certain news networks and newspapers will be permitted to enter the room, and they will have only three hours to examine the papers. No cell phones or Internet access will be allowed in the room, located in a resort outside Phoenix, Arizona. Copying the records is also prohibited. Anyone who leaves the room for any reason except the bathroom will not be allowed back. (source)

Why would a journalist want to take a bath whilst he is reading McCain's medical records? Odd.

For those interested in the details of McCain's medical history – fascinating to most doctors – the sanitised summary of his notes is available here.

The summary is written by:

Dr. John Eckstein is a physician in our Internal Medicine Division and has been caring for Senator McCain for the past 16 years.
Dr. Michael Hinni is a surgeon in our Otolaryngology/Head and Neck Surgery Department. Dr Hinni specializes in surgical oncology of the head and neck. He performed Senator McCain's left lower temple melanoma surgery in August 2000.
Dr. Suzanne Connolly is a specialist in our Dermatology department, with extensive clinical experience. She is Senator McCain's dermatologist.

That is some very special free publicity for those three learned physicians and will not do their private practice any harm. From them we learn that Senator McCain takes the following medication:

Simvastatin, which is a cholesterol lowering medicine
Hydrochlorothiazide, for kidney stone prevention and Amiloride to preserve potassium in the blood stream
Aspirin, for blood clot prevention
Zyrtec, an anti-histamine as necessary for nasal allergies
Ambien CR, as necessary for sleep when traveling
A multiple vitamin tablet.

Ambien CR is one of the “Z” drugs (not as addictive as valium and mogadon and Librium, honest, the drug companies have told us that…). Some dishonesty here. It is not NECESSARY for sleep when traveling. Drugs like this make elderly people more prone to falling over when they go for a pee in the middle of the night. But John McCain is not old, is he? Let us look at the side effects:

When you first start taking AMBIEN, use caution in the morning when engaging in activities requiring complete alertness until you know how you will react to this medication. In most instances, memory problems can be avoided if you take AMBIEN only when you are able to get a full night's sleep (7 to 8 hours) before you need to be active again. As with any sleep medication, do not use alcohol while you are taking AMBIEN. Sleepwalking, and eating or driving while not fully awake, with amnesia for the event, have been reported. If you experience any of these behaviors contact your provider immediately. In rare cases, sleep medicines may cause allergic reactions such as swelling of your tongue or throat, shortness of breath or more severe results. If you have an allergic reaction while using AMBIEN, contact your doctor immediately. Prescription sleep aids are often taken for 7 to 10 days – or longer as advised by your provider. Like most sleep medicines, it has some risk of dependency.

Does the leader of the free world occasionally engage in activities requiring complete alertness? Probably not.

Hydroclorthiazide and amiloride to stop kidney stones and preserve potassium in the blood. Plausible. Good for high blood pressure too. No mention of his blood pressure – an extraordinary omission that makes it difficult to take the report seriously. I presume (hope) it is mentioned in the full report.

I note with horror that he is taking a multi-vitamin tablet. Now we know he is a hypochondriac. It is inconceivable that a well nourished American multi-millionaire is vitamin deficient. This is wibble. I am amazed that Mayo Clinic physicians have let themselves be associated with that. They do not seem like purveyors of wibble.

The history of melanomas is of concern. I hope he is cured. He may be. But melanomas have a habit of recurring.

Finally, spare a thought for this:

He was a Navy pilot in Vietnam, and his plane was shot down in October of 1967. He broke both arms and a leg after ejecting from his plane. He was a prisoner of war in Hanoi for 5.5 years. As a POW, he was beaten and tortured repeatedly…

That reminds me of something:

Paranoid nonsense. Of course it is.

Should I take HRT? The perfect answer

2008-05-23T00:55:00.004+01:00

Shall I take HRT?

The pendulum swings backwards and forwards.

Too many women are missing out on hormone replacement therapy because of "overhyped" safety concerns, an international group of experts warns. At a global summit held in Zurich by the International Menopause Society, experts concluded younger healthy women should have no fears about taking HRT in the first few years of menopause to relieve symptoms. BBC

Oh! Goody, I will prescribe it more frequently.

Menopausal women who use oral hormone replacement therapy (HRT) more than double their risk of blood clots, French scientists say. (BBC)

Oh! Dear. I must stop prescribing it.

