"The Living and the Dead" (2006 film)

I admit it.  Within me is a gormless idiot who likes to be scared to death!  In view of this - when I finally get bored rigid with the computer - I watch movies on TV.  Last night was a time of ennui and I settled myself down to watching some movie - I can't even remember its title - on the Horror Channel.  Yawn!  I like high quality dross you see!  So I switched to Horror Channel Plus and came across The Living and the Dead and was awe struck by the genius of it.  If there was ever a film misplaced by genre - this was it!

It is a masterpiece!

Its genres are a mixed bag - placing it under drama, horror, thriller and mystery.  It is these entire plus more.  Its tag is that of 'Terror by good intentions.'  For it to be shown on a horror channel is a travesty of justice.

The Living and the Dead details a period in time of the life of Donald Brocklebank (Roger Lloyd Pack) - a man of aristocratic background living in fear of bankruptcy in a rundown country manor.  His wife, Nancy (Kate Fahy), requires constant care due to a terminal illness.

His son James (Leo Bill) is schizophrenic and also requires constant care.  James is overprotected by his family leading to an exacerbation of symptoms (and I know this to be true as some with mental illness overprotected by families experience serious personality damage and now reside in our home) but is intent on proving himself as 'the man of the house' during his fathers absence.

The Living and the Dead presents a vision of the nightmare of mental illness.  I implore all those who have an interest in mental ill-health to watch this disturbing jewel.  You may see a preview here - but it gives you nothing!  If you read the reviews - ignore the Neanderthals speaking of 'retards' and seeking blood and gore.

It is a gut wrenching masterpiece!  It is wonderfully awful in its honesty.  Okay if you watch it, you may think that there are gaping plot holes - and perhaps there are - but buy it, watch it, for if you don't - you can never truly understand the devastating effects of mental illness on those who suffer it and its effects on family members.

Images courtesy of Quiet Earth  I recommend you 'click' on Quiet Earth as it gives an excellent review.

Anna :o]

DNAR does not equate to DNT

Please read this article in the Colchester Daily Gazette.  It details a row that has erupted after Colchester PCT advised care homes not to automatically dial emergency services when a resident is dying.

I presume care homes in Colchester have become involved in the national drive to 'sign-up' en masse residents to Advance Decision to Refuse Treatment (ADRT).

Residents and relatives of those residents not deemed to have mental capacity are being coerced by Link GPs and indeed care homes (who wish to proudly boast they have achieved Gold Standard) to Advance Care Planning.

It has happened in my area with devastating results, many residents being highly offended and highly confused by this unrequested approach and relatives feeling pressured into making decisions they do not want to make.

What really concerns me about this article is that the family of Ellen Williams seem unclear as to exactly what they have signed, believing that she has been "put on the Liverpool Care Pathway "do not resucistate" plan."  What is this?  Clearly from the article she (Ellen) is not "on" the LCP - but clearly, her future (lack of treatment) is well mapped out.

I can only assume that the link GP discusssed placing Ellen on the LCP when she is in the process of dying and during this discussion the family requested or agreed to Do Not Attempt Resuscitation (DNAR).

However, it is important to state that DNAR decisions only apply to CPR (cardiac massage and artificial respiration) and not to any other aspect of treatment - such as comfort measures: antibiotics, analgesia, hydration and feeding (any route), oxygen, hospital admission and suction.  DNAR does not mean Do Not Treat (DNT).

Four residents in my home have ADRTs in place - three requested by relatives when their loved one was 'in the process of dying' and the fourth when the GP requested to see the relatives for the same reason.  All have a DNAR in place, relatives have requested no hospitisation for two of these residents and all relatives have requested active treatment should their loved ones become ill.  All of these residents are still alive!

So the question needs to be asked that if the GPs were wrong in these instances why nurses are deemed to have the skill of recognising 'dying' when it suits a PCT.  If I am concerned about the health of a resident - something which can't wait until a GP visit in the morning - I phone Out Of Hours (OOH) Services and often, when giving details I am informed that I should contact emergency services - because they can't be arsed to come out!  If I felt emergency services were required I would have done this.

Of the four residents mentioned previously, if thought required, I would contact emergency services for two of them.  The remainder I would contact OOH.  Nursing home nurses are between a rock and a hard place - with regards to requesting GP input - they are damned if they do and damned if they don't!  I will not take risks with a residents life - I am not a doctor.  Woe betide me if I sat by and did nothing should a resident become critically ill - I am a hundred percent certain no PCT or GP would back me up!  I would be hung, drawn and quartered!

I am concerned re Dr Shane Gordons statement, feeling he has totally missed the point that there is a lack of clarity, a lack of understanding of Advance Care Planning and an unawareness of the ramifications of signing same.

I wonder if he has read "This paper desribes the protocol of a multidisciplinary study that will provide timely and essential insights into an area of end of life care, ACP, which has become policy driven within the UK despite a weak evidence base." 

Advance/Anticipatory Planning (formerly Living Wills) is fine and dandy if it is a choice you make yourself.  If I had a terminal illness - I would request and sign one myself.  Okay dementia is terminal, but it is not a tomorrow thing.  Until it reaches end-stage you have a right to treatment.

We all get old some day - even doctors and those who manage PCTs.

Anna :o]

Perceptions

Perceptions

Restless ever changing hues
Shift endlessly
The colours of our lives.
Dark clouds morph
Into summer blues;
Livid reds dissolve
In sun-lit streams
And cascade
Into our fickle dreams.

Complex,
We shape ourselves
Upon the medley of our past;
Reasoning
Contrasting
With contingent facts.
Our future so well or ill defined
Hewn in the colours
Of our mind.

Complex emotions,
Self-denial
And delusions;
We perceive ourselves,
Our lives
In grand illusions.

Anna :o]

With thanks to Tess at Magpie Tales

Sunny Side Up!

Sunny Side Up!

Peggy had become quite exasperated since Egbert had been laid off permanently at the pig farm.  He continuously moaned on about how unfair life was.  Moan, moan, moan, moan, moan!  It wasn't as if he got the sack, she thought, the miserable bugger!

Initially she had been compassionate, clucking like a mother hen, taking him under her wing and trying to make wrong things right.  Now, overburdened as she was by his misery, she felt as if he had thrown a yoke round her neck, continuously dragging her down.  Living with him was akin to treading on egg shells.

Peggy had a reputation of being hard boiled and indeed she was.  Well, was, until she had taken in Egbert as a lodger.  Over time she had warmed to him, becoming softer in herself, her life no longer overshadowed by self-imposed isolation.  Why, she had even dipped into her nest egg to buy him a new suit for interviews!

