A Family Doctor’s Casebook (part 1)

General practice partnerships are like marriage without the sex, muses Geoff as he installs himself at his consulting room desk.  He knows that kind of marriage. Shoving aside the piles of letters that need answering, he begins tending to the sick of North London.

Geoff is a GP from my novels One Night at the Jacaranda and Hampstead Fever.  Despite his problems and hang-ups, he’s everyone’s favourite. Geoff is a firm believer in the NHS, but the changes he’s seen in the 15 years since he qualified frustrate him immensely.

1 The first patient is a three-month old baby with the Lexus of pushchairs and a Yummy Mummy who reminds Geoff of his ex-wife.  She begins by complaining about the 20-minute wait, and the perennial parking problems within a mile of the health centre. All this is extremely inconvenient as she’ll now be late for her Pilates.

Geoff asks what he can do for her.

“It’s Alistair’s head,” she throws down like a gauntlet.

She’s right in thinking her baby’s skull is a tad asymmetrical. Plagiocephaly is common now that babies all sleep on their backs.  Geoff reassures her that it’ll right itself in time, once Alistair lifts his head and becomes more mobile.

FreeImages.com/Johan Graterol POSED BY MODEL

Yummy Mummy is sceptical. “Doesn’t he need one of those special helmets?”

Geoff explains that there’s no evidence they help.

The mother seems unconvinced. She’ll probably go and splash out thousands of pounds on a contraption that will only cause discomfort and inconvenient. Still, she’s now ready to move on to the next symptom. The practice has a new policy of one symptom per consultation, which Geoff routinely ignores. It’s demeaning to patients and wastes everyone’s time in the end.

The rash on Alistair’s buttocks looks like a common yeast infection which should soon respond to the cream Geoff recommends. This pleases the mother, until Geoff asks her not to leave Alistair’s dirty nappy in his consulting room bin.

“I don’t want to stink out the car,” says Yummy Mummy.

Geoff eventually persuades her to take the offending object away, even though he thinks she’s likely to dump it in the waiting room on her way out.

2 Next it’s Mr Legg in his nineties, with an aching left knee. Sometimes it’s his right knee, and sometimes it’s both, which is no wonder since both legs are badly deformed by arthritis. He attends the health centre every couple of weeks, yet refuses hospital treatment. As he puts it, “I don’t want to be a bother. There’s plenty of younger folks who need it more.” Mr Legg adds that he doubts it’s arthritis anyway.  “It’s probably just down to the shrapnel what got me during the war.”

Geoff asks where the shrapnel got him.

“In a little village near Germany, Doctor.”

doctor's bag

3 It’s a relief to see that young Mohammed’s eczema is improving. For a long while, his mother believed that a mild steroid was totally unsuitable for a three-year old, but the cream, along with emollients, has made a huge difference. Mohammed sleeps well now that he doesn’t scratch himself to ribbons. All in all, he’s a happy chappy, apart from a streaming cold that’s not a problem until he flings himself at Geoff and plonks a kiss on his cheek.

Geoff usually washes his hands between consultations. Today he washes his face as well.

FreeImages.com/Toni Mihailov

 

4 Now a young man sits before him. Unemployed, with a squat nose and tats up one arm. “Pain in me bollocks,” he says.

Might be a torsion. Uncommon in adults, Geoff knows, but, unless treated promptly, it can lead to gangrene of the testicle.

“Right. I need to take a look,” Geoff says, pulling the paper curtains across.

As he waits for the fellow to undress, he wipes the photo on his desk with a tissue. It’s Davey, aged four, at the beach in Norfolk. Happy days before the divorce.

“Ready yet?” Geoff calls out, increasingly aware of how late his clinic is running.

“Yeah. Course.”

Turns out the man is sitting fully clothed the other side of the drapes.

Patiently, Geoff explains what he needs to examine. Another three minutes pass while the man undresses.

On examination there’s nothing abnormal about the patient’s tackle, apart from the stink. Geoff peels off his gloves and flings them in the bin. “Hmm. All’s well there. When did you first get the pain?”

