Bronchiolitis season = silly season

Dr Daedalus saw a child in hospital recently with quite severe bronchiolitis - she hadn't been eating for about a day and a half, sounded and looked terrible, and a chest X-ray showed she had one entire lung full of muck. So far, so easy - secondary bacterial infection on top of bronchiolitis. Treatment - iv antibiotics.

So we told mum this was what we needed to do - this mother who'd obviously noticed her child was sick, struggling for breath, and getting dehydrated, and had been worried enough to bring her to A&E. Her response? She wanted to talk to her homeopath instead.

Difficult situation, in that you don't want to terrify the parents but at the same time you can't let the child go home to take water - so you mention the severity of the illness, the possibility of lasting damage if it's not treated, and the fact that children do die from this sort of infection.

Outcome? We treated her with high-dose broad-spectrum antibiotics, and she got better.

I was reminded of the Australian homeopaths convicted of manslaughter for their (admittedly much more chronic) neglect of working treatments for their daughter in favour of the woo of homeopathy.

And of Andrew Lansley's comments on his healthcare reform:
"It is time to put patients in charge of their own healthcare. While that may lead initially to some catastrophic misdiagnoses and thousands of easily preventable deaths, it is surely better than some top down, centralised bureaucracy where ordinary patients are constantly told what to do by qualified medical professionals who see them as nothing more than a human being that is displaying a set of symptoms of which they have a high degree of expert knowledge."

When do these things become child protection issues? If you honestly believe the child is at risk of imminent death if they go home untreated, do you treat against the parents' wishes? If so, do you get sued afterwards?

I know what I'd do. But it's a tough call, all the same.

Laboratory jobsworths

Reading the superlative Jobbing Doctor's recent experience with a private contractor who refused to do the job they are being paid to reminded me of a current bête noire of mine at work: the labs.

I mean, all they have to do is take the bottles of blood I send them and put them into a machine, right? In exchange for this, they can make me do whatever they want. I'm obliged to include something like seventeen different patient identifiers on bottles for cross-match, for instance, and given that I'm working with newborn babies at the moment the bottles are about the diameter of a biro, and not nearly as long. In addition, they're frequently covered in blood, and to cap it all off the affluent population of the area I'm working in love double-barreled names.

I do understand the need to avoid putting results on the system under the wrong name, incidentally - but we have to include little sticky-labels in the "BIOHAZARD" plastic bags the bottles go in which have all this information on. Again.

All this microscopic calligraphy would be fine if the labs actually ran the samples - but no. One bottle I sent off recently came back - on the computer - with the comment "patient details illegible. Please ask the patient to state their name and date of birth." My immediate reaction, bizarrely, was to think:

But how would that help you read it?

followed closely by:

Can you still run the sample in two or three years when the baby has learned to speak?

The weird and wonderful world of baby checks

My recent inactivity is largely due to being insanely busy at work. On the upside, I regularly do baby checks, which for some reason get a bad rep among many doctors I work with. Several of the paediatrics trainees I work with currently find them boring and repetitive - which I can understand, as you do end up battling with dozens of intractable newborns every day to get them to (a) open their eyes and (b) not urinate on you.

There are lots of fun bits, though - the parents are normally in that fug of post-delivery hormones/relief and enjoy having baby MOTed. Some of them, though, do come out with some really extraordinary things.

One part of the check, for instance, involves putting a finger into baby's mouth to check the palate feels intact, and to assess baby's suck. Generally they are unsurprisingly good at this as it's how they feed, and I normally say something like "the palate feels fine and he/she's got a good strong suck". This often prompts mum to wince and say "I know". On one memorable occasion, however, dad piped up instead:

"Just like mummy!"

...and then sniggered. Mum took a playful swing at him and, feeling it best not to probe, I carried on with the examination.

This was noticeably better than the parents who were worried about baby jerking his arms in his sleep. They described a completely normal twitching of the arms during sleep which baby then proceeded to demonstrate to me, so I told them it was nothing to worry about.

Dad: "Can I tie his hands together to stop him doing it?"
Me: "Well, you can certainly swaddle him and keep his arms in that way, yes."
Dad: "And can I tie his hands together?"
Me: "No. No - don't tie his hands together. Just let him wave his arms around a bit. It won't hurt him."

I refrained from going on: "whereas your tying his hands together will", but am now slightly concerned this was a mistake.

Choose and re-refer

Today I received a letter in the surgery post from our local hospital, telling me that we'd asked for a choose and book referral for Mrs. Jones (I know), but that unfortunately at the time there were no appointments available and so her details had been forwarded to the "Central Booking Service" at the hospital. It went on to explain that:

"When we receive a patient's details in this manner, we are unable to access their referral on the Choose and Book software, this is a national issue, rather than a [local hospital] one. We subsequently requested, on three occasions, for your practice to fax us a copy of your patient's referral letter but we had no success."

They had therefore discharged the patient, because without the referral (which we sent through Choose and Book and they couldn't access) they couldn't make an appointment.

I checked the system. We had never had a request from them for the original referral letter. So we had sent them a referral they knew they had but couldn't see, and they had made three requests of us which we didn't have and couldn't see.

I called the hospital. Much confusion: she had an outpatient appointment booked, despite the letter saying exactly the opposite. The reason I couldn't find their requests for faxes is that "normally we telephone with them".

I know our reception very well indeed, and they invariably answer phones quickly and pass on messages efficiently. With this sort of thing they wouldn't even do that - the referral would just have been reprinted and refaxed.

All a bit suspicious - although at least my patient has an appointment. Despite the system.