Egged on by Peggy, Egbert had attended countless interviews only to be disappointed by the battery of rejection letters - the rejection exaggerating his low self worth.  Moreover, Peggy noted, he was becoming a mere shell of his former self.  "I shall phone Mr Williams (the pig farmer)!" she announced, "I hear business is picking up!"  Egbert just looked at her!

Two mornings later, both at the breakfast table, the familiar plop of letters falling on the door mat was heard.  Peggy scrambled to her feet and ran to the door, returning, beaming, and handed a letter to Egbert.

Egbert's face lit up as he read the contents of the letter!

"Well, I guess you'll be bringing home the bacon again Egbert?" Peggy smiled.

Egbert eyed the bread on his plate and raised it up.  "A toast to you Dear Peggy!" he grinned.  "As sure as eggs are eggs, I will!  As sure as eggs are eggs!"

Anna :o]

PS "Have you heard the joke about the three eggs?"
      "No."
      "Too bad!"

With thanks to Tess at Magpie Tales

Life and Death before the NHS

Before the NHS the provision of healthcare was very different from today.  Infectious diseases were rife and thousands died of pneumonia, diphtheria, tuberculosis, meningitis and polio every year.

Infant mortality was around one in twenty and there was little the healthcare system could do to change it.

Healthcare was not a luxury everyone could afford.  Those who could, paid for doctor's fees and medicine.  Workers who earned under a certain amount were covered by the 1911 National Insurance Act and paid a few pennies each week and received free treatment "on the panel."  Some woman and children could see a 'Club Doctor' as they paid into a 'sick club.'

Millions, the most needy and vulnerable were not entitled to free care - children, the elderly, women not at work and the unemployed.

Often, among the very poor a decision had to be made between buying necessary medicine or a loaf of bread.  The loaf of bread usually won.

The poem below is firmly based on a story a resident (now deceased) used to relate to me often.  He told of life before the NHS and we both shed tears whenever he told it.

The Coal Black Night

Short pants, scuffed knees, no warmth of coat,
I ill-dressed in drenching rain,
Panic in my heart tossed ragged coal
At Dr Humphries window pane.

Window opened he stretched a tired "Yes?"
"Dad's having one of his heart attacks!"
I screamed and he hurried forth
Hand clasped round his humble bag.

We raced into the coal black night
'Til we could run no more.
Breathing so hard it pained our chest
We found mother at the door.

"Hurry doctor!" she implored through tears
"I fear he is very near to death!"
Father clutching tightly at his heart,
Fighting dear for every breath.

I, cleared from the scullery
To the good room with baby Sis,
That dearest fragile scrap of life,
I gave her a frightened kiss.

I heard the wail of mothers cry
So anguished my blood ran cold.
Dr Humphriess came and hugged me tight -
His heart as good as gold.

"I'm sorry son, your fathers gone,"
His voice crackled with compassion.
Mother entered as if in a dream
Looking old, destroyed and ashen.

I ran to her shouting "No! No! No!"
My heart full of disbelief.
She crushed me deep into her arms
And we were joined in grief.

Embraced within my mothers love
We cried until our tears ran dry,
And deep within that shroud of grief
We heard the doctors anguished cry.

Tears streaming down his tired cheeks
Distraught and so distressed
He cradled Sis within his arms
Close to his heaving chest.

Baby Sis had been born to die,
So fragile, so small and weak.
We took her from the doctors arms
And left kisses on her cheeks.

The three of us stood empty then
No tears left to cry,
For death was not a stranger then
And rarely passed us by.

Anna :o]

NHS Reforms and Apparent Apathy of the General Public

This post is very different from the original draft and this is with thanks to Dr No and his recent post The Patient on the Clapham Omnibus

The draft focused on this interview with Andrew Lansley in which, when asked "Do you think you have done a good job of explaining these reforms?" he replied "... ... Yes" and later that he had "... absolutely engaged with people" and had indeed listened to all GPs! My!  That is a lot of conversations with GPs - how does he find the time?

How strange it is then that one week later on 13/04/11 he, Dave and Nick were holding a round-table session with voluntary health organisations to help reassure the general public that NHS reforms are "not about privatisation."

How strange it is that the afternoon of the very same day he apologised to nurses for poor communication of his health reforms.  How strange it is that he did not have the guts to address the RCN congress, instead meeting a select 60 for a Q&A session to 'listen.'

The rest of the post rambled on about the poor uptake (9%) of docs to the BMA commissioned Ipsos MORI poll, that it appears that GPs are to be frozen out of the NHS board and that there is no unity, no single voice representing 'health professionals' and because of this, I fear our fight is doomed.

However, my thoughts were diverted to Dr No's post and his last sentence: "Perhaps it is time we medical bloggers found a way to sing to a wider audience."

This is my proposition:  We email our concerns to http://www.info.doh.gov.uk/contactus.nsf/memo?openform   We email all our friends and colleagues and ask them to do the same and request (they) email their friends and colleagues and so on into infinity.

Below is an example of what your original email might be - but you can word it as you like:

Saving our NHS

As you must be aware, the very existence of our NHS is under threat, yet there does not appear to be a groundswell of resistance from the general public, that being US!

We take the NHS for granted as it is there when we need it - but what if it was no longer there?  Admittedly it may have a few warts, even several that are in need of treatment - but is an effective treatment to destroy the host?

Unless we unite we will lose our NHS, it morphing into some strange unfriendly beast that offers no asylum to those with complex and expensive medical conditions.

Please help save our NHS and email Andrew Lansley at http://www.info.doh.gov.uk/contactus.nsf/memo?openform and let him know your opinions.  Please forward this to all your friends and colleagues and ask them to do the same.

The only way to be heard is to speak out!  Please help save our NHS!

You could also start a petition limited to your street and send it to:

The Rt Hon Andrew Lansley,
Secretary of State for Public Health,
Department of Health,
79, Whitehall,
London,
SW1A 2NS

C'mon folks - lets do it!  Let's save our NHS!

Anna :o]

ADDENDUM.   Having received an automated reply from Andrew's constituency offfce - the above directions have been changed.  

Arousal

Arousal

As old as my years,
Embittered by memories,
I did not expect to be
Romanced by you.

Joie de vivre re-awakened,
We drink from loves chalice
With passions as florid
And as full-bodied as wine.

Heart full and heady,
I watch you lie sleeping,
My heart in safekeeping,
I know you are mine.

Anna :o]

With thanks to Tess at Magpie Tales

Summary Care Records

Last week two little envelopes plopped through the letter-box - one for me, one for husband.  They contained an information leaflet and an opt out form re the NHS Summary Care Record (SCR).