The man shrugs. “Maybe a week ago. But I ain’t got it no more, like. Not since I pulled that bird the other day.”

“Fair enough,” says Geoff, even though there’s nothing fair about it. The ugly, unemployed fucker gets laid just like that, while he, Geoff, has been celibate for ten months and counting.

***

Coming up soon, Geoff deals with a very personal problem. Meanwhile you may enjoy one of these posts:

How to Alienate Your Doctor in Ten Easy Steps

What Your Doctor is Really Saying

or, on a more serious note, an overview of sepsis in The Disease Nobody Knows About Until It’s Too Late.

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Four Hours in the Eye Surgery Day Unit

On looking back, the signs had been there for years. First, Nadia had trouble at night from the glare. Then reading got harder, especially the day she picked up an Egyptian newspaper in Paddington. Arabic, with its tiny script and its proliferation of vital dots above and below the letters, is the least appropriate language for someone with poor vision.

She wonders why she’d got cataracts by the age of 55. Probably to do with a stupid game they used to play at the beach in Alexandria.  She, Zeinab, Chou-Chou, and of course her sister Simone all dared one another to look straight into the sun for as long as they could. Nadia still has the memory of the after-burn. How was she to know, until Simone told her, that her school friends all cheated by shutting their eyes when she wasn’t looking at them?

“The Nile has cataracts too,” says Chou-Chou. She is still stupid despite being middle-aged now.

“They’re not the same thing,” Nadia replies loftily, even though she is unsure of the difference.

Nobody gets a bed on this day surgery unit. They get an armchair, but only if there’s one free at the appointed time. There isn’t. Along with three other patients, Nadia sits in the corridor. Waiting in corridors is normal in the NHS. It was never like this in Egypt, if you could afford bakshish.

An Iranian nurse and two Irish nurses seem to run the place. Each of them asks Nadia if she is diabetic.

“I’m not diabetic.”

In a nearby office, a doctor sits with the door open. Nadia can hear her complain about the computer system. Doctors always do this.

Once Nadia is installed in her allocated chair, an Irish nurse comes in to put drops into her left eye. “Are you diabetic?”

“No.”

After two lots of eye drops, her vision is so blurred that she can no longer decipher the stream of bile about immigrants, shameless young people, and disgraced celebrities in the newspaper someone discarded.

A young doctor comes to explain the op, reeling off a long list of potential complications. “There’s a one in 1,000 chance of losing all the sight in that eye.”

Nadia recalls a handsome man at Montazah who wore tiny briefs and an eyepatch. He liked to say he’d lost an eye in a duel, though, as her sister told her later, it was really a cataract operation gone wrong. She signs the consent form, sure that things have moved on and that it won’t happen to her.

The surgery is under local while her surgeon hums snatches of an aria and asks about her family.

“There’s nobody left.” Still, Nadia cradles the hope that improved vision will help her find her lost sister.

Everything is bright with a watery blue light. A machine buzzes, and the lens fragments are washed out before a new lens is put into place. She feels nothing.

Soon he says, “All done,” and peels the plastic drape off.

“You can sit up now,” says someone else.

So many voices she doesn’t know, and her head swims when she sits up.

Once back on the ward, a nurse offers her tea and asks again if she is diabetic.

Nadia checks in the mirror that she always keeps in her handbag. There she is, a plastic shield over one eye, with two long strips of tape holding it down.

The nurse returns with tea and instructions: eye drops for the next four weeks, eye shield on at night for a week, sunglasses for a few days, and no hair-washing for five days.

Of course Nadia will wear sunglasses! If her hair is going to be filthy, she doesn’t want anyone recognizing her.

The next day, she removes the eye shield for the first time. Everything is so bright. She can see every leaf on the trees, every speck of dust on the windowsill, every wrinkle on her face. They don’t make mirrors like they used to, that’s for sure.

***

Nadia is a character from my next novel, which is set in Alexandria and London.

If you’d like to know more about cataracts, try this link from Moorfields Eye Hospital.

You may also enjoy Six Lessons from the Eye Clinic.

