‘I’m sorry, but it’s not going to happen.’
For the first time I saw Simon losing some of his cocky swagger – and he displayed his fear by becoming angry.
He leaned forward in his chair, his face reddening and his eyes bulging.
‘Look, you slimy little jobsworth, if you don’t fucking write me that referral I’ll smash your fucking head in.’
I tried to remain calm although inside I was absolutely wetting myself. I had rapidly lost control of the situation and all of a sudden there was a very real chance that I was going to get hit. A confused 90-year-old lady once took exception to my attempting to perform a blood test and tried to bite me. Fortunately for me, her complete lack of teeth helped avoid any serious injury. Other than that I had managed to avoid ever being harmed by a patient. My run of good luck looked to be coming to an end though and unfortunately Simon looked like he could be capable of causing me some considerable injury.
‘Look, Simon, you’ve got a court case to prepare for tomorrow and the last thing you need is another assault charge hanging over you.’
I would like to think that I spoke calmly and confidently to Simon, but I probably sounded like the gibbering wreck that I truly felt.
Simon looked me up and down as if weighing up his options. Clearly giving me a good beating was one of them, but thankfully instead he opted to storm out muttering ‘wanker’ audibly under his breath.
A few days later I read in the local newspaper that he had been found guilty of racially aggravated assault and given a three-year prison sentence.
Removing patients from lists
According to a recent report in the press, there has been an increase in complaints about patients being unfairly removed from general practice lists. If the tabloid reporting of the situation is to be believed, these decisions are left up to heavy-handed receptionists and managers, who act like overzealous doormen and will boot you ‘off the list’ if you dare tut at the nurse running late or are unfortunate enough to suffer from the wrong sorts of ailment.
The reality is that, for the vast majority of practices, taking someone off their list is a rare occurrence and a last resort. I had been a GP for several years before I even knew that such a drastic measure was an option. It only crept into my consciousness when a patient suggested he was going to forcibly remove my testicles from the rest of me and then encourage me to ingest them. His language was more colourful, but you get the idea. I had refused to write him a letter that stated he was too unwell to attend his probation appointment that afternoon and it hadn’t been a popular management decision. To be fair to him, he hadn’t carried out his threat despite the fact that my room is frighteningly soundproof and exceptionally well equipped with scalpels and tongue depressors. I was regaling the consultation details to an amused colleague when the practice manager overheard and felt it suitable grounds to ‘off list’ him. I was quite surprised; after years of working in A&E and inner-city GP practices, I had become well-accustomed to receiving threats and abuse at the hands of patients and fully accepted it as just being part of the job.
The only other patient whom we have threatened to kick off our list recently is a serial non-attendee. She makes appointments and then doesn’t turn up. When this had happened 10 times in an eight-month period, we explained that it wasn’t fair on other patients and that wasting her appointments was increasing waiting times for everyone else. When she missed two more appointments in the following month, we threatened to take her off our list. It is the only weapon we have in our armoury to try to prevent her recurrent non-attendance, but my dilemma is that I don’t really want to kick her out. She and her family have been at our surgery for years and they have a lot of problems, both social and medical. The practice and our staff are one of the few constants in her otherwise chaotic existence. I also know that by throwing her off our list, I am basically just passing one of our most difficult patients on to another of the local practices. That practice would be unlikely to thank us and could take revenge by off listing a couple of their problem patients who would in turn come to us. The tit-for-tat patient dumping could last for generations. So far we have kept her on our books, but if anyone has any good ideas for encouraging her to keep her appointments, they would be much appreciated.
Far more common than forcibly eliminating patients from practice lists is patients voluntarily removing themselves. Doctors are human and you will get on better with some than others. Often patients shop around until they find a GP or a surgery that suits them and this system seems to work well enough the majority of the time. If I ever reach the point where I am regularly removing handfuls of patients from my list due to minor complaints or disagreements, it is probably time to hang up my stethoscope and find a different job. If you as a patient have just been forcibly ejected from your sixth GP practice in as many months, it is probably time you booked onto one of those anger management classes everyone keeps telling you about.
Bravery
Standing up to mildly threatening patients who are larger and better at fighting than me is about as bold as I ever have to be at work. Whereas other emergency services have to valiantly risk their lives fighting fires or arresting dangerous villains, medics are rarely required to face great personal risk in the line of duty. However, just occasionally there is an exception.
Karla Flores was a Mexican seafood vendor who was minding her own business selling seafood at the roadside in her home state of Sinaloa. Like many parts of Mexico, turf wars between rival gangs often result in violent street battles and, unfortunately for Karla, she was inadvertently caught up in one such skirmish. After hearing an explosion, she was knocked unconscious. She awoke in hospital to discover that she had been hit by a live grenade shot from a grenade launcher. The grenade was lodged between her jaw and the roof of her mouth. It was a miracle that it hadn’t exploded, but it was very much live and could go off at any time.
