The Noctor Diaries

Mark is 32 and an alcoholic, he has tried to fight the ‘demon drink’ for many years and has been referred to the local services more than once.

At the CAT team a few years ago he met a woman of similar age who also was in a battle with the ‘demon drink’. Mark and this woman struck up a friendship and within weeks both had stopped attending CAT and became form drinking buddies. The relationship ended when she became ill and died, Mark went on a bender.

I first met Mark when he came to me for help, at that time he was drinking a litre of vodka and a bottle of wine every night and was still managing to hold down a job, but just barely.

Mark had hit rock bottom and was ready for intervention, but due to the reconfiguration of the alcohol addiction services, I would have to refer him to what is called the ‘Initial assessment unit’, the staff that run this service are not medical or nursing professionals, but people who have been employed to direct patients to the appropriate services, after the PCT did away with the CAT team.

I was reliably informed that they would accept the referral but there was a waiting list for further assessment, I enquired about ‘home detox’ and was told that he did fit their criteria of drinking daily, but again there was a waiting list. I also found out that if he had started to reduce his alcohol intake or was only drinking 5-6 days a week he wouldn’t have been suitable for that service.

Mark was disheartened that his assessment could not take place for a few weeks yet, so we came to an agreement that he would see my weekly for support and I got him an appointment with the local NERAF and NECA team and then I looked on the web and found an organisation called ‘Team Challenge’. The organisation helps men with alcohol and drug addiction and is a religious organisation; Mark wasn’t interested when I told him about it.

I didn’t see Mark after that, he hadn’t attended our follow p sessions or the appointments set up with NECA or NERAF, but about four weeks later I received a letter from Mark, informing me he was with ‘Team Challenge’ and although finding it difficult he was determined to complete his year with them.

Today I received another letter from Mark, he has been off the alcohol now for 5 months, his health and fitness have improved remarkably and he informs me he has found ‘God’.

I will write back to Mark and congratulate him on his hard work, perseverance and strength of mind and look forward to seeing this new man when his year with team challenge has ended.

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I hate January! This January particularly!

In the last three weeks I have developed a friendship with the co-ordinator of the local ‘termination clinic’, due to the requests from patients for termination.

The decision to terminate a pregnancy is not an easy one and usually I have sympathy and understanding for the women who request this service.

Today however, that sympathy was put to the test twice!

Firstly, a young single mother’s dating scan showed she was 17+ weeks and our local hospital refused to do the procedure, which made her very angry as she said ‘don’t ya know I can feel the bairn moving’.

I asked her to wait whilst I contact a hospital close by, as I knew they accept women up to 20 weeks pregnant. I got her an appointment; coincidentally the date was her first child’s birthday and although I think 17+ weeks is too far into a pregnancy to terminate this belief has to be kept personal. I am aware that bringing another unwanted baby into her home would cause the existing child financial and emotional difficulties.

Secondly, a woman in her mid thirties, with five children, two miscarriages and four past abortions requested that I refer her for termination. This woman’s eldest child is currently living with her and is expecting a baby in the next few weeks.

I must admit I wasn’t as sympathetic with this woman who I have known for over 4 years, I asked why she had not used contraception and why after her termination last year (not arranged by me), she had not been sterilised or had an IUD fitted, she said the consultant refused!

I don’t believe her! I also didn’t believe her when she informed me she had used emergency contraception the day after the incident. Now she was on her own again as ex partner didn’t want a baby, just shag! Obviously his brains, if any, were in his balls!

I contacted my friend at the termination clinic, as to refuse this woman would mean she would just go to one of the doctors or bring another baby into a home that was already stretched to its limits.

My friend informed me that in the weeks since Christmas she had booked in over ninety women for termination. Those ninety women will come from all walks of life and some will decide to continue with their pregnancies and I will continue to put my personal beliefs to the side and refer where appropriate.

Obviously the hard work done in the practice and by the contraceptive services still falls on deaf ears!

Dumbing down health care

This Monkey has had to put her original research project on hold for a short while to retort to Dr Crippen and his crusade to slam all nurses that step outside of what he deems non-nursey roles!
Oh John how I have missed you!

