26 July 2009

Bad news: We are all going to die

It must be true because Karol Sikora says so. He says so in an excellent article which you can read here. Not a great supporter of socialised medicine, Karol Sikora does at least support the values of good general practice and calls for the return of Drs Finlay and Cameron. For once he is right. We are all going to die and we do need good GPs.

If the government had got less involved in the management of individual patients with possible 'flu and had left it all to the judgement of GPs Dr Grumble thinks the public would have been a lot better off. And if the powers-that-be hadn't wound the populace up and created all this hysteria the GPs might just have been able to cope. Most important of all the patients with 'flu-like illnesses would have had decent doctors diagnosing their problems accurately instead of window cleaners. Getting the Tamiflu out is not the important thing here. What is important is finding amongst the worried-well and those with flu-like symptoms those who really have meningitis or pneumonia or pyelonephritis or malaria or typhoid or one of the 101 other things in the differential diagnosis of influenza. How many will be misdiagnosed by window cleaners and given Tamiflu when what they really need is an antibiotic? We shall never know. But it certainly seems possible that the government's untested 'flu line is killing more people than it is saving.

Mrs Grumble who used to be a GP says there was no alternative. Dr Grumble is not so sure. He is sure Dr Finlay would have coped somehow. As it happens Dr Grumble has had two Dr Finlays who have worked for him quite recently. He asked if patients remarked on their name. Only if they are of a certain age was the unkind retort.

So, for those too young to know, Dr Finlay was the creation of the author A J Cronin who was himself a doctor. The books spawned a television series which Dr Grumble remembers seeing as a child. The best stories were early in the series and were written by Cronin himself. They always had a medical story line which challenged the diagnostic skills of any watching doctor. As the story evolved clues to the diagnosis gradually emerged and it would become increasingly apparent that the local village of Tannochbrae was suddenly in the grip of some terrifying and incurable infectious disease. Does that sound familiar?

25 July 2009

The best prepared country in the world

The Jobbing Doctor will tell you that swine 'flu is mild. He is sort of right. It was mild for Dr Grumble's two registrars who were back at work after a few days. But if you work in a hospital you may see one of the tiny number of patients in whom the disease turns out to be far from mild.

What happens, for example, if the dreaded 'flu virus invades your lungs? The answer is that your lungs won't work too well. But when you eventually get better from the 'flu your lungs should get better too. All your doctors need to do is keep you alive until you cure yourself of the 'flu. But keeping you alive if your lungs are riddled with 'flu virus is a challenge. Widely inflamed lungs cannot do their job. If they get really bad there could be only one option for you and that is to plug you into an ECMO machine that does the job of your lungs for you. Does it work? Probably. How do we know? We know from research done in the UK. Will you get this treatment in the UK? Probably not. Because in the UK we have only five ECMO beds for adults in the whole country. If you are very lucky you may be able to get treatment in another country.

Was the possible need for ECMO in a 'flu outbreak predictable? Dr Grumble thinks it was. Did the Department of Health plan for the 'flu? Yes. According to Alan Johnson, along with France, we are the best prepared country in the world. As is Australia by the way. How many ECMO beds do you think they have in Australia?

Of course ECMO doesn't come cheap. If you are not familiar with ECMO take a look at the video and then decide if you think it is worth it.

It is not easy to get funded to provide an ECMO service:

There is no funding stream for adults with respiratory failure at the time of writing (pdf).

There is money for 'flu planning ad nauseam, for unnecessary bottled water, for Connecting for Health, for Darzi clinics, for 'flu lines, for NHS Direct, for Walk-in Centres and for running an internal market. But ECMO funding is limited. Very limited. You could argue that to be right were it not for the very large sums of money wasted elsewhere on electoral bribes.

The Jobbing Doctor may be busy and Dr Grumble may want access to ECMO for his sickest patients but all most of us need is a good GP and not a window cleaner.

23 July 2009

We do NOT use Choose and Book

One of Dr Grumble's more boring jobs is reading the referral letters from GPs. They are mostly very good and definitely better on average than from his hospital colleagues. GPs have a better idea of what Dr Grumble needs to know.

