I repeated his question, playing for time. ‘So… they all said it was… in your mind? And now you… you want to know exactly what somatisation disorder is?’
At this point, almost involuntarily, I screwed up my eyes. I was reminded of an incident from my childhood when I spilt Ribena on my mum’s new carpet. A reasonable strategy at the time seemed to be to shut my eyes and pray that God might magic it all away. I’m an atheist, and I suspect that, even then, I didn’t really believe in God – but I was prepared to, especially if He was good with Ribena stains. Maybe, just maybe, when I opened my eyes, Mr Nickleby would have gone. Then I wouldn’t have to explain that somatisation disorder, which had so gloriously usurped That Which All The Other Doctors Said Was In His Mind, meant that it was all in his mind.
‘Dr Copperfield, are you OK?’
‘Oh, just feeling a bit woozy.’
‘OK, look doctor,’ he said, genuinely concerned. ‘Don’t you worry. I’ll book another appointment.’
And with that, he was gone.
HEART FAILURE
I MENTIONED HEART FAILURE earlier (it was one of the many illnesses suffered by Mr Endell, the elderly and distressed chap who suffered multiple inhumane frustrations at the hands of the hospital).
At least once a week, I find myself discussing this condition with a patient or relative and finding that they haven’t a clue what it actually means.
Yesterday’s contestant was Tom Traddles, who doubles as my trusty car mechanic. He was suffering from the classic symptoms: breathlessness on exercise, ankle swelling and profound tiredness.
‘Heart failure?’ he said. ‘Yeah, that’s when the coronary wotsit fails and the heart packs up, innit? And then you’re brown bread, ’cos your heart’s stopped.’
Not even close: congestive cardiac failure is not a synonym for cardiac arrest, the correct technical term for the situation Tom outlined; it is a medical condition in its own right and is the commonest reason for urgent hospital admission in the over 70s.
At medical school, I endured lectures about left heart failure, right heart failure, congestive cardiac failure, pure pump failure, low output heart failure, high output heart failure, third heart sounds, fourth heart sounds, HOCM (pronounced, amusingly, ‘hokum’), COCM (‘cokum’), cardiac asthma and something known as ‘Cor Pulmonale’, which I swear was the name of my great aunt Jessica’s bungalow in Blackpool. To be fair, even I find it confusing, which may explain why apparently only three per cent of ‘persons in the street’ have much understanding.
Put very, very Ladybird Book of Internal Medicine simply, heart failure results from heart muscle damage caused by prolonged high blood pressure, a previous heart attack or, in very unlucky young folk, a virus. The damaged heart is unable to pump as efficiently as it should. During exercise it cannot increase the amount of blood delivered to working tissues, clear excess fluid from the lungs or pump it back up from parts of the body nearest to the ground, which, unless you’re bed-ridden or a three-toed sloth, would usually be your ankles, hence the swelling.
A while back, the British Heart Foundation produced a graphic advertising campaign featuring an actor fighting for breath with his head in a polythene bag. If you ask anybody who’s in a position to know, this is exactly how a cardiac failure patient with waterlogged lungs feels. Moronically, the Advertising Standards Authority pulled the ads because the images might encourage ‘copycat’ behaviour.
Heart failure, at least in the early stages, is treatable. Combination drug therapy reduces breathlessness, cuts limb-swelling and improves exercise tolerance. Once in a while, there’s a treatable underlying cause such as an overactive thyroid gland, anaemia or an irregular heart rhythm. So if granny’s puffed out halfway up the stairs, her pulse is racing and her ankles are the size of tree trunks, a visit to her GP might be a wise investment of half an hour of her time.
I wanted to get Tom into Outpatients quickly for an echocardiogram – an ultrasound test which determines how much blood the heart is pumping.
