NHS Blog Doctor

Sick certificates

2009-11-03T22:15:00.005Z

King Andy's guide to faking a sickie

It has always suited governments to encourage the long-term unemployed to "discover" an illness and move on to incapacity benefit. The move is easily made, as GPs are a "soft touch" for a sick certificate. But while this move to incapacity benefit may please the government by providing a short-term "fix" for high unemployment figures, it creates an insidious long-term problem...

The Guardian, Tuesday 3 November 2009

Myalgic encephalomyelitis (ME) : science, quackery & mental illness

2009-10-21T18:13:00.000+01:00

The militant wing of the Myalgic Encephalomyelitis (ME) brigade broke out the champagne when a recent article in Science reported that a retrovirus had been found in 67% of ME patients compared to under 4% of the general population. Sadly, the study only involved just over 100 patients and is thus inconclusive...

The Guardian, Tuesday 20 October 2009

Public Stools

2009-10-06T07:17:00.002+01:00

Garderobe

A smartly dressed, middle-aged lady came in and sat down. Let's call her Angela. Angela was a child of the 60s, the decade of female emancipation. But, while other girls of her age were letting their hair down at Woodstock, Angela was still at school....

6 October 2009 The Guardian

The illusion of choice

2009-09-29T14:21:00.002+01:00

Last week, my ageing motorcar started making an odd noise. The service manager told me I needed a replacement camfleugal pin. He gave me a list of 10 suppliers. Which one did I want them to use? I don't know much about camfleugal pins. I told him to get it from where he normally gets them. The illusion of choice is important. Patients who need to go to hospital are now offered a "choice" under the government's much publicised "Choose and Book" (CAB) system. But how does CAB work in reality?

cont...

The Guardian 29 September 2009

GP boundaries

2009-09-22T15:53:00.002+01:00

Last week GPs were mystified when the health secretary Andy Burnham announced plans to abolish practice boundaries, which will leave patients free to register with any GP of their choice, regardless of where they live. But has the government thought this through? GPs are morally and contractually obliged, when medically necessary, to visit sick patients in their own homes: the elderly; the infirm; the terminally ill. It is the government that has previously insisted on predefined areas. It might be frustrating for a patient to find he cannot register with a particular doctor because he lives a couple of miles outside the doctor's area, but if you do not stick to the boundaries, a couple of miles soon becomes 20, and before long the doctor has patients in Manchester, Birmingham and Southampton. How are they all to be visited at home then?

There is a more insidious agenda.... (cont)

Roast swan and port

2009-09-15T10:50:00.002+01:00

BMA House

Dr Crippen: Is the BMA right to want to ban alcohol advertising?
I joined the British Medical Association almost accidentally, as did most doctors. I wanted to receive its journal, the BMJ, and, when I was a student, the association offered a good value "membership and magazine" deal, so I signed up. And you know how it is with direct debits; you never get round to cancelling them. But the BMA is not my "trade union", it does not consult me about my views and it is not authorised to represent my views.

The BMA's image is that of elderly medical crustacea who meet weekly to dine on roast swan, washed down with vintage port, before issuing yet another diktat about how less privileged folk should live their lives. The latest is that they want to ban alcohol advertising.

There are four teenagers in the Crippen household. Last week, yet again, we had the alcopops conversation. Yet again, I explained that if any of them were to drink a glass of neat alcohol, they would find it repugnant. Alcopops are a way of wrapping up alcohol to make it appealing to young, credulous teenage palates.

My 16-year-old son disappeared off to the small cupboard in the garage and returned clutching one of my two remaining treasured bottles of 1983 Chateau Palmer. "This," he said, "represents a transparent attempt by the French wine industry to disguise alcohol in such a way that it will appeal to credulous, middle-aged, jaded palates. This bottle is probably worth over £100. Why don't you sell it? At least alcopops are cheap. And," he giggled, "unpretentious on the palate."

Thus, as parents, we journey down the long and tortuous road of hypocrisy. I'm not a wine expert but there is no doubt that vintage Chateau Palmer slips down a treat, and I treat my remaining bottles with reverence. How can one compare alcopops to vintage wine? Vintage wine is "important". Alcopops are cheap and nasty.

But this cuts no ice with teenagers. Why should it? It's all booze. It's all alcohol, packaged to appeal to each and every age. A common problem I see professionally is teenage drinking. I am not convinced that stopping advertising and increasing prices is the answer. Setting a good example might be.

The medical profession itself does not have a good record as regards alcohol abuse. Perhaps, therefore, we speak with special expertise. The BMA's "roast swan and port" image is unfair, but I am uneasy that they chose, without consulting their members, to adopt such a prescriptive, parental role to society.

The Guardian, 15th September, 2009

Gordon brown is genuinely lovely...

2009-09-12T17:49:00.007+01:00

There have been some appalling rumours, originating from the blogosphere, but now circulating widely in the main stream media as well, suggesting that Gordon Brown is so seriously mentally ill that he has had to be treated with mono amine oxidase inhibitors. (MAOIs).

A generation ago, MAOIs had some currency. They were mainly used second line if tricyclic antidepressants had failed. They were said to be particularly good for depressives with severe anxiety related symptoms and social anxieties. They were not used often, even twenty years ago, for they had potentially dangerous side effects (high blood pressure crisis) if combined with certain foods. And it's not just "cheese and chianti"; the list is much longer and includes many commonly available "over the counter" medications. They are virtually never used now. I have only ever had one patient who took them. I would never initiate them, and I have not prescribed them for over twenty years.

4.3.2 Monoamine-oxidase inhibitors

(MAOIs)

Additional information interactions (MAOIs).

Monoamine-oxidase inhibitors are used much less frequently than tricyclic and related antidepressants, or SSRIs and related antidepressants because of the dangers of dietary and drug interactions and the fact that it is easier to prescribe MAOIs when tricyclic antidepressants have been unsuccessful than vice versa. Tranylcypromine is the most hazardous of the MAOIs because of its stimulant action. The drugs of choice are phenelzine or isocarboxazid which are less stimulant and therefore safer.

Phobic patients and depressed patients with atypical, hypochondriacal, or hysterical features are said to respond best to MAOIs. However, MAOIs should be tried in any patients who are refractory to treatment with other antidepressants as there is occasionally a dramatic response. Response to treatment may be delayed for 3 weeks or more and may take an additional 1 or 2 weeks to become maximal.

Withdrawal

If possible MAOIs should be withdrawn slowly (see also section 4.3).

Interactions

MAOIs inhibit monoamine oxidase, thereby causing an accumulation of amine neurotransmitters. The metabolism of some amine drugs such as indirect-acting sympathomimetics (present in many cough and decongestant preparations, section 3.10) is also inhibited and their pressor action may be potentiated; the pressor effect of tyramine (in some foods, such as mature cheese, pickled herring, broad bean pods, and Bovril®, Oxo®, Marmite® or any similar meat or yeast extract or fermented soya bean extract) may also be dangerously potentiated. These interactions may cause a dangerous rise in blood pressure. An early warning symptom may be a throbbing headache. Patients should be advised to eat only fresh foods and avoid food that is suspected of being stale or ‘going off'. This is especially important with meat, fish, poultry or offal; game should be avoided. The danger of interaction persists for up to 2 weeks after treatment with MAOIs is discontinued. Patients should also avoid alcoholic drinks or de-alcoholised (low alcohol) drinks.

