Alf
It’s a Sunday and I’m working a locum shift in A&E to make a bit of extra money. I used to work in A&E during my hospital training and quite like going back to work the odd shift. It helps keep me up to date with my A&E skills and also makes me happy that I’m not a full-time A&E doctor any more. I pick up the notes for my first patient of the shift, open the curtains and lying on a trolley in front of me is Alf.
‘Oh bloody ’ell. Not you. You’re bleedin’ everywhere, you are.’
Although these were Alf’s words, they also very closely reflected my own thoughts.
I had been visiting Alf at home all week as his GP and then I turn up for a shift in A&E to get a bit of excitement and escape from the daily drudge of general practice…and there is Alf lying in front of me.
Alf is in his late eighties and lives alone in a small run-down house that he can’t really look after. Alf’s notes state that he has had 23 A&E admissions in the last five years, which qualifies him to reach the status of ’frequent flyer’ in A&E talk. If hospital admissions could earn you loyalty points, Alf would be able to cash his in for two weeks of dialysis and a free boob job. Unfortunately, all Alf ’s hospital admissions have actually earned him is a bout of MRSA and a collective groan of disappointment from the A&E staff when they see him being wheeled into the department.
Given the large amount of time Alf spends coming in and out of hospital, you would think that he had a huge list of complex medical problems but, in fact, Alf doesn’t really have much wrong with him physically. His admissions have been almost purely ‘social’. This means that Alf is admitted to hospital costing a large amount in time, resources and money, because he can’t really look after himself at home. When they talk about bed crises and patients on trolleys in corridors, it is because patients like Alf are lying in hospital beds that they don’t really need.
This is what happened to Alf this week. I got a phone call from his worried neighbour on Monday saying she had heard him shouting through the wall. I couldn’t get into the house so I had to call the police to break the door down. Once inside we picked up Alf, who was basically fine but had fallen over as he often does. Sometimes there are specific reasons why elderly people fall over such as blood pressure problems or irregular heart rhythms. Sometimes elderly people just fall over because they are frail and have poor balance. Alf falls because he refuses to use his three-wheeled Zimmer frame (‘it makes him feel old’), because his house is filled with clutter that he refuses to allow to be tidied away and, finally, because he is still rather partial to a large scotch after lunch.
On the Monday I gave Alf a check-over and he was fine. He hadn’t bumped his head or broken his hip and insisted that we all ‘bugger off’ and leave him in peace. Alf looked terrible. He was thin and bony with filthy clothes, long straggly grey hair and quite frankly in need of a good wash.
‘How do you feel you’re getting on at home Alf?’
‘Fine, now piss off and leave me alone. The race starts in 20 minutes.’
‘What about if I got you some help around the house? Perhaps someone to clean up a bit and maybe give you a hand getting washed and dressed in the mornings?’
‘I’ve been looking after myself perfectly well for 70-odd years, I don’t need you lot interfering.’
‘How about just some meals on wheels to get some meat on those bones.’
‘I’m a very good cook, thank you very much.’
Alf had been offered support at home numerous times before, but he had always declined. He was a grown- up and knew his own mind. He sometimes forgot things but he wasn’t demented and was entitled to make his own decisions about his own house, health and hygiene. When I got back to the surgery, I phoned social services and asked them to make an assessment. I was specifically going against the wishes of my patient, but Alf was in desperate need of some support and if some nice friendly social worker came and had a chat over a cuppa, perhaps Alf could be persuaded… Needless to say the next day the social worker phoned to say that after a brief conversation through the letter box, she had been given the same ‘bugger off’ as the rest of us.
I can completely see where Alf is coming from. He has lived a long hard life and has managed independently, making his own decisions and doing his own thing. Why should he suddenly have strangers in his house interfering? He wasn’t harming anyone other than himself, so why didn’t we just leave him alone. I imagine his biggest fear was being carted off to a nursing home and losing his independence completely.
My problem was that as Alf’s GP, I had a duty of care for him. That and the fact that his bloody neighbour always called me first when she heard him shouting and swearing through the wall. At least we had a spare key now and so I visited Alf three times that week and each time I picked him up, checked him over and was given the same emphatic ‘bugger off’ when I offered to bring in some help.
On Sunday morning, the surgery was closed so when Alf fell over, the neighbour just called 999. The paramedics decided to bring in Alf despite his protests and here he was, looking uncomfortable and unhappy on the trolley in front of me. As ever, I checked him over and, being in A&E, I had the advantage of being able to get a quick ECG (electrocardiograph — heart scan) and urine sample checked. They were both normal and predictably Alf just wanted to go home. The problem was that there was no hospital transport on a Sunday to take him home. The ambulance crew wasn’t allowed to take him and he didn’t have any money for a taxi. We had no choice: Alf had to be admitted to a hospital bed. As he was being admitted to a medical ward, he was subjected to the obligatory blood tests and chest X-ray. Then he would be assessed by the physios and the occupational therapists who would each in turn be told to ‘bugger off’, until eventually Alf would be sent home only to fall over a few days later and hence the cycle would be repeated.
The government in its wisdom has worked out that patients like Alf are costing an absolute fortune because he is part of the 10 per cent of frequent flyers who are responsible for 90 per cent of hospital admissions. The problem is that it is very difficult to keep patients like Alf out of hospital. Even elderly people who do accept help still fall over or become confused when they get a simple infection. Carers, neighbours and relatives do their best but they don’t have medical training and when faced with an old person on the floor, they often call an ambulance. I don’t have an answer for what to do with patients like Alf. Perhaps smaller cheaper community hospitals or specially adapted nursing homes that offer short-term care would be a better option. It is such a shame that A&E departments full of well-trained staff and expensive equipment are seeing their beds filled up with social admissions like Alf rather than the accidents and emergencies that they are intended for.
Meningitis
Every six months or so, a newspaper will print an article with a headline something like: ‘GP MENINGITIS BLUNDER — My GP diagnosed my child as having a cold, ten hours later she was in intensive care with meningitis.’ This is the sort of story that terrifies every parent and every doctor. For GPs who are also parents, it is a double- fear whammy.
Meningitis is a frightening condition for GPs because it tends to affect children and young people and if we miss it, the patient can be dead within hours. The difficult truth behind the scaremongering headlines is that any child who is seen by their GP in the first few hours of meningitis will probably be sent home with some paracetamol having been told that they have a viral infection. Early meningitis symptoms are generally a fever, feeling a bit lethargic and not being very well. We see bucket loads of children like this every week. The symptoms of a rash and neck stiffness that give away the diagnosis are only seen much later on, by which time the child is already quite sick.
I know an excellent and experienced GP who sent home a child who then went on to develop meningitis. It is a horrible diagnosis to miss but only rarely is it a ‘blunder’. The only thing we GPs can really do for the thousands of snotty feverish children we see every day is educate the parents as to what danger signs to look out for and when to bring them back to see us.
I’ve only seen meningitis a handful of times and thank goodness never as a GP. The first time I saw it was the most memorable. I was working in casualty and a dad carried his four-year-old child into the waiting room. I took one glance at the child and went straight to the drugs cupboard, whacked some penicillin into his vein and