The 12 Allergies of Christmas

Think you’ve got enough to worry about in the run-up to Christmas? Spare a thought for people with allergies, for whom the festive season is fraught with danger. But, with a little consideration, you could prevent an allergic reaction, and even a trip to Accident & Emergency.

1 Real Christmas trees can contain moulds, a health hazard for those allergic to them, while the sap can trigger skin reactions. The mould content is highest when the tree is cut some time in advance and kept in a moist atmosphere. After buying the tree, it helps to store it in a dry place like a garage, and then shake it before bringing it indoors. Note that, once the tree is inside, mould spores can grow within two weeks. For those with symptoms, fake trees may be the answer.

2 Mistletoe allergy is uncommon, though it can cause skin reactions in some people. The main danger comes from the kiss. Proteins can linger in saliva for several hours, so a snog can deliver a sizeable dose of nuts or whatever else the person last ate. Those with food allergies may find their luck running out, just when they thought it had come in.

FreeImages.com/Stephanie Berhaeuser

3 Problems with latex are on the rise. About 4% of the general population is allergic to latex (the natural type from rubber), while nearly 10% of healthcare workers are. The incidence is growing because gloves are more often used for procedures which were done with bare hands in the bad old days. What has this to do with Christmas? Balloons and most condoms contain latex, and both may feature at the seasonal office party. 

4 Alcoholic drinks can lead to allergic reactions. There are often nuts in speciality beers, and there’s obviously dairy in Irish cream liqueurs. There’s even almond oil in Bombay Sapphire gin, as the Anaphylaxis Campaign reminded me. Besides, alcohol can lower your guard and make you blasé about risk.  And large amounts of alcohol tend to worsen allergic reactions.  

5 Presents that smell nice, like bath oil, soaps, hand creams, and reed diffusers, may contain almond oil or other essential oils. These cause no trouble for most people, but they can trigger nasty reactions in those with allergies to the ingredients.

6 Festive candles are, again, mostly harmless, unless you’re careless enough to start a fire. But, for those with allergies, the soya present in some posh candles can be an issue. Candles may also contain pine, a potential problem for anyone allergic to pine resin.

7 The poinsettia plant is related to euphorbia (spurge). It’s not often an allergen, but it can be, especially for those with latex allergy. Symptoms include rash, wheezing, and shortness of breath. It’s wise not to have a poinsettia if you’re latex allergic.

FreeImages.com/D Fleiderer

8 Chocolate can contain dried fruits and nuts (which you may not spot if it’s in the form of a paste). It usually also contains soya lecithin. If you have a food allergy, check the label before indulging – if, that is, the label is anywhere to be seen. This can be a problem when chocolate treats are unwrapped and passed around on a plate at Christmas.

9 Sulphites are food preservatives commonly used in sausages, as well as in many pickled foods, dressings, and soft drinks. Some people react to sulphites with asthma symptoms or an urticarial rash. In most cases, the reaction is a sensitivity rather than an allergy.  But occasionally there is a true allergy, with a severe reaction called anaphylaxis.

10 Fancy turkey stuffing can contain a multitude of allergens, including pecans and hazelnuts. One of the most widespread ingredients is celery. Although allergy to celery seems fairly rare in the UK, when it does occur, the reaction can be severe and may lead to anaphylactic shock.- see more about anaphylaxis.

11 The traditional Christmas pudding is full of nuts, an obvious problem to those with an allergy to them. But it is possible to source tasty nut-free versions in most large shops.

12 Christmas cake, as a rule, contains nuts. It’s easy enough to study the ingredients when out shopping and choose a product that doesn’t contain a particular nut or fruit (though it’s impossible to do without almonds if you want stollen or any other cake with a marzipan layer).  If you have a nut allergy, visiting friends and family can still be risky, though. It’s not always enough to avoid a food that’s a trigger. There may be cross-contamination, which can be critical with severe allergy.

This list of Yuletide allergies is obviously far from inclusive, so please take care and have a happy, healthy Christmas.