Other antidepressants should not be started for 2 weeks after treatment with MAOIs has been stopped (3 weeks if starting clomipramine or imipramine). Some psychiatrists use selected tricyclics in conjunction with MAOIs but this is hazardous, indeed potentially lethal, except in experienced hands and there is no evidence that the combination is more effective than when either constituent is used alone. The combination of tranylcypromine with clomipramine is particularly dangerous.

Of course, the fact that they are rarely used now is not proof that Gordon Brown is not taking them but the chances that he is taking them are so low that I believe they can be discounted.

Gordon Brown is a poor communicator and, particularly after his disastrous appearance on YOU TUBE, there has been much speculation about his mental state, not least from Tory blogger Iain Dale. Brown is in the public eye and being the object of such speculation comes with the territory. And, as David Owen showed in Disease, demented, depressed, serious illness in heads of state, high office is no guarantee of health or sanity.

As we approach a general election the knives are out and the Tory spin machine moves into a higher gear. The image of a mentally ill prime minister taking drugs with dangerous side effects is too good to miss. What, though, is the other side of the story? Indeed, is there another side of the story? Possibly. In a thought provoking article, the DK reveals some inside information from a source close to the prime minister. The DK is no cuddly left winger and the fact the he publishes this information very much increases its credibility. So get the Kleenex out and read:

...although his politics are not mine, Gordon Brown is genuinely lovely...

The Devil's Kitchen

I do not believe for one moment that Gordon Brown is taking MAOIs, and I think this is a smear too far. But I worry about what marriage has done to the DK. Is connubial bliss turning him into an old romantic? Put the Kleenex away. Gordon Brown employed Damiann McBride and Derek Draper as professional smear merchants. Live by the sword, die by the sword.

Going to the Devil

2009-09-09T10:59:00.003+01:00

I rise briefly from my slumbers to spring to the defence of the Devil, whose most recent post has caused a furore and even resulted in one of his devoted followers saying:

A blog too far for me I'm afraid. I though most of your rants were good but the standard recently has been dropping and this is one is just shite. Deleting your RSS feed from Firefox.

Poor, timorous soul. It is precisely this sort of balanced writing that first attracted me to the Devil's Kitchen. Long may it continue. Connoisseurs of the Devil, like Dr Crippen, have long known that it is instructive to look at the time of publication of the DK's articles. Those written in the early hours of the morning, when the DK is well into his second cup of Ovaltine, are particularly rewarding.

++++++++++

And see the always reliable Daily Mash

Swine flu immunisations

2009-09-08T14:25:00.038+01:00

The government's chief commissar for immunisations, Professor David Salisbury, has said that nurses have a "duty" to be immunised againstswine flu. A poll by nursingtimes.net showed that 30% of respondents would refuse to have it. If the government is surprised at the number of nurses who will not have the immunisation, just wait to see what happens when they offer it to doctors. On the facts available to date, I will not be having it. Nor will my family. I will not be the only doctor taking this view.
In 1976, after a swine flu outbreak at Fort Dix in the US, a vaccine was hastily manufactured. It had to be withdrawn a few weeks later as it was causing serious neurological problems. Science has moved on since then, you may say. That could not happen now. But, if governments have confidence in the safety of the vaccine, why has Kathleen Sebelius, the US Secretary of Health and Human Services, felt it necessary to sign a document making federal officials and vaccine makers immune from lawsuits related to any ill-effects from the vaccine? Why has the UK government sent letters to neurologists asking them to be on the alert for neurological complications caused by the immunisation?
I did trust the government when it introduced an emergency vaccination programme for smallpox. But smallpox was a deadly disease and the vaccination was tried, tested and proven. The swine flu immunisation is being rushed out. It is of uncertain efficacy. It is to be given to prevent a disease which, as yet, is mild. The second wave of swine flu may be worse. I do not know. But I do know that, if the virus mutates to a more virulent form, the immunisation may in any case not work. We are in the run-up to an election. The government has to be seen to be doing something.
Every year, like obedient sheep, thousands troop into their local health centre to have a "flu immunisation". You may have had one last year. Did it work? I am amazed that there has not been a public outcry of people saying, "Excuse me, I had a flu jab last year and I still got swine flu."
Millions of trusting citizens may have the new swine flu immunisation. If something goes wrong, as it did at Fort Dix, we could have a major medical disaster.

The Guardian, 8 September 2009

Time for a blogging break...

2009-08-31T10:21:00.005+01:00

Dr Crippen takes a break

Dr Crippen is signing off for a while.

I'm not going to stop writing but blogging is time consuming and other opportunities are on the horizon. A general election is looming. NHS BLOG DOCTOR has not endorsed any political party but regular readers will be aware how disillusioned I am with this government (for which, optimistically but naïvely, I voted in 1997). The damage it has done to the NHS is, I fear, irreparable.

Political doctrine and political allegiances do not matter. It is the blind pursuit of political doctrine that is destroying the NHS. New Labour has much to answer for, but the roots of the malaise go back a generation to the early days of Thatcherism.

All our NHS really needed was the funding it is now getting. But instead we have gone along the lines of private business and, with that, vast amounts of money are being squandered on commissioning and billing and measuring and bonuses and, bizarrely, even advertising and PR.

Our government, to its cost, worships markets. Even the baled-out bankers are regrouping and once again are spinning the roulette wheels of the flawed money markets. And in the NHS, private providers, despite their very poor track record, are still the order of the day. The NHS as we know it is doomed.

Why is the NHS being privatised? Dr Grumble

What matters is the provision of a reasonable standard of health care for all UK citizens without regard to their status or income. We no longer have that. We have a two-tier standard of medicine just as we have a two-tier standard of education. What should the government do for the NHS? The Jobbing Doctor elegantly sums it up in one word:

Whenever I am asked what I think that the Government should do about the NHS, I generally say "Less".

Here we go again...The Jobbing Doctor

It is time for a break from regular blogging. Time for retrenchment. My close colleagues, Dr Grumble and the Jobbing Doctor, both of whom I commend, will continue to tell you how it is, how it was, and how it should be.

+++++++++

Does anyone know from which Lake District mountain Mrs Crippen took the snapshot?

iPhones and PDAs, manbags and Moleskines

2009-08-30T10:50:00.018+01:00

Dr Crippen had always liked gadgets. As a child, when gadgets had not been invented, I liked stationery. To someone who is and remains perpetually disorganised, stationery promises an end to chaos. The more you buy, the more efficient you think you will become. My pencil case was always the biggest and best. Even though there was little to put in either, I had both a wallet and a diary. They too bring with them the illusion of organisation. Of course, I remained (and remain) as disorganised as ever but the thought was there. Then, electronic PDAs arrived. I started the quest to find the perfect one. In my view, the best one by far - and still unsurpassed - was the Psion 3a clam-shell

Remember those? The software was unfussily excellent. You really could enter data efficently with two thumbs. There was a simple and practical ToDo program built into the diary. Exchanging data with a desktop was challenging (for me) but could be done. I used one for several years and then, one day, it died and new ones were no longer availabe.

As mobile phones came in, until they merged with PDAs, it was necessary to carry two gadgets. I used a number of Palms (liked them) and then one of the Hewlett Pakard IPAQs, (not keen) but most of them come with a hefty dose of Bill Gates, and Windows on a PDA is a nightmare.

Last year, my wife bought me an iPhone. A good present, because I would never have bought one for myself. The £35 a month is expensive. I do not use a mobile enough to justify that. But the basic software is good and stable and there is a wide range of excellent, good value programmes. To give an example, iOSMaps enables you to track your position on an Ordnance Survey 1:50 map. It works (I have just been using it in Snowdonia) and it's free

Sadly, Apple and their monopoly supplier in the UK do not look after existing customers. If you already have an iPhone, and wish to upgrade to the latest model, you are held to ransom. I cannot understand the commercial planning behind this. It makes me so cross that, when my contract runs out, I may take my business elsewhere. That aside, there is another problem with the iPhone. The diary or calendar programme is hopeless. So bad it is beyond belief. I can't be bothered with it.