The job of reading the referral letters is an important one. Sometimes Dr Grumble is really not the best person for the problem so he can write back to the GP and suggest somebody better or he can divert the letter to a colleague. He will allocate each patient to the best clinic for their problem. Some patients who appear to have nothing much wrong with them will take a long time and need a long appointment. Others with obvious pathology can be dealt with speedily. It is possible to redirect referrals that have arrived via Choose and Book but it is not easy. The letter system works well usually but reading a large pile can be boring. But you do have to keep your wits about you and occasionally you spot something interesting.

Today it was the letter from the Highgrove Surgery that took Grumble's interest. For a moment Dr G thought the Prince of Wales might be heading to his clinic but it wasn't to be. But he was amused to see at the very top of the referral before anything else in big letters:

Please note: We do NOT use the Choose and Book system.

This blunt sentence was obviously designed to make a point so at the end of the day Dr G decided he would take a look at the Highgrove Surgery website. It's a very nice website. There is something very frank and straight about it. Somebody there must have a bit of spark. Dr Grumble particularly liked this sentence which comes after an apology for blunt treatment at reception:

We all actually really like our patients!

There is something endearing about this. Essentially they say that they are a bit of a stroppy lot at times but they are under pressure and can get a bit tetchy so please forgive them. It's very honest and much less annoying than the standard cloying and insincere how-can-I-help approach. Or for that matter the world-class performance offered these days by, well, almost everybody.

It seems that you are a whole lot freer as a GP than a hospital doctor. GPs can say what they think. If managers annoy them they come out with it. Dr Grumble has to doff his cap to these people. His job is at stake. There is no way Dr Grumble could write on a website intended for patients that he had a special interest in 'annoying PCT managers'.

As it happens, of course, Dr G works with such high calibre world class managers that he actually wants to doff his cap to them. Of that there is no doubt. The point is only that he would have to kowtow even if they were not up to standard. But they are. Most definitely.

19 July 2009

Harold Lambert

You don't really thank your parents for meeting the demands you made of them. You pay off the debt you owe to your own children and one day they will do the same. It's the same with teaching. The debts you owe to your teachers you repay to your students.

Teachers don't get rewarded. Not in this life anyway. Good researchers do but good teachers have to wait for heaven. Just occasionally teachers will get thanked by their students. Dr Grumble hopes he thanked his teachers. Sometimes he definitely did. Probably he often didn't. One teacher he cannot remember ever thanking was Harold Lambert. Harold Lambert taught Dr Grumble about infectious diseases. He was a very clear-thinking teacher. Most good teachers are.

When Dr Grumble was a student he thought of Harold Lambert as an old man though he would have been way younger than Dr G is now. He was amazed that he had managed to live so long working alongside all those nasty infectious diseases. Dr Grumble can still remember going to see a case of open TB with him. The young Grumble held his breath in the corner of the room trying not to inhale. Today Dr Grumble's students also retreat to the corner of the room when they meet infectious patients. With time this fear passes to the extent that seasoned doctors risk becoming complacent about infection control. It's better that way. When Dr Grumble knows the patient is not really as infectious as the protocols say he often takes off his mask to help put both patient and students at ease. You cannot work well if you are fearful for your own safety.

It was this 'flu business that led to Dr G thinking about his former teacher. Here are some video clips from the People's Archive of Harold Lambert reminiscing. Notice how well he speaks and how clearly he thinks:

University College Hospital: developing an interest in clinical medicine (Part 1)

Communication with patients: a story about denial

Beginnings of my interest in infectious diseases: doing research in the Army


The importance of cleanliness in hospitals

The hospital environment; St Georges Hospital garden

Thank you, Harold Lambert, for teaching Dr Grumble. He appreciates your teaching to this day. Dr Grumble always hoped that one day he would become a good teacher like you. Whether he has or not is not for Grumble to say but he has tried to repay the debt he owes to his teachers by teaching those that follow. When you get to a certain age that is, perhaps, your most important role. It's a shame that the powers-that-be don't recognise that.

Good teachers

Everybody remembers a good teacher. It's true of school teachers and it's true of medical teachers. To this day Dr Grumble can remember teaching sessions he had as a medical student decades ago. Sometimes he remembers what he was taught but not who taught him. And sometimes Grumble passes on word for word what he was taught to his own students. Just occasionally they are things that are not directly medical.