SCRs are computerised data of patient information containing demographic details, medications, allergies and adverse reactions; information that could make all the difference when a patient needs emergency or unplanned care.  Well, that's what the blurb says!

The SCR has a chequered history, concerns being aired with regards to those who might gain access (porters, Mrs Miggins the domestic, etc) and thus the security of personal computerised data and also the pace at which it was being rolled out.

Those who like IT (and the then government) were hell bent on reaching critical mass before end of March, 2010; the government to push its baby through prior to the election and the five Strategic Health Authorities taking part in the hurried roll out becoming eligible to take advantage of central funding.

This haste despite researchers at UCL finding inaccuracies in stored data, i.e, failure to indicate allergies or adverse reactions to drugs or indicating that patients did have allergies or adverse reactions when they didn't or listing 'current' medications that were no longer taken.  The researchers found that no patients suffered harm - but purely because doctors didn't trust the information and double checked it.

There was no evidence that records led to safer care although access to the database could reduce rare medication errors.  No clear evidence either that consultations were quicker and in some cases the use of the SCR made consultations longer.

The BMA expressed concerns about the speed of the roll out meaning that patients were not adequately informed about electronic records.  An independent evaluation of the early adopter areas found that seven out of ten patients were not aware of the SCR and therefore did not realise that they had given consent (by not opting out) and that their interesting little medical details were available for all and sundry to access.

Come the coalition government the whole SCR kerfuffle came under review, things looking good as in 2009 the Conservative party pledged to 'dismantle central NHS IT infrastructure' replacing it with local systems and Liberal Democrat health spokesman Norman Lamb called last year to an end to the 'obsession with massive central databases.'

But politicians aren't well known for keeping their word and honouring pledges, are they?  So the SCR has been given the green light again and it is go baby go!  The mass mail out has begun!

This time around it will be clearer that you can opt out.  I suggest that you do - for do not believe what you read in the pretty little leaflet.  I don't.  During my research today, I was lucky enough to find Summary Care Record Info - an eye opener by the excellent Dr Neil Bhatia - read and learn!  Home in on how your 'core' details will be added to!  Home in on everything!

Worried about security, will Mrs Miggins (the domestic) be reading your private data and selling the sordid details to The Sun?  Possibly yes!  Read this interesting article in Pulse which informs that celebrities (the most important people in the universe), politicians and other patients with 'sensitive' information will be excluded from SCRs.  Wonder why that might be?

While you're at it - you might as well read this!   Gives you a hint of who might be able to access your details in the future!  'I don't have specific reservations about giving pharmacists access to SCRs - it could have benefits in the future - but I'd actually be more interested in getting the basics right first.'

Anna :o]

Link: The Witch Doctor "If you have nothing to hide..."

One Night Stand

One Night Stand

An elaborate ritual,
You dance behind
My shower screen.

Intimately connected,
I watch
As you wash away
The memory of me.

Cleansed,
You leave,
Passing me
Without recognition.

Anna :o]

With thanks to Tess at Magpie Tales

In Praise of Psychiatric Services?

What does a Community Mental Health Team (CMHT) actually do?  Of course I do know what the remit of their existence is:  Meeting the needs of people with mental health problems who don't need a psychiatrist.

But what if your GP decides you do need the input of a psychiatrist, why isn't her/his decision acknowledged, respected and action taken, rather than the CMHT swoop down on you instead?

We have a sixty year old resident ('Winnie') with complex mental health problems including ongoing addiction.  You might think we are being remiss in not addressing her addiction but our hands are tied by Safeguarding Vulnerable Adults (SVA) and Deprivation Of Liberty Safeguards (DOLS) legislation, and of course, importantly, whether this legislation exists or not, Winnie has the right to choose her own path in life.

Winnie presents as quite a strong character with a seemingly happy disposition, but there are strong suggestions (of late) that all is not well.  I love my job and see my main purpose as that of promoting well-being and being 'there' for the residents.  I have regular daily chats with many residents and these chats, quite rightly represent the bulk of my work.

Winnie is one of these residents.  We chat about everything past, present and future.  As said, of late, there are obvious signs that all is not well and our chats have taken on a deeper nature.  She talks of a deep depression that she hides under her happy veneer and indeed, my last post is based loosely on that she has disclosed - the real Winnie.

Her depressions is something that she has coped with for the majority of her adult life.  She receives antidepressant medication and it has been enough - along with her own self-medication of alcohol - to control her symptoms until a recent event led to feelings of helplessness and hopelessness that dogged her in her early twenties.

We contacted her GP who is a good GP who visited Winnie in the home and spent time with her, listened to her, increased and augmented her antidepressants and referred her to psychiatric services.

Psychiatric services initiated a CMHT visit, although which professionals were represented in this team we do not know as we were not privy to this information.  Why might this be - perhaps the bad reputation of care homes and the assumption we would not be interested?  If this is the case - it is bad practice.

The team spent half an hour with Winnie and left - no staff being approached to give input into Winnie's situation.  A few days later, my manager was contacted by a psychologist (who had not been part of the team) to advise that the home was to be reported re SVA and DOLS issues in relation to Winnie.  Flabbergasted my manager asked why and the reason given was incredible.  He asked why he had not been contacted previously as to enable the team to be aware of the true facts and was met with an embarrassed silence.  We were not reported, nor did we receive a cc of the letter to the GP which is good practice and good manners as we are very much involved in Winnie's care.

Winnie continued to deteriorate both mentally and physically and my manager contacted the CMHT again requesting further input, only to be told that their work was done.

What is their purpose?

The good GP is bringing together a CMHT of her own making and being a good GP visits Winnie weekly as she shares our concerns.  In the meantime Winnie continues to suffer.  Hopefully, somewhere in the near future, Winnie will receive the input of a good psychiatrist, emphasis on good as we have four psychiatrists who serve the residents in our home.

One is a good psychiatrist - the old school variety of 'doctor knows best' who listens to and understands the real needs of his patients and follows up their care regularly.  His patients have the best outcomes.

The remainder are of the newer breed who offer choice-ism.  "Which tablets do you want to take?" and/or "I hear you attempted to strangle X - can we discuss this?" (if "No" to the latter it is not addressed!) and is all well and good until  you display florid psychosis and/or come very near to actually strangling X and are sectioned.  What kind of care is this?

You are never offered the choice of mental ill-health - but hey, even if you lack insight you can choose your medication based on the knowledge you acquired while being a medical student!  You were not a medical student?  You don't have a degree in psychiatry?   Never mind, your mental health issues may not be addressed - but hey, you do have choice!

