Sick Notes: True Stories from the GP's Surgery

by Dr Tony Copperfield

  I LIKE TO play a little guessing game with myself where I try to work out why a patient is here before he or she opens his or her mouth. It helps me to avoid being driven bonkers by the viral and emotional sniffles of the average surgery.

  So: elderly man hobbling in with sore foot in a slipper? Gout.

  Two teenage girls, one of whom says, ‘Go on...’ while the other stares at her feet? Morning-after pill.

  Try this one from the other day: a determined-looking woman, all but dragging a blushing, sheepish man behind her?

  No idea?

  Here’s a clue: he’s protecting his gonads in the manner of a defender facing a Ronaldo free kick.

  It was Mr and Mrs Meagles, and her opening gambit was, ‘He needs the snip, doctor.’

  Bingo! If only I was as good with the lottery numbers.

  ‘He’s not keen, but I’ve told him it’s that or no more… you know. Only, we’ve already got five kids and I couldn’t cope with any more.’

  I looked at the great inseminator, who was studiously examining the pale brown nylon carpet.

  ‘How do you feel about this, Mr Meagles?’ I said.

  ‘He doesn’t want it, but I’ve told him he’s having it and that’s all there is to it,’ said his wife. ‘Ignore him.’

  ‘Someone said he’d heard it was like having it cut off,’ said her husband, meeting my gaze temporarily, before developing a keen interest in the wall above my head.

  Bloody Richard Madeley. A while back he apparently said on some chat show or other that the pain from his vasectomy felt more like the doctors had chopped rather than snipped. Ever since then, men ‘requesting’ the same procedure will attend the surgery only if dragged there by the short and curlies.

  By implying that this simple operation could leave the average bloke an unwilling member of the No Member Club, Madeley gave men an excuse they really don’t need. They already had a long list of objections to trot out to dodge the scalpel – such as the concern that it might increase the risk of heart disease and prostate or testicle cancer.

  Wrong, wrong and wrong. In fact, there is some evidence that vasectomised men actually live longer than average, though this probably reflects the detrimental effect of having any more than 2.4 children swarming around you, rather than any magical benefits of the snip.

  ‘Look,’ I said, ‘there’s nothing to it. After a week or so, you’ll forget it was ever done.’

  He met my eyes again. ‘I just don’t like the idea of it,’ he said.

  ‘Who would?’ I said. ‘Any man who does like the idea of cold steel meeting warm scrotum needs a psychiatrist, not a surgeon. But grow up and stop whining and think about someone else for a change. Your wife’s done her bit – give her a break.’

  ‘I told you,’ said Mrs Meagles, with a note of triumph in her voice and a glint of fire in her eye. ‘You listen to doctor Copperfield, if you know what’s good for you.’

  I was warming to her by the second.

  ‘But what about… you know… will it affect whether I…’

  ‘For God’s sake man,’ I hissed. ‘We’re all adults. You mean will it affect your sex life? Yes, it will – for the better.’

  Which is true. What you lose in fertility you gain in spontaneity and safety. You can say goodbye to flailing around in the dark, not knowing whether you’ve grabbed a pack of condoms or your contact lenses, and you can stop panicking that an in flagrante attack of cramp in your partner is a pill-induced DVT.

  ‘Look,’ he said, with a sidelong glance at his wife. ‘How about if I just have one side done, just to see how it goes?’

  I sighed, and began tapping on my keyboard. For some reason, men don’t seem to have any of these problems requesting a vasectomy reversal. From a psychodynamic perspective, that’s probably because they see this as a restoration of machismo rather than a form of castration. Which is why, when they walk in with their new partner to request unvasectomising, they look pretty confident and relaxed.

  Or maybe it’s just that they know it’s not actually available on the NHS.

  ANOTHER BLOODY MEETING

  TUESDAY MORNINGS AT the pebble-dashed pillbox that is our branch surgery are never much fun.

  Firstly, I’m often the only doctor there and as well as looking after my own cases I get to provide second opinions for the nurse and to sign all her prescriptions.

  Judging by the number of antibiotics she doles out she’s a major shareholder in several pharmaceutical companies. I don’t have time to query them, I just sign ’em and send the happy punters on their way.

