Further Confessions of a GP

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‘Are you gonna have to stick your finger up my arse?’ he stammered.

‘What? No, Lee. Why would I need to do that?’

‘’Cos my mates told me you ’ad to have that done before you could get in the army.’

‘They were winding you up, Lee. Although I can’t vouch for what they do to you at military training college.’

Lee broke out into a broad smile, clearly very relieved by the fact that my finger and his anus would be remaining unacquainted.

‘So you’re terrified of the prospect of having a rectal exam from a doctor, but not scared of being blown up by a Taliban bomb in Afghanistan?’

‘I’ll be all right, sir.’

‘I’m not your teacher, Lee; you don’t have to call me sir.’

‘Oh right, yeah, sorry, Doctor.’

It felt like child abuse agreeing to let this 18-year-old boy go to war. My job was just to fill in a form declaring any previous medical history that the army might want to know about. Nobody really cared about my opinion on the war and the effect it might have on this poor boy.

‘Lee, are you sure you want to join the army?’

‘Yes, sir, I want to serve my country,’ he said proudly.

‘But do you really know what could happen out there. Do you even know what they’re fighting about?’

‘It’s about 9/11 and what Osama bin Laden did and that … and my mum says that joining the army will keep me out of trouble.’

That seemed a fairly stark reflection of life in modern Britain. Lee’s mum clearly felt that going to Afghanistan would get him into less ‘trouble’ than letting him stay here and hang out on the local council estate.

I started scanning through his notes hoping to find some sort of ailment that might be picked up on by the army doctors who would review my report. A few childhood illnesses and some more recent weekend A&E visits were all that I could see. The previous month Lee had fractured his fifth metacarpal, a hand injury that is almost always caused by punching someone. The other injury four months earlier was a ‘periorbital haematoma’ (a black eye), again, most likely resulting from fighting.

Maybe Lee’s mum was right. Maybe the army would be the best thing for him. He is from a really rough part of town and he has minimal education, and no skills or qualifications, not to mention that there really aren’t many jobs going at the moment. His brother has been in a lot of trouble with the law and perhaps the army would stop Lee heading in the same direction.

‘You sure you don’t want me to say you’ve got flat feet or asthma or something? There must be something else you can do other than go into the army?’

‘No thanks, sir, I’ll be all right.’

I asked Lee to sign the form and with great concentration he wrote his name in a mixture of capital and small letters. His writing was that of a six-year-old and I could see why he didn’t feel able to go on to college.

Some doctors refuse to refer patients for abortions due to religious and moral objections. I could probably do the same for army medicals, but it would be a pointless gesture that would only put extra work onto the other doctors at the practice.

As I stamped the form, Lee beamed me a big smile.

‘You look really happy, Lee. You must be looking forward to joining up.’

‘What, oh yeah, I definitely am, Doctor, but mostly I’m just pleased you didn’t have to stick your finger up my arse.’

Tummy aches (#ulink_83300d59-df9d-52d4-b907-00997743f498)

Tracey was in, yet again. I was also still receiving letters stating that she and her family were attending the emergency department too frequently, but I’d long since given up on trying to persuade Tracey not to visit so often. The latest hospital attendance was for ‘tummy aches’ in six-year-old Bradley and it was for that same reason that Tracey had brought him in to see me today.

‘They said up in A&E that they didn’t know what was wrong with him and to visit you instead,’ Tracey said.

Bradley was sitting sullenly in the chair rather than tearing around the room, which was out of character.

Once upon a time I had wanted to be a paediatrician and had spent a fair bit of time working on the children’s ward as a junior doctor. I could usually fathom out the cause of tummy pain in kids and I was confident that Bradley’s case would be no exception. I asked Bradley and his mum all about his symptoms. I asked about diarrhoea or constipation and if it hurt when he went for a wee. I asked if he was vomiting or had a fever and I made sure his glands weren’t up. I spent some time prodding his tummy, but it didn’t feel out of the ordinary, and when I tested his urine it was completely normal.

The next step was to ask about school. ‘Are any of the other children nasty to you at school?’ I asked. ‘Are you being bullied?’ Bradley shook his head.

‘He’s got loads of mates at school, Dr Daniels,’ Tracey butted in. ‘He loves school, but the teacher says he’s sitting out of games more and gets tired more easily.’ Bradley nodded gloomily in agreement at this. I got Bradley to get on the scales and when I plotted his weight on his growth chart it was dropping off a bit. Weight loss in children is a real worry and I urgently organised some more tests.