Following recent studies linking HRT to ill-health, the Royal College of Obstetricians and Gynaecologists said it advised women to use the lowest dose which gives symptom control, for the shortest possible time. (BBC)

Lowest dose possible for the shortest possible time. Does not sound good. That confirms it for me. I must get all my patients off HRT as soon as possible.

Dr David Sturdee, president of the International Menopause Society, said women should not be afraid of taking hormone replacement therapy. He said: "The BMJ publication confirms present knowledge. Although the risk [of blood clots] is raised in hormone users when compared to non-users, the absolute risk is indeed very small. This very slightly increased risk of a blood clot should not discourage healthy women from using HT if it is needed." (BBC)

Oh! Bugger. Wrong again. I CAN prescribe it. And then, of course, the pushy middle class woman, who has been on HRT for two years and is full of BBC GP bashing “news” items, will ask to see a “specialist”.

Of course you can, my dear. Who would you like to see? I can send you to Professor Studhead. She is very eminent in the world of HRT. Her whole life has been devoted to it. She has lectured on the benefits of HRT. She will advise you to take it. She advises everyone to take it. Or I can send you to Mr Jones, the well respected gynaecologist at the local teaching hospital. He will put his arm round you and say, “Well, lassie, you have been on it long enough now. Time to stop.”

Take your pick. Or shall we discuss the pros and cons, and then you can make up your own mind?

Big Pharma funds the American election

2008-05-22T21:17:00.003+01:00

Never underestimated the influence of the big pharmaceutical companies. During an American election, Big Pharma will make large financial contributions to the political parties. During the last six elections they contributed, on average, twice as much to the Republicans as to the Democrats.

So what is happening this year?

At the moment, donations have gone to individual candidates rather than parties. That will change once the Democrats have finally made their decision. So far, Big Pharma has contributed the following amounts (top to bottom):

$636,327
$567,581
$434,961
$200,875
$172,750

To these politicians (alphabetic order):

Hilary Clinton
Rudolph Giuliani
John MaCain
Barack Obama
Mitt Romney

But who got what? And why? Answers here.

Stopping children from drinking

2008-05-22T17:28:00.005+01:00

An interesting reaction on Conservative Home, where I just did a short post on the dangers of Alcopops.

I seem to have awakened a legion of "angry of Tunbridge Wells" and they are all committed boozers. They are screaming "paternalism" and "nanny state".

Frankly I think Dr Crippen must of had a few when he wrote that tosh! If we are honest most of us were drinking by the age of 13. I and my contempories certainly did and it's done me no harm. Drink and be merry I say. Bottoms up! (here)

Oh dear. Believe me, I hate state paternalism. I worked for Patricia Hewitt. And I don't much care for the goverment/BBC current alcohol campaign. But I do not like drug companies targeting 13 year olds who lap up alcopops because they taste like fruit juice.

Destroying the English legal system

2008-05-22T16:55:00.003+01:00

Crown Prosecution Service

Regular readers will be in doubt as to Dr Crippen's determination to expose the Government's policy of dumbing down professional services. Everywhere you look there are "health care professionals", teaching assistants, and pretend policemen.

Do you remember those two amateur policemen who would not pull a drowning child out of a pond?

Jordon Lyon leapt into the water in Wigan, Greater Manchester, after his eight-year-old stepsister Bethany got into difficulties on 3 May. Two anglers jumped in and saved Bethany but Jordon became submerged. The inquest into his death heard the PCSOs did not rescue him as they were not trained to deal with the incident. (BBC)

What a pair of prats. They would not go into the pool because they had not got their swimming badge. I bet they are both Consultant Nurses in real life.

I have mentioned the Crown Prosecution Service before. They are being groomed to take over the criminal legal services because the properly trained lawyers, the barristers, refuse to work for £5 a day.

This morning, the CPS Inspectorate (note - it's so bad, it needs its own inspectorate) has issued its own devastating report. They focus on the state of CPS case files, a basic essential of the lawyer's business. They find that the "majority of files" are incomplete in important respects. Things are not recorded clearly and legibly, and have vital bits missing. Bail records are particularly weak - one-third of bail conditions are not recorded at all - the CPS lawyer just can't be fagged.