Crippen said.

Nurse specialists, EMTs and the whole collection of “health care professionals” who front end the “free” at the point of entry NHS continue to play “doctor”.

What you don’t understand John or want to accept is that we are not playing!

I take my role as first contact practitioner very seriously and respect the relationship I have with my medical colleagues, if I thought for one minute that my colleagues thought of me as a ‘Monkey’ I would resign tomorrow!

I have never met an advanced practitioner, EMT, NP who claims to be a ‘doctor’. Alternative practitioner’s working either in secondary or in primary care offer the patient a choice. Choice to see a well trained, highly intelligent professional who can give good clinical care, surprisingly often better than than some doctors.

Job’s evolve no matter what profession you are in and medicine and nursing are no different!

What we need to do is work together to ensure the extended roles that nurses take on are validated, have recognised strict competencies via the NMC.

Lobby the privvy council and ask why advanced practitioners are still waiting for a register which will ensure those registered have attained a high level of clinical ability and knowledge and don’t just call themselves ‘nurse practitioner’ just because its fasionable.

Also John remember we are the servants of the people not the other way round!

Doctors Inappropriately Prescribe Antibiotics for Coughs and Colds!

It is nine o’clock on Monday morning and I’m looking down a patient’s throat. I see no sign of infection and the patient is not unduley unwell, so I patiently explain why there is no need for antibiotics but advise if further problems to return. Many minor illnesses such as these will clear up on their own, but many doctors in general practice continue to over-prescribe antibiotics for common coughs and colds, meaning the NHS is wasting millions on unnecessary treatments.

Official guidance advises against antibiotic prescriptions for upper respiratory tract infections, sore throats and ear infections, but patients continue to receive them. Today the Daily Mail reports that researchers reviewed more than three million cases of common colds between 1991 and 2001 recorded on the UK General Practice Research Database. This included antibiotic prescriptions for more than 90 per cent of those with chesty coughs, 80 per cent with ear infections, 60 per cent with sore throats, and 47 per cent with upper respiratory tract infections. Dr Hayward reached the verdict that antibiotics would not have been justified in reducing the risk of complications and said, "He had legitimate concerns regarding the overuse of antibiotics in primary care."

As an advanced practitioner with many years’ experience in general practice, I spend a great deal of time trying to explain to patients who have been given antibiotics inappropriately in the past by their GPs that they are not required for the majority of minor infections. Recently and after a great deal of hard work my GP colleagues agreed to stop prescribing antibiotics over the telephone, but only to patients under the age of 15. I will continue working with my GP colleagues to stop all antibiotic prescribing over the telephone, unless extenuating circumstances are present and get them to agree to reduce antibiotic prescribing for many minor illnesses.

Professor Hugh McGavock, visiting professor of prescribing science at the University of Ulster and a former member of the Committee on Safety of Medicines, dared to say in ‘Pulse’ recently that he had ‘serious concerns’ over indendent nurse prescribing. He said, ‘Nurses’ knowledge of diagnosis was pathetically poor. I feel Professor McGavock is failing to grasp the point. The majority of nurse prescribers like myself take time to prescribe responsibly and we are fully aware of the responsibility that prescribing holds, and what damage irresponsible prescribing can do, can we say the same for some doctors?

Is the reason why some doctors do not like nurse prescribers down to the fact that they wish to monopolize prescribing as they have done up to now?

Would they prefer the old system where nurses in primary care prescribed, printed the script and then interupted the doctor so it could be signed by a medical doctor?

No doubt this post will anger some doctors, but can they tell me that they don’t prescribe antibiotics over the telephone, or prescribe to patients inappropriately due to the expectations of their patients leaving the consultation with more than just advice?

I am an independent nurse prescriber, but the fact I am able to prescribe most drugs is of little consequence to me as I only prescribe those drugs which I am familiar with and competent to prescribe. My antibiotic prescribing percentage is much lower than that of my GP colleagues, not because my clinical knowledge or ability to diagnose is pathetically poor, but because I understand the problem of over-prescribing antibiotics for minor illness and take the time in my 10 consultations to educate my patients.

