Archive for July, 2009

Demographic…

Posted on July 30, 2009. Filed under: Uncategorized |

The demographic of your patients is an important factor, and the sooner you understand the basics of it the sooner you can understand how the general populous tick!

Every street, village, town, city, county and country have a different demographic.  I think it is time I revealed a little about this one.  Lets call it Sickton-on-the-Naze!

Al worried about trimming his nasal hair!

Sickton-on-the-Naze is an old village that has gradually grown into a town.  Traditionally the general population is not very mobile – regardless of age.  I mean this in two ways…

Firstly - Literally not mobile - Zimmerframes. There is a LOT of old folks around here.  This is because very few people leave the area so they grow old here, it also has a high elderly population as people come here to retire.

Secondly – socially mobile.  It’s kind of miles from anywhere, so the folks that grow up in Sickton-on-the-Naze, seem to stay here. They don’t seem too bothered about getting a driving licence, the driving test centre is miles away.  If someone decided to leave and go to college it’s considered a major event.

Due to the culture of not leaving town, people don’t seem to consider it. They stay here with the crap jobs, little chance of promotion, and little expectation. 

Before I start to sound too snobby I would just like to clarify something – I love it here.  From a clinicians point of view it is an interesting place to work.  The people in general are lovely. Sure we have a fair few drug addicts and lots of little old ladies and even a few little old lady drug addicts!  It makes for an interesting day.

The sad thing is that we seem to have a lot of young women who are stuck here and really should be bound for better things, but just don’t consider it.  With obviously some exceptions, the young men seem to be unmotivated and quite ugly, but do alright for themselves in the love stakes as the young women don’t considering casting their love net a little further out to sea.   So if you are an ugly bloke with poor prospects who wants a pretty girlfriend, this really is the place for you.

We also have a few great stereotypes and they probably exist in every surgery across the country. 

We have the Colonel. 

His grandfathers grandfather founded the town and half the streets are named after his dogs. He went into the military and enjoyed blowing things up, and still sometimes forgets that he has left active service and thinks that motability scooters are enemy tanks and takes pot shots at them with his air rifle.

We also have several old ladies who previously had high powered jobs, in the times before ladies were supposed to have high powered jobs.  The type of  woman the Colonel likes to call “Bloody lesbians”, despite the fact they are infact widows. Now with free time on their hands and their minds still agile they decide they can take on the world again and “fight for the little people”.

“Unhand me…I’m not a lesbian!”

We also have a few eccentric old ladies. One of which brings all the Doctors a banana every-time she passes by, and writes messages to them on the skin.  Then there is the lady who denies she has dementia and every-time you mention it to her, she informs you that “nobody ever mentioned it before”.  My personal favourite is a eccentric variant of the previously mentioned high powered ladies, that are waiting for a good murder for them to solve…

.…”Why won’t anyone come on holiday with me?”

oooh, and the 78 year old nurse who still receives a wage from a nursing home where she helps “the old people”, some of which are considerably younger than she!

…and that is why I love my job!

Just added my “Rate this” stars at the top…feel free to use them, so I can get a bit of feed back into what type of post you like best!  I’m insecure and need your help!

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Legends of the past…

Posted on July 23, 2009. Filed under: Benign |

I want to hear about the legends you have worked with in the past, and for this I shall tell you about mine.  The idea from this post came about for two reasons, one being that we all have legendary figures and some of mine recently came to mind with a strange dream sequence…and the other being that my legendary blogging mum and dad have met in Washington (with lots of other bloggers) and I got very excited and wished I could have been there…only 3528.45 miles away…

Mum and Dad!

Max’s Legends

Some of these may have been mentioned in the past posts and the list is not exhaustive. The names may have been altered to protect the innocentguilty. Disclaimer: the following examples are not examples of recommended practices!!

 Charge Nurse Snack…Most legendary for sitting in a busy waiting room do triage assessments for the minor injury patients, realising that the rest of the department was exceptionally busy and knowing that no patients were being seen from the waiting room because of this.  Snack bravely fought off constant bouts of patients moaning:  “I’ve been waiting 2 hours and nobody is being seen here”. Until he had finally taken enough abuse from one patient in particular and took him through the rest of the emergency department. They stopped at the resus room, where three patients were actively being resuscitated following a nasty RTA(MVA) and Snack asked which one of the resuscitating doctors the patient would like to call away to see to his sprained wrist.  The patient now understood why his minor injury was not being dealt with and sat quietly back in the waiting room, only speaking to stop other patients approaching and asking Nurse Snack about how long the wait was!  Legendary move.  Always wished I had the balls to do it!

