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