You may think from the above that I believe those with mental health problems have no rights at all - but this is not the case as I am very BIG on the rights of residents, as is my home.  I believe they have a right to the best of treatment and not the superficial fluff of caring they receive now, although as said, even receiving superficial fluff takes an awful lot of time to get to as there is an awful lot of hoops to jump through first.  And you continue to deteriorate.

What say you?

Anna :o]

Depression

You watch me
Through those damn dewy eyes
That torment my soul
And steal
The very heart of me.

The warning growl
Through snarling teeth;
The putrid breath
Feeding despair
And souring hope.

You're are my black dog,
Forever vigilant.
There is no escape.

Damn your dewy eyes.

Anna :o]

The Art of Death

The Art of Death

I paint in brilliant red;
Swift indiscriminate brushstrokes
Rend the canvas
Of my battlefields.

You hang me like some
Clumsy masterpiece.

Strip away the security
Of my shield
And see my stark imagery,
My epitaph
Of battles won
And lives forever lost.

I am Death
Cold and clinical.

Anna :o]

With thanks to Tess at Magpie Tales

Saving our NHS Forest

I love my NHS.  It is probably true that I love it less than I did.  The steady privatisation, fragmentation, low staff moral, the illusion of choice has left harshness, a coldness that is felt by patients.  It is also true that within the NHS there are many good people who genuinely care and in themselves are part of the healing process.

The NHS that I knew and loved is so eloquently described by Dr No in Alma Mater.  I was so taken with it; I emailed it to David Cameron's election HQ, then naively believing that the Conservatives would indeed look after our NHS and perhaps even attempt to recover the NHS as it once was.  Whether he read it or not - I don't know.

Of course I wasn't a doctor and not yet a nurse then in the NHS that Dr No described, but a patient.  Several admissions during childhood and for the delivery of my own children, I was aware of the warmth and camaraderie for it indeed rubbed off on patients.  Times have changed and changed the NHS, the sense of temporarily belonging to that family during admittance is very seldom apparent.  Yet the NHS is still worth saving and I am grateful that it exists.

The NHS can be likened to a great oak that stands proudly in an ancient forest existing on the peripheries of our lives; not a constant requirement - but there when we need it.  Its great branches supporting its lush green canopy offering us shelter when we are diseased or injured; its roots searching and probing for life saving cures; its leaves providing us with the oxygen we require for our very existence; its fruits offering new life; its whole self offering a place of refuge in times of need.

Our real forest have recently been under threat, the coalition government planned to sell 15% of the public forest estate by 2015.  Critics objected to the sale on the grounds that it might be more difficult for the public to gain access to them, and even wildlife and the very existence of forests themselves might be threatened as timber companies and developers took control - unfettered by the protection of public management.

The public were up in arms and in a short space of time, a cyber petition gained over 500,000 signatures and our forests were saved.

The very existence of our NHS forest is under threat under the guise of the White Paper: Equity and excellence: Liberating the NHS.   Its apparent aims appear laudable: putting patients at the heart of everything the NHS does; focusing on continuous improvement and empowering and liberating clinicians.

In reality, I believe the White Paper to be a terminal illness masquerading as a miracle cure; its true aim to be that of opening the NHS to privatisation; where the very NHS will be threatened as private providers take control, destroying all that is seen as unprofitable, unfettered by the protection of public management.

The public (as patients) will find in increasingly difficult to gain access - especially if presenting with an illness that threatens the confines of a budget.  GP Consortia - unless a true commercial enterprise - will be doomed to failure and be swallowed up by the private sector.  The NHS as we know it will cease to exist.

You would think that the medical and health professions and all in healthcare would be up in arms about the destruction of our NHS forest - but no, bar a small few!  You would think that the general public would be up in arms about the destruction of our NHS forest - but no!  A Save our NHS petition has only gained a mere 37,489 signatures.

A recently published survey commissioned by the BMA would suggest that the great majority of the medical profession have great concerns re NHS reforms.  It is a fact that the key findings are a sham with less than 9% of doctors contacted even bothering to respond.  Amongst its real findings are: under four in ten do not understand what the reforms mean to them individually; over a third are waiting to see what happens; 11% of GP practices have taken no steps in preparing for the reform; 37% know very little or nothing at all about current NHS reforms; 33% of doctors (excluding GPs) have taken no steps to prepare for reform - and so it goes on.  Read the real results of the survey here: Ipsos Mori.  Read it (the downloads!) and weep!

If those in the medical profession and indeed those in nursing and allied professions do not appear to care - how in hells name are we going to engage the general public?

Some of us care and I am thinking here of all the good doctors who blog: Dr No, The Witch Doctor, Dr Grumble, The Cockroach Catcher et al, Militant Medical Nurse and the lovely Julie at Campaigning for Health - but are these fine bloggers truly representative of their professions - or are they the voice of the minority, the majority just waiting to see what happens?  I would hope that they are not and would echo Julie's sentiments in that all who work in health professions - and care about the NHS - should not just 'stand there and moan - do something!'

When we mourn the death of our NHS in years to come, we will throw our hands in the air and exclaim "Why didn't somebody do something?"

Anna :o]

Addendum:  I have been made aware of another petition that seems to be enjoying more success.  Please visit 38degrees, sign and help save our NHS.  (These are the folks whose petition saved our forests!)

The Shamrock

The Shamrock

He stands the proud sentinel,
No more the Irish rover.
True to his love of sweet Violet
They spend their days in clover.

Anna :o]

With thanks to Tess Kincaid at Magpie Tales for the inspiration.

Cafe Alliaceous

Cafe Alliaceous

Night black recesses
Offer
A masquerade
Of flickering candles,
Disguising infidelities
Met at
Red frocked tables.

Escargot Bourguignon.
Every breath savoured,
All passions melded,
Tongues licking lips
In excited anticipation.

Bon appetit!

Fellow bloggers.  Take a break from the norm and excite your creative juices!  Visit Magpie Tales every Monday and let your imagination run wild!

Anna :o]

Never Events

The lovely Andrew

Never events should never happen - but they will, for to err is human.  Never events happen in health care settings and sometimes in a patients home.  Never events cover wrong site surgery to an overdose of insulin.

A previous list of eight never events has recently been increased  to twenty-five and details can be found here.  There are one or two detailed there that I have great concerns with -  with regard to inappropriate use and one of them reminds me very much of Dr Jane Barton.  We have a guidance plastered on the clinic wall at work re the opioid naive patient and as said, whenever I read it - I think of her; but that is another matter.