Sister Pensioner…

No doubt many legendary tales to tell in her past, but really should have retired by now. Most legendary activity in my experience was during one shift while two nurses (one of which was little old me) tried to defuse a very odd, rapidly worsening family argument about to end in a fist fight.  I looked out of the cubicle and saw Sister Pensioner, looking in the room and using the phone. I assumed she was ringing the police in an attempt to stop us getting our arses kicked.  We managed to defuse the situation and got out and when I asked Sister Pensioner “where the hell are the Police”, she informed me that she hadn’t rang them, and was in fact ringing social services to get more background information… thanks for that!

Sister Essex…one of the younger sisters, everyone loved to work with her, very hard working when the muck hit the fan, but a good giggle and chilled out when the opportunity allowed.   Apart from generally being a legend, her most memorable moment to me, was on a night shift when a hyperventilating girl came in and nobody could calm her down. We even medicated her I think, and still she was hyperventilating and hysterical. Sister Essex went in to her again, shut the cubicle door and left the room again about 5 seconds later, having resolved the patients issues by administering a good old fashioned slap around the face.

Sister Wings…Another elderly sister, but this one still as sharp as a knife and bought back the old fashioned values to being a sister…basically most junior staff where scared pant-less of her, and never knew what kind of mood she would be in. However the more experienced staff had worked out the key. She has now retired and I can share the secret with you….

Eye liner… she normally wore eye liner that extended past her eye lashes, the rules were easy:

Eye liner extended in a downward direction = bad mood.

Eye liner in an upward direction = good mood.

Eye liner straight = approachable, but don’t push it.

No eye liner = call security.

Mr H…the boss. Our emergency department was essentially nurse led, as the consultant Mr H used to tell all the new doctors.  Fair enough really, we lived and breathed it and the new doctors invariably used to pass through for a few months.  Mr H was formidable in a completely spaced out kind of a way. This is the guy who could never be found in his office, he may have been in there but nobody could see through the smoke.  People thought he was rude as he used to walk through the department and ignore everyone saying their good mornings to him.  He wasn’t ignorant, he was thinking. I thought he was the most important person in the building, but he thought he was the least important. I sutures his finger once, I was trying to stitch up a patient, but he got in the way. He swore (not at me, but the burst of pain), sucked his glove and then carried on. I tried to manage him as a needle stick but he wasn’t interested.  He actually came to work having a heart attack and tried to ignore it. Eventually Sister Essex and I had to practically rugby tackle him to do an ECG.

You’ll notice that all my listed legends are from my days in the emergency department, I think this reflects my nursing blood, however I’ve been out of there for a long time now, and that is why of all the people I’ve worked with these are the legends. Unforgettable spirit and style. Love you guys!

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Referral’s nightmare week!

Posted on July 16, 2009. Filed under: Journal from behind the desk... |

Good Grief.

Obviously part of my role is to identify patients who can’t be managed in Primary care and need to be referred on to a specialist consultant.  In days gone by there were concerns that a mere Nurse Practitioner surely wasn’t competent to refer onto a super human like a consultant. Mostly we have worked very hard to prove that we could.

Despite initial fears, we proved that our referral rates were much the same as other clinicians and in some case less (probably because if we were ever unsure we referred to the GP who then may have referred on anyhoooo..)

One service still refuses our NP referrals despite our best attempts to convert them. I still refer and the GP just state: “I completely agree with this referral” on the bottom and thus it gets through.  Otherwise I have no problems, except for…..the bleeding patients.

On a very few occasion (about one every three months), a patient may feel they need a referral, and this can usually be addressed and either agreed or rationally explained and disagreed, but apparent this week is “National Be Snotty and Demand a Referral Week!”  Did anyone else see the publicity campaign???

My first case was a dad presenting with his school aged son, immediately demanding a referral to a Respiratory consultant to “cure his asthma” as nothing else worked.

I looked in the notes and the child had last attended surgery 6 months ago, with a mild cough and was simply advised to monitor his peak flow and increase his steroid inhaler if it dropped below 80% of his predicted range (which as yet it hadn’t).  I also noted that he had not had a repeat steroid inhaler prescription since.

I tried to ask the basic questions, and also asked whether they had been using a steroid inhaler recently. The torrent of abuse worsened and continued. I was advised that the patients mother was an “big in the city” ….

