Thursday, 29 January 2009

The buck stops

There has been considerable expansion of the role of nurses in the NHS over the past few years. We now have Nurse Prescribers in general practice and Nurse Practitioners in hospital. Some people say that this is just a way of getting doctors “on the cheap”, although one can certainly make a case for tasks to be done by the person who is adequately rather than over-qualified to do them. Doctors command higher salaries than nurses - what do you get for your money?

I read an interesting article in the British Journal of General Practice a year or so ago which suggested that nurses are very good at working at the oases of knowledge whereas doctors are better at roaming the plains of uncertainty. Doctors aren't as good as nurses when it comes to following protocols and treating patients where the pathways to be followed are clear-cut, but they come into their own when the paths are vague and guidelines don't apply.

This evening I arrived for my evening surgery to find a message from one of our District Nurses. A patient had taken too many codeine tablets so would I please ring him to sort things out. He is a likeable chap but he occasionally does slightly daft things. He was recently prescribed some codeine tablets for some pain he was getting, but because the codeine did not seem to be working he had taken forty tablets between 8am yesterday and 2am this morning. I rang him to find out what was going on and he told me that he hadn't been trying to harm himself, just to get rid of the pain. He felt perfectly well, had not felt nauseous and was breathing normally. What was to be done? There is no guideline covering this situation so I had to work things out for myself.

He had taken 1200mg of codeine, which is five times the recommended daily amount and can be lethal if taken all at once. However this was spread over an eighteen hour period, and the last tablet had been taken fourteen hours ago. The half-life of codeine is about three hours, so most of the codeine he had taken would have been excreted by the time I spoke to him. Since he was fully conscious and breathing and talking normally it did not seem necessary to arrange for him to be given the antidote for codeine poisoning (naloxone) so I simply advised him about the dangers of taking too much codeine in future. We also discussed how he might deal with any constipation that occurs.

To be fair to the District Nurse she realised that he probably didn't need treatment for this overdose, otherwise she would have rung for an ambulance rather than asking me to get in touch. And yet she did not feel able to leave things as they were. She needed to speak to a doctor about it, and the buck stopped at the telephone on my desk.

Friday, 23 January 2009


The other week I saw a man in his mid-twenties who had recently arrived in this country. Before he left home his doctor there had started him on three different tablets for his blood pressure. He had been reluctant to take his tablets and had in fact stopped them when he saw our practice nurse for his registration check. We still offer this check to all patients joining our list. We used to be paid a small amount for doing it, but although we no longer get any money it still seems a useful thing to do. The nurse will take a basic history, discuss health promotion and check routine things like weight, blood pressure and urinalysis which give us some baseline measurements. With women she can confirm details of smears, and with children she can ensure immunisations are up to date.

Nurse had suggested that he restart his medication, and when he saw me his blood pressure was completely normal. He had no signs of chronically raised blood pressure in his retinal vessels and there was no protein in his urine. But I got terribly excited because I thought I could hear a “bruit” in his left renal artery. This is a "whooshing" sound over the artery which can indicate narrowing (“stenosis”), and this can be a cause of high blood pressure. It is also extremely rare, and a GP would only expect to see one case in his professional lifetime. But since “idiopathic” hypertension (with no known cause) is also very rare in people in their twenties, renal artery stenosis is more likely in such patients. I have already made one diagnosis of renal artery stenosis, which really made my day at the time. The hospital doctor couldn't hear the bruit but referred for investigation because I had heard it, and my hearing was accurate on that occasion. I was rather hoping that I had found another.

But I thought that I ought to start from scratch before referring him to the hospital. So I asked him to stop taking his medication again, and arranged some blood tests and an ECG. These were all normal, and when I saw him again today so was his blood pressure! Moreover, on listening to his abdomen again I realised that what I had thought might be a bruit from his left renal artery was really just normal heart sounds transmitted from the chest. I was a bit disappointed, but of course it's much better for him and so I am pleased. One diagnosis of renal artery stenosis is quite enough for one career. :-)

I am going to see him again in a month just to make sure that his blood pressure continues to behave itself, and he will buy himself a BP monitor and take some home readings in the meantime.

Wednesday, 21 January 2009


By chance I saw two patients from other European countries in my surgery this morning. Both of them irritated me, although I tried very hard not to let this show. And because I was aware of my irritation I also tried to be fair to them.

The first was a young man who has booked an arthroscopy for his knee pain, to be carried out by an eminent orthopaedic surgeon in his home country in just two months time. Since he pays taxes and national insurance in this country he would like the NHS to pay for his operation, and he has found out that he needs an E112 form for this to happen. Guess whom he was advised to see about this? You have guessed correctly - his GP.