  A few skirmishes with the ASBO-toting crowd from the Staffordshire Cross estate and a couple of lunatic visit requests from the local nursing home set me right up for our Tuesday lunchtime staff meeting back at Bleak House. I arrived with enough time to spare to take a much-needed leak, grab a sandwich and wash my hands, not necessarily in that order. I certainly didn’t have time to check my pigeon hole for messages, urgent or otherwise.

  I dashed from the surgery door to the loo and, via a brief encounter with the wash basin and hand dryer, into the coffee room to find out which sandwiches the gannets had turned their noses up at. A grated yellow cheese and tomato sandwich (‘Reduced’), a prawn mayonnaise baguette that I knew from previous encounters would reset the bar as far as slime-based snack products were concerned and a plastic package containing a selection of tired lettuce leaves were on offer.

  It’s not like this on fucking Peak Practice, I thought to myself. I’ve been grafting like a navvy and I get to eat crap whilst listening to some berk from Berk Central prattle on about...

  Which reminded me, I had no idea what today’s meeting was about. Or who was presenting it. If it was my turn to lead off, it was going to be a disaster.

  I glanced up at the Big Board to check the week’s timetable. Out of the corner of my eye I caught sight of the ‘Recent Deaths’ section: two B-list Hollywood actors, a Russian ballet dancer, a Portuguese poet and a familiar name.

  Rebecca Bagnet.

  RASH HOUR

  ROUGHLY HALF OF the patients I saw yesterday were young children with sniffles, dragged along to surgery by their worried mums.

  I’d known it would be like this since seeing the front page of the local paper at the petrol station on my way in to work that morning.

  MENINGITIS HITS TOWN, it yelled, and I didn’t need to be Nostradamus to predict that everything would immediately go into meltdown – it always does after that sort of headline. The phone lines go bananas and GPs and casualty doctors are confronted with florid descriptions of children who are consistently ‘at death’s door’, dramatically failing to ‘keep anything down’ and invariably ‘burning up’.

  It was all depressingly familiar: welcome to the meningitis season!

  Considering that any individual’s chances of getting bacterial meningitis are pretty remote, an astonishing number of out-of-hours phone calls and emergency consultations result from mothers and fathers with the dread fear that their kid might be the next victim.

  By now, most people are surely aware of the ‘classic’ symptoms of meningococcal infection: the unholy triad of neck stiffness, a dislike of bright lights and a blotchy red rash which doesn’t fade when a glass is rolled over it. After all, every winter, well-meaning charities publish millions of leaflets advising parents and teachers what to look out for and when to seek help if they think a child is ill.

  Unfortunately, these textbook diagnostic clues are not the whole story. For starters, they tend to affect teenagers and older children, rather than toddlers. Plus, they don’t always all show up, and when they do it’s often not until the disease is in its later stages, when it can be too late: within two or three hours of the tell-tale rash appearing, for instance, it’s entirely possible that a hospital paediatrician will be in the Sister’s office breaking bad news to sobbing parents and offering them tea and sympathy. I have been there, done that and have the T-shirt: it’s a terrible thing, trust me.
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  The ‘stiff neck, rash and photophobia’ mantra is so ingrained into our minds that even GPs – many of whom have never seen a child with meningitis outside hospital – can quite easily dismiss the diagnosis in error purely because one or more of those symptoms is absent.

  But that’s not the worst part. The truth is that meningitis usually kicks off with ‘non specific’ symptoms like fever and vomiting. Unfortunately, just about every childhood infection starts exactly same way. And – contrary to public belief – there is no magic meningitisometer available to us by which we can distinguish, at this early stage, between a simple virus and something rather more catastrophic. So you can imagine the fun we have in the middle of a flu epidemic. We can’t send every feverish child up to hospital – it’s overloaded as it is. All we can do is hope mum remembers our advice to contact us again if junior gets worse, and accept that someone, somewhere is going to have to take the ‘My baby had meningitis and the GP said it was just a virus’ headline on the chin.

  Over my career, I’ve seen four cases – as far as I know – and none of them had a rash.