Were the grenade to explode, anyone within a 10-metre radius would almost certainly be killed, and so understandably the Mexican doctors weren’t exactly falling over themselves to take on Karla’s care. Eventually four brave medics stepped forward and agreed to operate on her. In order to avoid the very real possibility of blowing up the entire hospital, it was decided that the operation would take place in an open field some distance from any civilisation.
Two anaesthetists, a surgeon and a nurse operated on Karla in an attempt to dislodge the live grenade. The team wore no protective clothing and risked their lives during the four-hour operation. It had to be done under local anaesthetic, which meant that poor Karla was awake for every second. It was a success. Karla has a scar on her face and has lost half her teeth, but she is now alive and well. To those brave Mexican medics, I salute you. You are much, much, much braver than me!
Amazingly, Karla Flores isn’t the only person who has required the surgical removal of live ammunition from her person …
Foreign bodies
… According to urban legend, an old World War Two veteran was admitted to a London hospital with a live artillery shell lodged up his rectum. He had apparently been struggling with large haemorrhoids, the worst of which would hang down and get stuck on the seam of his underpants. In order to rectify this nuisance, the resourceful old chap would use an old artillery shell he had lying around to push the haemorrhoid back up into his rectum. This technique worked well for some time until the shell got stuck and he had to hobble to the local emergency department for it to be removed. It was only when the doctor was about to stick his fingers in the gent’s rectum to remove the shell that he casually mentioned that the shell was still live. Apparently the bomb squad were called and they constructed a protective lead box around his anus and then defused the shell while it was still up his bottom.
For most of us, the idea of placing any sort of foreign object up our anuses is objectionable, but it is in fact a surprisingly common A&E presentation. So much so these days that it may barely raise a snigger from your seasoned e
mergency medics. However, there is no getting away from the fact that everyday household items stubbornly wedged in a rectum make for fabulous X-rays. There was a time when copies of these precious X-ray films were kept hidden away in the secret drawer of the head radiologist, but with the advent of the internet, we are all now just a few clicks away from being able to enjoy their irresistible attraction. My personal favourites are:
1. A key (I’m always losing mine, but hopefully not there)
2. A torch
3. A mobile phone (apparently there were several missed calls before it was removed)
4. A jar of peanut butter
5. A handgun
6. A light bulb (like a eureka moment, but in reverse)
7. A pint glass
8. Cement (it went in as liquid, but didn’t stay that way for long)
9. A perfume bottle
10. A vibrator and a pair or salad tongs (when the vibrator got stuck, rather than bother the busy A&E staff the patient decided to remove the dildo himself using a pair of salad tongs … until these got stuck too!)
Retrieving the gerbil
Before finally leaving the essential medical subject of funny bum stories, it would be a travesty not to mention the marvellous story of the two gents who ended up in the severe burns unit of a Salt Lake City hospital.
As part of their foreplay, Eric and Andrew frequently enlisted the aid of their pet gerbil Raggot. Eric inserted a cardboard tube into Andrew’s anus and then slipped Raggot in. Normally Raggot would make his own exit, but on one occasion he refused to leave the relative comfort of Andrew’s back passage. While peering into the tube, Eric decided to strike a match, hoping that the light might attract Raggot and lead to his departure. Unfortunately the match ignited a pocket of intestinal gas and a flame shot out of the tube setting fire to Eric’s hair and severely burning his face. Raggot the gerbil was also set alight and with his whiskers and fur ablaze went on to ignite a larger pocket of gas further up the intestinal tract. The resulting explosion propelled poor Raggot out of Andrew’s anus like a cannonball. As well as second-degree burns to his face, Eric suffered a broken nose from the impact of being hit directly in the face by a rocket-propelled gerbil. Andrew suffered first- and second-degree burns to his anus and lower intestinal tract. The extent of Raggot’s injuries were not documented.
The chemical cosh
I hadn’t known Stan before his dementia set in, but by all accounts he was a placid soul. His wife Eileen described him as a devoted husband and father who wouldn’t hurt a fly. The Stan before me now was very different. Most of his time was spent passively in his chair mumbling incoherently to himself. At other times he became agitated and angry and struck out. He rarely recognised his nearest and dearest, and the previous week in his fear, frustration and confusion, he’d hit his wife Eileen with his walking stick. Eileen was devastated. She kept telling me that the real Stan would never hurt her and would be mortified if he could comprehend the consequences of his actions. Eileen’s love and commitment towards her husband never ceased to amaze me – it took a lot for her to ask me for help. This particular morning she was in floods of tears as she requested something to sedate him. Her biggest fear was that unless his aggression was controlled she would end up having to put him in a nursing home, which, in her words, ‘would break both of our hearts’.
I read recently that one in four patients with dementia are being prescribed antipsychotics in order to sedate them and control difficult behaviour. Some have interpreted this as carer laziness, believing that carers don’t want the inconvenience of actually looking after people with dementia. Eileen is often distraught and exhausted but never lazy. She is a devoted wife who wants to try to care for her loving husband who has been transformed beyond all recognition by the dementia caused by his Alzheimer’s disease.