At first I was affronted - why should this man come to live here and then expect the NHS to pay for an operation back home? But I could also see his point of view that since he was paying his contributions he was entitled to an operation, and why shouldn't he have it done in his preferred European country? Fortunately I had a fair idea of how the system worked and a quick search on Google confirmed that I was right. The NHS will pay for such an operation provided that an NHS consultant has confirmed that the treatment is necessary and that it is not available “without undue delay” in this country. I think that the local waiting list for knee arthroscopy will not be considered as constituting “undue delay” and so the NHS commissioners will turn down my patient's request. I also suspect that he will run out of time before the decision can be made. In either case he will be faced with the choice of a free operation in the UK or paying for it to be done back home. I told him all this and he asked to be referred to an NHS consultant, which I have done.

The second patient was a woman who has had several miscarriages and is now in the early stages of another pregnancy. I have already referred her to our local experts and she is due to see them in a few days time. However she has just been back to her own country to see her own gynaecologist and has brought back a list of treatments that he wants me to prescribe and blood tests that he wants me to order. She wants the results of those tests to be sent to her gynaecologist so he can continue to monitor the situation.

I can foresee problems here with the patient running between two experts in different countries and expecting me to carry out the wishes of the foreign expert if they differ from those of the local expert. That is really an untenable position for me to hold. And although my patient undoubtedly has great faith in her “home” expert I don't know him from Adam. I do not want to act as his proxy in this country. But of course I understand that my patient will treat his word as gospel and may have little faith in “our” expert. I felt I had to take some sort of stand, and fortunately she has a sufficient supply of the treatments recommended by her expert to last until she sees our expert so I declined to prescribe anything until she sees him. As far as the blood tests are concerned, some of them are routine antenatal bloods which will be done in due course and have no bearing on her problem of recurrent miscarriage. The problem with the other tests is that I would not know how to interpret them if I ordered them. It would not be right for me to order blood tests on behalf of her expert and then take his advice, with all the problems of language barrier (he does not write very comprehensible English) and medico-legal problems of responsibility. I also think it will be a bad thing for my patient to be under the care of two experts. I have tried to explain all this to her, but her command of English is not perfect and I don't speak her language at all.

I hope I have not upset her or appeared rigidly unhelpful. She may yet need my help if things go wrong in the pregnancy despite the best efforts of experts in two countries.

Psalm 139

Last Sunday we sang part of Psalm 139 to a haunting Anglican chant whose beauty has remained with me all this week. The words speak of how God is always with us.
Whither shall I go then from thy Spirit,
or whither shall I go then from thy presence?
If I climb up into heaven thou art there,
if I go down to hell thou art there also.
If I take the wings of the morning
and remain in the uttermost parts of the sea,
even there also shall thy hand lead me
and thy right hand shall hold me.
You might imagine that the Christian breezes through life safe in the knowledge that God is with him or her. Perhaps some do, but you will know that that is not my style. I have been unsure of my abilities as a doctor, been aware of my weaknesses, and found the needs of my patients wearisome. I have certainly not seen myself as God's agent sorting out his children's needs with a deft hand while the Holy Spirit perches lightly on my shoulder.

And yet strangely this week has been different after singing that psalm. I have dealt effectively with some serious problems and become aware that I provide more than a technical service. One slightly deaf elderly lady said “isn't he nice” to her daughter as she left my room, which pleased me because as well as being nice I had managed to make some technical adjustments which had improved her condition. Another rather “proper” elderly lady spoke frankly of her fears about her illness. I have known her a long time and although I could not reassure her since I think her fears are well founded, I did comfort her in the sense of strengthening her. I don't quite know how I did this, it wasn't anything I said but it was more to do with my manner and our long relationship. As she left she said “I'd kiss you if I dared” and although I was a bit nervous I proffered my cheek, to her evident satisfaction. This week I have also become aware that my colleagues whom I admire are occasionally fallible which did not exactly induce Schadenfreude, but did give me a sense that I am pulling my weight in the practice. And I spoke to a consultant friend concerning my worries about revalidation and he said there are many other GPs the authorities would want to get rid of before me.

So although I did not have a direct sense of God being with me as I worked through the past two days, looking back I suspect that he was there as the psalmist suggested. I don't know whether this insight will help. I'm sure that I will still find my patients' demands infinite, and will feel inadequate to deal with them. But perhaps a little less so. Deo gratias.

Wednesday, 14 January 2009


I have not posted anything on this blog for nearly two months, and several people have left comments and emailed me hoping that I am alright and that I will write again soon. That is most kind.

I seem to be taking a sabbatical at present. I'm not sure why I stopped writing, I probably just ran out of energy. You might not think so, but it takes me some time to consider and then write a blog entry. What is written without effort is, in general, read without pleasure. I suspect I have also been subconsciously worried about letting standards slip, and about whether I have anonymised the details of my stories enough. The more you remove inessential parts of the story, the less interesting the story becomes. And my mind has been on other things.

But I'm still here, still in good health, reasonably cheerful and with no major disasters to report. Thank you for your kind wishes. I expect I shall write again soon. I must prepare my Appraisal material shortly, and something may well come out of that.

Best wishes to you all for the new year.