I do not think that any surgeon, nurse or technician deliberately leaves instruments. etc in operation sites, nor do I think that a doctor or nurse deliberately overdoses a patient - forget nutters like Beverly Allitt for this is not about them.  Errors should never occur - but they will.
Now the list of never events is greater - it stands to reason that the number of actual events per year will increase.

I have given the wrong medicine to residents twice - perhaps more than this and I am unaware of it?  It wasn't a deliberate action, but caused by a moments distraction.

Health Secretary (the lovely) Andrew Lansley has declared that understaffing is not an excuse for 'never events'.  What's that you say "Understaffing?"  So he finally admits that wards are understaffed!  This issue of course does not limit itself to nursing and includes doctors and midwifes.  The more doctors and nurses are made redundant or not replaced (despite election promises to protect front-line staff) - the more never events will occur.

However, this post is based on an interview with dear Andrew in the Nursing Times (which occasionally rises above the banal) in which he declared he would not tolerate excuses from nurses who blamed life-threatening mistakes on understaffing and being over-stretched.

A wag left this brilliant comment:  "Presumably if staffing levels have nothing to do with safety, one nurse could run the entire NHS?????"

Beware doctors and nurses - the shit won't hit the fan - it will hit you!

Anna :o]

Internet-informed Patient: 27th & 28th March, 2011

A one-day symposium and hack day is being held at the Moller Centre, Churchill College, Cambridge on the 27th & 28th March regarding the Internet-informed Patient.  Full details can be found here.

My - how I would love to attend - but I can't as they are my work days and I have no annual leave left.

Please - if anyone reading this is lucky enough to attend - I would really be grateful if you would email me after the event and let me know the outcomes.

Cheers in anticipation!

Anna :o]

Today is Rare Disease Day

Not many people know that and I must admit that I didn't until an email friend recently pointed it out to me.  She ('Susan') wrote to me not long after the 'Dr Google Revisited' post, perhaps to inform me that for some, the Internet is the only source of medical information available.

Rare Disease UK conducted a survey  "Experience of Rare Diseases: An Insight from Patients and Families" in 2010 and some of it will make your hair curl!  Click on the link provided in the summary and you can read a fuller version of the survey

Amongst the findings in the summary are that patients and families affected by rare diseases wait too long for a correct diagnosis (some unfortunate souls wait as long as twenty years).  A worrying number receive the incorrect diagnosis before the final diagnoses and patients and families worry about the level of awareness of rare diseases among healthcare professionals.

Importantly patient organisations play an important role in the diagnosis of, and are often the main or only source of information for rare diseases.

I asked 'Susan' whether she had consulted Dr. Google - for although we have corresponded with each other for nearly two years - I had never asked her before.  With her kind permission I detail extracts from her response.

"Yes I did consult Dr Google, this was during my diagnosis period, but the first reason I did this was because I had been tested for things I had never heard of, and it was never explained to me (what the test was and why and what it was for) - (I thought this was because they were protecting the patient, not wanting to scare me, but later my thoughts were - they don't know!)  This I found quite daunting because I grew up thinking like most, that if you're ill, you go to the doctor or hospital and they make you better!... So I was thrust into a situation of also finding out that doctors don't actually know everything as I had previously thought...

"I googled phaeo (phaeocromocytoma) because when I got home from hospital I saw this written on my letter, (this was a chance viewing as I would never have known what I was being tested for).  I had never heard of such a thing, so curiously I wanted to know what it meant... this was it fact the first time I used Dr Google... so my experience of Dr Google was one of learning and the computer told me more that I need to know, but it also helped me to understand that what was going on with me was unusual and rare.

"I was also lucky that my cardiologist knew of these rare things, as I later found out many doctors have little or no knowledge of rare illnesses..

"Comments actually said to my by the doctors were that my illness was unusual and rare and mysterious and they would have to think about it; they also said there is definitely something going on with you that they have never seen before and were baffled by the intensity and resilient and debilitating tachycardia I was suffering...

"What I did not expect to happen was that they would go away scratching their heads and leave me to face my life with a debilitating rare illness that turned my life upside down.  I do understand that they don't know everything (who does) but I wish they would at least say they don't know and have some empathy with the patients left to live their life with chronic debilitating rare diseases..."

My experience with Dr Google began with the very same search; my consultant informing me that he thought 'it' was one of two things; the first affecting "two glands that secrete hormones" and I should not be on beta blockers - but he would say no more.  It was a simple task to check the contra-indications in the BNF and google the next day.  Perhaps it would have been helpful if we both had been told that "It might be this - but a simple test will rule it out."  I should state that neither 'Susan' nor I had a phaeo.

Due to us sharing a joint (long way down the line) diagnosis, we 'met' through a patient forum and it was on this forum that we began to understand our condition.  Without the Internet we and many others would be totally isolated.

It is sad that many people have had the 'anxiety' label attached in their long journey for a diagnosis - you will see this mentioned at times on the report of the survey - as it is very difficult to get the medical profession to see past this, once attached.

I found my diagnosis on the Internet - but in took a good few months (and a good few consultants) before I was finally listened to.  I realised that I would have to 'admit' to anxiety (even though I knew it incorrect) as it had become a barrier, and once I did, I was listened to.

There are over 6000 recognised rare conditions - some extremely rare and some more 'common' rare conditions and it would be impossible for a doctor to know them all.  But please docs, if a patient persists with "I know something is wrong!" please accept that they may be right!

Anna :o]

A Love Affair

The Remote Computer Says "No!"

I called you up; gave you my name.

You dealt the cards, I played the game.

The more moves I made,
The more it all became the same
And bored with you,
I left you..

Years on
We reconnected.

I was so surprised
In how you'd grown.
So much more erudite
Than the friend I'd known
And erroneously rejected.

If truth be known,
Second time around
I had become afraid of you.
So much power at my finger tips!
The power of technology;
You can't teach old dogs new tricks!

This old dog did learn
And was able to discern
The sublime
From the ridiculous;
A method so meticulous;
A honing of skills;
A separation of facts from frills;
You offered:
Intelligence as a panoramic view
And, I then again
Became friends with you.

You have given me so much:
(Have I just taken and you have given?)
This arena where I spiel forth;
Forums for debate -
Of how human kind can
Love or hate,
And passions
So passionately driven
Can unite or rent the world apart;
Subscriptions to the world of learning -
The world at my finger tips;
Affairs of the heart
In email-ships;
Of cunning asides
And clever quips;
My, you have opened my eyes!

But of late I have sensed
Your disaffection
With our relationship;
You sometimes cut me off,
But I must admit surprise
That you no longer
Accept my calls.