This is where my frustrations began. As we know, if he’d been suffering from a suspected cancer he would have been in within two weeks, whether he needed to be seen that quickly or not, in order that the government could issue press releases about cancer waiting times. But although congestive cardiac failure is in many ways more serious than a lot of cancers, Tom has zero hope of being seen within two weeks. In fact, I doubt I’ll get an echo done on him within the next eight to ten weeks – valuable time when it comes to identifying and alleviating a pretty unpleasant condition, leaving him suffering needlessly in the interim. Scandalous? You may think so. I suspect the trouble is that cardiac failure is not a sexy topic, as it primarily affects people in the last few years of their lives. The Heath Secretary gets no brownie points for announcing schemes to combat it, and the do-gooders rattling tins outside Sainsbury’s cannot compete with charities that fund research into conditions that make grown men go dewy-eyed, such as childhood leukaemia: they’ll put their hand into their pocket for their little Princess, but not for their dear white-haired old mum.
Perhaps it’s simply the use of the word ‘failure’ that needs addressing: let’s change the name of the diagnosis to ‘reduced cardiac success’ and see if that makes any difference.
WHY MEN ARE BETTER THAN WOMEN AT DEALING WITH PAIN
‘IT’S OFFICIAL,’ I said. ‘It says here that there is a difference between the sexes after all.’
We were waiting to begin our Monday meeting. I was flicking through the newspaper, Dr Emma was diligently reading the agenda and Sami Patel was filling his face with Hob Nobs (this is my third or fourth attempt at product placement – I hope McVitie’s are reading).
‘Tell me about it,’ he said, spraying crumbs everywhere in the process. ‘Women look terrible with moustaches, for a start.’
Dr Emma took a more mature line. ‘What’s the difference?’ she said. ‘Apart from the obvious?’
‘According to this report by the Chronic Pain Policy Coalition, whoever they are, you lot feel pain more than we do and you cope with it less well, too.’
‘Yeah,’ said Sami. ‘So let’s have no more of that guff about women being designed to endure the pain of childbirth or that rubbish about man flu. Our pain is real, do you hear? Real.’
Dr Emma snorted and went back to the agenda. Sami grabbed another Hob Nob and I read on.
According to the coalition’s spokeswoman, GPs haven’t noticed that men and women behave differently – a statement so nonsensical that it actually gave me a headache.
There are at least a dozen important things that a patient can tell me about their pain. Getting these details from a man is like pulling teeth, but a woman can sit down and rattle them off without so much as a pause for breath. And I have noticed this difference.
Mrs Westlock can tell me where it hurts, when it hurts, what brings it on, what makes it worse, how long it lasts and what makes it better. These diagnostic nuggets whizz past so quickly that I barely have time to write them down.
But asking Mr Westlock to describe the pain he’s in is a complete waste of time. He almost certainly won’t have the vocabulary and I’ll have to resort to putting words in his mouth: ‘Would you say it was a sharp, stabbing pain or is it more like a dull ache? Does it build up and then fade away, or is it pretty constant? How about when you move; does that makes it worse or better?’
‘I dunno Doc, but I’ll tell you one thing ...’ Here he will pause for effect, as though he were about to divulge the combination for the bullion vault at the Bank of England. ‘It hurts like buggery.’
When faced with a bloke in pain it’s usually better to ignore the words and check out his body language. Pointing to where it hurts with a single finger is manspeak for ‘sharp and stabbing’. Waving the palm of the hand over the abdomen means ‘stomach cramps’ and clutching a fist over the chest means, ‘It’s not really indigestion and I should have dialled 999.’
Brain scans apparently
show that when men are in pain – typically created by having their arm stuck in a bucket of iced water for an extended period – the area concerned with analysis and problem-solving is the most active. When women are subjected to the same painful stimulus it’s the limbic system, the part of the brain concerned with emotional responses, that kicks into overdrive.
When men are asked to forget how annoyed they feel about being in pain and to focus more on the unpleasant sensation itself, their level of pain reduces. This doesn’t happen in women; it’s as if they can’t divorce the emotional from the physical aspects of discomfort.
Consider these real world examples, two painful conditions with no apparent physical cause – fibromyalgia and irritable bowel syndrome. Both are much more common in women than men and don’t get better if treated with standard painkillers. But they often improve if the patient is treated with an antidepressant.