Within a couple of weeks Bradley had been for blood tests, X-rays and an ultrasound scan. Everything came back completely normal. I was relieved that Bradley didn’t have leukaemia, which had been my initial fear, but he was still having tummy aches and wasn’t himself. Most six-year-olds will complain of tummy aches at some point or another, but usually it doesn’t last once they are distracted by something fun. I asked Tracey to bring in Bradley to get weighed regularly by our nurse and it was this that led to a breakthrough.

‘He’s hungry,’ our practice nurse said to me triumphantly one morning after Bradley had been in.

‘Who’s hungry?’

‘Bradley, that boy you’ve been worried about. He’s having tummy aches because he’s hungry. That’s also why he’s stopped growing and losing weight and why he’s had no energy. It was obvious really. I asked Tracey about what he’s been eating and it turns out she’s been having problems with a debt collector and hasn’t been able to afford to buy food. She’s got herself in a right mess with it all and hasn’t told anyone.’

I had asked Bradley and his mum about every possible symptom and ordered a multitude of medical tests. But I hadn’t even considered asking if there was food in the house. Bradley wasn’t such a medical mystery after all. He was suffering from something unfortunately felt by millions of six-year-olds across the world. There was a famine in Tanzania when I was working out there and I saw hundreds of malnourished, hungry children. It just wasn’t something I was expecting to see in modern Britain. Our brilliant practice nurse Brenda had already put lots of things in place to help. The Citizens Advice team were working on resolving the debt issues and a charity was going to help with food donations until the family’s social worker helped sort out Tracey’s finances.

Bradley was an example of how easy it can be to give a medical diagnosis for what is actually a social problem. I wonder how many times I have labelled the misery of long-term poverty as clinical depression, and I once nearly diagnosed an old farm worker with eyesight problems, when the real reason he couldn’t read my chart was that he had never been taught to read. I see poverty on a daily basis, but never thought that I would see malnutrition in a six-year-old boy in Britain. We live in one of the richest countries in the world and food here is plentiful. I would like to think that Bradley was a one-off case, but as everyone is becoming increasingly squeezed financially, I fear that he may well not be.

Glass test (#ulink_414ac8bb-69cf-55fb-9404-47e6520ea9d7)

My first experience of treating children was during my third year at medical school. It is at this time that we are allowed into the hospital to start seeing real-life patients. This is an exciting time for us as medical students, but there is always a fear that we will be asked difficult questions by a scary consultant on the ward round. This was the situation we found ourselves in as we started our first attachment to a paediatric department. Everyone had been very friendly up until now, but we had just started a ward round with Dr Bowskill. He was an odd man, most memorable for his 1970s side parting and very thick glasses with large brown frames. He looked more like an Open University physics lecturer than a doctor who needed to interact with small children and anxious parents.

My friend Jess and I were on his ward round and shuffled along behind him as he mumbled incoherently to the parents of the various children on the ward. We were mostly ignored until we reached the bed of a young boy with a rash.

‘Now medical students, this boy has a rash,’ he declared excitedly and then peered closely at the boy’s skin through his jam jar-sized lenses. ‘Fortunately for him this isn’t a meningitis rash, but what test might we use to see if it was?’

Dr Bowskill turned to Jess.

This is easy, I thought. Everyone has heard of the glass test. I was sure Jess would know how to hold a glass against the skin to see if the rash disappeared under pressure. Unfortunately, it was becoming apparent that she hadn’t ever heard of the glass test. Her expression was completely blank and she clearly didn’t have a clue how to answer Dr Bowskill’s question.

Rather than put Jess out of her misery or turn to me for the answer, Dr Bowskill just kept staring at her in silence. This silence just kept going and going and going, but Jess’s expression continued to remain completely blank. Come on Jess. I was trying to transmit the answer into her brain using telepathy, willing to try anything to end this excruciatingly awkward silence. If she’d just looked up at me I could have mouthed the answer but she just continued to stare vacantly at the small red spots on the boy’s arm.

After what seemed like an eternity, Dr Bowskill took off his glasses and handed them to Jess with great dramatic intent. ‘Perhaps these might help?’ he suggested in a loud, patronising voice.

Jess took the pair of glasses in her hand and I was sure she would click that she just had to hold the glass lens of his spectacles against the rash on the boy’s skin and end this whole tortuous affair. But Jess continued to look just as vacuous, holding those glasses in her hand. I could see her getting increasingly desperate.In a final moment of panic she put the spectacles on her nose and peered closely at the boy’s arm. She then looked up, shook her head and said, ‘Nope, still don’t know.’

At this point I absolutely fell about laughing. The painful awkwardness of the long silence accompanied by the hilarious sight of Jess wearing these ridiculous old-fashioned glasses was just too much for me to bear. Jess started laughing as well, still absolutely clueless of the relevance of the glasses to the whole meningitis diagnosis but aware that putting them on her nose in case she might be able to see the rash better had clearly not been Dr Bowskill’s intention. Particularly as the strength of the lenses meant that she could see practically nothing at all.