  I admitted three of them after the first visit, which puts me slightly ahead of the game, and they all made complete recoveries.

  I only caught a glimpse of the fourth, who just happened to be playing quietly in the corner of the bedroom while I examined her elder brother. She died in her sleep the next night. Awful.

  Each of my three survivors had a subtle early warning symptom that had me worried enough to send them in to hospital. One had freezing cold hands and feet despite a high fever, another looked pale and was unable to stand without help, the third had a blueish tinge to his lips and a slightly bulging fontanelle, the soft spot where the skull bones join together just above the forehead. These symptoms are pretty vague, but any doctor worth his or her salt will take them seriously.

  My three patients all looked sick enough to need admitting to hospital and they all got a potentially life-saving antibiotic injection while we waited for the ambulance to arrive. As a result, my credibility with the local hospital’s children’s ward was assured. For a time, local graffiti artists modified their handiwork to read ‘Copperfield is God’ – a nice change from the usual ‘knobhead’ stuff – and eminent paediatricians would seek me out at post-graduate meetings to congratulate me on my astute clinical acumen.

  Fourteen years later, the kid who’d had the freezing cold hands broke into my car and nicked my CD player.

  COMMUNICATION PROBLEMS

  MEDICINE IS ALL about doctor-patient communication, according to the experts.

  Mind you, these are ‘experts’ who run ‘consultation skills workshops’ at which one usually learns nothing except that anyone who uses the word ‘workshop’ without reference to light engineering is to be avoided.

  The fact is that doctor-patient communication is not the whole story, or even the biggest part of it, as the little drama of Barry and Sharon Varden showed.

  ‘Doc,’ said Barry the other week. ‘It’s the wife. She’s seeing double.’

  ‘Hmmm?’ I said. Most people who say they’re seeing double, aren’t, they’re just dizzy. ‘Are you sure?’

  ‘Yes, I’m absolutely sure,’ he said. ‘She can see two of me and she ain’t sure which one to slap. Plus she keeps falling over. And them tablets the other doctor gave her ain’t helped, neither.’

  I arranged for her to have her blood tested and started digging. What I uncovered was… interesting.

  Sharon suffers from epilepsy, and her condition is difficult to control.

  Until recently she took a 200mg dose of an anticonvulsant drug, carbamazepine, twice a day.

  Her neurologist wrote to us asking that her dose be doubled, so we rewrote her repeat prescription to issue a 400mg tablet, twice daily.

  The following week she saw a general physician at the same hospital.

  He told her to take three tablets a day, rather than two.

  Now, either he wanted her to move from 800mg to 1200mg, just after she’d been bounced up from 400mg (most unlikely, as raising anticonvulsant doses needs to be done very carefully indeed), or he wasn’t aware that the tablets had changed.

  I suspect the latter: he assumed she still had 200mg tablets at home, not 400mg, and thought he was raising her to 600mg.

  But assumption is the mother of all screw-ups. In fact, she’d already picked up a month’s supply of the double strength version, something she unfortunately neglected to mention to him; this meant he was actually trebling her dose in a matter of days.

  Why he wasn’t aware of the earlier change in dosage, I’m not sure. Maybe he didn’t have the neurologist’s notes. Maybe he did, but mis-read them. Maybe he only looked at Sharon’s medical clinic notes and not the neurology notes, thinking they weren’t relevant.

  Whatever, this was quite dramatic, to say the least. As I say, anticonvulsants are dangerous things: too little and they don’t work, too much and we’re talking toxicity. I usually ask patients to increase their daily carbamazepine dose by 200mg every Monday until they start to throw up or fall over. Then they go back to whatever dose they were taking the previous Monday and have a blood level estimated a few days later.

  Luckily, despite the sudden ramping up of her dosage, Sharon was still with us and at least things couldn’t get worse – at least, not until a psychiatrist showed up and decided she needed an antidepressant to cheer her up and, hey, it might even help her worsening giddiness.

  He gave her fluoxetine, better known as Prozac.

  And that was the cock-up that broke the camel’s back – if you’ll pardon a mixed metaphor.