I’ll be back in the New Year. Meanwhile, for more information about allergies, including anaphylaxis, visit the Anaphylaxis Campaign.

You may also enjoy The dreaded Christmas newsletter.

CPR: Why You Should Jump on a Stranger’s Chest

We’ve all seen spectacular examples of CPR (cardio-pulmonary resuscitation), especially on TV, where it leads to equally spectacular results: the previously pulseless patient sits up and tucks into pizza while vowing undying love for his family.

CPR ventilating with bag

In real life, the story is different. Outside Casualty, Grey’s Anatomy, and other small screen dramas, CPR is far less successful. Cardiac arrest in hospital has a survival rate of around 35%. Out in the big wide world, survival is more like 8%. This UK figure is especially dismal when compared with other western countries.

I learned all this and more at a CPR refresher course this week, courtesy of the Hospital of St John and St Elizabeth in North London. Tutor Philip Howarth is a brilliant mimic as well as a gifted teacher, and he was assisted by his fellow resuscitation officer Christilene Kiewiets. I can’t actually think of a more worthwhile way to spend a rainy Wednesday afternoon.

CPR manequin

We went through various scenarios of increasing complexity, but the principles are simple and they’re things everyone should know.

In a cardiac arrest, the heart stops pumping. This deprives the body of vital oxygen.

After five minutes without treatment, this damages the most important organ in the body (that’s the brain, in case you wondered).

CPR buys time. After a cardiac arrest, it can keep life going for up to 20 minutes (possibly even longer). That means time for paramedics to get there.

But CPR needs to start as soon as possible, ideally within two minutes.

Classic CPR uses chest compression and rescue breaths (in a ratio of 30:2 for adults). But hands-only CPR is a useful alternative. (Chest compressions make the lungs move, so they deliver some ‘breaths’. And people are more likely to give CPR to strangers if they can avoid mouth-to-mouth.)

Chest compressions should be fast and deep. A rate of 100-120 compressions a minute (two per second) is better than the old advice to keep time with the BeeGees’ Stayin’ Alive. ‘Deep’ usually means to a third of the depth of the chest. It’s tiring, and it can be noisy. The sound of ribs cracking is par for the course.

AED

Defibrillators can make all the difference to the outcome. In the UK there’s an increasing number of public-access defibrillators in airports, stations, and the like. The best bit is that these automated defibrillators are very easy to use, with voice prompts that are simpler and far more reliable than sat nav.

The most important thing of all?

Have a go. If someone has a cardiac arrest and you stand idly by, that person is dead. So there’s nothing to lose.

If you’re wondering about the best place to cash in your chips, a Las Vegas casino is probably the safest location of all in which to suffer an out-of-hospital cardiac arrest. Security guards trained in CPR and the prompt use of defibrillators can achieve impressive results.

FreeImages.com/Bob Townsend

Photo credit Bob Townsend

***

The free app Lifesaver is a live-action movie you play like a game. It’s a great way to learn how to save someone’s life.

The British Heart Foundation runs HeartStart training courses around the UK.

First aid courses for the public offered by other charities such as the British Red Cross also include CPR.

Some ambulance instructors also teach the public. Get in touch with the Community Defibrillator Officer or the ambulance training school nearest you for more details.

The latest Resuscitation Council UK guidelines can be found here.

Here’s an easy tweet:

CPR: Why You Should Jump on a Stranger’s Chest http://wp.me/p3uiuG-1qC via @DrCarolCooper #CPR #cardiacarrest 

What Your Doctor is Really Saying

Confused when you see the doctor? It’s no great surprise. Medics are famed for their jargon. But, even when they remember to use simple English instead of medicalese, they come out with euphemisms and other phrases that conceal what they really have in mind.

FreeImages.com/Carlos Paes

I know, because I do it too. Now, with the benefit of years of experience, I can help you decode what your doctor really means.