As I am stuck with the iPhone and cannot use the calender program, after many years of electronic wizardy, I had no alternative but use two gadgets. But which one should join the iPhone? I decided to go back to the old fashioned method. Pen and paper. But in what form does one want "pen and paper"? I played with a Filofax for awhile but found them ugly, cumbersome and unpocketable. And the layout irritated me. The small ones are not well-enough designed to use as a wallet and the big ones don't go in a pocket. I need something to carry it all around in, but I will not buy a manbag or murse.

Er...no.

Finally, I have settled on a Moleskine. Joy. Moleskines have been around, on and off, for a long time and, if you want to buy into the PR, you can pretend that Picasso, Hemmingway and Chatwin used one just like yours. Moleskines are utter simplicity. No fuss. No ceremony. Brilliant. In the time it took me (before I gave up trying) to enter "Practice Meeting - lunchtime" into the iPhone Calendar program, I can write an essay in my Moleskine. The fact is, you simply cannot beat good old-fashioned pen and paper and, in reality, one can only but laugh at the time and investment lavished on failed attemtps to duplicate electronically all that can be offered by a pencil and back of an old envelope, never mind a Moleskine. The handwriting "recognition" program that does not work and the quirky cheap looking stylus that is no longer cheap when you have to buy a replacement are both risible.

Flybook Touch screen laptop £1478

I want one. I want one. I want to play with it. But it is of no conceivable practical use to me. On the other hand, although I do not feel the need to play with it, my Mokeskine does everything I want and I can carry it in my pocket.

18 Months Pocket PlannersSOFT cover £9.95

There is still a problem, though. Unlike the Flybook, the Moleskine does not have a built-in input device. So I have bought a pencil.

Ovarian cancer : GPs accused of murder by gutter press

2009-08-26T14:56:00.016+01:00

More of this at "The Natflap"

It's enough to make one wish that the Times did "bum and tit" on page three like their red top colleagues. Mind you, it probably won't be long before they do. The Times is not the paper it was, but I have read it ever since the personal adverts were on the front page. It's become a bit like the lavatory. Where else is there to go?

Today, on page three, the Times accuses me of negligence, incompetence and, in American terms, culpable homicide. What have I done? I have ignored the symptoms of women who have ovarian cancer.

As I drove into work, I could recall two patients of mine, both now dead, who had ovarian cancer. I pressed a few buttons on the computer. Over the last ten years, I had in fact had three women with ovarian cancer. One I diagnosed myself. She presented with pelvic pain and persistent bloating. The ultrasound I ordered diagnosed the problem. The second patient presented with general malaise, a borderline iron deficiency anaemia and epigastric tenderness. I referred her to the gastroenterologists. Her endoscopy was normal. Her colonoscopy was normal. Finally, a CT scan of her abdomen gave the diagnosis. The third woman presented with a DVT and pulmonary embolism. I sent her into hospital. The diagnosis of the underlying ovarian cancer was not found for another two months, by which time she had developed ascites.

So, as a GP, I have had three patients with ovarian cancer in ten years. That is it, and that is all. But those three cases make me something of an expert for I have seen ovarian cancer more often then most GPs. Let me hand you over to an eminent colleague:

Today's report is about ovarian cancer. There are around 6,000 new case of this cancer a year, and there are around 33,000 GPs in the country. So (pro rata) I would see one new one every 6 years. As I am an older, male GP, I would see even fewer - say a new case every 10 years. I would see about 2 women with new abdominal symptoms as week, so doing the maths, of all the people I see, 1 in 1000 will have early ovarian cancer. It is difficult to diagnose, the early symptoms are vague or non-existent, but we keep looking for it.

The Jobbing Doctor - Another Day, Another Report

As the JD says, it really is like looking for a needle in a haystack. Those well-meaning but naive people at the Ovarian Cancer Club actually sent me a Raising Awareness Pack. They probably send eggs to their grandmother too. These dear ladies may not be barking, but they certainly are barking up the wrong tree. They want to "educate" me about the early symptoms and signs of ovarian cancer.

Take tummy pain, increased tummy size (sorry about the use of the word "tummy" - too twee for me, but who am I to argue with the ovarian cancer club?), difficulty eating, feeling full, unexplained weight loss, indigestion, nausea, changes in bowel habits, and excessive tiredness. I see a dozen or more patients a week with one or more of these symptoms. It would be exceptionally unusual for any of them to have ovarian cancer. Most of them will not have cancer of any sort but, if they do have cancer, bowel cancer is far more likely. And I can give you a list of fifty conditions, all far commoner than ovarian cancer, that could be associated with these symptoms.

This does not mean that one should not be alert to the possibility of ovarian cancer. Of course one should be. But one has also to be more alert for the possibility of other cancers. Remember the old adage? "Common things happen commonly." Bowel cancer. Bladder cancer. Kidney cancer. And that other equally diagnostically challenging diagnosis, pancreatic cancer. I could go on. And on. The list is long. If these symptoms are the beginning of a cancer (and mostly they will not be) then bowel cancer is the more likely diagnosis.

The job of the GP is to sort the chuff from the chaff. There is hard evidence that we perform well as gatekeepers and there is hard evidence that we are more skilled at correct early diagnosis than hospital doctors. But then, we would be. That is our specialist skill. That is why it is dangerous to replace us with intermediate quacktitioners. That is why you cannot draw up a protocol to do our job.

It is much easier for the gynaecologist. We have already screened and filtered the patients he sees. Thousands of women present every day to a GP with the symptoms of abdominal bloating. Most of them will have nothing sinister. We recorded the fact that it became persistent bloating. We noted the borderline anaemia. We then organised the ultrasound, and the Ca125 and then referred the patient to Mr Smug, the gynaecologist. Mr Smug leans back in his leatherene swivel chair and asks the customer when the bloating first started, and she says, "Oh! I think about a year ago". Mr Smug glances at the ultrasound report and the Ca125 result and puts on his "concerned" look. Yes, I am caricaturing a little. But only a little. The retrospectoscope is an infallible instrument.

We do not need glossy and expensive "awareness packs" from misguided amateurs. Spend the money on finding a reliable screening test for ovarian cancer. A Ca125 may be helpful but it is not precise enough to use as a screening test. The best diagnostic test is an ultrasound, done both abdominally and transvaginally. Does every women who presents with abdominal bloating or urinary frequency need (or want) a transvaginal ultrasound? Of course not. So, until the definitive test arrives, judgements have to be made.

You may argue that GPs do get it wrong on occasions. If getting it wrong means not making the correct diagnosis the first time a patient presents with mild non-specific symptoms then indeed sometimes we get it wrong. But GPs "safety net" and say something along the lines of "If you are not right in a couple of weeks, come back." It's not a fob off. It is the correct use of time as a diagnostic tool. But you cannot explain that to the Daily Mail, who revel in their hysterical and exaggerated reports. "I went to the doctor 20 times and he said it was sinusitis" says ovarian cancer sufferer.

Cancer missed 20 times: Sue's horrifying story shows how bad doctors STILL are at spotting the silent killer

By ISLA WHITCROFT

Sue went to her GP in agony for over a year but was told she just had a sinus bug. In fact, it was ovarian cancer. Her horrifying story shows how bad doctors still are at spotting this killer.