Prescribing an antipsychotic is not something I take lightly and it was not my first course of action. We had tried normal antidepressants and also non-pharmacological techniques such as keeping good lighting and getting more help in. Antipsychotics really are a final resort. They are strong drugs with potential side effects and I spent some time talking through the possible pitfalls with Eileen. We decided to start with a low dose of quetiapine. This antipsychotic is not licensed for dementia care, and may well increase the risk of him having a stroke, but with Stan, I believed it to be the right decision.
Dignity is a word that is now regularly associated with regard to caring appropriately for the elderly and some relatives have complained about antipsychotics robbing their elderly relatives of their dignity through over-sedation. Decisions on whether to prescribe the drugs or not are a delicate balancing act and each case has to be looked at individually. Antipsychotics are not used to treat people whose dementia is at an early stage. They won’t be thrown down the throats of people who have misplaced their door key or forgotten a dental appointment. They are prescribed for agitated, disturbed patients during the last stages of this awful disease.
As always, when I’m making these difficult decisions, I resort to the simple question of ‘What would I want if it was me?’ If I was suffering with advanced dementia and striking out at my family, would I want to be chemically coshed with an antipsychotic? It might sedate me and I might even die sooner as a result, but wouldn’t that be better than the painful indignity of confused aggression directed towards the people I love and who love me?
Medical science
‘Dr Daniels, I’ve decided I want to leave my body to medical science.’
‘Oh right … okay. Is that the only reason you’ve come to see me today?’
Donald clearly sensed my general lack of excitement, and he looked more than a little disappointed.
‘I’ve been thinking long and hard about this, Dr Daniels, and I want medical science to benefit from my death. A cure for cancer could be discovered thanks to experiments on this very body,’ he proclaimed proudly, patting his beer belly. ‘What a legacy that would be to leave for the human race.’
‘Well, yes. Erm … thanks very much for that,’ I managed to muster, trying not to give away my feeling that Donald had a slightly over-inflated view of his potential value to medicine. I wasn’t convinced that the corpse of a retired used-car salesman from Liverpool was necessarily going to unlock the secrets of eternal health. However, despite the slightly narcissistic nature of his offer, his heart was in the right place.
His wish made me think about the poor people who had donated their bodies to my medical school. Perhaps they too thought that their remains would offer great benefits to the world from which they had departed. Little did they know that instead they were being left mercilessly in the hands of a horde of incompetent first-year medical students. Every Thursday morning we would prod away at bits of body with very little clue as to their anatomical whereabouts, often while nursing a terrible hangover. Looking back, I wonder quite what I gained from the dissection experience. It did help desensitise me early on to the brutality of being faced with a dead body, but I always found it easier to learn my anatomy from the anatomy colouring book rather than from poking around inside real dead people. I just hope that a few of my more studious colleagues achieved greater enlightenment and inspiration from the experience.
On reflection I decided that Donald deserved more encouragement for his decision: ‘I think it’s really great that you are willing to donate your body to medical science, Donald. Well done you. Are you on the organ donor list too? Wouldn’t it be amazing to have one of your organs live on in someone else’s body and keep them alive when you are no more.’
‘Yeah, I thought about that, Dr Daniels, but I’ve had to say no on that one.’
‘Oh, why’s that?’
‘Well, what if my organ went on to help someone who I didn’t agree with?’
‘What do you mean?’
‘Well, what if part of my body was given to a terrorist or a suicide bomber or something? I wouldn’t want that.’
‘I think a blow
n-up suicide bomber would probably need a little more than one of your kidneys to keep them alive, Donald.’
‘Well, yeah, but you know what I mean. What I’m saying is that I would want some sort of clause on my donor card to say that my organ wouldn’t go to a religious extremist or a paedophile or someone like that.’
‘Isn’t being an organ donor about just helping someone else regardless of who they are? It’s about giving a complete stranger the gift of life. A stranger to you – but for someone else, a beloved father or daughter or wife. Through your generosity, you could extend someone else’s life for potentially decades to come.’
Donald paused.
‘I can sort of see what you’re saying, Dr Daniels, but I just couldn’t die peacefully knowing that one of my organs could live on in a Manchester United fan.’
Gastric bypass
‘It’s this gastric band. It’s not working. Something has to be done, Doctor!’
I’d never met Donna, the woman sitting in front of me, before, but I recognised her. Every morning I pop into the local Tesco Express near my surgery to grab a sandwich for lunch. Normally this task is carried out in a foggy blur of early-morning grogginess; I rarely notice my fellow shoppers. However, today had been an exception. And now, the patient facing me in my office, I realised, had been in front of me in the check-out queue that morning. She had caught my attention because she’d bought herself an entire chocolate cheesecake for breakfast and proceeded to tuck into it even before she’d left the shop. Please don’t think that I am some sort of evangelical health-food fanatic; chocolate, cheese and cake are three of my favourite things. A chocolate cheesecake is a thing of great splendour, something in which I have indulged on many occasions, but this was 7.45 on a Monday morning. Who eats a chocolate cheesecake for breakfast?
Further Confessions of a GP (The Confessions Series) Page 14