Rules for seeing your General Practitioner

Just a few guidelines.

(1) Courtesy
(1a) You are well advised to be polite to the reception staff. This is chiefly because they run the place, but also because they invariably tell me if you've been rude to them, and you will get short shrift from the doctors if you then come in and are all deferential sweetness and light to us.
(1b) Despite (1a), I am a polite person. Honestly I am. But if you've just spent six minutes telling me about your diarrhoea and vomiting, and then watched me carefully wash my hands after prodding your belly, don't offer me your hand to shake on your way out.

(2) Children
(2a) For some reason, every child that enters my office tries - and succeeds - to dismantle the scales. They unscrew the lid, and then try to pull the needle off which tells me how much they weigh. I don't like to ask you to rein them in, but they
(2a) Amoxicillin is not the answer.

(3) Sick notes
(3a) Do not ask for a reissue of a sick note you've lost. If you are sick enough to need one, you are sick enough to look after it properly.
(3b) Do not ask for a backdated sick note. If you were sick enough to have needed one three months ago last thursday, you were sick enough to have mentioned it at the time -and if you haven't been working for the intervening period, you've had plenty of time on your hands to come in and see the doctor.
(3c) Do not ask for a sick note if you are also claiming carer's allowance. You cannot simultaneously be so unwell that you can't work, and well enough to claim an allowance for looking after someone full-time.
(3d) You will not get a sick note "because I've always had them". I am interested in how you are right now, not in how you were seven years ago when you had your car crash / breakdown / stabbing / overdose.
(3e) I appreciate that your having not attended court / gone to a job interview / made it to your wedding / attended the birth of your child is inconvenient. It does not, however, mean I'm obliged to write you a sick note to "cover it" if I don't think you were so unwell that you couldn't make it.

(4) Hay fever: if you haven't tried an established hay fever medication, you will be trying that before I give you an identical one the drug companies have churned out to keep the patent alive (see also: gaviscon advance). There is nothing 'neo' about neoclarityn, and desloratadine is the same as loratadine. Yes, I know there are some people who respond to one but not the other - I blame regression to the mean.

(5) Contraception: yasmin is really expensive. If you haven't tried older pills we know more about, you will be. Please don't try to bully me into giving you it by saying you won't take another pill if I give it to you - if you want to get pregnant because you'd rather throw a hissy fit about your pill than try another one, that's entirely your choice, and similarly a convenient recollection of every pill side-effect you can remember from the packet just makes me think you're not telling the truth.

More to follow. Maybe.

Elitism in politics

Doctors' leaders have today called upon the three main political parties to draw up plans outlining how they will make their profession less elitist. Medicine has a proud tradition of training ethnic minorities dating back decades, whereas until the 1980s there was not a single black, Asian, nor openly gay MP in parliament, and so few women that the advent of all-women shortlists was necessary. About a third of all politicians were educated privately (7% of the population are educated there), with almost half of the Conservatives' ranks hailing from fee-paying schools (not all, however, went to Eton, although in 1966 when 81% went to private school a lot probably did). The BMA have therefore announced that they feel MPs would be well-served by taking as an example the medical schools around the country which are working to improve the representation of the communities they serve among the doctors they train.

Not really, alas. In a display of rank hypocrisy which is up there with the worst of them, unnamed "ministers" have told doctors, lawyers, and accountants they have to draw up plans for making their professions less elitist. That's doctors et al have to make their own professions less elitist - not MPs'.

Alan Milburn appears to be the architect of this nonsense, and although his own credentials fit the bill (raised by a single mother, working-class background), his eagerness to sell the healthcare system out from under the feet of the public by taking 30k a year from private healthcare firms makes one rather question his judgement. Do any of these firms provide private medical education, one wonders?

The best thing about this pitiful pre-election vote-grab? The BMA raised this issue in 2004, urging MPs to back an early day motion to the effect that medicine should not be an elitist profession. Six years later, Alan and the largely privately-schooled oafs in Westminster have adjusted the plank on one eye, noticed that several medical schools (notably King's College London) have already begun transforming their admissions policies, and have told doctors' leaders that doctors need to come from a wider range of social backgrounds.

We know. We told you so six years ago. Back to your port, cigars, extraordinarily long holidays, and your lucrative taking of the shill from the private sector.

Drunks, psychos, and drunk psychos

I have been working nights recently, which is a joy; the old adage that half are fine and half are drunks or psychos is not that much of an exaggeration. There is of course relatively little to be done about this - the recent journalistic throwing-up-of-hands about it, while entirely correct, will not result in any action. That story from 2010 was written in similar form six years ago. Comparing the two plucked-from-air numbers suggests that alcohol is costing the health service an extra billion quid a year. Without digging through the numbers, my guess is rather than reflecting there being more boozers or their somehow contriving to piss on the floor in A&E in a more expensive way, the percentage cost they amount to is similar, and the burgeoning admin, management, and "consulting" fees spent on the NHS inflate the figure artificially.

Anyway, last night one of my patients was both drunk and psycho (NB: not a technical term), but was perfectly pleasant and to his credit made an honest if unsuccessful attempt not to urinate on the floor. In the end he got admitted to an observation ward overnight to sober up, and that necessitated handing him over to the morning team. I ran through the history, and mentioned that he had a mental illness "with some inappropriate behaviour - for instance, he commented on how handsome I was, and asked if I had a boyfriend - but he wasn't acutely psychotic."

Whip-smart, one of the day team piped up, "Well - I don't know...". I was smiling about it all the way home.