A loss;
A bereavement
That I initially denied;
But by day five
Emotion
(Tears welling in my eyes)
I cried openly and thought
What the hell is this?
And sought comfort
In self-analysis.

I have said for years
That you are my social life;
But now think it is much
Deeper than that -
You have become my husband
And I your wife.

I am having an affair with you.

Before we reconnected
I had adapted
(Accept the things you cannot change)
To my situation;
But losing you
Has resurrected
My loneliness,
My emptiness
And total isolation.

Knowing you and losing you
Has left me vulnerable
And I don't like that.

Anna :o]

PS  Writing this at a friends house - so no pretty pictures!  Also ajolopies for another morose post!
It must be my blue period!

Yay!  Came home today and my boyfriend's back!

He did bring seven viruses with him which took

two hours to clear - but I will forgive him anything!

Remote computer - I love you!

Pretty (sad) picture now added above!

Happy one too!

.

Brothers

The scallywags!
Playing soldiers,
Playing tag;
Jump in puddles;
Rugby huddles;
Sly smoke of fag
Behind bike shed.

When at school
Defy the rules.
Spotty youths now -
Heart rules head.
Brain in trousers;
Hormone led.

Trainee men now;
Stories aimed to vex.
Sibling rivalry
Based on sex
And notches on the bed.
The easy cow,
So easily laid and
The triumph
Of the virgin maiden made.

Married now
And life passes by;
Kids grow up
And you heave a sigh
As you
Cannot realise
Where the years have gone
For that baby
That once was your son,
Your child,
Is now a man
And history
Repeats itself
As he relates
His conquests.

Many years ago
A quirk of fate
Decided
To rob you of your mind;
No more shared crosswords
Of the intellectual kind;
Or shared cross words
That is sometimes
Found in partnerships;
But not ours -
It was a melding of minds.

Your brothers
Who were supportive initially
Dropped by
Now and then
No longer do
Or phone
To enquire after you.

Where are you?

This was the first Christmas
And New Year
There was not
A sound from you.

Where are you?

My God
I know how hard it is
To lose someone
Who still lives.
But I will not
And cannot forgive
Your silence!

I hope you rot in hell!

Bitter Anna :o[

Dr Google - a patient opinion (revisited)

Why do patients consult Dr Google?  It may be that they simply want to check out (self-perceived) minor symptoms so as not to bother their GP - or conversely checking those same minor symptoms as they misinterpret same as the first sign of a major illness; they may be in the midst of investigations and feel left out of the information loop, vulnerable and frightened; they may have a diagnosed condition and wish to educate themselves in and understand how their illness will impact on their lives and thereby develop coping strategies.

Disregarding the 'worried well' and those who seek antibiotic therapy for the slightest sniffle - patients (I am thinking of me here) seek GP advice in an effort to provide an answer to their presenting symptoms.  Often doctors are able to diagnose immediately, prescribe medication if required and the patient, reassured, will go on their way.

Sometimes a diagnosis may take a little longer and the patient will receive the full input of their doctors skills and appropriate care during and up to the time the diagnosis is finally made

At times, the illness may not have evolved into something recognisable and a 'wait and see' period may be necessary and perhaps following this, the patient will be referred to a specialist - at times the referral may be immediate if red flag signs/symptoms are apparent..  This is the time when patients feel most vulnerable as they lack an answer, at times, they are fed little information as it would be inappropriate for a GP to state positively "I think you have this" without medical evidence; whatever reassurance is given at this time is meaningless (to them).

Patients need a name to give to their illness - whatever it might be - as they need an end to uncertainty; I quote Balint here:  "Perhaps this case may also help us to understand why patients have a great need to be told what their illness is, what fears may be rampant in them if no name is given, and, last but not least, what the inevitable implications of any diagnosis, however innocent-looking, may be."

Patients who are referred to secondary care, that of a consultant specialist, often find themselves going to and fro between specialist and specialist and their GP.  Speaking from experience this is a terrible time where the patient receives very little information and in a sense, is on the outside looking in.  I think that doctors tend to forget that patients exist (and think) outside of the time of the consultation and feel abandoned by the profession whose help they are seeking.

This is The Collusion of Anonymity where no physician has full responsibility for the patients as he sees doctor after doctor (all offering their own differing opinions) and the patient is left in a no-mans land; respectfully I quote Balint again:  "Nobody mentioned, and perhaps nobody was even interested in, what happened inside the patient while he was being whisked from doctor to doctor....."

What ever the original driver, however simple or complicated the presenting diagnosed or undiagnosed illness, patients consult Dr. Google purely and simply because they need an answer.

Doctors and Dr Google

As I am not a doctor, I am not qualified to offer a doctors point of view and therefore what follows is based on information gleaned from research or personal observations.  Please, if I am totally wrong docs - tell me as I live to learn.

The doctor-patient relationship is an unequal one and must always be so.  Doctors  have a vast knowledge base regarding medicine and we patients have very little.  A patient arrives voluntary and submits to medical attention.  There has to be an element of trust in our doctors' skills and ability to provide the answer we are seeking.  The relationship is not always therapeutic in that both doctors and patients personalities are sometimes opposed.  However, even in this case, we attend our doctor and provide him with clues in the expectation that he can provide us with a name for our illness.  At times we may not accept a given diagnosis for a variety of reasons.

Doctors at times feel threatened and insulted by the arrival of Dr Google - the unwanted and uninvited interloper who upsets the dynamics of the doctor-patient relationship.  The doctor may also be fearful for the mental health of his patient who might have read something on the Internet that is pure nonsense - and there is a lot of it out there - that might instill in them fear or provide them with false hope.

Some doctors welcome their patients interest in their condition - whether diagnosed or not - and see it as a positive step in the doctor-patient relationship.

Doctors visit Dr Google - but very differently from the average patient - recognising where quality lies in peer reviewed articles, professional medical sites and a multitude of other sources.  It is estimated that there are 3 billion Internet medical articles.

It is true that Dr Google is not going to go away and doctors will have to accept this.  It is also true that patients remember perhaps a half of what doctors tell them, so will seek information elsewhere.

Is Dr Google a friend or foe?

He can be either.  A recent survey by BUPA covering 12,000 people around the world found that globally, 47% of respondents used the net to self-diagnose and 68% sought information on a medicine.

The problem lies with the quality of information looked at and its potential to make a person imagine the worst for minor symptoms or ignore symptoms that would indicate a serious condition.  The term cyberchondria was coined in the year 2000 to describe how patients' symptoms escalate as they self-diagnose.  It has to be remembered that a search engine cannot diagnose - it needs a person, or more accurately a doctor to make the final diagnosis.

