Recognise that this really is a very difficult job - if your trainer sometimes makes it look easy, remember that professional musicians or sports stars make their complex task look easy too.So next time journalists tell me I'm doing it wrong, expert consultants want me to do more to manage their pet diseases, and the Government gives me a pay cut and tries to replace me with a nurse, I shall remember that the RCGP president thinks I'm doing a very difficult job.
I had a difficult decision to make today, and I feel that I did the wrong thing but the alternative was worse. I want to tell the tale, because if I only blogged about things that went well I should paint an unduly rosy picture of myself.
Susan is a middle-aged woman with severe learning difficulties who lives in a care home where the staff are extremely caring and solicitous. She is a cheerful little soul who can only talk in grunts but responds well to the attentions of her carers. However she is suspicious of strangers and will only allow the most limited examination. I have managed to listen to her chest, but she will not allow blood pressure to be measured or blood samples taken, even after some oral sedation. Around Christmas she developed mild right-sided facial weakness which my partner thought was probably Bell's palsy. This settled, but over the past few weeks it has recurred and she has become unsteady on her feet. Today she went off her legs completely, because she was unable to put her weight on her right leg. But otherwise she was well, apyrexial and with a normal pulse.
She might be having TIAs, or possibly has cerebral metastases of the breast cancer for which she had a mastectomy a few years ago. But in any case investigation and monitoring of treatment would be difficult. We can't give her aspirin for possible TIAs as we cannot measure her blood pressure. Whether she has cerebrovascular disease or metastases her outlook is poor, and a good case could be made for not doing any investigation at all and simply providing palliative care. However it was clear from the attitude of the staff at the care home that they expected something to be done. In addition she was now “off her legs” and they were having great difficulty managing her. It was also the Friday afternoon before a bank holiday weekend and her GPs will not be available again for another four days. And although my partners agreed with me that palliative care would be best, it was a “brave decision” that I didn't feel brave enough to make. So I arranged for her to be admitted to hospital, though I am far from sure that this was the best thing to do.
We await events.
Meanwhile there has been a little good news about the lady in her eighties I mentioned yesterday who recently had a laparoscopic sigmoid colectomy. I have just read the discharge letter which reports that her sigmoid tumour was a moderately differentiated adenocarcinoma, Dukes stage C1. This would give her a five-year survival rate of about 40%, which by my reckoning is probably the life expectancy of a woman in her eighties without a cancer. That has cheered me up a little as I start a short holiday. I shall be back at the end of next week.