Mr Lorenzo (#ulink_7126bbcd-ed64-5408-84f2-ed4ee88c3708)

By far my least favourite part of being a junior doctor was covering the medical wards at night. As darkness fell, one or two of us would be on duty to cover any potential emergencies that might crop up in any of the many medical wards that were spread over several floors of the hospital. I say emergencies – the reality was that many of the jobs were far more trivial. The nurses wanted us to rewrite a drug card or re-site a drip. Occasionally, though, a call would come through on my bleeper that wasn’t quite so routine.

‘I need you to prescribe something for one of our elderly gentlemen,’ the nurse was saying. ‘Something to calm him down sexually.’

‘Eh?’

‘Is there anything you can prescribe to reduce his testosterone levels or something?’

‘What, you want me to chemically castrate one of your patients at 3 a.m. on a Sunday morning. What is he doing?’

‘He keeps touching all of the nurses up. He rings his call bell every five minutes and as soon as we come anywhere near his bed, or the one next to him, for that matter, he reaches out his hand and grabs whatever he can.’

‘Can’t you tell him not to?’

‘He doesn’t understand English.’

When I arrived at the ward in question, I was greeted by a group of very irate looking nurses who led me over to the gent causing all the problems. Mr Lorenzo looked too frail and decrepit to be creating such a debacle, but as the nurse in charge escorted me over to his bed, sure enough, he made a grab for her behind. Clearly ready for this, the nurse nimbly dodged his flailing hand and gave him a hard stare. Mr Lorenzo looked at me, gave me a wink and then let loose a massive toothless grin and cackle.

‘You mustn’t touch the nurses,’ I told him firmly.

‘Funnily enough, we’ve tried telling him that. He only speaks Italian.’

‘No touchee the nurseees,’ I tried again, this time shouting in English but with a terrible Italian accent.

In the very unlikely scenario that Mr Lorenzo did understand me, he chose to ignore me and instead continued to give me his toothless grin before this time trying to grab the bosoms of a health-care assistant who had foolishly strayed within his groping range.

‘Senore Lorenzo, por favori, no touchee. No touchee!’ I shouted firmly. I then turned around and decided to stride away purposefully as if I had successfully resolved the issue when of course I hadn’t. The nurses didn’t bother waiting for me to be out of earshot before loudly commentating on how bloody useless I was.

I’d almost forgotten about Mr Lorenzo when about an hour later I got a frantic call from the nurse back on Mr Lorenzo’s ward.

‘It’s Mr Lorenzo. He’s fallen out of bed and he’s unconscious.’

I ran to the ward to find the nurse in charge in floods of tears. They had become so fed up with Mr Lorenzo’s constant bell ringing and subsequent groping that, despite it being against the rules, they had moved his call bell just out of his reach. He had reached and reached to try to get it and had fallen out of bed. Sure enough, down on the floor Mr Lorenzo was lying on his back, motionless and grey.

‘I think he might be dead,’ blubbed one of the nurses.

‘We’ll all lose our jobs,’ another wailed.

‘Stop crying and help me check for a pulse,’ I interrupted.

We all stood over the moribund Mr Lorenzo, then just as the nurse in charge leaned over to try to find a pulse in his neck, as if by magic, his arm sprung into life and reached up her skirt. He opened his eyes, gave me that toothless grin and a wink and the rest of us collapsed into relieved laughter. So relieved were the nurses that they weren’t going to have to explain to a coroner’s inquest how they had moved his call bell out of reach that they happily tolerated his wandering hands for the rest of the night; well, for an hour or two at least.

Pseudoseizures (#ulink_bdbfffd7-e8bd-519c-a85a-5e4739944e6c)

A pseudoseizure is a pretend fit. The person flails their arms and groans a bit as if having a real epileptic seizure, but in fact they are completely conscious and are in full control of their actions. This may seem to you as a very odd thing to do, but surprisingly they are really quite common. In fact, when I qualified as a doctor I witnessed three pseudoseizures before I saw a genuine epileptic fit. As I have become more experienced, it becomes easier to differentiate between a pseudoseizure and a real one.

Barry, the nurse I work with in A&E, is particularly unsympathetic to the condition. When he sees one of our regulars coming in pretending to be fitting, he rubs his knuckles hard on the patient’s chest. If the patient sits bolt upright and tells him to ‘fuck off’, we can all be reassured of the true diagnosis. Personally I prefer a slightly subtler approach. By gently stroking the eyelash, someone conscious won’t be able to help but flicker their lower lid. It avoids unnecessary swearing or potentially bruising the chest wall of some poor bugger who is genuinely having a seizure.