Nevertheless, Dr Google can provide a wealth of quality information for a patient if they know where to look, and can also 'talk and give time' to patients about their presenting illness in a way that doctors cannot do because of time constraints.  Doctors and patients must reach a happy medium.  Perhaps doctors could prescribe helpful sites?

Dr Googles BIG limitations

Dr Google can only offer what has been fed to him and as said, the potential to mis-inform and instill fear in the heart of the reader is dependent on the quality of the information provided, and the readers ability to interpret what is said and to sift out the dross.

I decided to 'consult' Dr Google myself as an exercise to discover possible pitfalls.  I keyed in just two words (the site on the body and the presenting symptom) of a benign condition and visited the first two pages.   I did not enter the 'question' sites - just those that appeared to be true medical sites - just three in total.  The first offered a doctor to patient differential diagnosis and I was able to locate my 'problem.'  The remaining two offered doctor to doctor differential diagnosis and these confirmed my 'problem.'

I then transposed the two words and inserted 'on' in the middle and was met with totally different results.  Of the three quality sites (including Medline) I visited, two suggested quite strongly that I had cancer and Medline inferred in the first sentence that I had.   I don't!

I then visited http://ffff.at/dr-google/ (this will not provide a direct link so you must google it and click on) - which I presume is an official google site?  I keyed in the same three words and clicked 'I'm Feeling Icky' and the one result was cancer - no ifs or buts!   I then clicked 'Second Opinions' and was then redirected to the pages I had originally consulted.

I then read this article on Cyberchondria: The perils of Internet self-diagnosis (interesting read) and then visited the 'trusted' medical sites listed at the end keying in the same three words.  Medhunt had the dross Wrongdiagnosis as the first entry, followed by three identical entries of the first site I had visited on my search - the doctor to patient differential diagnosis - and the rest were related to plastic surgery; NHS Direct, although offering the body site did not offer the symptom and was therefore useless;  Patient Line gave the best results and was quite informative and finally WebMD offered a mish-mash of irrelevant and unrelated results to the question posed.

So beware patients - Dr Google, if you look in the right places might be helpful if you understand and are able to discriminate in what you are reading - or he may scare the hell out of you.  That said - I have used him and not found him wanting - but it is about recognising quality sites.

If you should find something out there, don't take the printouts to the doctor - but inform him what you have found.  If he is a good doctor he will ask you to bring them to the next appointment.  Respect him (or her) and he will respect you.

Michael Balint: 'The Doctor, His Patient and the Illness'  (Churchill Livingstone)

Anna :o]

Wilful Neglect

Although a nurse - I am indeed lucky to work outside of the NHS - for if not, I would feel very threatened, undervalued and unprotected.

I would bring your attention to this statement from the DoH which was briefly reported in the media and has now disappeared into oblivion.  It states that doctors and nurses should be charged with a new crime of 'wilful neglect' if they fail to look after patients.  Sounds fair to me

It also states that ".... ensuring that providers have sufficient qualified, skilled and experienced staff and patients are protected from the risks of inadequate nutrition and hydration."

I can't speak for doctors, but if nurses such as Nurse Anne go home in near tears, as she is terrified that she has made a mistake or killed someone, as she is stretched to the limit by dangerous (qualified) staffing levels - how will nurses cope when this becomes more widespread?

Nurses in hospital are natural scapegoats.  If a doctor makes a drug error and the nurse carries out his/her orders, the nurse is responsible and accountable for carrying out said orders.  If a cadet/HCA fails to assist a patient with feeding, come 'wilful neglect' the nurse will be responsible and accountable - even though she will be unable to supervise as she is carrying out doctors orders, doing meds rounds, attending to patients in difficulty and completing the mass of required paperwork

The Conservative Health Manifesto stated "We will cut the cost of NHS administration by a third and transfer resources to support doctors and nurses on the front line."    Aint happening.

If nursing levels sink even lower - patients are going to starve and become dehydrated (outside conditions where a patient declines food and hydration at end stage illness) and yes it does happen now due to dire staffing levels  - nurses will pay the price for something that will become increasing beyond their control.

Can anyone speak up for the medical and nursing professions please?   We meed more - not less!  Why can you not imagine they are forests/woodlands and raise Cain?

Anna :o[

Heartsink Doctors (revisited)!

We all know that feeling; we crawl out of bed in the morning, not quite full of the joys of spring but near as dammit, and then ten tonnes of reality drops on our head as we realise that we are on Dr Nasty's list that morning, and our heart sinks.  We are filled with anger, despair and frustration as the all pervading feeling of doom overwhelms us.  What should be a therapeutic encounter will be the exact opposite.  Why oh why was Dr Bubbly not available?

Oddly enough, Betty next door swears by Dr Nasty - one man's meat is another man's poison - and has elevated his status to that of a living saint and you begin to think is the problem me or has Betty got something wrong with her mind?

You arrive at the surgery and take your place in the waiting room.  Your anxiety levels rise and if you weren't hypertensive before you came - you certainly are now!  You are buzzed and make your way to his room - like a lamb to slaughter - and the consult was as awful as you thought it would be.  But was it a self fulfilling prophecy?  Was he the heartsink or were you his heartsink?

The following consults are based on appointments I have experienced.  Was I the heartsink or were the docs?  Dr Bubbly perhaps doesn't really deserve a place there - but he had his moments!

Dr Computer

Dr Computer is (in his own mind) a time management wizard and he can fit almost everything re logging data of a ten minute consultation slot into 10.5 minutes - the only thing that prevents him reaching 100% perfection is the damn patient!

He will be keying in info as you enter his room and doesn't acknowledge your existence for the run over thirty seconds.  "Ah and what are you here for erm, erm, Mrs Erm?"  He has no idea who you are or your history as he has just finished detailing his last patient - who coincidentally was also a Mrs Erm!

"Mrs Brown.  The hospital said I should visit you monthly to check on how my thrumbocritis (fictitious condition - but real for the purpose of this exercise) is progressing.  They said it's required to prevent deterioration."

"Don't know anything about it."

"But you referred me!"

"Did I?  Erm - just let me check the computer.  Ah!  Yes - so I did!  What did you say you've got?"

"Thrumbocritis."

"Never heard of it!  You'll have to tell me what it is!"

"Surely you'll have a scanned letter from the hospital on your computer?"

"Have I?  Hang on a minute... ah... yes I have!  But I still don't know what it is.  What is it ?"

"Why don't you Google it?"