Daily Mail

Thanks for that, Isla. Isla specialises in gutter medical journalism. Lots of examples of the kind of drivel she spouts can be found here.

And not only does Isla pen drivel about non-existant conditions such as fibromalgia, (the second commonest refuge of the malingerer) Isla is also part of the Daily Mail's cervical cancer hypocrisy - see this story in the "other" Daily Mail, then read The Lay Scientist : "Campaigning for and against the HPV vaccine in different countries simultaneously"

So, a memo to Isla Whitcroft's GP. Make sure you order a transvaginal ultrasound every time Ms Whitcroft presents with have a "tummy" upset.

We’re not homebirth wingnuts, we just want equal treatment

2009-08-24T18:33:00.008+01:00

You can never please some people.

The Australian government has recently, much to the chagrin of some doctors, introduced what is effectively a midwives' charter:

On the morning of 24 June this year, Nicola Roxon entered the House of Representatives and proudly introduced three bills that amounted to a revolution in midwifery in Australia. Midwives have been able to access some limited Medicare items since November 2006, but Roxon’s bills would dramatically extend Medicare and Pharmaceutical Benefits Scheme funding to midwifery and nurse practitioner services.

Roxon’s bill also gave effect to the growing push for collaborative care, making midwives more central in maternity care as part of a team-based approach. It can’t be said that doctors are particularly enthusiastic about the reforms, which is usually a good sign.

Bernard Keane - "Crikey"

You would think women would be out celebrating, and maybe some are, but it is not only our little song thrush above who is unhappy:

If Roxon was thinking this major reform might have attracted support from proponents of choice in “birthing”, as it’s now called, boy was she wrong. The reforms deeply offended homebirth advocates, partly by failing to extend Medicare funding to midwives providing services outside clinical settings like planned home births, and partly by requiring midwives providing homebirth services to have professional indemnity cover.

Home birth wingnuts shouting down major steps forward for midwifery - "Crikey"

Justine Cairns, an avid, blinkered Australian homebirther mounts a defence.

As part of this scheme a health professional must hold professional indemnity insurance in order to register to practise. Private midwives are presently unable to obtain such insurance because there is no insurance product available for them to purchase: collectively they form too small a pool to make it financially worthwhile for an insurer to provide that product.

We’re not homebirth wingnuts, we just want equal treatment

Got it in one, Justine. The problem for Justine, and our songthrush, and others (see the tragedy visited upon another eminent Australian home birther described in "Did your rapist wear a gown and mask?") is that Nicola Roxon has specified that the midwives must work in a proper clinical environment and, most of all, they must be properly insured. It seems it may be a criminal offence to offer a home birth service if you are not insured. At a stroke, that is the death knell for the Australian madwives. Like their English counterparts, they are so dangerous that no insurance company will cover them. This is not emotion, or prejudice. It is financial prudence.

Fruit and Nuts

2009-08-23T09:25:00.014+01:00

Steve Ford, of Nursing Times, advises me that the health commissars in Essex have earmarked another large wedge of taxpayers’ money to provide salaries and tee-shirts for a group of bright young things to go out into the community to tell people to stop smoking, to stop drinking and to start eating bananas. The Essex commissars intend to "ensure that all parts of the community are reached".

Excellent. This gives an opportunity for Dr Crippen to announce another NHS BLOG DOCTOR competition. Please write in not more than 800 words an account of the first meeting between one of these bright young things and either the Filthy Smoker or Mr & Mrs Kitchen. The competition is open to all, including the Filthy Smoker and the Kitchens

The Filthy Smoker has of course been holding the fort for the DK who, as aficionados will know, has just returned from his foreign nuptials and so is now ensconced in connubial bliss. Congratulations to both the Kitchens. Will marriage have a calming influence on the DK? Will his righteous indignation be tempered by a surfeit of uxorious pleasure? Not if his affectionate portrait of Alan Johnson is anything to go by.

Have a banana.

The Essex stuff is all plausible crap. Hard to criticise because you fall foul of the Vera Lynn syndrome. (Will someone please tell poor old Vera where Afghanistan is and why we are fighting out there?). Look at the Essex PCT website. It's the "healthy young thing" approach. "It's never too late to change" says Essex PCT. Trouble is, for most of people who look at PCT websites, it is too late to change. Please understand this. Most people have never heard of PCTs. They only hear of them when they start to research the failings in their health care. Why they are not getting the most modern treatment for their macular degeneration. Why they can no longer see a doctor about their cancer, unless they go privately. Why only private patients are getting Tarceva (see "A tale of two cancers"). Don't get lung cancer.

Have a banana.

It's not as easy at that. Lung cancer has been in the news recently because some arsy oncologist in Yorkshire has said that poor people have a worse prognisis from lung cancer because GPs do not bother to do Chest X-Rays on them.

All lung cancer patients in the UK are let down by the NHS. Because, having made the diagnosis, most chest physicians lose interest and pass the parcel. There are not enough oncologists who are interested in lung cancer and what interest there is is often confined to the private patients. I have just had an NHS patient with disseminated lung cancer who was kept on a medical ward in a DGH for six weeks with intractable bone pain. During that six weeks the consultant did not visit him once. He would have been better at home or in the hospice. At least his pain would have been properly controlled. When he did come home, I asked him if he wanted to see the Macmillan nurses at home. He said, "Oh! Please God, no. She was all over me. She kept stroking me."

Have a banana.

I've got news for arsy oncologist. Poor people get worse medical care than rich people. It's a universal truth throughout the world. If you are a chronically unemployed manual worker in late middle-age who has chain smoked for thirty years, you do not look at PCT websites and decide to go out and buy a banana. You do not know what the PCT is. You do not go to the doctor if you can possible avoid it and, when you do, you probably ignore the advice. Finally, when your lung cancer is diagnosed, the chest physician falls asleep with boredom. There is a long delay before you get the radiotherapy or chemotherapy, and your care is swiftly delegated to quacktitioners and hand-patters. You may well not get Tarceva. Depends where you live.

Have a banana.

It's a resource issue. We need more chest oncologists. We need more radiotherapy kit. We need more radiographers. We don't need to waste money on swine flu hysteria (see Nothern Doc's hysterical take on swine flu) Most of all, we don't need a bunch of bananas.

The DK and the Filthy Smoker become angry about the Essex commissar's approach because it is patronising and intrusive. I agree with them. But most of all, it is a waste of money. The hospital is on fire, burning to the ground. Why is no one doing anything? Where are the fire-fighters? They are in the local school lecturing children on the dangers of matches.

Have another banana.

Paranoid doctors

2009-08-23T08:02:00.002+01:00

The Jobbing Doctor is back from his holidays:

So I go back to work tomorrow, and one of the first things I will do is look at who has died in the practice whilst I have been away... I will hope that none of them have died unexpectedly, or due to any decision I have made. I will also look into my inbox to see if there are any letters from patients or relatives accusing me of incompetence or negligence. Or official looking letters from solicitors.

Every GP will say, if they are honest, that that is the first thing they do when they return from holiday.

Tomorrow is another day

Phew! I thought it was just me. So I can stop my medication. And thank God we don't live in America, or we might all be gettting a call from Dallas.

Fat slobs in the NHS

2009-08-19T18:38:00.009+01:00

Unfit fat slob

The NHS Health and Well Being Interim report has been published today. You may read it in full, here. The main stream media have, of course, had a field day. They have filleted the "tasty" bits without really taking the report as a whole.