Full report from Wat Tyler here - worth a look just for the wonderful short film he has unearthed.

The Crippen Diaries - 2008 : May (1)

2008-05-22T14:20:00.007+01:00

What do you want to do when you grow up...

May 2008 (1)

Amy is 29 and lives alone in sheltered accommodation that has been specially provided for the mentally ill. One of the odd anomalies of the area in which I work is that, although we have poor psychiatric services, we have excellent sheltered accommodation both for the mentally ill and the elderly. Amy has what is called a “borderline personality disorder”. She was badly sexually abused as a young teenager by an uncle who is now in jail. You don’t want to know the details. She gets flash backs to that and so there is another label, post-traumatic stress disorder (PTSD) on her notes. She suffers from at times severe depression, sometimes with psychotic elements. Her mother died two years ago. Her father is still alive somewhere, but she has not seen him for years. There is a caring grandmother but she is now old and frail and in the early stages of dementia.

Amy has not seen her psychiatrist for over six months and, when he did see her, she did not feel she could talk to him so went into “very well, thank you” mode which he chose to take at face value. It’s easier. I have lost count of the number of overdoses Amy has taken; half a dozen at least. Usually her anti-depressants. She will take a good handful. She never takes paracetamol because, her care-co-ordinator says, she knows that would be dangerous. When she is depressed (frequently) she cuts herself on the forearms with a razor blade. Never deep enough to sever tendons but deep enough to cause permanent scarring. Her forearms are a mess.

Her CPN is good but has a large case load and so only sees Amy once a fortnight. She has told Amy that if ever she is really desperate, she should take herself to the local A and E department. She has done that once. She was told that there were no psychiatrists on site (there aren’t – the psychiatrists only provide a 9 to 5, Monday to Friday service) and the psychiatric nurse was at the other hospital. She was advised to go home and “see you doctor tomorrow.” So she did. She will not be troubling the A and E department again.

I have known Amy a long time, and she will talk to me. So I have been seeing a lot of her recently and I hope I am providing her with some support. But what about the psychiatric services? She has been under their care for years. Which of them is looking after her? No one, really. Starved of funds, the CMHT is dumbed down and not helpful. The government would say I am exaggerating. They would say there are three “health care professionals” involved with Amy. Her CPN, who does see her occasionally. And then there is her “care coordinator” - someone who works in social services though is not a trained social worker. It is a grandiose title and a classical bit of New Labour flummery. Amy is not getting much care, and so little “coordinating” is needed. I have seen Amy more than any other doctor, and no one has ever attempted to coordinate me. Finally, there is Sharon. Sharon works with several “clients” in the same accommodation. She does shopping, and some cleaning, and is usually around to have a coffee if Amy wants to talk. Sharon is kindness itself. She is a patient of mine. She is not a doctor or a nurse or a social worker. She has no qualifications in mental health, and would not dream of making diagnoses or interfering with medication. Because she is the least qualified member of the “team” it is essential in the modern world of New Labour that she has a title. Sharon is therefore Amy’s “key worker.”

Thus, Amy is a success for the mental health services. She has both a care-coordinator and a key worker.

What more could some one with serious mental health problems want?

Nadine Dorries loses the abortion debate

2008-05-21T09:36:00.004+01:00

Nadine Dorries MP

The Abortion Debate is over for another few years, and the status quo has been maintained. Leaving aside the merits of the issues for a moment, I always enjoy these non-partisan “conscience” debates. As Iain Dale reports here, and rightly so, the Government should learn some lessons about the merit of free debates.

In terms of the upper age limit, I would have favoured a reduction to 22 weeks. When I was doing neonatology, I spent many, many long hours trying to resuscitate 23 and 24 week babies. If a line has to be draw, and I think it does, I would be more comfortable with 22 weeks. But I am still strongly pro-choice. I have been trying to get Iain Dale to explain exactly where he stands. Today he says:

Has this issue been permanently put to bed? No. And nor should it be. It deserves periodic debate and review and I fully expect it to be revisited after a change of government. Iain Dale

Nadine Dorries will be disappointed. She only has herself to blame. Her views are so rabid, and so strongly put, that she antagonises people on both sides of the debate. Even now, she continues to plug the mawkish and uttlerly misleading story about the foetal hand. There is a good case for a 22 week limit but it was not properly heard in all the brouhaha of Nadine's extremism. Trouble with Nadine is that she is not truly pro-choice although she will purport to march under that banner when it suits her. Had she put her case in a more temperate manner and emphasised that a woman’s right to an abortion up to 22 weeks is absolute and must both be protected and facilitated more might have listened. Sadly, that is not what she believes and, in any case, Nadine does not “do” temperate.