Drugs such as ibuprofen and paracetamol are said to be less effective for women, not because they work differently in men but because they have no effect on the psychological aspect of pain.
But men don’t have it all their own way. A woman is three times more likely to have her recurring headache correctly diagnosed as migraine and treated appropriately. Perhaps this is because migraine is best diagnosed by a careful analysis of the patient’s description of their symptoms, and women are better at delivering that analysis. A chimpanzee with a clipboard could get the classic history of a one-sided thumping pain, triggered by stress, tiredness or caffeine, accompanied by nausea and preceded by a bit of visual blurring, from a woman. All it would get from a bloke with the same headache would be, ‘I’ll tell you one thing, Cheetah, it bloody hurts.’
Things might improve after some aspirin and a nap in a quiet dark room. For the chimp at least.
WHAT IS IT WITH PARAMEDICS AND ‘INFORMED CONSENT’?
THEY SAY PEOPLE are funny, but I prefer the term ‘mad’. I had cause to reflect on this earlier in the week as I was confronted in our waiting room by a father carrying the limp form of his young child.
Imagine you have a six-year-old daughter, and you treat her to a KFC takeaway. Let’s further imagine that while gorging herself on a family-sized bucket, your daughter gets a chicken bone stuck in her throat and starts choking.
Now, what would you do?
Do the numbers ‘999’ figure anywhere?
Well, when that all happened to little Sophie Wackles, dad didn’t do the obvious. Instead, he carried her a quarter mile down the road to Bleak House and stood there in the doorway like the Creature from the Black Lagoon holding the lifeless remains of another victim.
Luckily, it didn’t take us long to realise that the drooling and rapidly deteriorating kiddie needed to be shifted to a brightly-lit room staffed by girls and boys who had paediatric laryngoscopes and weren’t afraid to use them.
So we rang 999 for those who are clad in green and first on the scene. I refer, of course, to our esteemed friends and colleagues the paramedics.
To be fair to them, they were with us inside five minutes. A good start – no time to lose, you’d have thought. A&E here we come, blues and twos, the whole thing.
Not so. The next thing I heard wasn’t the squeal of gurney wheels on a laminated floor and the flap flap flap of the waiting room door as it caught the breeze of the departing stretcher. It was, ‘Hello, Sophie. My name’s Zoolander. How are you feeling? Is it OK if we move you from the examination couch onto this nice blue trolley?’
WTF? Guys, she’s six. And even if she was in a position to give informed consent she isn’t actually able to talk BECAUSE THERE’S A FUCKING CHICKEN WING WEDGED BETWEEN HER VOCAL CORDS! However, her mother is running around my waiting room like the proverbial and entirely non-ironic headless chicken, screaming, ‘Help! Help! Help! Won’t somebody save my baby!’ Could you possibly consider that as implied parental consent and get her the hell out of here and into your big yellow taxi?
And this is absolutely not the time to start filling in your time sheets. Not while she’s going a bit blue around the gills. I don’t usually worry about much but even my ‘Give a Toss-o-Meter’ was starting to register high levels of giving a toss. Just get up and go. Really. Go to Casualty. Go directly to Casualty. Do not pass ‘GO’. Do not collect 200 brownie points for asking a moribund child meaningless questions.
Eventually they left.
The end of this morning’s surgery brought another similar run-in.
Mrs Peggotty buzzed through with a call from the 999 service. They had their hands on a middle-aged patient of ours who had started acting oddly at work – rambling slightly, unsteady on his feet and unable to focus on his computer screen. His BP was a sky-high 240/120 and – insofar as he was coherent at all – he was refusing to go to hospital, even though:
(i) He is a known hypertensive
(ii) He is a heavy smoker
(iii) He’d had his first stroke at the age of 43
(iv) He was having problems focusing on his PC screen.
‘We’re going to drop him off at home and you can visit him there,’ said the voice on the end of the phone.
‘Like fu.... er, like hell you are,’ I said. ‘Bring him to the surgery, I’ll see him immediately.’
There was a pause. ‘Hang on, doc,’ said the voice. ‘We’ll just ask if that’s OK with him.’