Fat, unfit NHS staff top the sick league

More than 45,000 NHS workers call in sick each day — one and a half times the rate of absence seen in the private sector. The first national audit of staff habits has found that high rates of obesity, smoking, absenteeism and poor mental health are having a direct impact on the quality of patient care.

Sam Lister in The Times

Over 45,000 NHS staff call in sick each day

Annual NHS sickness levels are 10.7 days a year per employee - higher than the public sector average of 9.7 days and 50 per cent higher than the private sector average of 6.4 days.

Andy Bloxham in the Daily Telegraph

The gutter press seems to have ignored the report. The Daily Mail is concentrating on far more important matters.

Fury as paedophile pensioner is given Viagra on the NHS

Child safety campaigners have reacted with horror after it emerged that a convicted paedophile pensioner is still being prescribed Viagra on the NHS.

Anonymous Daily Mail reporter

Dr Crippen has actually read the interim report from cover to cover. First impressions?

This is yet another expensive NHS glossy brochure, costing God knows what (How many copies will they print? Can anyone advise on the likely unit cost?), crammed with pictures of fit-looking, happy, smiling, perfectly racially balanced NHS employees none of whom look like they have ever had a day’s illness in their life. Why does New Labour keep doing this? Why is this brochure full of fit, young, attractive people when it is supposed to be about poor health? Where are the pictures of the elderly West Indian cleaners? The Polish kitchen porters?

The interim report is a blunt instrument. There may be further and better information in the full report, when it comes, but I find it impossible to draw conclusions from this report as there is no detailed breakdown of which NHS employees are taking the time off. I rather doubt it is highly paid administrators and consultants. It's the workers - probably not thought photogenic enough to appear in the brochure (where is Hogarth when he is needed?) - at the bottom end.

Why would the staff want to have a sickie?

How many doctors replied to the survey? Few doctors admit to illness until they are close to death. If the illness from which they suffer is anything to do with mental health or alcohol, they may never admit it.

The NHS is the largest employer in Europe. Most of its employees are not highly paid professionals like doctors and senior administrators. The bulk of NHS employees are porters, cleaners, auxiliaries and so on. These people are just as essential to the NHS as are doctors and nurses, but they are rarely seen and never mentioned.

Who are these people? I can tell you about some (not all) of them.

One of the most difficult tasks facing those with mental illness is finding employment. The mentally ill tend to drift around minimum wage jobs in the catering industry or the bottom end of the NHS. Then there are the first generation immigrants, many with poor English. And the chronically unemployed in the 'last chance' saloon. Where ever they come from, what ever their back story, they work unsocial hours, often on shifts; they are poorly paid, frequently criticised and badly treated; and a lot of them are subjected to racial prejudice, which is alive and well in the NHS.

You did not need a multi-million pound glossy brochure to “discover” that these people have a poorer health record and worse sickness record than workers in the "private sector". Many of these people would not get a job in the "private sector".

Is there any meat in this report? Not as far as I can see. We need to look at each sub-group of employees within the NHS. Junior doctors and nurses are badly treated but the treatment they receive is wonderful compared to the treatment received by the kitchen porters and cleaners.

You certainly won’t solve this problem by asking doctors and nurses not to smoke in the same area as patients. You won't solve this problem by appointing more occupational health nurses and, can you believe this, more occupational health "nurse consultants" :

We welcome the increasing number of consultant occupational health nurses and their leadership of occupational health services in some places. We believe that such nurse consultants have a critical role to play in developing services and should increasingly be employed in all units. In the meantime, we recommend that there should be a regional consultant nurse in occupational health in each region to provide leadership to the function and advice to individual unit

New Labour's answer to everything these days is a glossy brochure and a "nurse consultant". More millions to be wasted on glossy presentation and plausible process. More large salaries to be paid to officious nurses to go round telling others how to do their jobs.

What is really needed is better pay, better incentives and better working conditions.

The coffee-shop feminists are back

2009-08-18T16:57:00.017+01:00

The scenario

Anne is in the process of giving birth, with assistance, to her second child. She has been in the second stage of labour for nearly an hour. She declined an epidural and has had a lot of pain. She is very tired, and becoming emotional. The baby's head is not coming down. She is being managed by John, an experienced consultant obstetrician, who she knows well. John thinks he has a good relationship with Anne. He delivered her first baby. He advises Anne that he needs to assist the delivery by using forceps. With her consent, he gives her a pudendal block and puts the forceps on the baby's head. He starts to pull gently and steadily and thankfully the baby's head comes down relatively easily. He reaches the stage where he knows that one more contraction, one more pull and the baby's head will be delivered. At this stage, Anne starts screaming and screaming, "Get those bloody forceps out of my vagina, now." She repeats the instruction several times. John looks at David, Anne's husband. He shakes his head.

Outcome 1
John takes the forceps out immediately as instructed. The baby's head does not come down. The baby dies. Anne is distressed and hysterical. She has to be sedated and the dead baby can only be removed under a general anaesthetic.

Anne and her husband sue John for negligence. They claim he should have realised she was emotionally overwrought and ignored her request in order to save the baby.

Outcome 2
John continues. He ignores Anne. Within thirty seconds, the baby is safely delivered. Mother and baby do well. David and Anne thank John for the wonderful care he provided.

Outcome 3
John continues. He ignores Anne. Within thirty seconds, the baby is safely delivered. Mother and baby do well. David and Anne thank John for the wonderful care he provided.

Two weeks later, John receives a visit from the police investigating allegations that he sexually assaulted a patient on the labour ward. The next day, a writ arrives from Anne's solicitors

Please consider these three outcomes. Let me say now that I have seen Outcome 2, in one variation or another, on numerous occasions. I have never seen Outcomes 1 or 3.

I have in the past crossed swords with a group of women who I have labelled "the coffee shop feminists". These are, in my view, a group of disturbed women who cannot distinguish between appalling medical care, and rape. Having over the years counselled more rape victims than I care to think about, I am furious that their appalling experiences should be equated to experiences in hospital, however bad. Some would say it is merely a semantic argument. What exactly is meant by "rape"? I do not accept that. No women who has been raped would be under any doubt as to the nature of the experience and, from the many emails I have received on the subject, most of them are shocked that anyone would dare to compare what they have been through with a bad experience in labour.

I discussed this in "Coffee shop feminists do not understand rape" I had many supportive emails from genuine rape victims and, sadly, a tirade of abuse from said "coffee-shop feminists". I cannot better sum up these extraordinary women than by quoting from a leading coffee-shop feminist site which says:

This blog is a safe and friendly space for feminists and feminist allies. Debate and critique are welcome where it is constructive and deepens analysis or understanding. Anti-feminist comments will not be approved. We get to decide what's anti-feminist.

The F-Word

Well, quite.

And now, out of the blue, an OT letter arrives under one of yesterday's posts. I quote it verbatim and in full. Sadly, in true coffee-shop feminist style, the author, having unleashed her tirade of abuse, is not going to hang around for the discussion. She says:

Dr John Crippen,  

I think it is horrible that doctors like you exist.  

The basic fact of this matter is that a woman has had something inserted into her body and that it was causing her discomfort and pain. Her repeated requests for the source of this discomfort and pain to be removed was IGNORED and she was further subjected to more pain and discomfort AGAINST HER WILL.  

Why is it so difficult for a educated man like you, who made it to medical school, understand that when a woman says "NO" and "STOP", people should listen?  

Are these words difficult to understand?   Has becoming a doctor given you such a God-complex?  