The recent death of Henry Allingham reminded Dr Grumble of a tip he was given on his first medical firm. Who gave him this tip Dr Grumble has no idea but Dr Grumble has remembered it to this day. The tip was to talk to his patients about their experiences in the First World War. Dr G was told that they were a living link to history and that they would not live for much longer. Dr Grumble was not taught about the Great War at school. He found it difficult to grasp. He still does. But through contact with his patients he learnt something of the horrors of war. Quite often his patients would decline to talk about their experiences. But sometimes they would tell the stories of life in the trenches. Sometimes they would tell about how they were wounded. Many probably owed their lives to having been so severely wounded that they could not fight again. Others were gassed. All had lost friends.

Sometimes it is worse for those left behind. The women told stories of how their sweethearts were sent to fight never to return. Many, perhaps it was most, had never married. After the carnage the loss of life had been so great that there were just not enough men left to go round. Occasionally a handbag would be opened and Dr Grumble would be privileged to see the remains of a cherished last letter brown at the edges from oxidation. Whether these letters were carried all the time or whether they were keepsakes to be brought in to accompany the patient to hospital as a comfort at a time of special stress Dr Grumble was never sure. But reading these letters even after the many years since they had been written brought tears to the patient's eyes and had a similar effect on the young Grumble.

Dr Grumble cannot tell his students to ask their patients about the First World War. It is too late. But he does tell them to ask about their patients' experiences of the Second World War. The horrors of the Second World War do not quite match those of the Great War but occasionally you can uncover stories of incredible bravery. Recently Dr Grumble and his students were rewarded with one such tale. Dr Grumble's patient had been parachuted into France where she had worked undercover helping the French Resistance. Eventually she was arrested and was to have been taken to Paris where she would have been interrogated by the Gestapo and shot. Fortunately D-day prevented this from happening and the patient was instead sent to a concentration camp in Germany. The story is very much more exciting and interesting than that. Sadly Dr Grumble has had to take out the most interesting bits because of identifying details. He will only say that he has the highest regard for this spirited old lady and he gives thanks to the unknown teacher all those decades ago who encouraged the young Grumble to talk to his patients about their experiences of the past.

Over the top?

One of the neighbours children is a medical student. Two or three years ago his parents asked Dr Grumble to see him as he was going to Cambridge for an interview. Dr Grumble gave him a mock interview and concluded that he had no chance whatever of getting into Cambridge. But he didn't say so. Except to Mrs Grumble. Of course he gave the hapless child some advice on interview technique and likely interview questions. And, to Dr G's amazement, he got in and is now studying as a clinical student at a hospital in Cambridge.

In the early days of the 'flu outbreak his parents spoke to Mrs Grumble. They were shocked to discover that their offspring had been in contact with a patient with swine 'flu and that, allegedly, the right protective equipment was not available. Mrs Grumble just shrugged. She knows how the NHS is. She knows that all the hype about thorough planning is more hype than anything else. There has been a vast amount of planning but its value to those at the coalface is doubtful. It's always like that.

But that was weeks ago. By now you would think that the top hospitals would have sorted out the right protective equipment for staff. But when Dr Grumble saw a case of suspected 'flu just yesterday his staff told him that the right equipment was not yet available. So he instructed them to record this in the records in the hope that Mrs Grumble might possibly get some compensation should Dr Grumble succumb. The slightly odd thing is that Dr Grumble cannot remember using any special protective equipment with 'ordinary' flu which also kills a few of Dr Grumble's patients each year. In fact Dr G has never ever seen the protective equipment he is supposed to use. It is apparently so sophisticated that you need special training to use it.

Already some of Dr Grumble's staff have gone off with suspected 'flu. One announced his illness on a ward round as he became unwell by which time Dr Grumble had been in contact with him for longer than he would have spent with any single patient. Another was already sick which left Dr Grumble without middle grade support. It's probably an age thing. Dr Grumble has lived through a few epidemics. He has had 'flu. More than once. Probably it has left him with some protection. Preliminary figures bear this out. The staff who have gone off are in an age group at higher risk of catching 'flu but their risk of dying from it is low. For Dr Grumble it is the other way round.

What's the message to this? The message is that we cannot ring fence ourselves from this infection and that the likelihood is that sooner or later those of us who do not have some sort of protection from previous exposure are going to catch this disease and that attempts to keep the lid on its spread are futile.

In China they have a different approach. Judging by the video, they are better equipped with protective equipment - though some of the masks the public use seem useless. It's their country. They can do what they like but Dr Grumble thinks they are wasting their time and money. They are never going to contain this disease that way. It is just not going to be possible. But common sense does not stop the madness of planners either in China or closer to home.