Nursing Shortages Contribute to death of 90 Patients

The Healthcare Commission report into Maidstone and Tunbridge Wells NHS Trust blames nurse shortages as a contributory factor to the deaths of 90 patients. Along with a lack of nursing staff, last weeks report exposed old and dirty facilities, high bed occupancy and managements concentration on cost cutting and DoH targets.

The report states nurses were too rushed to undertake hand hygiene, which I think, is a total disgrace. I used to work in an inner city hospital emergency admissions unit, which was always full of very ill patients. My hand hygiene was second nature to me as all my colleagues as we were fully aware of infection risk.

The nursing staff at Maidstone and Tunbridge Wells NHS Trust was also found to be too busy to empty or clean bedpans or commodes. This again is very basic patient hygiene and nurses are fully aware of the infection risk to other patients due to the over-crowding on the wards, especially if they are dealing with patients infected with clostridium difficile.

It has also been claimed that the nurses on these over-crowded wards did not wear gloves or aprons appropriately. Firstly did the trust supply the wards with enough equipment such as aprons and gloves? Secondly, if the basic equipment was present then there is no excuse for not using it. Lastly, the report identified that some nursing staff had such poor attitudes that they instructed patients to defecate in their beds.

This is just totally unacceptable! Florence Nightingale will be turning in her grave.

Men with Depression

Men are not invincible. Like women they have experiences in life that cause emotional pain such as broken relationships, they lose their jobs, they perhaps experience the death of someone close. Sometimes the emotions that these life experiences cause feel unfamiliar and frightening and they can feel unable to cope with them. Depression may even show as physical symptoms such as lethargy, interrupted sleep patterns or lowered libido.

I saw David on Thursday morning; his sister who did all the talking accompanied him. As she talked David just looked at the floor, his shoulders were slumped and he avoided eye contact. His sister told me she was concerned about him, as he had told her he wanted to die.

The senior GP partner had seen David 5 months ago and prescribed Fluoxetine 20mg, unfortunately the only time he had been reviewed was when his medication was changed to repeat 4 weeks after initial diagnosis. This is not an odd occurrence by this particular GP and is something that causes me concern and annoyance.

David had one previous episode of attempted overdose 6 weeks earlier to him coming to see me and still there had been no review of his mood and had not been referred on to our CPN or had any documented diagnosis, apart from the GP writing two lines stating low-mood.

The practice decided back in 2003 to follow a clinical pathway that I developed and we have kept updated to reflect DoH changes. I have spent the last four years increasing my knowledge in mental health and have an excellent working relationship with the local psychiatrist and CPN’s.

Some men, such as David find it particularly hard to talk about their feelings and it is widely acknowledged that this can cause reluctance in seeking or receiving professional help for problems such as stress, anxiety and depression. My role is to offer the patient the chance to build a trusting, caring, confidential environment within which they feel safe so we can start to look and hopefully discuss difficult thoughts and feelings.

David’s sister decided to wait outside my room as she thought he might discuss how he was feeling on his own. Initially, getting information from David was like getting blood from a stone, he did however give me some eye contact, so that was a start.

I knew earlier when his sister started talking that my consultation time of 10 minutes was out the window and I was now over running by 5 minutes. This is what annoys me, if the GP had just done the basics and documented the initial cause, which brought David to his surgery, and then at least I would have a starting point. Well I managed to get to the problem, a relationship break-up and his ex partners accusations of physical violence and her refusal for him to see his daughters. The courts have granted him supervised visits, but his partner so far has not complied.

On further discussion with David he admitted to some suicidal ideation but no intent. I discussed my concerns with the local ‘Crisis Resolution Team’, who were no help what so ever. The CRT advised I send him to A+E if I thought he was going to attempt suicide, I reiterated that he denied intent.