"Google it?  That's a good idea!  Hang on!  Googles it and spends three minutes scanning.  "Mmmm... that's interesting - never heard of it.  Hang on a minute!"  Spends two minutes entering details of the consult on his beloved comp.  "Look, I'll have to read up on this!  How are you feeling?"

"Okay I suppose."  I'm not! - Why the hell am I saying I am?  Because I feel like I am intruding on his quality time with his damn computer!  "Should you not check something?"

All eye contact with me has now ceased and he is glued to his computer screen.  "Nooo: you look fine!  Tell you what; come back in a month and I'll have had a chance to read up on this.  Come back sooner if you think you must.  Okay?"

"I suppose so.  Thanks?"

"Fine Mrs erm, erm, Erm?"  He is still glued to the computer!  Little fingers typing away.  I leave feeling totally bewildered.  What was all that about?

Dr Nasty

As you enter his room, Dr Nasty engages you in his (I am not interested in you at all!) glare.  His facial expressions and body language betray all.  "What's the problem then?" he demands.

"The hospital said I should visit you monthly to check up on how my thrumbocritis is progressing.  They said... "

"Ah yes," he cuts in.  "The thrumbocritis lady!  I don't buy into it!  God!  They'll be medicalising burping as Postprandial Stress Disorder next!"

I can feel my hackles rising - determined to stay calm I smile pleasantly and ask "Pardon?"

"I don't buy into it.  It's anxiety!  Why don't you accept that?"

"Because I know it isn't.  I know me!"  Getting a little defensive but still smiling pleasantly, I add "And it's medically demonstrable, evidence based medicine and all that!"

"Oh - have it your way!  How are you then?"

"I feel awful."

Utter disbelief in his voice he says "How can you say you feel awful when you're smiling all the time?"

"I am smiling all the time because I refuse to rise to your bait and I refuse to adopt the sick role.  I am me - not my condition."  All said in a perfectly calm voice.

He shakes his head and his eyes roll.  "What do you want me to do then?" he demands.

"I have just realised I don't want you to do anything Dr Nasty.  I'm going now.  Goodbye."

Dr Nasty is the doctor who (apart from Betty) nobody, but nobody wants to see.  When you leave you think - What the hell did I do to deserve to be treated like that?

Dr Bubbly and Nice but sometimes Role Reverser

Most of the time Dr Bubbly is just bubbly and nice;  he makes you feel valued and comfortable and dammit - sometimes you just want to marry him and have his babies!  He is so lovely that I am sure that if you entered his room with depression - you would leave elated!  Sometimes though his dark side enters the consult - but it won't be obvious at the start and therefore takes you by surprise!  Really 95% of the time he is not a heartsink - but when his is, well, you leave very confused.  What did I do?

"Hello Mrs Brown!" he enthuses as you enter, "How's things?"

"Fine thanks Dr Bubbly!"  If someone is kind to me, why do I say I'm fine?  I am not a miserable sod perhaps?

"Mrs Brown, our thrumbocritis Lady!  Y'know, I am really excited.  I've read about it but never seen it before!"

There follows a general discussion about thrumbocritis, his favourite football team and his holiday in Bulgaria and life is tickety boo!  BP and heart rate checked.

"You'll need a new sick note then?"

"Yes please."

"You're quite tachycardic there!  The hospital suggest I up your meds if this happens.  I'll write you a script for Thrumbosolol 150mgs.  Okay?"

"I've still got a months supply of 100mgs left, so a months supply of 50mgs..."

"No!  I will write you up for 150mgs," he says harshly.

Thinking of the dire straits of the NHS, practice budgets,etc, I persist "But I have a months supply of 100mgs left, would it not make sense to... "

"No!  I will write you up for 150mgs!"

As this is the second time this 'change' has occurred during a consultation, I ask "Are you fed up with me?"  After all, I might be a heartsink and not realise it!

"No.  What makes you think that?"

"It's the second time you've become short with me, treated me differently.  I just wondered if you are fed up with me?"

"No - not at all; its just, well; I'm fed up with being put upon here.  I want to be a partner - but Dr Computer doesn't want a partner.  I want to make a difference to the practice."  He chats on about his unhappiness with his position and honestly - I don't mind - we all need to vent at times.  He finishes with "Did it come across?  I didn't realise."

We part as friends.  Often, when I go for my sick note we end up talking about him or he ends up talking about him really.  And I really don't mind but wonder who's seeing who?

Dr Bubbly finally left after achieving a partnership elsewhere.  Our practices loss is another practices gain.

Dr I Am the Doctor - You Are the Idiot

Dr I am the Doctor is a strange woman.  She is delightful with children and nobody minds making an appointment with her in this case.  With adults it is a totally different matter; she is very intimidating, very brusque and if she should visit you at home - when you have broken your toenail - she is able to diagnose from the door.  She has the propensity to make the happy depressed; the calm enraged and the sane mad.

"Yes!"

"The hospital said I should visit you monthly to see how my thrumbocritis is progressing.  They said it's required to prevent deterioration."

"Oh, they said, did they?  Well, I suppose they must  know what they're talking about."  She sighs and shakes her head.  "Well!  How are you then?" she demands.

"I feel awful most of the time - but I am adapting.  I am not going to let this rule my life."

"Bully for you!" she snorts.  "What do you want me to do?"  She is beginning to make me angry - I knew she would!

"I think it says in the letter that you should monitor my BP and heart rate."

"Oh does it now?" she sneers.  "Well, I'd better do it then!"  I am really getting hot under the collar!  "Arm!"  She takes my BP, twice, and then takes my pulse.  She writes out a script increasing the Thrumbosolol and shoves it across the desk.  "There!"

"Whats that for?"

"Well you must know you're tachycardic and your BP's through the roof!" she sneers, eyes widening by the second.  I'm not surprised my bloody BPs raised - I am surprised that steam is not coming out of my bloody ears!  I wouldn't dare mention the month's supply of meds that could be topped up with a month's supply of 50mgs!

I leave totally enraged!

All these doctors existed at the practice I attend several years ago.  No more - just them.  At this time I actually was on the sick and noticed the waiting room became emptier and emptier across the months.  Now perhaps the doctors' approaches led to patients not attending with trivial complaints - but I don't think so, as an ANYONE WISHING TO REGISTER AT THIS PRACTICE WILL BE ACCEPTED appeared on the board at the Health Centre entrance and remains there to this day.

Heartsink patients are the bane of a doctors life - but heartsink docs are the bane of a patients life too.  Do heartsink patients/docs really exist or is it about transference and counter transference - or simply the doctor-patient relationship, poor communications skills and a lack of shared understanding?  I realise that difficult patients exist and are a poor example of humanity - but difficult doctors exist too!

Anna :o]