A "bad obstetric experience" is just that until it was administered without the consent of a patient. The point of the matter is that rape is not about sex or about penetration. It is the violation of a woman's body without her consent and the loss of control about what she wants or does not want. That is the cause of the trauma that a woman endures during rape versus a mere "bad sexual experience".  If the medical practitioner she went to was truly caring and concerned, then when the patient said "Please stop", the procedure would have stopped.  It is as simple as that.  

I find your reaction to harshly reprimand this woman who has spoken out about her feelings despicable and disrespectful.   As a man who is responsible for women's health and well-bring, calling a woman all kinds of names, labeling her and accuse her of mental illness just reminds me of the behavior people who justify rape.  I hope that this knee-jerk reaction to a woman's valid opinion is not indicative of similar abuses in your own practice where you disregard women's opinions and discomforts and trivial.  I will not return to this blog as I am truly disgusted by a medical practitioner with so little regard to women's comfort and well-being.

  I strongly am of the opinion that you are a shameful disgrace to the medical profession and I fear for your patients. I pray that my loved ones will never be among the unfortunate.

Mrs J. W. Brown

I will let you make up your own minds as to the fairness of all those remarks. I will let you conduct your own outcome analysis of the obstetric scenarios above. If you were Anne, in labour, which "John" would you want? Was John (1) negligent to stop? Was John (2) and (3) a rapist? If he was, then every obstetrician in the UK is a rapist too.

I have seen women in labour wards subjected to some awful treatment, and I do not condone the doctors and midwives who were responsible. But bad medical care, however traumatic, is not rape, and it trivialises the dreadful experiences of women who have been raped to suggest that it is.

Fraser Nelson loses the plot

2009-08-17T20:55:00.005+01:00

I am grateful to an NHS BLOG DOCTOR reader for pointing me at an article by the normally reliable Fraser Nelson. Fraser has penned an ill-judged and uncharacteristically inaccurate rant about thiomersal (aka thimerasol). One of the two swine-flu immunisations that the government has ordered contains thiomersal. Most of you have probably not heard of it. It is a preservative that has been used in vaccines with great success for over fifty years. Nobody would have heard of it now had a group of parents of autistic children not decided that it was thiomersal that caused their children to develop autism.

There is not one jot of evidence to support this belief and there is a vast body of evidence to the contrary. Thiomersal is safe. The chemical name of thiomersal is sodium ethylmercurithiosalicylate. So, yes, it contains a mercury related compound. But it is not mercury, any more than it is aspirin, and we are not all about to turn into Mad Hatters. As a commentator under Fraser Nelson's column points out, cholorine gas is poisonous but table salt (aka sodium chloride) is not.

It is deeply depressing that someone of Fraser Nelson’s intelligence can spout cod science of this nature and, frankly, it is even more depressing that his editor at the Spectator allows him to.

There is, however, one strong point that emerges from his article. It is clear that the government had not intended to inform the country that one of the two immunisations that will be available contains thiomersal. It is clear that the government did not intend to allow people to make a choice. I have no doubt that thiomersal in vaccines is safe and, were I going to have the swine-flu immunisation, I would have no problem having the one with thiomersal. But that is not the point. By behaving in this high-handed, secretive, non-consultative manner, about a subject that is known to be controversial, they have provided the loony-tune anti-immunisation brigade with ammunition.

It is important to have a debate about the value of the forthcoming swine flu immunisations but now there is a danger that the debate will be hijacked. There are many reasons not to have the swine-flu immunisation, but thiomersal is not one of them.

Swine flu news : update (12) - nurses are called upon to do their "duty"

2009-08-17T17:21:00.006+01:00

Nursing Times has carried out a survey to find out how many of their members would be prepared to have a swine-flu immunisation.

Overall 30% of survey respondents answered ‘no’ when asked if they would get immunised when the vaccine became available, compared with 37% who replied ‘yes’. A further 33% remained undecided and answered ‘maybe’.

Nursing Times

The Government’s chief Commissar for immunisations said that nurses had a “duty” to be immunised.

Nurses who opt to have the vaccine can expect to be given one of two products, both of which will require two jabs roughly three weeks apart. The majority of swine flu vaccine will be the adjuvant version manufactured by GlaxoSmithKline, which contains 4mcg of antigen. The second type, manufactured by Baxter, is a whole virus vaccine containing 7.5mcg of antigen.

You can write-off Dr Crippen as a curmudgeonly old fart if you like. I have not yet prescribed Tamiflu and, frankly, I rather doubt I will. On the facts available to date, I will not be having the swine flu immunisation. Nor will my family. I will not be the only doctor taking this view. And if the government is surprised at the number of nurses who will not have the immunisation, just wait to see what happens when they offer it to doctors.

Do you trust governments to make the right decision? In 1975 the soldiers at Fort Dix did, but then soldiers have to trust the government. It is their duty. In fact, I do trust the government to make the right decision on carefully thought out immunisation programmes, including MMR. And I did trust the government when, many years ago, it introduced emergency vaccination programmes for smallpox. But smallpox was a deadly disease and the vaccination was tried, tested and proven. That is not the case with the swine flu immunisation. It is being rushed out. It is of uncertain efficacy. It is to be given to treat a disease which, as yet, is very mild. The second wave of swine flu may be worse. Possibly so. I do not know. But I do know that, if the virus mutates to a much more virulent form, the immunisation may in any case not work. We are in the run up to a general election. The government has to be seen to be doing something. Hence the scientifically insupportable reliance on Tamiflu. Hence the need to rush out an immunisation programme.

Every year, like obedient sheep, thousands troop into their local health centre to have a "flu immunisation". Most of them have not got a clue what they are having. There is an air of camaraderie in the queue. Many who have had the immunisation are bitterly disappointed when, the next month, they get a bad cold. They really do not understand. I am amazed that there has not been a public outcry of people saying "Excuse me, I had a flu jab last year and it seems to have been a complete waste of time. I still got swine flu."

How can you trust a government that sends out secret letters to neurologists? I wonder if Tony Benn will have the swine flu immunisation? That's a thought! If millions - and children are to be targeted - have the new swine flu immunisation and something goes wrong, as it did at Fort Dix, we will have the worst medical disaster of all time.

Labour can win the next general election

2009-08-15T13:29:00.004+01:00

Elsewhere, Dr Crippen discusses the now real prospect of Labour winning the next general election. And, as always, the NHS is central to the arguments.

Shitting on your own doorstep

2009-08-13T17:26:00.007+01:00

According to "Dying for Coverage, New State Reports" (from Families USA, March-April 2008), "In 2002, the Institute of Medicine released a groundbreaking report, Care without Coverage: Too Little, Too Late, which estimated that 18,000 adults nationwide died in 2000 because they did not have health insurance. Subsequently, The Urban Institute estimated that 22,000 adults died in 2006 because they did not have health insurance. To find out what this means for people across the nation, Families USA has generated the first-ever state-level estimates of the number of deaths due to lack of health insurance. In Minnesota an estimated 1,100 people between the ages of 25-64 died from 2000-2006 because they didn't have health care. Across the US, the numbers who die from lack of health care is twice that of people who die from homicides."

There is worse news. Uninsured Americans are sicker, uninsured adults are 25 percent more likely to die prematurely, and Americans between 55 and 64 are at much greater risk of premature death than their insured counterparts.This makes lack of health insurance the third leading cause of death for the near-elderly, following heart disease and cancer.

Rob Shumer
University of Minnesota

+++++++++++++++

God knows, all is not well in the NHS.

If I were a multi-millionaire and/or insured up to the eye balls, I would be delighted to have any acute, serious medical condition treated in the USA. Acute medical care does not get better than the best of American medical care. If, that is, you can access it. If, on the other hand, you have a chronic medical condition, like rheumatoid arthritis, don't got near the USA.