What the doctor says

What the doctor really means

I see you’ve brought a list. Splendid! Now we’ll be here all day.
Any thoughts yourself as to what it might be? OK, what did you find on Google?
As it happens, my colleague has a special interest in your problem. I’m all out of ideas.
It’s a classic example of Tsutsugamushi Fever. Never seen a case of it, but doesn’t it sound grand?
You’ve got a case of pendulum plumbi. You’re swinging the lead.
I think I should examine those feet of yours. Hope you’ve had a bath recently.
Or perhaps I’ll get Nurse to send toenail clippings to the lab. Actually, I’m bloody sure you haven’t.
I’m not in the slightest bit worried, but I think you should go to A&E just to get it checked out. I’m shitting myself.
This won’t hurt a bit. It’ll hurt a lot.
Now just a little prick with a needle. Now just a little prick with a needle.

 

So, with the benefit of this little chart, you can make the most of your next appointment. If you can get one, that is.

National Health Service logo

 

A Day on a Hospital Trolley

Even though he’s a fictional character, GP Geoff is not so very different from most other medics. If he needs to see a doctor, all he does is look in the mirror.

hospital entrance

But the swelling and dragging sensation in his left groin have become hard to ignore, and today he’s going into the Day Surgery Unit of his local hospital. Hernia repair used to mean a sizeable incision and several days in hospital, but, with keyhole surgery, Geoff will be home the same day.

About 90% of operations are now done as day case surgery. Beds are as rare as unicorns, thinks Geoff as he meets Cecil, the day care nurse who’s looking after him today.

Today Geoff doesn’t get a bed, just a trolley on a six-bedded ward. If a patient turns out not to be fit to go home the same day after all, then he gets to stay overnight. On that same trolley.

Geoff has been qualified just 15 years and already things have changed beyond measure. Or have they always been like this for patients?

surgical dressings

A junior surgeon pops round with a consent form, then the anaesthetist visits. Geoff is distracted by her dazzling smile, her shock of red curls, but mostly by her multiple nasal piercings. What happens when she has a cold?

“With modern anaesthetic drugs,” she tells him, “you wake up so clear-headed that you can do The Times crossword.”

Which is wonderful because Geoff’s never been able to do The Times crossword.

He won’t get a pre-med, which is a shame. It used to be the best thing about having surgery, but there’s no scope for such things on the day surgery conveyor belt. Besides, Geoff needs to be in charge of his feet, because, when he’s changed into a flimsy gown and paper underpants, a nurse takes him for a long trek to the operating theatre. He hopes he doesn’t run into any of his patients.

Geoff meets the consultant surgeon for the first time in the anaesthetic room. He’s more Doogie Howser than Dr Finlay. Geoff resists asking if his mother knows where he is.

scalpel

When it’s all over, he can hardly feel he’s had anything done, but he’s lying in a large well-lit room where a nurse is telling him to drink. He had not realised he was clutching a small Styrofoam cup.

Back on the Day Surgery Unit, Nurse Cecil checks his pulse, blood pressure, and oxygen saturations every half hour, and reminds him to eat and drink. There’s an obligatory six hours before he can go home. There’s also the requirement to consume the tea and roast beef sandwich placed next to him.

The man on the neighbouring trolley is smiling at a film on his iPhone. Geoff can’t see the man opposite, as his girlfriend is busy delivering a prolonged post-op snog.

Geoff decides against powering up his phone. The pre-op instructions were clear: do not do anything important in the next 24 hours. The last thing he needs is a spirited twitter exchange with one of those anti-vaccine types.

Geoff doesn’t have a newspaper so he can’t test the anaesthetist’s promise. He brought the latest British Medical Journal, but he doesn’t much feel like it now. Or the sandwich. 

British Medical Journal

The patient by the window has already regained his appetite, judging by the takeaway his family brought in. The red and white packaging is already open, filling the ward with the heady aroma of grease, along with 17 different herbs and spices.

Eventually Geoff does what’s required of him: drink, eat, and pass urine. Post-op pain is breaking through by the time he gets to the tiny WC, where someone has already hosed down the floor.

In the corridor, one of the female patients is asking Cecil where she can find a nurse, oblivious of the fact that she is speaking to a nurse. “I’m a nurse,” says the nurse. The patient’s face is blank.