I would be more interested to hear what Iain Dale believes. One can have a temperate discussion with him.

Dinosaur Grand Rounds

2008-05-21T00:31:00.002+01:00

And now, from somewhere over there, Musings of a Dinosaur presents this week's pick of the best of medical writing.

Looking after the boozers

2008-05-20T20:36:00.014+01:00

Lardy

Jesus H. Christ. Look at that square-faced lardy. Apparently, he is some sort of journalist, so he’s probably a boozer. Looks like the sort of guy who would get into a fight in a pub. Look at those flabby chins. Yuk. Must be a boozer. You don’t get flabby chins like that from drinking Perrier water. I don’t think his GP has been doing his job properly. If he was my patient, I should be taking a detailed drinking history from him as soon as he sat down.

For the second time in a week, Eddie Mair, the mellifluous BBC Radio 4 PM presenter has taken the opportunity to indulge in some gratuitous and inaccurate criticism of family doctors. I suppose we should get used to it. Not a day goes by... But, sadly, I never get used to it and each time it happens it is another slice off the morale salami. For a brief second I hoped that the government spokesman might have said something sensible, but it was not to be. Dawn Primorolo talked vaguely of “more training”, and of “writing round” to every GP in the county.

A new Dawn

Dawn, have you any idea how much it costs to “write round” to every GP in the country, and how cost ineffective it is? We don’t read your circulars, Dawn. They go in the bin.

What was it all about this time? Alcohol. The BBC is “doing” alcohol this week and the BBC medical “news item protocol starts” off with “GPs do not know how to…. (insert topic). You can listen to Eddie Mair here. Please do. It only takes ninety seconds. The bit about GPs starts at 50:38. Eddie says GPs are “not experienced” and “not terribly well trained” (sic) and “that needs to be looked into.

Eddie, you can’t get through medical school without learning about alcohol. It has taken over from syphilis as “the great imitator”. Every speciality medical students rotate through exposes them to the dangers of excess alcohol. An experienced doctor can spot most alcohol abusers at a hundred yards. As I have said several times recently, this is not about clichéd alcoholics. This is about the housewife drinking two bottles of Tesco plonk every night; the solicitor or the accountant who does a bottle of wine and three large whiskeys; the medical student or bricklayer’s apprentice who drinks five pints of beer a night. The list is long. Take a step back, Eddie. Are you a boozer? I don’t know. But you are a journalist, so you are high risk. And you do have flabby chins. All warning signs of excess booze. If you go to your doctor about a minor medical problem, will you mind if he cross-examines you about your drinking habits? You won’t find that offensive, will you?

Hello Dawn. I have got news for you. It is not difficult to spot boozers. The question is, though, when we have spotted them, what are we supposed to do? You did not tell us that, did you? And Dawn, it is a tad impertinent to tell someone who has come about their athletes’ foot that they look like a lush and then offer some gratuitous advice. You see, Dawn, in real life it does not work like that. We are doctors, not top-down control freaks like you and the rest of New Labour. It’s a free world. It is not for me to lecture patients about alcohol. If someone wants help with alcohol related problems, I will provide it. And when I detect alcohol problems in patients who have not mentioned them, I gently give them the opportunity to talk about the problems. Sometimes they do, sometimes they don’t. I am not going to push harder than that. I’m not like you, Dawn.

And now to both Dawn and Eddie. Let us suppose that I have just identified hitherto undiagnosed alcohol problems in a patient. What do you want me to do next? I tell you what I can do. I can check out the physical side, measure the liver chemicals and so on and so forth. That is easy. And I can and do offer advice. Some take the advice. Some do not.

