Unresponsive

I spent another afternoon “On Call” today as a Community First Responder. I am either jinxed or blessed as today, like the three times before, no-one called and I got no chance to try out my newly aquired skills. I spent a week in the ambulance centre last month updating my practical skills in emergemcy situations and had spent some months before that on-line and in the classroom getting my general knowledge brought to current standards. At the start of each ‘on call’ session I checked my kit to make sure it is all present and ready . The defibrillator, the oxygen cylinder, airways and masks, the tourniquets and bandages; it was all there pristine in its packs at the start of my session ready for use, and it was still there virginal and unused at the end of my on call. As I said, in some ways I feel jinxed as each time I have not had a chance to use the kit and test my skills. I did get to check that I know how to log-on to the emergency response system but have not has a chance to check I know what to do when I get the call to respond. However, I also feel blessed as my inactivity thankfully means nobody actually needs my help. Nobody has had to call the emergency services because of accident or illness and I have to think that this is good news for my neighbours.

It is an unusual feeling being “on call“. It reminds me of when I was in work. There is all the excitement of waiting for the alarm to ring. The hours of mental preparation of what to do when it does. Checking the alarm to check that it is still working and its silence is not a sign that it has broken and the rereading the text books to make sure that the information in my head is accurate and not a figment of my imagination. All these emotions are generally pleasant but there is also a background fear that accompanies them. The fear that one will be called to something beyound my abilities, or called to deal with something with which I have no experience. In sum, just the fear of finding that you fail somebody in a time of need. That when they needed help, and called you, were found wanting. I was surprised to find these memories coming back.

I recalled with pleasure the recollections of emergency sessions when I was a young medic. The rush of high intensity work and the pleasure of managing to deal with a crisis and pull someone back from the edge. Working against the clock, in a team that was functioning well, is one of the greatest pleasaures there is. Even on occasions when illness ot accident prevailed, as long as you and your team pushed everything to the limit and gave every chance to the patient, the sadness could be tempered by the knowledge that everything possible was done. I could understand why emergency medicine gave its practitioners such rewards. My skill set was not well matched to A&E (I have never been very dextrous) and I moved into psychological medicine but still enjoyed my emergency sessions even if these were less hands on.

But although I recalled “the buzz” I also recalled the “dread“. In my latter years working, and partially one of the reasons why I retired, I came to dread being on call. Over the decades the general drift of mental health services had lead to a general over-reach. Rather then being limited to mental illnees, mental health services had suggested that they could answer many personal and social problems. This increasingly lead to crises, which were largely social in nature, being presented to mental health services for resolution. Distress that arose from poverty, or spousal abuse, violence or drug abuse was presented to the emergency doctor for solution. While we did what we could, there was always the awareness that there was little we could do. There was also the recognition that others, a social worker or policeman, may have been able to help more and the bigger fear that sometimes we were making things worse. Pretending the problem was depression rather than the poverty or poor housing never seemed helpful. Suggesting that the battered wife had mental health issues didn’t empower her in her marital problems and possibly weakened her position. The recognition that you would face crises, you were not equipped to solve, lead to this growing feeling dread when on call came around.

I encountered a little bit of that feeling of dread again today. However, this in itself was valuable as it reminded me why I retired and made me happier with my lot.

Dark, sticky, concoctions.

Dark, sticky, concoctions.

When I was an inexperienced junior doctor, and clearly more uncouth than I am today, I and my colleagues would often call for Gerifix® when treating the elderly patients admitted to the emergency medical wards during the winter months. These patients were often severely ill with a varied combination of heart failure, chronic obstructive lung disease and an intercurrent infection. Our poorly developed diagnostic skills made if difficult to tease out the primary disorder and thus we called for our panacea – a bit of everything – a combination of an antibiotics, a diuretic (water tablet), digitalis (to strengthen the heartbeat) and a bronchodilator (to open the airways). In really severe cases we’d use Gerifix Forte®, which was the same combination with the addition of a steroid. Although we believed that the Geri in the name related to the age of our patients (over 65 and hence geriatric), I think with hindsight the name was actually Jerryfix and derived from the rough and ready work that we junior doctors did,  and an allusion to the term Jerry-builder.  In any event I was taken back to these late nights in the emergency department yesterday when two of our kid goats managed to be poisoned.

Goats have the reputation of being able to eat anything, and this is deserved in that they will manage to eat a wider range of things than horses or sheep and are also much more curious and adventurous in exploring what is edible – stand beside a goat and it will check every part of your apparel and anatomy to make sure it does not miss any tasty morsels. However, there are also many common plants that are extremely dangerous to them. Indeed, I sometimes think that the prior owners of my house had a deep seated unconscious animosity towards goats as they planted a drive with Rhododendrons, Azaleas, Pieris, Acer, and Laurel – each one potentially deadly for goats if they nibble at their leaves. I have done little gardening over the last years, and the little I have done has been to steadily remove these plants from our land. (A useful list of dangerous plants for goats can be found here.)