…and was demanding a referral and that his father was also an important figure in the health service and thus I should refer him to a consultant….

MY HECKLES ARE NOW UP…. but I stayed cool!  “I only refer based on clinical need” I explained and I add “Any respiratory consultant in the country would insist that you use the basic treatment and they will only accept a referral if this is not effective”.

But still he fires on.  At not point during the consultation was the child allowed to be examined. In the end I copped out a little and told them if they were unhappy with my decision to feel free to discuss it with a GP and I made them an appointment for 5 minutes later, to which he continued… “this is not good enough”.   I think he’d stopped listening at this point.

They stormed out and saw the GP, who gave them a steroid inhaler!

Apart from winding me up because he was point blank rude and ignorant (no matter how “influencial” he was!), I felt really sorry for the poor child, firstly having to witness such a tantrum, secondly for having to see their own parent behave in such a manner and thirdly for having a physical condition that simply wasn’t being managed properly due to ignorance, for which I could have given good advice but wasn’t given the opportunity.   I felt a little like asking the father to leave, so that I could help the patient…not sure that would have gone down so well ( I also avoided mentioning that holding back on prescribed medications was essentially child abuse!… I know, somedays I  am just too weak!!)  If I could have done a referral it would have been for the father to see someone in a mental health facility.

My second case was a teenage boy who had been convinced by his mother that he had a neurological condition, when infact he had a fairly convincing case of tendinitis. The teenager himself understood what I was saying and my rationale for why it wasn’t a neurological concern.  The mother however just kept on and on. In the end I think they went to the Emergency room to demand they see a neurologist.  Good luck with that one then!!!!  At least they were not aggressive, but just persistent.

I need a dwink! hic.

Apparently it reduces my risks of dementia…according to research a moderate drinker has lower risks…or at least they might just be too pissed to tell!  I’m sure if I drink enough I actually get dementia symptoms, but I just stop caring about them and anyway who would notice.  “Ahh , he’s just drunk”

Anyway….I frunckin’ lurrrrve you….hic.

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Before I go…

Posted on July 10, 2009. Filed under: Journal from behind the desk... |

It’s been a bit of a mad recently.  I’ve been running a bit late all week, normally if you have a 10.30 appointment with me, you get seen at 10.29! But not this week, and as I have mentioned before, if you are ever running late, you always end up with no quick and simple patients. The later I run, the more complicated the next patients problem is! 

Too pretty to rescue?

(Sods law).  Luckily I am accepting, rather than stressed and luckily so are my patients… 

(Incidentally has anyone heard a patient say: “I know you are running late so I’ll just be quick!” and then actually be quick!)

Anyhooo..

I had a very pleasant lady come to see me while I was running late and she had a nice simple infection, was intelligent enough that she understood simple instructions and was in and out my room within 5 minutes…or at least she would have been.  She was out of the door, when she turned round and said in a pleasing and buoyant voice:

“My husband died a month after you saw him!” 

She wasn’t cross with me thankfully, and so we extended our consultation to have a little chat…well I couldn’t exactly say: “Really, bye then, must get on!”

She expected me to remember my consultation from over a year ago, which I obviously couldn’t, but I followed the conversation and she told me how he’d died peacefully next to her in his sleep after he’d been discharged home to die.  I asked how she was coping, and after a little further chatting she happily went off as buoyant as she was before.

She was definitely not cross with me. So I assumed I had recognised he was critically ill and referred him to the hospital. Sod the fact I’m running late, I need to look at this guy’s notes…

It made my heart sink a little bit. 

A heart sink! Fab!!

I had not recognised his terminal illness and sent him in, but in fact given him some antibiotics and sent him home, with a plan to review him in 2 days.

So here is the last month in his life:

1/12 before he died…

Seen by Max E Nurse: 4 day history of cough, fever, off food and sore throat. Diagnosed with Pharyngitis and a chest infection, given antibiotics and to return in 2 days for review.

2 days later seen by Dr (I was on a study day…”Recognising imminent death for beginners” or something).  Brief doctors notes reading. “Better. Continue treatment”.

The next week he was not better and in fact worse and another doctor sent him into hospital as a Pneumonia…

A few weeks later he was sent home to die with a diagnosis of lung cancer with brain secondaries!

Lessons learnt – well not a lot really, but it keeps your feet firmly on the ground!

Neils feet were firmly on the ground…”I was here before Michael Jackson”…perhaps that’s were they’ve taken his body… tangent thought processes sorry…

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