Let’s suppose the patient wants more help. The days of easy access to in patient de-tox have long gone. New Labour closed them all down. There is always good old AA. Better than most things the NHS has to offer, but too evangelical for some. There is a local NHS “alcohol group” run by some nurses. They will see the boozers provided they are sober. If they tip up drunk, they turf them out. “Not committed”. They always come back to me, and it annoys me that the NHS is not more interested. And yet, Dawn, even if you had given us more resources rather than taking them away, what else can we do? You cannot help a boozer until he is ready to accept help.

Dawn, did you know that most boozers have underlying psychiatric problems? Did you know that a lot of people with psychiatric problems take refuge in alcohol? Obviously not, as you have not provided satisfactory mental health resources for these people. Approach someone in the psychiatric services smelling of alcohol and they lose interest. They are too busy with people who will accept help. Why waste time on people who will not? Can you blame them?

I tell you what Dawn. Go down to the Accident and Emergency department at the local hospital in Crewe at 11.00 o’clock tonight, and tell the nursing staff that they need more training to enable them to identify people with alcohol problems. That should win you some more votes.

Abortion in the boonies

2008-05-19T17:59:00.005+01:00

My son, a long time guitarist, has recently taken up playing the banjo. What a fun instrument it is. It immediately reminds me of Deliverance, "Duelling Banjos" and the American boonies. Talking of the boonies, I see the great state of Oklahoma has just passed a new law requiring any girl requesting an abortion first to undergo an ultrasound examination, either abdominal or transvaginal. The decision as to whether it is transvaginal is the doctor’s, not the patient’s.

“For first-trimester abortions, the fetus is so small, you don’t get a good look unless you put in a vaginal probe. So, Oklahomans are forcing them to do that so the women can see the body parts better. You can have some 14 year old girl who got raped by her uncle Billy Bob, and she will still have to have that vaginal probe put up her an hour before the procedure. To me, it’s unconscionable. It’s all about shaming you". Dr Kathryn Brewer.

Abortion is still legal in Oklahoma, but a tranche of legislation has introduced endless rules designed to restrict access to abortion and also (deliberately or not) to humiliate women who choose to have an abortion.

So here's to the victims of incest and rape: we know you've been through a tough time, but we're going to need to stick one more unnecessary piece of medical equipment inside your vagina, and subject you to a humiliating procedure when all you want to do is move past the traumatic experience and get on with life. Oh! Oh look! See that fetus? Now, where did you want to schedule your abortion?
(Government has no place between my legs)

Meanwhile, in the intellectual boonies of British politics, the appalling Nadine Dorries seems to be using the Oklahoma legislation as a template for her mendacious campaign to restrict abortion. If her amendment to reduce the foetal age limit to 20 weeks is passed, she will not stop there. See her “Time to slow down abortion” campaign.

I would like to chain Nad to a cinema seat and make her watch endless films of terrified teenage girls dying in agony from perforated uteruses after botched backstreet abortions.

Despondent nurse practitioners

2008-05-19T15:59:00.003+01:00

The essence of postmodernism theme is that of an epochal shift, discontinuity, or rupture with modernity, bringing new social conditions and sociological principles with it. Postmodernism views that the authority and status of the medical professionals does not exist anymore in the area of health care consistent with the postmodern message about the deconstruction of traditional centers of postindustrial authority...

A Post Modern Society is a one where there is no one, single, universally agreed principle of knowledge or organisation. Postmodernism does not accept punishment as a transformative practice and is based on self reference. Patient's perceptions of health care, particularly disagreements of various kinds with doctors and nurses have caught the attention of every one since 1980s and these disagreements have turned often into legal complaints (Annandale et.al 1998). These disagreements turned legal complaints have evolved into long medical litigations and punishments. Strangely, the medical or nursing process is a series of steps that lead to a usual expected conclusion called 'the cure'. Whereas, the legal process of medical litigation is a conclusion called 'the negligence' for which a series of steps are formulated towards the conclusion

Rising litigations against nurses and the return of punitively orientated punishments (Pratt, 2000) have given rise to a doubt if key defining characteristics of western penal modernity have been replaced with a qualitatively different postmodern penality in medical litigations.

