Monday, February 6, 2012

No meaning

Don't worry, i am not here to talk about the meaning of life, the argument between creationists and evolutionists or even the bigger questions like petrol versus diesel cars, or the yet bigger and far more important questions such as should i have my satellite navigation system in a male or female voice


But what I actually wanted to talk about was directions; not the sort my Tom-tom give out, but the sort we (GPs) give out, and in particular, on medication. Ever since I can remember I, like my colleagues, have prescribed paracetamol 1g four to six hourly. But what does 4 to 6 hourly actually mean. Does it mean i should leave alternating lengths of time between doses; if i take my next dose in 4 hours, the following dose should be in 6 hours. Or does it mean i should take an average and leave 5 hours between doses. Does it mean if i don't take the next dose in the two hour window of 4 and 6 hours since the previous dose that i will come to some harm if I were to, say for example, leave 6 hours and 5 minutes between doses.

As we all know, it means none of the above. In fact it doesn't really mean anything does it? Yet we see it all the time. What the instructions should say is take as required – leaving a minimum interval of 4 hours between each dose of 1gram and not taking more than 4grams in any 24 hour period.

Most patients probably just ignore the instructions on medication anyway...or at least they seem to with most medicines


But what happens when we prescribe oramorph in terminal care. All sorts of variations on prescriptions are seen. Some examples are 2.5-5mls 2-4 hourly prn. Some will prescribe 5mg 4-6 hourly. Others will prescribe a more exact dose – but prescribe it hourly. Now i know what I would do when I do the prescribing; But, these sort of vague prescriptions leave patients confused and its hardly surprising. Those of a more cautious disposition will be at risk of under-using and leaving themselves in pain when they could be, quite safely using shorter intervals between doses.

As a locum you see just about every conceivable variation

What's even worse, of course, when all that is written is "as directed" as a direction; most frequently seen for children's medications. Take as directed....directed by whom? The which case it should be on the prescription, as directed by the manufacturer? Or just take as the patient feels like self directing? Whenever I see that i simply interpret as the person issuing the prescription was too lazy to look up the dose in the BNF or weigh the child

Anyway i am going to get off my soap box and head home directed by by sat nav. Although if it simply says – at the next roundabout proceed as directed...I will just have to do as I am old. Oh and in case you were wondering what the correct answer to the above conundrum was the first option which is correct. Only a man can read maps and give directions, so i am not about to let a woman's voice come though on the sat nav.

Wednesday, February 1, 2012

Not Much Ado about Paperwork

Scene – a surgery in fair Basingstoke


[receptionist enters]

Receptionist    Where for art thou locum tenens? Thy presence is requested to scribe your signature on prescriptions, to sign off the results from the leeches and to scribe your knowledge on many a document in the parchment workflow. Thee must come hither now; C'mon, lest you have a break for the olde English tea and we not feel that we have got our worth for the gold we have paid ye! Where thou in Denmark the word lokum would mean a toilet, and we could quite gladly cast our sewage wastes into your being, but in this country we will dress it up, as were it a loftier package.


[locum enters]

Locum    I hear ye oh reception wench. Thou dost holler in lofty tones. Yet thy voice – sweet as a birdsong in morn' dost carry the folly of misconception. The parchment workflow be not the burden of the locum, but the toil of the partner. For he or she be at the helm of such responsibility and better kin with the patient to whom such toil pertains to perform the act of completion. Likewise the agreement to which the NHS and GP contract enslaves the holder of the contract, engages that it be the GP to which thus errands fail.

Alas I am already engaged on the toil of seeing thy patients and engaging the guide to lead me unto the abodes of the patients that require my tinctures and remedies for their maladies.

I implore ye to kneel at the shrine of thy boss and engage him in your toils, lest he be ignorant of their measure

[Exit locum to house visits] [exit receptionist to whine at anybody who will listen]

[Enter narrator]

Narrator    Sadly ladies and gentlemen, this is not a comedy. Despite much education, it is still the misconception in practices that it is safe for locums to do workflow and sign of repeat prescriptions for patients they have never seen, in systems they are not party to. It's not about the workload, it's about patient safety. Progress....i bet it was the same in the days of Romeo and Juliet. And while this passage may try and capture the language of the time, I suspect it be deemed a tragedy in its prose. For that, please forgive me.