Monday, October 10, 2011

Lauding Laudanum

"Of all the remedies it has pleased almighty God to give man to relieve his suffering, none is so universal and so efficacious as opium”, Thomas Sydenham1624-89

Sometimes it feels like we need a dispenser outside surgeries – press.....
1.      UTI sx – press 1 get 3 days of trimethoprim.
2.      UTI symptoms not better after (1) – press (2) and pass some urine into the pot.
3.      Pain in your joints/head/back/foot – get 100 paracetamol
4.      Option (3) not working – get some co-codamol 8/500
5.      Option (4) not working – get some co-codamol 30/500
6.      Option (5) not woking – add amitriptyline at night
7.      Option (6) not working  - add gabapentin
8.      Option (7) not working – change (7) to pregabalin
9.      Option (8) not working  - refer to pain clinic
Ok I know it simplifies things a little, and in the meantime we might have done the odd mssu or blood test, but sometimes it feels like “the pain ladder” is little more than a game of snakes and ladders but without the snakes
In days gone by we didn’t have codeine, oxycontin, fentanyl or pethidine, only the natural derivative of the poppy plant, opium which was made up of morphine, codeine, and thebaine. Use of this dates back to several thousand years BC, although in western medicine only back to the 1500s. Its use increase once it was discovered it could be dissolved in alcohol (it is not water soluble) to form laudanum.
In days gone by it was used as a panacea – to treat all sorts of pain and suffering, diarrhea, colic and so forth
But sometimes I wonder just how far we have come in 6000 years. Yes we have more refined opiates, mostly now formed synthetically. But although they are more refined, we still don’t have much different to treat human suffering; sure we can prolong it and treat illness and disease, but when it comes to chronic pain – the pharmaceuticals may be more refined, but the treatment hasn’t moved forward much
It’s not as doctors that we are doing wrong; we just want to alleviate the suffering of our patients. But for all modern medicine has to offer – are we really “modern”.

Monday, September 26, 2011

LCP - maybe coming to a Nursing Home near you

The Liverpool care pathway is arguably one of the real progressions and success stories of recent years. It has improved care of dying patients, classified it and helped bring about uniformity were before there was chaos (sometimes). It has helped improve understanding and treatment of the end stages of life for patients and medical staff alike and improved the care of countless patients in their final days

Nursing homes seem to have been slow to take up the LCP and still I am seeing patients in nursing homes whose care could be improved. The reasons for this seem quite clear – the nurses in nursing homes are surprisingly inexperienced when it comes to palliative care (often they are quite junior in comparison to their district nursing colleagues, to say nothing of the language barriers), equipment such as syringe drivers is often not available and homes have been slow to implement the new paperwork. The problem partly lies, in the areas that I work in anyway, that because patients are under the nursing care of the home, that they are not on the caseload of the district nurses, and this is where the expertise is

Of course it would be unfair to tar all nursing homes with the same brush and I have come across some nursing homes with excellent terminal care, but these sadly seem to be the exception rather than the rule.

Take for instance the situation I encountered this week. On a night shift for the local out of hours, a call came in for a nursing home. The initial blurb read – “on LCP, deteriorating, BP 70/40, nurse requiring advice”. It was triaged by a colleague who designated it as a home visit and I was duly dispatched.

On arrival I was greeted by a HCA who rushed me into the room. She was breathless and sweating (the HCA, not the patient) and the nurse was standing with her hand on the carotid pulse “I think she is dying”, I was informed. The lights were on full, an alarm beeped loudly from the wall, a patient with dementia was wondering in and out of the room. This was indeed the last moments of this poor patient’s life

To be placed on the Liverpool care pathway a patient has to be deemed to be in the last hours or days of life, so for the nurse to be so shocked that the patient was dying showed complete lack of understanding of this; quite what she was doing checking the patients blood pressure when the patient had ceased to become responsive was beyond me. The patient’s relatives had not been informed the patient was deteriorating and the death seems to have been – anything but peaceful. At least in terms of the attention made to the surroundings of the patient.

To top it all off, once it was clear the patient had passed, the nurse informed me we should contact the police because of “the care commission”. Quite what she meant by this was beyond me – this was a natural and expected death. I suggested this was not necessary.

I would like to think that this was an isolated incident, that the care up to that moment had been excellent. I suspect I would not be alone in thinking that this would be a naïve assumption.

I am not going to make any cheap jokes or comments – its not appropriate to the circumstances. For my part I made clear documentation as to the situation I found and passed this along to the patient’s own GP. Its just a depressingly familiar scenario in nursing homes. I might add I don’t blame the nurses – it all comes down to money – the cheapest nurses at the lowest rates, the minimum of training, the minimum of expense.