One should understand that there is a distinction between medical malpractice litigation and patient safety awareness, although they are interrelated. If is true that medical malpractice litigations threat makes a nurse more accountable. But, there are always situations in nursing practice which are beyond the control of human limitations. For example, the law always target individual nurses for their negligence. During the process of litigation, the circumstances surrounding the negligence are not probed into, especially the errors that arise of faulty systems in which proficient nurses work. Medical litigation threat diminishes interest of the nurse in patient safety/welfare activities, because they are offered no legal protection for the errors that may be an accidental outcome of the patient welfare activities.

A reader pointed me at this article from the American Society of Registered Nurses. Documents like this always appear when nurse practitioners are around - which may explain why so many doctors are despondent. I tried hard to understand it but failed.

A challenge. Can anyone translate the full document into English?

What is wrong with the Prime Minister?

2008-05-18T16:25:00.006+01:00

Teenage train-spotter

There is much medical gossip at the moment as to the correct diagnosis of Gordon Brown's problem. Yes, it has got that bad. Some have suggested an autism spectrum disorder and much consideration has been given to the possibility of Asperger's Syndrome. Well, he would be in good company:

Sir Keith Joseph, the father of Thatcherism whose free market principles are still followed to some extent by Tony Blair, had a form of autism that is reflected in his political philosophy, a psychiatrist believes. The former Conservative education secretary, who was Mrs Thatcher's mentor in the 1970s and 1980s, had Asperger's syndrome, a condition that renders sufferers unable to interpret social situations or to empathise with other people, according to Michael Fitzgerald, professor of child and adolescent psychiatry at Trinity College Dublin. (The Independent)

My ageing Greek friend takes a more simplistic approach. Maybe Gordon Brown has just lost the plot. Maybe he has had too much exposure to aluminium frying pans. Look carefully at what Gordon Brown said yesterday:

The Prime Minister, in a speech yesterday in Edinburgh to the general assembly of the Church of Scotland, billed as a strong reaffirmation of his personal and political vision, said the Government had to work harder to create a fairer society.

"If anyone had said 50 years ago that the people of our world would achieve black civil rights, tear down the Berlin Wall, end apartheid, no one would have believed it." (Daily Telegraph)

Truer than you may think, Prime Minister. Can you spot the "deliberate" mistake? Answer here for those who cannot.

Edward Kennedy : seizures

2008-05-18T10:48:00.009+01:00

Ischaemic stroke

Over breakfast this morning, my youngest son asked, “What exactly is a ‘seizure’”? I had to admit that I don’t really know. It is not a word that has much diagnostic precision. It probably joins “being on the danger list” (I always loved that one) and “having a nervous breakdown” (I still don’t know what that means) as yet another expression that is loved by the media, misunderstood by the people and not used by doctors.

It seems from my paper that Edward Kennedy has just had a “seizure”. Always fascinating to watch the way that the media deals with illness that affects the great and the good or, in this case, the American Royal Family. Hushed tones of reverence. Lots of understatements. Edward Kennedy has probably had a stroke. He has a previous medical history of having had a carotid endarterectomy (reaming out a carotid artery clogged up with cholesterol) and so a stroke would not be too surprising.

To give a thumb nail sketch of strokes (I refuse to follow the modern absurd and illogical fashion of referring to them in the singular), they are either caused by a bleed from a broken blood vessel or from a blood clot wedging in and blocking off a blood vessel. You don’t want either, but if you get the choice, go for the blood clot. Things can be done about blood clots; there are defined and occasionally treatable causes (such as an erratic heart beat, or semi-occluded carotid arteries) and good preventative treatment (blood thinners). A bleed is more worrying. Sometimes the bleeding continues and there is no easy way to stop it. There are not the same treatment options for bleeds.

Strokes are commoner in heavy drinkers and Ted Kennedy has reputedly been a toper of Churchillian stature. He will currently be receiving the best that medical science has to offer. It was always so for the great and the good. They live in a different world. Who knows what really happened at Chappaquiddick but an ordinary member of the public would likely have faced more serious charges than “leaving the scene of the accident”.

As a family doctor working on a far distant planet to the one upon which the Kennedy family lives, I cannot but think about the difficultly I have in getting urgent medical treatment for elderly patients who present to me with so called “minor” strokes. Forget the air-ambulance to a centre of excellence. I will settle for a same day CT scan.