Usually the goats will keep clear of dangerous plants only being tempted by them in winter if they are starving and these are the only green leaves left visible through the snow. Also it appears that the mother goats will teach her kids to avoid these plants while they are too young to know better. One of the complications we have had, after loosing one nanny to a nasal cancer, is that her two kids are being bottle fed and don’t have their mother’s wisdom when they are out in the field. In any even yesterday afternoon it quickly became apparent  that two of the kids (the orphaned boy and girl) had eaten something they should not have and had been poisoned.

If you have never seen a poisoned goat here is a handy tip for you – Keep it that way!. A poisoned goat is a terrible sight. There is profuse and projectile vomiting, gallons of frothy green vomit spread everywhere in a four foot radius of the goat. On the walls, on the floor. on the goat, the mother goat and on you. They make Linda Blair’s vomiting in “The Exorcist” look tame.  There is also the colic which causes the goat to be distressed. They will grind their teeth when in pain and I fully understand why “weeping and gnashing of teeth” is mentioned seven times in the Bible as one of the torments of hell. It really is pitiful to hear them grind their teeth, only punctuated by ear-splitting screams when waves of colic overtake them. Faced with this it is your duty to fix the situation and, I assure you, you are going to try and do anything to try and stop this nightmare.

Fortunately, on the web there are many accounts of people dealing with this and reports of various mixtures which are reported to work. I noticed that there were some components which were common to all concoctions and decided to use them. This was a mixture comprised of :-

  • 1/2 cup strong tepid breakfast tea. Not any fancy herbal teas, this component needs the tannins which bind the toxins, so strong builder’s tea – tea in which a spoon would stand up.
  • 1/4 cup cooking oil. This seems to line the gut to prevent more toxins entering the system.
  • 2 tablespoons activated charcoal. This is to neutralize toxins.
  • 1 teaspoon ground ginger. This acts as a painkiller.
  • 1 teaspoon of baking powder. The Bicarbonate of Soda acts as an effective antacid. Some people use Milk of Magnesia in place of this.
  • 1 teaspoon of brandy. Brandy or sherry act as analgesics. My kids were lucky. We only had one bottle of very expensive cognac, a present I received in my previous working life, so this had to substitute for ‘cooking’ brandy. I hope they savoured its fine balanced flavours.

When mixed you have a dark, 20180519_165954.jpgsticky concoction that no self-respecting goat is going to want to take. Especially no colicky and panicking  goat is going to be happy with the idea of drinking this mixture. Therefore it is your job to try and get this into the goat between screams with a syringe. This process will at least mean that instead of being covered with green vomit you will now be covered with black goo.  After having got the first quarter of the volume drenched into the goat in the first sitting then  repeat with small amounts of the mixture every hour until the goat is settled and normal.

In our case this was in the early hours of the morning; they started to settle with the first dose but weren’t comfortable much before midnight. However, I am glad to report that by today they were their usual selves, fighting for food and climbing on the walls and gates. Most of these items are in the average kitchen cabinet so the only thing that might be necessary to make sure you keep in stock is activated charcoal, though some mixtures do not call for this. In any event it is worth keeping the ingredients in stock, for whatever recipe you are going to use, as you won’t want to waste a minute collecting the materials together if you are faced with this emergency. It might also be worthwhile pinning the recipe near the phone just in case someone else is looking after your goats and the worst happens. Fingers crossed you will not need it.

 

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Everyone oblivious to last night’s horrors

 

 

 

In Loco Parentis – the terrifying tale of Charlie Gard

In Loco Parentis – the terrifying tale of Charlie Gard

As a doctor I have found the unfolding tragedy befalling Charlie Gard and his family extremely upsetting to follow.  This poor boy and his family are butterflies being crushed on a wheel to press home a legal point, they are unfortunates being punished having committed no crime.

Let us firstly be clear what this case is not about. Despite protestations to the contrary this case is not about the best interests of Charlie Gard. The best interests of the child (1)  are clearly important and made paramount both in the UN Convention of the Rights of the Child (2) and in British Law with the Children Act of 1989 (3) . It is clear that all the parties involved in this debate are acting because they have the best interests of Charlie at heart. The doctors and hospital feel that they, by virtue of their knowledge, know what is best to do. His parents, through love and affection, also believe that they can see the best plan and hope for their son. Both are acting in the best interests of Charlie, this is not the problem. The problem is who decides what exactly are Charlie’s  best interests.