Obama is tackling the festering sore, the national disgrace, of those millions of Americans who have no health care at all. They would love to wait a few weeks for a hip-replacement. Beats not getting one at all because you have no money. The uninsured Americans are from no definable constituency. They are poor, they are black, they are Latino. Few will speak up for them. This President is trying and he might, he just might, for the first time, get something done.

There is nothing like health care reform to get the fly-over zone, Ku Klux Klan supporting facist-hyena, boonie-bred American to sit up and take interest. The American right-wing, the insurance companies, big business, and all the racist red-necks are mobilising. They are misrepresenting the NHS, they are tarring it with the word "socialized". We have seen nothing like it since the "better dead than red" paranoia of the 1960s. And they are mobilizing rent-a-quote malevolent shits like Professor "please don't mention Imperial Collge" Sikora and Daniel Hannan to buttress their cause.

There is much good in both health care systems. But, if you are poor, unemployed and seriously ill, you are better off in the UK. We may not have got it right, but we do not have diabetics dying because they cannot afford insulin; we do not have teenagers dying prematurely of leukaemia because they cannot access treatment;

Hannan had his day in the sun, slagging off Gordon Brown in Europe. And very entertaining it was too. But it was a soft target, and the publicity went to his head.

What a smug, deeply unpleasant man he is.

Ronald Biggs - cruel and unnatural punishment

2009-08-12T14:45:00.007+01:00

Ronald Biggs has been condemned to spend the rest of his life begging for care from the NHS. Jack Straw, the Justice Minister said:

Biggs has shown no remorse for his appalling crime. I see no reason why the British taxpayer should continue to foot the bill for his medical care. He has been discharged from prison with immediate effect and will have care in the community like everyone else in this country.

Jack Straw

Bigg's son, Michael, was outraged.

"This is cruel beyond belief. Dad is doubly incontinent, cannot feed himself and is lapsing in and out of consciousness. He returned to this country to get the medical care to which he, as a British citizen, is entitled. Now he has been refused support in the community by a young girl who is not even medically qualified."

Local social services, who had been accused of ignoring the advice given by the team of doctors looking after Mr Biggs, said that the "key worker" appointed to the case, nineteen year old Kylie Smith, had three GCSEs, one of them in 'social care', and was thus well able to assess the needs of all her clients. She had personally seen Mr Biggs drink a cup of tea from a plastic cup with a feeding spout and, even though he spilt half of it, therefore concluded that he was not eligible for state help.

"There's plenty wot is worse off than him", said Kylie.

Dr Crippen is now advising his elderly, demented patients to rob a train and beat the train driver to within an inch of his life. They will then be entitled to free, long term hospital treatment and, at all times, one of a team of 'carers' will be handcuffed to them to attend to their every need.

Swine flu news : update (11) - the Tamiflu side-effect back lash starts

2009-08-10T15:52:00.004+01:00

Before you take that pill...

As expected, Tamiflu is beginning to cause problems. Dr Crippen has just been asked by an eminent man from the main stream media for his opinion. This is what I said:

I have not yet prescribed Tamiflu and I doubt I shall.

The John Radcliffe work is in line with our more anecdotal experiences though I have yet to see a child who is dehydrated.

I know of no hard evidence prior to this JR study showing that Tamiflu has dangerous side effects but, anecdotally, there is no doubt that it does have significant side effects and that these are particularly common in children. I am getting calls from people, both adults and children, who have obtained Tamiflu from the various “swine lines” that the government has set up, and who are getting mild to moderate symptoms which may be side effects. This is still not scientific proof. Remember that swine flu itself causes gut symptoms.

My biggest worry is this.

When a drug has got through clinical trials, passed FDA tests and so on, it is then deemed to be safe to go out on “general release.” Normally, you then build up experience of the drug over a few years. Occasionally, unexpected side effects, that did not emerge in clinical trials, appear. Remember TRILUDAN (terfenadine) the hay fever treatment that turned out to have cardiac side effects? Or Opren, the arthritis drug? Both drugs were heavily promoted by Big Pharma. With Tamiflu, there has been no gradual build up of experience in the UK. We are going from a situation in which it was rarely prescribed (in my practice we have 18,000 patients and ten doctors and none of us had EVER prescribed this drug until six weeks ago) to one in which literally millions, including children, may take it. If Tamiflu were a proven life-saving treatment for a life-threatening condition, then of course it should be prescribed. But that is not the case. Far from it.

The present position is that we are dealing with a common virus that, in the overwhelming majority of cases, causes a mild, self-limiting illness. As always, there are many other viral illnesses around. It is impossible therefore to diagnose swine flu with accuracy. The best you can say to someone is that “you may have it” or “you probably do not have it.” Tamiflu is of uncertain efficacy, but has been heavily promoted by Big Pharma. It is a very big earner. (Have you investigated the possibility of input from Donald Rumsfeld in the USA? There’s a can of worms if you have not) Tamiflu has also been enthusiastically adopted by the government because media hysteria (so, it’s your fault!!) has put them into a position where they have to be seen to be doing something and this is all they have to offer. Given that the condition is almost universally mild, given that Tamiflu is of uncertain efficacy (best reports on Cochrane review suggest reducing duration of symptoms by 18-24 hours, and there are no data about reducing mortality), given the diagnostic uncertainty and now given the increasing number of side effects, I am continuing to advise my patients not to take it.

I would not take it myself and I would not give it to my children. How then can I possibly prescribe it?

I find that nearly all patients are happy with this advice. I have not been pressured into prescribing it. Of course, a lot of people will already have obtained it themselves. Some of them have phoned in with side effects. Most, I suspect, have not had problems; or, if they have, they have not contacted me.

Finally, there is a huge problem with data. The government is logging all people who have been given Tamiflu as having swine flu and therefore the swine flu numbers are likely to be grossly inflated.

This is of course a personal opinion but is it is one based on a lot of experience.

Does anyone, apart from Donald Rumsfeld, disagree?

Lobsters : boiling water?

2009-08-10T15:02:00.005+01:00

As usual at this time of year, my mind turns to the best way to kill and cook a lobster. I have written about this before but never received a definitive answer. Despite (? because of) the bad weather we had a particularly good haul this year. My normal way to kill lobsters is to immerse them in warm tap water for a few seconds, and then drop them into boiling water.

The scientifically minded teenagers were not impressed. OK, it's tap water, not salt water, but what mechanism could I postulate and justify as to how this would reduce the lobsters' suffering? If, indeed, they do suffer at all. Difficult. Some sort of osmotic crisis due to lack of sodium in the water? I did not get far with that one.

I am not taken by the "deep freeze" method and nor were the teenagers. "Would it help to put you in the deep freeze for an hour or two before the guillotine?" they asked? Well, no, but I am more sophisticated and more warm blooded then a lobster. Many subscribe to a swift cut through the head with a knife. And it seems to work here. But I'm not so sure. A helpful teenager found me this video (not for the squeamish). Same method, but this time it does not work. You can tell me it's all reflex spinal neurological jerking. Maybe it is. But I don't think I could ever do that again.

I shall continue with the boiling water.

Swine flu news : update (10) Dealing with the "swine-line" fall out.

2009-08-05T10:18:00.010+01:00

Swine-line

Back to the grind. The weather does not matter as much now, though irritatingly it is sunny. I was on edge during the last week of the holiday, worrying about how hard it was going to be dealing with swine flu hysteria. I knew from emails that my partners were stressed and, from the detached safety of the North Wales coast, I followed the Jobbing Doctor's day to day experiences.