David and I came to an agreement, he consented to referral to CPN, I increased his medication and will review him on Monday. His sister however was a little shocked as she expected me to have him sectioned. I informed her that I didn’t feel that course of action was necessary. I understand her fears regarding her brother’s earlier threats that morning to commit suicide, but that he advised me that he had no intent due to the love he has for his daughters and that he had admitted feeling frustrated and powerless due to his current situation.

I hope David returns on Monday, but I have a sneaking suspicion that he won’t!

DIY Abortions

DIY abortions moved a step closer today as reported in the Daily Mail. Currently women who have a medical termination go to hospital or designated clinic, there they are administered Mifepristone, which blocks pregnancy hormones and makes the foetus detach from the womb. Two days later they return to for a second tablet, Misoprostol, which leads to an enforced miscarriage normally within a few hours.

Gosh! Doesn’t it sound so easy and pain-free?

Wrong!!

Nine years ago my youngest daughter became pregnant at age 17. Through discussion and a lot of soul searching she decided to terminate the pregnancy. She was due to go to university and decided that a lapse in contraception and judgement was not a good enough reason to have a baby. It was arranged for her to attend the local hospital for the dispensing of the two-stage medication process.

Once administered Misoprostol as a day in-patient at the local hospital, she was advised what she should expect by the staff nurse. The enforced miscarriage did not take a couple of hours as reported in the Daily Mail. It took over 12 hours, with her experiencing excruciating pain, a lot of tears and recriminations. The staff offered pain relief but informed my daughter that if administered would slow the whole process down.

Watching my daughter go through that process was not easy, although now married with a lovely husband and a good career, she still experiences the emotional aftermath caused by her decision.

I personally feel that women have the right to choose whether to have a termination or not. But I think it is wrong to expect women and teenagers to have DIY abortions at home, or hidden away until it’s all over so no one will know, in the case of some teenage girls.

This experience should be supervised. Supervised by caring non-judgemental medical or nursing staff.

There is a rabbit away!!

I’ve been studying for my MSc for over three years now and at times I have found it hard balancing a full-time job with a full-time distance learning programme. My last module was completed online using ‘Blackboard’ and concerned ‘Research Methods’. All students had to complete and pass three formative and a Summative assignment, all concerned with developing a researchable question prior to completing a research proposal and original research for our dissertation.

Now to say this was hard work is an understatement! The feedback from my online tutor was very good and I passed all three formative assignments, with my research question being deemed appropriate for the subject matter to be researched.

I worked hard completing the Summative assignment but unfortunately failed so had to resubmit. I waited patiently for the feedback form, which did not arrive until three weeks before the new submission date. I ensured that I met the criteria and addressed each comment given on the feedback form, even got the help of a research fellow to peruse my work, as I knew if I failed this time I would be off the course. When my assignment was re-submitted I was proud of what I’d accomplished so waited patiently for the results.

The day the results were to be given the learning manager visited my home as usual; she was bright and cheerful even though she had no job at the end of the month as funding for her role had been pulled. We sat and chatted a little and then she told me ‘failed’ well I was devastated! I found it hard to believe that I was now off the MSc programme, as you know on any academic course two strikes and you’re out. My learning manager tried to comfort me and suggested I take this time to reflect; the verbal feedback given to her by the new marker was not positive, in fact very negative. Obviously she had not heard of the feedback sandwich!

Thankfully I was away for the weekend hill walking and I soon realised it wasn’t the end of the world and that there were more important things in this world than gaining a MSc and if I wanted to continue I could register with the local university in the new year. If I’m being honest I was looking forward to having a social life over the next five months.

On Wednesday on my way home from work I had a phone call from my learning manager asking me to give her a ring. On contacting her she said she had discussed with the programme director my disappointment and she who would now like to talk to me, my instinct told me there was a rabbit away!!

The next day when I finally spoke to the programme director imagine my surprise to be asked if I would like to re-register for module 5, now call me a cynic if you want but there is definitely something going on as I know the other students that failed this module for the second time were not offered the same choice.

Was this offer made to me because I told my learning manager that I would appeal and also request the statistics of how many had failed this module? We will never know!!