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Edward Kennedy's office are now denying reports that he has had a stroke (CVA). They are back to talking about "seizures" by which they mean what we would call fits, though one fit alone is not enough to make a firm diagnosis of epilepsy. There are numerous causes of fits occurring for the first time in a man of his age (including strokes, tumours, alcohol, particularly acute alcohol withdrawal, metabolic abnormalities, trauma... the list is long) and so he will need detailed investigation.

On the other hand, the Sydney Morning Herald reports:

Senator Kennedy suffered what appeared to be "stroke-like symptoms," a Democratic Party aide said. He experienced one seizure in Cape Cod and another while on a helicopter to Boston, The Boston Globe reported.

Strokes, or CVAs, can cause fits and a prolonged fit could cause "stroke-like symptoms". We shall have to await further information.

Spooks, MI5, Michael Bettany & Max Molsey

2008-05-18T09:27:00.003+01:00

Spooks

Michael Bettany was a counter-intelligence officer working for MI5 who started passing information over to the Soviet Union. Dr Crippen, Wat Tyler and Michael Bettany have one thing in common. We were all at the same Oxford College. When Bettany was recruited by MI5 he will have been positively vetted at great expense to the taxpayer. A lot of money could have been saved if MI5 had just taken Wat and me out for a pint. Poor old Bettany was bonkers (I use the word as a laymen, not as a psychiatrist). He used to march around the College quads in army fatigues. Had it been suggested to us that HMG was considering taking him on as the new James Bond, we would have been able to put them right, once we had stopped laughing. By all accounts even the Russians found him an embarrassment and did not offer him permanent employment. Poor old Michael.

It did not give one much confidence in MI5 then, and it seems that not much has changed. Now we learn that an MI5 “surveillance agent” has had to resign because his wife is a prostitute who was involved in Max Mosley’s sexual shenanigans. I know, I know, when you go for a job interview, you do not expect to be asked what your wife or husband does. But I would have thought there might be different standards for spooks. Obviously not.

I wish Max Mosley would go away. I really do not mind what he does in his spare time, but motor racing gets precious little sensible media coverage and now all we Formula 1 anoraks are getting is endless tiresome smut about Max. We want to know about Lewis Hamilton.

Cheap laugh

2008-05-18T00:23:00.007+01:00

Why do people keep doing this? Iain is a kind guy but does not understand. Emma would have been cross.

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visit Pizzimentiart here and he is a doctor, so he should know

King's College Medical School dumbs down

2008-05-16T13:55:00.009+01:00

King's College Medical School, London

The Times has today picked up on the BMJ report from King’s College, London on “Widening participation in medicine” or, to give it its correct name, the “Extended Medical Degree Programme” (EMDP)

(EMDP) aimed to attract bright students from state schools in inner London who had A-level results that were far too poor to gain entry to medical school and show that, with the right help, they could succeed. Students would normally require two As and a B at A level, but the scheme, called the Extended Medical Degree Programme, accepted those who had managed no better than three Cs. (The Times)

This is a warm, cuddly Shawshank Redemption sort of story. Select a small number of students from sink comprehensives, measure their IQs and, if they are high enough, let them into medical school and follow them through. Early outcome analysis shows that most of them do well. Have a cup of cocoa and listen to this:

If only life were like that. Let us look at the reality of the EMDP programme:

The selected students have an extra year at medical school and they are hot-housed. They have regular additional tutorials compared to “ordinary” students. Currently, the programme is supported by two full time academics; one part time administrator; four part time academics and 15 postgraduates and academics who provide about 130 small group tutorials per year. A conservative estimate for the total cost for this is £190,000.

…many of the students who are from lower professional and managerial groups have a Black African heritage and from families headed by women….Many of the students classified as being from semiroutine and routine backgrounds are from South African families. (BMJ)

Two days ago we looked at Cambridge Univeristy dumbing down its entrance requirements. Now the medical schools are at it. At least Cambridge has done it fairly, by doing it across the board. That cannot be said for this initiative. This initiative is positive discrimination with distinctly racist undertones. It stinks. It depended on trawling through a predefined list of inner London sink comprehensives and selecting “suitable” students. It was not open to all schools or to all students. It was not a "double blind trial" and probably only succeeded because a huge amount of time and money was spent on hot-housing the selected students. It is not something upon which you can generalise.