  Carbamazepine, like most other drugs we prescribe, is broken down as it passes through the liver. Unfortunately, Prozac is broken down by the same enzyme system. So while the liver is busily dealing with the Prozac that Sharon’s just necked, more of the carbamazepine gets through unscathed. Net effect, another unintentional increase in Sharon’s already excessive dose. (Unintentional but entirely predictable, if only Dr Freud had been bothered to check the ‘Interactions’ section of his drug textbook. Most doctors know that every other drug in the world interferes with carbamazepine, so before handing over a prescription to a patient taking it we consult the British National Formulary. It’s there on page 642 of the current edition: ‘Plasma concentration of carbamazepine – increased by fluoxetine.’ In layman’s terms, ‘plasma concentration’ is the amount of the drug floating around in the bloodstream where it can do what it does.)

  No wonder Sharon couldn’t see straight: the lab tests I ordered showed that her plasma carbamazepine level was four times the ideal. She stopped taking the drug for a few days and her double vision, dizziness and loss of balance evaporated.

  So what’s my point?

  Communication breakdown about dose increase somewhere between neurologist and physician; then psychiatrist didn’t think about the carbamazepine/fluoxetine conflict. No one, apart from the neurologist, told her GP – me – anything.

  Except Barry, that is, who told me that his wife really was seeing double.

  Whatever the workshop people say, it’s when doctor-doctor communication slips up that things really kick off.

  FUNNY TURNS

  THE FIRST LETTER I opened in my morning post the other day was from a consultant dermatologist to whom I had referred a hatchet-faced old boot called Mrs Rudge.‘Dear Tony,’ it began. ‘Thank you for asking my opinion regarding this delightful lady’s…’ I put the letter down, rubbed my eyes and re-read that opening sentence. Delightful lady? Mrs Rudge? Then I remembered: it was a private referral (the ‘Dear Tony’ should have provided a clue). Mrs Rudge may indeed be ‘delightful’ in the sense that she has a valid Mastercard with a five-figure credit limit, but for an honest description I refer you to my opening line, above.

  At least if she ever demands to see the letter, it will be clear that the obsequious consultant knows upon which side his bread is buttered.

  Because you do kn
ow that you now have the right to receive copies of letters that your GP and consultant have exchanged about you, right?

  That doesn’t mean it’s a good idea to ask. Most of them will consist of educated guesses about diagnostic possibilities, the results of any ongoing investigations and the odd bit of banter. Mine might begin: ‘Dear Simon, I thought I’d waft this kiddie past you and see if your paediatrician’s syndrome detector twitches…’

  Letters about undescended testicles will invariably include the clause, ‘spot the ball’, or an oblique Peter Cook reference: ‘I have absolutely nothing against this young chap’s right testis; the problem is, neither has he.’

  So, yes, doctors’ letters can be fun. But, be warned, don’t read any unless you can cope with finding the words ‘multiple sclerosis’ somewhere in one about you.

  Everybody, but everybody, has a letter in their file that contains the abbreviation ‘MS’. It’s the inevitable result of telling a doctor about any episode that involved dizziness, numbness or double vision.

  When I was in my twenties, I developed a painful burning sensation down my left thigh. I was convinced I’d finish my studies in a wheelchair. I have never seen my medical record, but I’ll wager there’s a letter in there reading: ‘Narcissistic med student plonker with trapped nerve. Jeans two sizes too small. Thinks he has MS. Advised look up meralgia paraesthetica in textbooks and buy baggier trousers.’

  If there isn’t, there should be.

  You, too, will have a funny turn one day. Whether it’s a midsummer faint or a low blood sugar incident after skipping breakfast, it will probably be trivial but your GP will record it. The first thing to figure out about fits ’n’ faints is which diagnostic basket to put them into. There’s one labelled: ‘Funny turns – cardiac’ and others called ‘neurological’, ‘diabetic’ and ‘miscellaneous’.

  Assuming that your pulse is regular and you’re not an obvious drunk, he will write: ‘Funny turn – ?epilepsy ?diabetes ?MS’ (the question marks meaning ‘possible’). If you need a specialist opinion, the same list of possibilities will appear in your referral letter to confirm that they have been considered.