Thursday, September 15, 2011


Did you know that if you want quilted toilet paper it has to be made from virgin paper, i.e. straight from the tree? The more times paper is recycled the shorter the paper fibres get and thus to get the nice velvety quilted sensation your anal sphincter deserves, only brand new paper can be used. What is more is that it can only be used once and not recycled as I doubt the recycling centres would welcome the arrival of faecal stained toilet tissue – even if it is velvety quilted

And this creates a conundrum, does it not? Either treating your anal sphincter as it deserves to be treated or using inferior somewhat coarser toilet tissue made from recycled paper. Well, I think I have the solution

Almost every day I am presented with a guideline, protocol, information booklet, news story, or email on how non-GPs think us GPs can do things better. The glossier and thicker the paper on which the information is provided, the faster it finds it route to the bin. There are so many guidelines and protocols to choose from – often conflicting – that it’s all too easy just to send these in the general direction of the recycling bin and ignore them

Of course this would be folly, because in some of them are good learning articles so I can show my appraiser that I am in fact a enthusiastic and dynamic GP locum and I am not a burnt out bit of drift wood, washed up on the shores of the land of evidence based medicine.

But the long and short of it all is that tons of paper and card are used just to go straight into the bin and be recycled. These poor paper fibres have missed their one chance at being velvet or quilted toilet paper, and know the best they can hope to achieve, if their vocation as a paper fibre was thus – is to end up as recycled and somewhat inferior toilet paper

Thus there’s a simple solution. If all medical information and all medical journals and information leaflets were printed on quilted super velvety toilet paper then we could cut out the middle man of the paper recycling plant. What’s more, some of them might actually be read.

Tuesday, September 13, 2011

Snow White and the 7 dwarfs....a modern tale

Once upon a time there was a fair maiden called snow white. She had run away from home and moved into her own council house in a block she shared with 7 other shorten than average gentlemen. They had all bent over backwards to help this beautiful maiden and she had soon got into the way of life of the area

So much so that Snow white was now on the game to fund her heroin addiction. And of the 7 male friends she has....

Grumpy is off long term sick with his depression. Each time his GP tries him on a different antidepressant he finds a reason to stop taking it after a few days. He hasn’t worked for some years now and had to attend anger management classes. This was after the courts made it a condition of his sentence for assaulting Sneezy with whom he had lost his temper. His defence had been the constant noise disturbance of his coryzial neighbour sneezing all night had made him just “lose it”.

Sleepy is constantly complaining of chronic fatigue, cant possibly work because of it, and has self diagnosed himself with ME.

Happy recently was sectioned and has started on lithium and antipsychotics whilst an involuntary patient in the local psychiatric hospital. He’s doing very well apparently although is going to change his name by deed pole to Shaky as he has had some problems with extra pyramidal side effects from the antipsychotics.

Sneezy is constantly at the doctors complaining of his hay fever symptoms and how it stops him sleeping and he couldn’t possibly work as a result.

Bashful is too crippled with social phobia to work despite numerous medications and CBT sessions to help him improve. Whilst his social phobia stops him working, he finds alcohol helps, and can frequently be found down at the Unicorn’s Head having a few drinks.

Dopey is off long term sick with drug addiction problems and is currently appealing his failed DLA application. .

In fact the only one doing any work is of course doc. Hi ho, hi ho, its off to work I go

Monday, September 5, 2011

"Just" the locum

It’s just a word isn’t it…just. Yet it can have such a derisory tone. For instance – once of the receptionists looks at me admiringly and asks another one who that handsome fellow is, and the reply “it’s the locum” as she shares the admiring glances of her colleague is quite matter of fact. But add a little word in, “it’s just the locum,” and suddenly there is a whole different tone; implying that I am somewhere below the medical student in the practice when it comes to the pecking order of the hen house. I am certainly not a worthy rooster to be admiring.

Patients use it too, although I hear it less from them. Usually it’s “Are you the new doctor?” which I take as a compliment both of my youthful good looks and my slick modern medicine* But when it comes to more difficult patients wanting something I don’t want to give, then it oft turns into “you’re just the locum”, or in other words, they think I am useless for not giving them what they want

Perhaps I am over-sensitive. Perhaps as a locum I feel I am on the defensive, aware that to many, the option to be a locum is seen as an option taken not out of choice, but out of lack of choice. In much the say way as GPs were perceived twenty years ago as second rate doctors by those in medical schools, even though 70% percent of us were destined to become one. It may not have been the precise words that only the best 30 percent will succeed as hospital doctors, but it was certainly the sentiment handed down to us.