If you don't want to risk being confined to barracks, Dr Grumble would advise giving China a miss for the time being.

18 July 2009

The National Portait Gallery

There are rather few pictures on the Grumble blog. It would be nice to give you more but once or twice Dr Grumble's lawyer has warned him about copyright infringements. One particular organisation that objects to Dr Grumble using its images is the National Portrait Gallery. One post had a picture of Sir Cyril Chantler but Dr Grumble had to take it down. Curiously they allow you to link to their website so you can see the picture after one click. It's just that you cannot see it here.

Dr Grumble thinks the attitude of the National Portrait Gallery stinks. They claim that their strategic priorities are:

  • To extend and broaden the range of audiences for the NPG and its work

So you might think that they might like people to look at their pictures. Dr Grumble as a taxpayer has helped pay for this self-centred organisation. If they are going to continue stopping taxpayers using their images the taxpayers should stop funding them .

11 July 2009

How mad can you get

Emeritus Professor Joe Collier
Mad at fast track drugs proposal

The British are quite an innovative lot. The UK has contributed in no small way to some major advances in medicine ranging from DNA and test tube babies to CT and MRI scanners. Yet the NHS is said not be be innovative. Dr Grumble is not so sure that this is entirely true. Certainly we were slow to get the scanners we invented but that was at a time when the NHS was very much underfunded. And not all innovative treatments are worth having. We are said to be conservative when it comes to new drugs but that is not necessarily a bad thing. Many new chemical entities are not quite as marvellous as they at first seem and it is not unusual for serious, though rare, adverse drug reactions to become apparent after marketing rather than in the clinical trials. Some drugs just do not live up to the marketing hype and some drugs cost so much for such a minuscule benefit that it is just not reasonable to expect the taxpayer to foot the bill. And it is in dealing with this problem that the NHS has been innovative in requiring NICE to evaluate the value for money of treatments.

According to the Guardian:

The pharmaceutical industry has been fiercely critical of Nice since its inception in 1999 because it blocks sales of expensive drugs to the NHS that are of only limited benefit.

How can you be critical of curbing unreasonable spending on medicines? Surely expensive drugs that are of very limited benefit should never have been developed? If the pharmaceutical industry cannot produce drugs that are reasonably cost effective that is their problem and not the taxpayers'.

So, after all the effort put to developing NICE, why is the Office for Life Sciences proposing a system which bypasses current NHS procedures for safeguarding taxpayers money? See if you can work it out. There are clues in the Guardian article.

10 July 2009

When to read books

It seems like only yesterday but it was probably 6 years ago that Dr Grumble had a young somewhat green but very able registrar. He seemed a promising sort to Dr Grumble. But then he told Dr Grumble that he did not want to continue. Dr Grumble was perplexed. "I've seen how hard you work, Dr Grumble. I don't want to do that. I want to have time to do things like read books." Those were his exact words. Dr Grumble remembers precisely what he said. He even remembers where he said it. But what Grumble said in reply has left the memory banks. Probably it was along the lines of about having to decide what is important to you and making the appropriate choices on that basis and also something of the positive side to the Grumble work.

A few years have past. Grumble is working harder than before. The earliest clinic in the Grumble hospital now starts at 07.30 hrs. Six years ago it was at 09.00 hrs. Today the clinic was locked shut. Even security aren't in by then. They can make doctors work harder but the support staff are not so malleable. But the delay in getting the clinic unlocked gave Grumble time for this quick post.

What has happened in those short years? One of the Grumble children has gone from being a schoolboy to becoming a doctor. One of Dr Grumble's dearest colleagues has died suddenly and another has just emailed from the other side of the globe saying he is terminally ill. Yet another lies ill not far from Dr Grumble having had a terrible accicent. Sometimes it seems that disaster only strikes the nicest of people. It can't really be like that but it does seem that way.

And what do you think happened to Dr Grumble's disaffected registrar? Can you guess? He has applied for a job working alongside Dr Grumble dealing with the sickest of patients. Whether he will get it or not Dr G has no idea. But if he does he will be pleased. But when is he going to read all those books?

Life is short. Some of us have more time than others. But for all of us books will go unread.

01 July 2009

RemedyUK versus GMC

The details are here. Dr Grumble has patients to see so he won't be able to get there. He has never been to the High Court so he would go if he could.