30 July 2006

Diarrhoea - or was it?

Dr Grumble has had a tough week. In fact he has been working for 12 days non stop: a normal working week followed by a 168 hour week of medical 'take' when he has been responsible for the acute medical admissions and the sundry other acute medical problems of a large teaching hospital. During this time he has seen some 150 acutely ill patients and been responsible for many more dealt with by a vast array of constantly changing shift workers. In the first draft of this blog he accidentally typed 'shit' workers. Sadly, sometimes this might be true. But last week the junior doctors that supported Dr Grumble were excellent. Mostly anyway.

Does Dr Grumble make a difference or is he there just to rubber stamp and cover the backs of the managers in the process of clinical governance? Actually, he feels he has made a difference. Were any of the changes he made life saving? Possibly. Certainly, some of the changed diagnoses driven largely by the gut feeling of experience were important, very important.

But Dr Grumble doesn't want to crow about these. Not yet anyway. But he does want to tell you about the old man admitted with 'infective diarrhoea'. The care homes around Dr Grumbles hospital are privately run. The have a maximum of patients and a minimum of staff. This means that they cannot cope if there is any deterioration whatsoever. They don't seem to have GPs attached to them any more. We get a note from Matron (yes, they still have matrons in the private sector) describing some (usually exaggerated) symptom and the patient is bundled into hospital. Amongst these poor people are individuals that are dying - slowly. When they deteriorate they should be looked after and kept comfortable and not bundled into an acute hospital. The oldest we had was 105.

But back to the poor old man with 'infective diarrhoea'. Dr Grumble found him in a side room (to help with infection control). He had had no treatment. None of it seemed quite right. There's not much time to examine patients on the post-take ward round but Dr Grumble called for a glove and carried out a rectal examination. He could have got somebody else to do this but he wanted to make a point. It wasn't easy. The patient was embarassed because he was lying in a pool of liquid stool. It wasn't too pleasant for Dr Grumble either. There was no nurse to help. We don't always have a nurse on the round any more in the NHS. Dr Crippen will tell you where they have gone.

The diagnosis was made clear. There was hard faeces in the rectum. This poor man had constipation with overflow. This should have been dealt with in the home. The hospital should never have been bothered with this. And the hospital should have got the diagnosis right from the start.

Dr Grumble broke the news to the poor patient that he was constipated. "I know" he said. There it was. The diagnosis, as always or almost always, was there in the history. In a few days, when the nurses eventually get round to giving him an enema he will be better. High, hot and a hell of a lot was what we used to say. But things have moved on.

Dr Grumble sighs.