I come in to work and as Carrie the healthcare assistant pops into my room to borrow a thermometer in the morning, I ask for my hand soap to be replaced as I can’t find any in the store cupboard. I receive a blank look.
‘The soap. It needs replacing.’ She rustles away.
‘We can only find moisturiser.’ She looks at me quizzically.
‘Well I can’t wash my hands with moisturiser!’
She points at the soap dispenser — ‘Why can’t you use the soap from the dispenser?’
‘Because someone has put alcohol gel in the soap dispenser.’
‘Oh. That’s not good.’
‘Listen, Carrie, I wouldn’t be asking for soap if I had access to soap.’
‘I see what you mean.’ She stands there still gazing at the soap dispenser.
‘I cannot work a clinic without soap! SOAP!‘ She scurries off again.
She’s back: ‘There’s no soap in the building.’
‘Right, well someone needs to go and get some, please.’
Someone from reception comes back with a 1/4 bottle of hand soap. ‘Will this do?’
‘For today, yes. Tomorrow maybe. Next week, no.’
Yes. Maybe. No. Help me.
Mr Marine
Mr Marine, 70, hobbles in like a heavily overpregnant woman who’s had a hip replacement. He had a spinal fusion a few years ago, and is actually waiting for his second hip to be replaced — it was cancelled a month ago. He’s in excruciating pain in his back and both legs. He’s struggling. Struggling to walk. Struggling to sleep. Struggling to sit on the toilet.
He doesn’t want to complain but he’s broken. He feels ignored, devalued and let down by the system.
Sometimes, you hear a patient’s words or see a patient’s face and it snaps you out of autopilot. In Mr Marine’s case it was both. I turn and give him full attention. Spinal fusions are rarely a success story, and can even be worse in the long run.
He tells me with a voice on edge about how after the operation was cancelled, no one contacted him. He had to make phone call after phone call, waiting on hold for ages, only to be told by a curt voice that the previous secretary who knew him and his story had left. He had to tell his whole painful story all over again. And then at the end of it, all he received from the new receptionist was a clinical ‘well… you’ll have to wait till you hear from us’ without any time frame.
Unfortunately, his painkillers have stopped working and he worries how dependent he’s becoming on them. He thinks his Multiple Sclerosis (MS), which has been well controlled for a while, might be getting worse too. He’s losing hope.
We discuss CBD oil as an option and medical cannabis from his MS team. De Rastafarian protocol. I optimise his pain meds as best as possible and tell him about nervous system regulation and the potential power of meditation which really can help. I explain tools like cold water showers, breathwork and meditation help down-regulate the pain receptors in the body — this is proven. If you learn to sit still with pain, you can (not saying it’s easy or that I could do it!) break through it in deep meditative states. He’s desperate and downloads an app. I’ll see him in a month. Not because I can help him medically but because he needs to feel like someone is on his side supporting him.
Jemima, one of the front desk girls, pops in to ask for a prescription to be signed. I tell her I’ve quit refined sugar and she tells me she’ll bring me some dates back from Egypt. ‘You just need to make sure you’re still here in July.’ A stern look at me.
It’s like she can see into my soul.
The Usual Suspects: Eczema, Headlice and Haemorrhoids
Then Tiara, a 7-year-old with facial eczema and recurrent headlice. She keeps getting it because of breakouts in school so grandma is fed up. I give some light steroid cream for the face, lots of moisturiser and some medical head lice treatment.
Then I see Joao, a Portuguese burly builder in his 40s who has back pain and some fresh red bleeding from his back passage from time to time. His bleeding is most likely from haemorrhoids. There are blood vessels in the rectum that can bulge abnormally if there’s lots of pressure in the tummy. Then when one is opening one’s bowels, those bulging blood vessels can rip and bleed as the stool passes through. (Delightful sentence — feel free to read it again.) They are more likely to occur when overweight, heavy lifting or constipated.
When I mention ‘overweight’, a big smile peels across his face and he says in a husky, powerful Portuguese accent:
‘I like my food man.’ Followed by an infective loud bout of laughter. I join in.
‘In the last 4 years, I don’t know what happened. I used to be razor thin, like you. Now look at me!’
I examine his back and check for nerve impingement. There’s a small lump there unrelated, he’s worried about — called an episacral lipoma* — common benign cysts that are nothing to be concerned about. He declines a rectal exam to confirm the diagnosis of haemorrhoids but I trial the treatment anyway.
I draw a diagram of the spine and its intervertebral discs to explain the process of back pain, disc bulges and nerve compression. I explain the importance of taking pressure off the spine by regularly stretching the back muscles and strengthening the core and back in the long-term so he’ll see the physio and swim more regularly. I issue a short script for pain relief.
Two more identical back pains. One with an episacral lipoma* on the same side. Weird.
(*Full disclosure: I only discovered the name of this cyst because I am writing about it.)
One of them is about 18 stone and shuffles in. After drawing the same picture and repeating the same advice like a robot, we discuss weight loss — he tells me about how he runs a Scouts and Beavers school for children and takes them on expeditions. He also has a bee colony to look after. He might be large, but he’s pretty bloody active. We go through his diet, and whether he eats snacks, or drinks problematically. He’s pretty switched on about his health. Some people really do have slow metabolisms and get a lot of grief from the world for it.
Drawers, DIY Abortions,
I rush lunch as I ran late. Cut myself some fruits but decided to get clinic started so pop my fruit plate and fork in the top drawer. If you ever get a chance to ask your doctor to show you what’s in their drawers, take it. (Desk drawers.)
Beggars belief. Echel, a 32-year-old who had a medical termination (induced abortion) of her pregnancy last year comes to see me. Medical terminations comprise ingesting one or two tablets of Mifepristone and it causes the expulsion of the contents of conception, ending the pregnancy. It’s a significant intervention that should only be initiated by healthcare professionals.
Today Echel has come in with lower abdominal pain. For some reason, she had 2 Mifepristone tablets left over from her termination last year so last week when she realised she had missed her period by 10 days, she took the remainder of the medication. Without even doing a pregnancy test. Today, 20 days later, she has developed significant lower abdominal pain indicating a possible complication, although her remaining examination is reassuring. Her pregnancy test is indeed positive. I’m not quite sure what’s going on but she’ll need to go in for scans.
I call the gynaecology on-call and tell her the situation and she can’t believe it. She chuckles and says:
‘Wow. This is a new one, not had this one before. She’s tried to terminate her own pregnancy without a healthcare professional. Wow. Wow.’
Her exasperation persists for an entertainingly long time whilst the patient is sat right next to me — I do a bad job of trying to disguise my entertainment.
And finally at the end of the day, a phone call from the paramedic home visiting crew — an elderly lady needing antibiotics. The daughter is also worried about a specky red rash at the base of her mum’s ankles. She’s been started on blood thinners recently and I advise it’s likely related to that and is nothing of concern but to contact us back if worse, new symptoms or concerns.
If I had a pound for every time I’ve written down ‘contact us back if worse, new symptoms or concerns’ I’d order a tonne of soap to deliver to Carrie’s home with a note saying ‘THIS IS WHAT I MEAN WHEN I ASK FOR SOAP.’
Time to wash my hands of another dirty day down under in primary care.
Mindful Medic 