As an A&E doctor, I viewed pseudoseizures as yet another odd preserve of the crazies who dog the department, but as a GP I have been given the opportunity to gain some insight as to why people have them.

Carrie has them frequently, and recently she had one in my surgery waiting room. Picture the scene: Carrie comes to the desk wanting to see me on a busy Monday afternoon. The receptionist tells her that there are no appointments until the following day. Carrie then falls to the floor dramatically and shakes all her limbs. Everyone in the busy waiting room clambers over to help her and I get an emergency call interrupting both myself and the patient I am seeing. As I rush into the waiting room, I think I can see just the faintest of self-satisfied smiles on Carrie’s face. She has got the attention she was craving. If the waiting room had been empty, I could have told Carrie to get up and stop making such a scene. This of course looks a tad on the unsympathetic side to her worried audience who are expecting me to offer suitable emergency treatment for what they believe to be a poorly epileptic.

I compromise and help Carrie into my room, apologetically upending the poor patient I had been seeing and delaying the remainder of my afternoon surgery. Carrie gets my attention and the appointment she wanted at rapid speed.

Her pseudoseizures also commonly occur when her boyfriend splits up with her or when she has had a big row with her mum. In these situations, the pseudoseizures are a brief and effective distraction from the current unpleasant realities of her life. They also result in her receiving the sort of sympathy and attention that she normally struggles to elicit. Carrie offers plenty for a psychotherapist to get stuck into, but for a lowly GP like me it is just a matter of trying to manage the situation as best as possible in the 10 minutes I have. I do feel sympathetic towards Carrie and hope the psychotherapist I referred her to helps her to manage her symptoms. Having said that, I can’t say there aren’t moments when I wish I had Barry at hand to offer a couple of hard knuckle rubs on her sternum the next time she dramatically collapses in my busy waiting room.

Antibiotic resistance (#ulink_482634d5-270a-5c3f-b305-85ca6eff7141)

The national newspapers today are full of reports on the worrying increase in resistance to antibiotics and the potential return to an era when we have no discernible medical treatment to use against severe bacterial infections. The following is how antibiotic resistance was explained to me at medical school. I’m not sure who first came up with the comparison, but the concept can be best explained by thinking in terms of straightforward evolution:

A farmer has a problem with rabbits (think bacteria) eating crops on his field. He employs a few hunting dogs (think antibiotics) to kill the rabbits. Initially it is a great success and the rabbits are almost all gone. The farmer’s crops are growing healthily and the farmer celebrates, assuming that rabbits will never be a problem again. He declares a great victory (think the remarks in the 1940s by doctors who thought that the days of infectious diseases were over). However, not all the rabbits are killed. Like all groups of organisms, there is variety. The few rabbits still alive are the ones that are the fastest and have the best hearing. These rabbits can hear the dogs coming and outrun them. These remaining ‘super rabbits’ breed with each other (like rabbits) and soon all the rabbits on the farm are extra fast and have great hearing. The old hunting dogs can’t kill any of them, so effectively the rabbits have ‘developed resistance’.

The farmer decides to get some new dogs, which are even faster and can hunt very quietly (think newer antibiotics). Initially the new dogs are killing the rabbits despite their speed and good hearing; however, one or two of the rabbits are brown rather than white and the dogs can’t see them very well. These remaining brown rabbits breed with each other and soon all the rabbits are brown and the dogs can’t see them (think super-infections such as MRSA and C. diff). This cycle continues, with the farmer continually trying to adapt his dogs to keep his farm healthy. The rabbits aren’t being cunning or clever. They are simply evolving and reacting to the environment which is being manipulated by the farmer.

The other issue the farmer notices is that the dogs cause other problems. They occasionally kill some of his hens (think unwanted side effects). He also finds that when his dogs have killed lots of the rabbits, there is suddenly more food and space for the mice, so they now flourish. The mice now become pests themselves (think fungal infection such as thrush).

Sometimes the farmer sees that his crops are being eaten and assumes it is the rabbits. In fact, this time it is a caterpillar infestation (think viruses) eating his crops for which the dogs are of absolutely no help. He foolishly sends out his dogs again even though the rabbits aren’t the culprits. The farmer has given himself all the problems that the dogs cause without any of the advantages. This is what happens when we give antibiotics for viral infections such as colds. We cause resistance and inflict side effects without helping clear the infection. After the farmer sends the dogs out, the caterpillars turn into butterflies and fly away leaving the crops to recover. This recovery had nothing to do with the dogs, but foolishly the farmer just sees his crops recuperating and assumes that his dogs are the saviours. He sends out his dogs every time the caterpillars arrive not realising that they are causing more harm than good to a problem that is self-resolving.