I choose to be a locum because that is what I like doing; I like seeing patients (mostly) and dislike meetings, naval gazing, partnership bickering, practice politics, paperwork and monotony. Working as a locum brings with it many challenges, challenges which aren’t to everyone’s taste; be they clinical – in that you usually only see patients once, you don’t know them from previous encounters and you are judged solely on your performance that day – organisational, or financial. It is, in essence, a very unique subspecialty of General Practice that is easy to do, if not badly, then ineffectually but very difficult to do well. I guess that’s once of the good things about the NASGP in that it represents not just (there’s that word again!) locum GPs, but it represents and stands for the fact that being a sessional GP is not just a stop gap, it is a career in itself.

Which brings me back to being “just” a locum; the phrase seems so, well, unjust!

* To any American readers, we call this sarcasm or irony and is not meant to be taken literally, but in fact quite the opposite

Wednesday, August 31, 2011

The Locum Motion

(to the tune of the loco-motion)

Everybody's doin' a brand new job now
(C'mon baby do the locum-motion)
I know you'll get to like it
If you give it a chance now
(C'mon GP do the locum-motion)
The little NP can’t do it with ease
It's easier than understanding ABGs
So come on, come on,
Do the locum-motion with me

You gotta swing your tubes now
Come on patient, sit down, be quick
Oh hell, dont think I'm a quack

Now that you can do it
Let's write a line now
(C'mon baby do the locum-motion)
rub a rub a lotion on an itchy rash now
(C'mon baby do the locum-motion)

Mrs Smiths feeling dizzy and is off her feet
A little bit of admin and a lot of slots
So come on, come on,
Do the locum-motion with me

You gotta swing your tubes now
Come on, come on,
Do the locum-motion with me

Move around the town in a locum-motion
(C'mon baby do the well formed-motion)
Do it wearing gloves if you touch the motion
(C'mon GP do the locum-motion)
There's never been a patient that’s easy to please

SSRIs makes you happy
When you're feeling blue
So come on come on
do the locum-motion with me
You gotta swing your tubes now

Thursday, August 25, 2011

Hidden Gems

One of the great challenges of being a GP locum is finding things in the consulting room. You can tell a lot about the owner of the room just by what you can find, or more specifically can’t find

For instance if you decide to be a good little locum and decide to do some of your own phlebotomy and cant find any equipment with which to perform the task, then it doesn’t need Sherlock Holmes to deduce that not much phlebotomy normally goes on in that room

Of course there’s the family photos; I would have thought it was bad enough being married without having to look at pictures of the wife/husband whilst at work as well; but then as a divorced cynic maybe I am too clichéd in my opinions

Neatly arranged, and labelled ring box files with appraisals listed by year always intrigue me. I couldn’t usually fill my wallet with the paperwork for my appraisal, far less a box file. I secretly like to think that these contain bottles of vodka, but I feel its an invasion of privacy to look, which if course it is, but more importantly I am not sure I could face the disappointment that they were in fact full of attendance certificates and the like

Out of date drugs are not unusual, and large stashes of MST are not as unusual as they perhaps should be. They are usually labelled with a patients name and date back from 1974; presumably taken from the patient’s home with the good intention of disposing of them correctly, but instead shoved in the back of a cupboard and long since forgotten. I am quite sure the practice CD register didn’t list these

One of my personal favourites was when in my (then) appraisers practice; I had to go off in search of a peak flow meter and mouthpiece. I discovered, much to my amusement that all of the meters in the practice were old style non EU PEFR meters which had been phased out 6 years previously. This included the peak flow meter in the asthma nurses room.

Second to that was a practice where every surface in the consulting room was piled high with unopened medical magazines that dated back 10 years; under the desk, on top of the desk, on top of the filing cabinet, in every cupboard and even the sink draining board was weighed down. It probably won’t come as a surprise to hear that the doctor I was covering was off long term sick.

I don’t go looking out of curiousness or nosiness, I go looking out of clinical need, on the seemingly naïve assumption that the cupboards will contain the urine/blood/faeces/sputum and other bodily fluid/part receptacles I seek. . When I was a partner I shared my room with locums and other visiting doctors and midwives. I, admittedly, had some personal touches, which didn’t include a picture of my wife (now ex), but did include a picture of my dog just to remind me there was someone who would be pleased to see me when I got home. It was a clinical area first and foremost; I kept the closet skeletons firmly under lock and key.