Robert is a patient of mine. He is 19 now. He failed to get into medical school last year. He does not belong to any modern “right-on” minority. He is white and heterosexual. He does not have dyslexia, tracking disorders or ADHD. He probably puts C of E on forms that ask about religion. He is the only child of a single parent family. His father was killed in an RTA when he was a toddler. Robert went to one of the local comprehensives. It is not a sink comprehensive but it is not good. They rarely get anyone into Oxbridge. They supported Robert as best they could. He got 4 A*s, 5 As and a B at GCSE. He went on to do Maths, Physics, Chemistry and Biology for AS level and got 3 As and a B. He was offered 2 As and a B to get into medical school (probably a slightly lower offer than he would have got had he been at a private school). He got an A and 2 Bs. By his own admission, he “cocked up” the maths paper. So Robert is not going to medical school.

How would Robert view EDMP? I will ask him the next time I see him. How would Hillary Clinton view it, and why does she get so many blue collar votes? Listen again to Barack Obama’s towards “A more perfect union” speech.

…the scheme is politically correct, but costly. The extra cost is £190,000 a year. Professor Chris McManus, of University College London, and Hugh Ip, of the journal, question whether this is justified. The scheme involves sacrificing equality of opportunity for the quest for social justice, they say.
“Is it worth our while to widen participation, particularly if this risks reducing standards?” they ask. “Political ideology says yes, but the evidence is pending and the costs are rising fast.” (BMJ editorial)

You cannot legislate to impose equality of outcome. You cannot achieve equality of outcome by crude social engineering. Equality of outcome is an egalitarian fanatasy. But you can work towards equality of opportunity. It is a searing indictment of the state education system that more and more universities are finding ways (with a New Labour fiscal dagger at their throats) to let poorly educated teenagers from sink comprehensives through their doors. Of course some of the children at these schools are getting a raw deal. Of course children from first generation immigrant families find it more difficult to cope in the education system. But you do not solve the problem by dumbing down university entrance requirements.

You solve it by improving the schools.

Politicians who take drugs

2008-05-15T14:28:00.004+01:00

Iain Dale dips a toe in shark infested water today when he unearths an excruciating interview with the Home Secretary, Jacqui Smith, in which she is slowly spit roasted by a member of the public about her admission of having smoked cannabis a number of times as a student. Iain's headline is "Jacqui Smith admits she should not be home secretary". She does nothing of the sort.

Like most family doctors, I frequently see young people who are dabbling in drugs, a small number who are serious users. Those who are politically aware are amused that half the Labour Cabinet admits to having indulged. As teenagers, as students, we are all on a learning curve, and we all have skeletons in the cupboard. I am comfortable with Jacqui Smith's behaviour. I know she is human and honest. I am less impressed with David Cameron's prevarication on both cannabis and cocaine. I know he is human.

Cherie Blair and the Balmoral Bonk

2008-05-15T14:10:00.006+01:00

Balmoral

I have been having a quick glance at Cherie Blair’s memoirs in The Times. They are so extraordinarily badly written that it is hard to believe that the author is a highly experienced lawyer. They are also profoundly distasteful.

Too much information about the contents of her “distinctly ancient toilet bag”. I am not interested in her religious beliefs though I do not suppose that her frank admission about contraception will be going down well in the Vatican; still, a couple of Hail Marys after the next confession will sort that out.

But what about poor old Leo? Children are affected by these things. Poor lad, the accidental fruit of the infamous Balmoral Bonk. He will be subjected to sustained ridicule at school, all because of his mother’s avaricious vulgarity. As regards Leo’s MMR, I support the right of any politician not to expose their children to the public gaze, but it would have been a good and positive photo opportunity had Cherie chosen to go public about it when it was done. She chose not to, as is her right. Now she has gone public about it to help flog her tawdry memoirs. “Greater love hath no man….”

What a dreadful woman she is.

The surgeon as rapist

2008-05-14T23:10:00.005+01:00

Abdominal rape

Entirely co-incidentally, an eerie juxtaposition from the recently discovered and wonderful Musings of a Dinosaur. Meanwhile, a few posts down, the argument about medical rape continues. But what would Amity and Debs make of Surgery and Rape? On their definition, this surgeon is a rapist.