It has always been the case that the parents of the child decide what is in the best interest of the child. This is as it should be as it reflects the natural law and ensures that the people most attached to the child’s interest are those who act as the child’s guardian. There are very few circumstances when this can be changed and they depend upon proving that the parent is being either negligent or malevolent. Neither of these factors are in play here and, if anything, the parents have taken extraordinary steps to secure chances for their child, well over and above what many parents would have been able to do.

It is interesting that, at the 24th hour, Great Ormond Street Hospital has made an application to court to revise its plans (4) possibly starting to realise that the parents’ opinion may have been closer to Charlie’s best interests, than had their own opinion been. So in this difficult calculus of what is the best plan of action it appears that Charlie’s parents may have been the better judge all along.

While these arguments over the ‘best interests’ may mean that the parent disagrees with the medical team it does not mean that the parent can compel a doctor to do something they feel is inappropriate or wrong. But again this is not the case in this situation. Charlie’s parents have never asked GOSH or the NHS to undertake treatments they do no agree with. They have gathered together sufficient resources to enable Charlie to receive this treatment by doctors who believe it is, worth a trial, in the child’s interests. This should have been the end of the dispute. Charlie and his parents should have used their money to go and try this last ditch attempt, to catch this glimmer of hope.

GOSH and its staff, however, stopped this. Their court battle stopped the treatment and refused the parents the ability to move their child. In their paternalism they not only refused to help but also stopped anyone else helping. The thousands of people who collected money to help Charlie were thwarted by this as well as Charlie’s parents and the other hospitals and doctors who wanted to help.

I am a very old-fashioned doctor and I don’t fear paternalism per se. A desire to act like a father, is a a desire to be benevolent, guiding, helpful and wise. In itself not a bad thing. It becomes bad when it belittles another party and reduces their agency. When doctors worked in a professional relationship with their patients, the doctor’s paternalism would drive them to seek the best for their patient and was usually leavened by respect for the patient’s autonomy. This combination could be valuable when there were difficult scenarios – when the future was unpredictable and  the efficacy of plans of action difficult to assess. Much of the placebo effect of medical intervention depends on this aspect of the relationship and large parts of the benefit of of healthcare comes from this caring, guiding, advisory aspect of medical care.

There was always one very good safeguard against this paternalism becoming intrusive or  belittling, when the relationship was between doctor and patient, the patient could always terminate the relationship. If they felt that the doctor’s approach was wrong they had no need to continue to use them. This was a way to safeguard the patient and also a way in which the doctor would know that they had overstepped the boundaries and they could learn where paternalism started to erode patient autonomy. But in the NHS this is difficult. The patient can’t change their doctor without a great deal of difficulty. If they change they will probably be labelled a “difficult patient” which might mar relations with their next medical practitioner.

In addition, under the NHS the patient is no longer the employer of the doctor in the UK. The most important relationship for the doctor is the one with his employer – the state, the NHS – not the the patient directly. It is the state who pays his wages, sets his targets and assesses his performance and we know “he who pays the piper calls the tune“. In this scenario paternalism is largely unchecked and can be very dangerous. Paternalism, appearing kindly and wise, can mask actions that are not in an individual patient’s best interest. Rationing and refusal of therapy is hidden as medical advice and choices are withdrawn from the patient. Doctors often find, when working in the NHS, that their attempts to maintain professional standards and a focus on their relationship with the patient can cause them difficulties. They are made to feel as if they are being disruptive when they call for what is appropriate for the patient. They can be told they are jeopardising the budgets, failing to be a team player by not following the organisation’s line, and generally made to feel awkward if they behave in a manner that was formed by their vocation and training.

In this case paternalism seems to be being employed to sweeten a bitter pill. The state wants to end Charlie Gard’s life before all options that are available have been tried. Despite having seen parents act heroically and selflessly for their child, without an ounce of malice, they would prefer Charlie died rather than allowing the parents to try all they can do. But rather than admit this we are told that they are the wise and kindly people who know what they are doing, we are awkward and unruly children causing a fuss.

Well thank God for the fuss that Charlie’s parents have made;  it may not save Charlie but they will have opened the eyes of many people and might save future families from the horror that they have had to endure. They truly are a heroic family who deserve our support (5)

 

 

 

 


[1] https://en.wikipedia.org/wiki/Best_interests

[2] https://en.wikipedia.org/wiki/Convention_on_the_Rights_of_the_Child

[3] https://www.publications.parliament.uk/pa/cm201012/cmselect/cmjust/518/51807.htm

[4] http://www.telegraph.co.uk/news/2017/07/07/hope-charlie-gard-great-ormond-street-seeks-explore-new-evidence/

[5] http://www.charliesfight.org/