Tuesday, August 23, 2011

The Ultimate Sin as a locum

“Forgive me father because I have sinned”. I have committed the ultimate of sins as a locum and for reasons I cannot fathom managed not to put a booking for an afternoon in my diary. What made this worse, if there is a worse sin, is that I, thinking I was free, had done an overnight shift at short notice the morning of my sin, and then gone to bed with my phone on silent, blissfully unaware of the list of patients waiting my attention. By the time I woke the practice had closed and my name was mud

“Yes father, thank you for that, I will recite the 7 deadly sins of a locum and say three hail GMCs”

Thou shall not make errors with your diary
Thou shall not criticize the partners that pay you
Thou shall not moan when asked to do work
Thou shall not bark at the practice staff
Thou shall not fornicate with the practice staff
Thou shall write your name after each entry in the notes
Thou shall not eat the last digestive biscuit

“But father, do you think this means I shall never get to enter the pearly gates and pass in the land of partnership. Will I have to spend forever in the purgatory of the locum world?”

“Thank you father, I understand you – and of course it makes sense when you say it is easier for a camel to pass through the eye of a needle than it is for a locum who has committed any of these sins to enter the heaven of partnershipdom”

Oh woe is me!

I am sure we have all done it, a simple administrative error, either one of omission or forgetting to save properly an entry in a diary can have disastrous consequences. Even though I insist on email booking, or at least confirmation by email, and all my entries are synched on my phone with my Google desktop calendar, we have to accept that mistakes will happen.

The one thing about being a locum is you can’t share the blame; you can’t shift the locus of fault. Because it falls fair and square at your own feet.

Thursday, August 18, 2011

August Rollover

It’s that time of year again, August. The death month ,when it’s the merry go round of doctors rotating, is as enshrined in medical culture as it is notorious for patients. Medical alumni get their first bleep and are excited by it. Junior doctors rotate into new specialities, careers in speciality jobs are born and its time for everybody to move on to pastures new. This of course means there are hundreds of newly qualified GPs, the majority practicing as locums. Some might describe it as embracing new challenges, getting to use their newly perfected skills of sharing management options, responding to cues; fresh faced and eager they arrive on the locum scene

Yes some might describe it as that, but the reality most of them are bricking it! The cosy and coveted role of being a GP trainee, having regular income, sick leave, holiday pay and a regular place of work, all protected by training guidelines and standards is replaced by the grim and slightly less comfortable world of being a GP locum

In one day it is off with the water wings, there’s no more stabilisers and out of nappies! It’s a time when these fresh faced and innocent hot shots suddenly find out all about being a locum.

Of course its an annual cycle and we have all been through it at some point. For those of us who are established locums there always a slight dip in demand for work – the combination of a flooded marketplace and all the partners returning from their holidays. For most newbies being a locum is a stop gap – something to pay the bills and a way of expanding their abilities and skills before they take the plunge (or retreat) into the depths (or safer waters) of taking a more secure role. The marketplace product becomes the consumer.

By Christmas the numbers of locums will have dwindled markedly and by next summer practices will be desperate again, taking the scraps from the diaries to manufacture a patchwork quilt of holiday cover

I would heartily recommend taking a holiday in august – and not getting sick

Friday, August 12, 2011

Introduction - Locum post 1

I am not new to being a locum, I have been a GP partner in the past and prior to this I did a stint of locuming. My reasons for choosing this line of work are fairly simple - I like the job of seeing patients - I dislike meetings and I like variety. I enjoy doing the job i was trained to do; some dont and seek other avenues such as being an appraiser or more often - those that cant (or dont like to) do, try to manage.

This post will serve mostly as an introduction rather than anything else - witty or otherwise.

My working pattern is rather random - I do some shifts in A&E, I do daytime practice work and I do some out of hours sessions too! Filling my diary as a general rule isnt a problem, although I do get the odd quiet month - but fallow days where i would want to work and cant get work are few and far between. Of course I may have to choose a day off during the week instead of a week day, or an evening instead of a day session, but as I am single and only see my offspring on a fortnightly basis this doesnt interfere with my life too much. I guess if I wanted I could choose daytime work only, and by doing so would amass a larger number of practices that use me regularly - but I choose not to work this way

In terms of my income - hour for hour I probably earn less than a principal in General Practice, but I supplement that with more profitable out of hours sessions and because I am not worn down by seeing the same old patients every week and a 'change being as good as a holiday' and all that, i am able to work a little more and still not feel stressed or strained by it.

Anyway - a bientot