Finally Geoff goes home with a paper bag. It has spare dressings, a packet of painkillers, and instruction leaflets on not picking your scabs.

There’s supposed to be a responsible adult with him for the first 24 hours at home. Geoff, who’s single, fibbed about that bit. Luckily nobody checks, and he absconds in an Uber.

Nothing will go wrong, Geoff tells himself. Aside from the little lie he told the hospital, he plans to be a good patient and take careful note of all the instructions. At first, he is a little confused by the stated telephone times.

Then he realises it’s exactly like Sainsbury’s, trolleys and all.

 

Geoff lives in North London where he looks after patients, longs for a meaningful relationship, and rants about the NHS. You can find out more about him and his life in the pages of Hampstead Fever.

You may also like these posts:

How Are You Today, Grandma?

Germs and Geriatrics

 

When Beer is an Aid to Diagnosis

With the FA Cup semi-final, pubs attract their fair share of crowds. Today I spotted a Spurs supporter with deposits of cholesterol around his eyes, along with a physique one can only get from eating all the pies.

This spot diagnosis took me back decades to my days as a medical student at the Middlesex Hospital, when we’d try to convince ourselves that time spent in a local hostelry was equivalent to the same amount of time spent poring over textbooks.  

Three essential texts

I say ‘we’ but the pub pathology sessions were a guy thing. There were just four women in my year. Swots that we were, however, we often tagged along to make sure we didn’t miss out on anything educational.

We didn’t just think of the pub as a causal factor in disease, though it must have been in some cases. One of doctors would regularly claim that the King & Queen had given him spider naevi (small blood vessel swellings typical of liver disease).

In the interests of presenting both sides of the story, I’d like to add that Steve from my year was convinced that impurities in the beer were to blame for all the complications of excess alcohol.

“Pints of Beer” by Simon Cocks is licensed under CC BY 2.0

Anyway, someone would go, “That’s a basal cell cancer over there.”

“Where?”

“Guy at the bar. Left cheek. Don’t stare.”

“So it is.”

“Also known as rodent ulcer,” another student might offer.

“Doesn’t spread to distant organs,” said someone else at the table. “Not ever.”

“Unlike squamous cell carcinoma,” added a show-off.

“You’d never know I had PSORIASIS – SIROIL 1959” by Nesster is licensed under CC BY 2.0

A pint or two later, one of us claimed to have spotted psoriasis. All nodded sagely, even though at that stage we barely knew the difference between psoriasis, cirrhosis, and sclerosis.

It was like winning the jackpot when a man with a stomping gait entered the pub one winter evening. This type of gait occurs in late syphilis, when foot position sense is lost, so the person bangs the foot down hard at each step. Although it’s possible that the man was just been getting the snow off his boots.

I like to think that the fictional GP Geoff from my novels will have once given pub pathology a whirl. On the whole, however, education has moved on. Sitting in the pub is not a learning method I’d recommend to my current medical students. For one thing, misdiagnosis is common. For another, it’s rude to stare.

Though sometimes it’s impossible not to. In one saloon bar, there was a man with a massive swelling down there.  So ginormous did it grow that he needed a wheeled trolley to help him (and it) get around. He finally did seek expert advice, but, it was said, only when one of the wheels fell off the trolley and needed to be replaced.

One keen student was desperate for the chance to shout, “Let me through – I’m a medical student,” but we never witnessed a medical emergency. Lucky, really, as our life support skills at the time would have done nobody any favours.

We never saw anything as dramatic as the stripper and the snake, though we all heard about it, naturally. This particular lady had a snake as part of her act, until the night her sidekick decided to hug her neck a tad too tightly. She was rushed to A & E wearing little more than a sizeable reptile, where an anaesthetist injected the snake with muscle relaxant and saved her life.

Photo FreeImages.com/Marcel Herber

As I say, we all heard about it. But we missed it. We were in the pub instead.

***

GP Geoff and other characters can be found in my novel Hampstead Fever.

You may also enjoy these posts:

What They Don’t Teach at Medical School

What Happens When You Become a Doctor

Hampstead Fever