Ten minutes later the ambulance pulled up outside Bleak House. There’s no way our hypertensive, CVA-surviving smoker could have given reasoned consent to anything, including the question of whether he wanted to be dropped at home, hospital or here. He was walking and talking alright, but he was walking sideways and talking gibberish, despite being stone-cold sober. I checked his BP. It was now 230/110. I had a quick peek into his eyes with the ophthalmoscope: no signs of papilloedema or retinopathy. So far so good. But he still needed to be taken to hospital.
‘This is a no brainer,’ I said. ‘This patient should be in hospital now having his BP lowered while he’s under obs.’
‘Obs’ are what the soap operas call ‘observation’ and what we call ‘having a student nurse reading Heat magazine somewhere at the other end of the ward.’
‘He doesn’t want to go to hospital,’ said one of the paramedics.
‘He doesn’t know what day of the week it is, never mind what’s best for him,’ I said. ‘I’m telling you to take him to hospital. Tomorrow he’ll wake up and thank you.’
If they’d taken him there in the first place, despite his protestations, he’d have walked straight in, just like he did to my surgery – but that would have conflicted with his right to choose; in this case, to take his chances at home.
I’m all for patient choice but I don’t expect patients to be asked to risk their lives for it.
PAPILLOEDEMA, RETINOPATHY, CVA AND CONSENT
IT MIGHT HELP to explain a few terms from the above piece. Papilloedema is swelling of the optic disc inside the eye. Retinopathy is non-inflammatory damage to the retina. Both can be caused by uncontrolled high blood pressure, which can lead to a stroke or even death if left untreated. A stroke (or CVA – cerebrovascular accident) is a rapid loss of brain function due to a failure of blood supply to part of the brain because a blood vessel has either been blocked by a torn-off piece of its lining or has split along its length as a result of the pressure it’s been subjected to over the years, causing a leak or haemorrhage. Hypertension contributes to both, but especially the latter. When a patient’s BP suddenly goes through the roof, bad things can happen very quickly.
There’s no such thing as ‘normal’ blood pressure as it naturally varies depending on circumstances. A typical resting BP for a healthy person would be in the order of 120/80; the ‘120’and ‘80’ here refer to the height of a column of mercury that would be supported by the pulse, measured in millimetres and as seen in old fashioned blood pressure machines. The first number indicates the pressure produced by each individual heartbeat and the second the resting pressure in the system betw
een them.
As blood pressure is so variable, no-one should be diagnosed as having high blood pressure – in other words, ‘hypertensive’ – unless their BP has been measured on three or four occasions (preferably by the same doctor or nurse using the same machine) over a period of weeks; dangerously high blood pressure is extremely rare.
Most cases have no underlying cause and we give them the slightly odd title of ‘essential hypertensives’ as, essentially, there’s nothing else wrong with them. A few cases, around 5% of the total, are the result of kidney problems, hormone imbalances and structural abnormalities of the blood vessels themselves.
There are links between essential hypertension and family history, obesity, drug use, excessive salt intake and smoking. You can’t choose your parents but you can address all the other issues if need be.
For a definition of ‘Informed consent’, à la Sophie Wackles, you could try visiting www.NHS.uk, where a search for those terms will reveal 258 articles in the NHS Choices section alone. But basically it means that you are provided with all the necessary information about a given medical procedure and then asked if you’re happy for us to do it to you. Parents can usually give consent to treatment on their child’s behalf. If you can’t give informed consent (because, say, you’re in the throes of a stroke – are you listening, paramedics?), then things get more complicated, but the general idea is that you should act in the patient’s best interests, even if that sometimes means ignoring cries of ‘leave me alone’.
IS IT ALWAYS MEA CULPA?
‘IT’S LIKE Latin lessons all over again,’ I said, looking up from my paper. ‘And I was never any bloody good at that, either.’
Sami Patel was over in the other corner of common room, devouring Top Gear magazine with the slavering concentration of a teenaged boy perusing a copy of Penthouse.
Sick Notes: True Stories from the GP's Surgery Page 19