Monday was catch-up day. First, the bit that all family docs dread when they return from holiday. The unexpected deaths. This time there was only one, a previously fit lady in her late seventies who had been admitted with a strangulated femoral hernia and died a few days after surgery from an unexpected pneumonia. As I get older, these deaths affect me more. Perhaps it is my own ever increasing proximity to death. Perhaps it is the emotional maturity that comes with age. What ever it is, I was sad but also felt that sense of relief that all doctors feel, but few articulate, that this death was not something I could have prevented.

On Tuesday, yesterday, I was the duty doctor, which means I dealt with all the swine flu problems, most of which were generated by the stupidity of "swine-line". Like many practices, we find it easier to have a designated "swine flu" doctor each day. It makes for a hard day, but it allows the practice to function as all the other doctors can get on with the real job. I did an abbreviated morning surgery, finishing at eleven o' clock, did my own visits (only two, thank goodness) and then settled down to the flu calls. There were a total of 51 throughout the rest of the day. 11 of these were about other matters, but 40 were purely flu related.

I would not suggest that one doctor's experience during one day represents the precise situation nationally, but I bet it is not far from it. From my "mini-audit" of the calls received, I had the following impressions:

1. The overwhelming majority of people I dealt with were thoroughly sensible. They were not hysterical. They were not panicking. Mostly, they were asking entirely reasonable questions and they were all grateful for advice.

2. I decided right from the beginning that if anyone of any age was significantly ill, I was going to see them personally. I'm hopelessly bad at telephone medicine. I am not clever enough to make confident diagnoses over the phone.

3. Of the 40 flu related calls, I asked 18 of the patients to come down. Quite a few of them said, "But the "swine-line" says we should stay at home and not go out, and we don't like to bother you".

4. Of the 18 I saw, 14 had called the "swine-line". 9 had been "diagnosed" (sic) as having swine flu, and 5 had been told they did not have it. Assessing the patients myself, I had not the remotest idea of the rationale underlying "swine-line" decisions. Perhaps they throw a dice. Very soon I found a formula which I used with everyone. It went like this:

On the symptoms you have it is possible/unlikely that you have swine flu. I have no way of telling for certain and it is beyond me how these non-medically trained people on the telephone can live in such a world of certainty.

Every one to whom I said this was satisfied, and most said that they also could not understand how these decisions could be made on the telephone.

5. The 9 patients who had been diagnosed as having swine flu had been given the code number that would enable them to get Tamiflu. 2 patients had not yet got the Tamiflu and wanted to know if I would recommend it. 7 patients had got the Tamiflu but "were no better" and so were worried. 4 of the patients taking the Tamiflu complained of side effects, and two had stopped taking it. So what advice did I give:

I am uneasy about Tamiflu. It is not a cure for flu of any sort. There is some evidence that it may shorten the duration of symptoms for a day or so, but that is about it. I am concerned about the side effects of the drug and I would not take it myself. However, if you wish to take it, it is easy enough for you to obtain a supply.

This advice was clearly acceptable to all the patients. No one asked me to prescribe it, and no one said they were going to try to get some themselves. I was only tempted to prescribe it for 1 patient, and that temptation arose, not for medical reasons, but from my hatred of government micro-managing interference. A very sensible young mother, who has been my patient since she was in her early teens, has a fourteen month old toddler. The toddler had been unwell for three days and the "swine-line" had diagnosed flu, and "prescribed" Tamiflu. Mother got the capsules from the chemist. Toddlers do not take capsules so the chemist advised opening the capsules and putting the powder on a spoon. No success with that, either. So, reasonably enough, mother phoned the "swine-line" back and asked if she could have the liquid Tamiflu instead. She was told that it is government policy that the liquid medicine is only to be given to children under the age of one. When I come across "policy" like this, I reach for my revolver. I told the mother that, whatever it took, I would obtain the liquid Tamiflu for her.

Before going into battle, I took a detailed history of the child's illness. It was none specific other than a high temperature. Examining her, however, she had a bulging right otitis media. An ear infection. She did not need Tamiflu. (Yes, before anyone writes in, the ear infection could have been secondary to a flu virus. But this was not just the pink ear drums that you see in most hot children, the pink ear drums that "health care professionals" at walk in centres incorrectly diagnose as otitis media thus enabling them to build up a fraudulent, amoxicillin-rich relationship with the frequent attenders. This was a unilateral, bulging, greyish purple otitis media.)

6. The 2 patients who had been told that they did not have swine flu both could have done but had fallen at one of the protocol hurdles. Temperature not quite high enough or whatever. They did not have any physical signs other than temperature, but one (female) mentioned slight urinary symptoms, and a dispstick test was suggestive of a UTI.

7. One of the patients I phoned but did not see had come back from Spain with a high temperature last week and been put on Tamiflu by the swine-line. She also had bloody diarrhoea. My partner had sent off a stool specimen at the end of last week, and the result was phoned through today saying that she had campylobacter. By the time I spoke to her, the gut symptoms had resolved. She asked if the diarrhoea could have been a side effect of Tamiflu. I would have loved to answer that question in the affirmative (I know, I know - but at least I have insight into my psychopathologies) but reluctantly stuck to the truth.

8. The most difficult one was a mother who is 22 weeks pregnant, with a nine year old who had just completed a course of Tamiflu after a "swine-line" diagnosis. Should she have prophylactic treatment she wanted to know? The idiot's guide from "swine-line" says something like Relenza when you are pregnant, Tamiflu when you are breast feeding.

4.6 Pregnancy and lactation

Pregnancy:The safe use of Relenza during pregnancy has not been established.

In rats and rabbits zanamivir has been shown to cross the placenta. High doses of zanamivir were not associated with malformations in rats or rabbits and only minor alterations were reported. The potential risk for humans is unknown. Relenza should not be used in pregnancy unless the expected benefit to the mother is thought to outweigh any possible risk to the foetus.

Lactation: In rats zanamivir has been shown to be secreted into milk. There is no information on secretion into breast milk in humans.

The use of zanamivir is not recommended in mothers who are breast feeding.

Government policy may now be that we have moved on from general prophylactic treatment but as always government policy holds little sway in a consulting room with an intelligent pregnant woman asking entirely sensible questions. I would not take either drug if I were pregnant or breast feeding. I would take my chances with the swine flu. The mother agreed.

By the end of the day I had seen two patients in whom I thought there was a reasonable possibility of swine flu. I discussed Tamiflu with them, and they both decided not to take it, even though one of them had already obtained the capsules.

I have no idea, of course, what is going on with the thousands of people who are obtaining Tamiflu from the "swine-line" without involving a doctor. There will be some using it as a free ticket for a week off work. Each one who gets a positive "diagnosis" from the "swine-line" becomes part of the statistics. The statistics are therefore meaningless. I have, in one day, seen two flagrant misdiagnoses; thankfully, only an otitis media and campylobacter. No serious harm done. But soon there will be a disaster. There will be an avoidable death of a child from meningitis, pnuemonia or acute leukaemia and then the illiterate, protocol-bound automata front ending "swine-line" will be running for cover.

"There's a lot of it about, doctor." I'm sure there is. But, for the time being, it is mostly a mild, self-limiting illness which is best treated with fluids, rest, paracetamol or good old fashioned aspirin. We are told the "second wave" in the winter may be more serious. Who knows? I don't. The media, thank God, is getting bored, and moving on. The bankers' bonuses and Freddy Flintoff's ankles are much better copy.