Diary of a GP 3: phobias, heart attacks, abscesses, dental issues.

Had a hectic weekend, back and forth to London at the moment. Nothing like a bit of instability. Came back with a stinking cold. Called in to delay starting my clinic by an hour. Luckily first 40 minutes are usually telephone calls so can catch up in the lunch break quite easily.

The first patient has emetophobia. Where they have a fear of vomiting. With phobias, anything can happen. I once had a patient have a phobia of laughter. Imagine that? Anyway, the fear of vomiting= it’s taken over her life. Started 10 years ago when she vomited in front of people. Apparently can be something to do with losing control. She can’t be around people who might vomit and so has stopped going out at night, and she can’t be around people drinking alcohol. Now she’s struggling to go out at all. Has stopped eating certain foods. She’s been in and out of the emergency department for the last 2 weeks. She’s been started on a medication called propranolol. It works by blocking the effects of a stress hormone that’s released in anxiety so it reduces the physical effects of the stress. It is useful to give a bit of respite from the pains of the condition. But like most medications, it’s rarely a long term fix.

The thing about anxiety is it’s an insatiable beast. Once you let it dictate the terms in one area of your life e.g. avoiding exposure to the fear, then it usually spreads into other areas and eventually you can’t leave your house or even your room. The treatment I advocate is a blend- and it can be supported with medication but the medication generally should be avoided as a long term option .

We discuss various aspects of management including counselling and other medication. But I emphasise the challenge she must rise to; to test the validity of her fears. If her brain is telling her she can’t spend time around someone who has drunk a bit of alcohol, where is the evidence that this person will vomit. If she can manage to spend even 5 minutes around them and they don’t vomit, then she begins to dispute the fears and their validity and begins to gain part of her life back. The more she leans into her fears and learns she can cope with them, the greater her progress will be. Fears are like dragons, guarding our deepest treasures. I love that quote but in her case, the dragons are guarding her treasures along with all of her activities of daily living. We need Khaleesi. We discuss coping strategies for the sense of panic. We will set small targets and check in every 3 weeks.

In the afternoon a patient, Katie, with a prolapse that has not been able to see gynaecology despite a referral 5 months ago. She is now incontinent occasionally and passing urine 15 times a day. She has also been hearing voices for many years following unprocessed childhood trauma (assaulted by a stranger) and they have got worse now. They are talking to her all the time and knock her confidence. Sometimes in public she accuses people of saying things to her when they haven’t said anything. Her husband gets embarrassed and so he avoids taking her out now. He also calls her crazy and so she tries to hide her symptoms from him but can’t. He still cares for her though, but he’s obviously struggling himself. She has insight but genuinely sometimes cannot tell what is real and what is not. She has a lot of guilt and self-hatred. She asked for help from me 4-5 months ago. I referred her urgently twice but no-one has got in touch with her. She has visibly deteriorated since I last saw her. She has always struck me as a stoic, kind person, who endures an enormous amount. She doesn’t like asking for help. It is really sad to see her getting so much worse.

I have asked the secretaries to urgently contact the MH team and find out what is going on as no-one is answering my calls. I started her on specialist medication that GPs should ideally not be initiating but given the severity of hallucinating symptoms, something needs to be done. I have written to gynaecology and made a plea to upgrade her referral as an emergency given the state of affairs both physically and mentally. We talked about ways to manage the stress including her relationship with the voices, movement and breathing techniques. I have written it all down on paper as she is struggling to concentrate. I will her next week.

I also reviewed a couple of children with safeguarding alerts because of parents who have been taking drugs. Then there is a lady who has had a complication following a dental procedure and now she has an abscess but the dentist cannot see her for 6 weeks. The emergency dentist cannot see her either so she had no one else to go to. I have given her antibiotics but it wont help, she needs a drainage of her abscess so have given her 2 more numbers to try and if not, she will need to attend A&E.

Then there is a 60 year old lady who is nothing short of a car crash in terms of her health – she is probably having a heart attack so she’s gone off to A&E. Then a lady whose c-section scar has come apart and become infected who needs urgent surgical input and IV antibiotics. Other cases include irregular periods, ear infections, new diagnosis of diabetes, medication queries and blah blah blah. Get me home!