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Another quiet day in the minor illness clinic

Just another morning for Janet Webb. A queue outside, the phone ringing and a cuppa, given half a chance. However, you never know what life is going to throw at you, and on this particular day Janet met a patient who she really wished had come to see her sooner …

Janet Webb
BSc(Hons) RGN DiPN(Lond)
Practice Nurse
Lindum Medical Practice
London

I am used to the banter from my GP colleague in the minor illness clinic. It's a drop-in session and he and I take patients in turn - at least that's the theory, but he usually takes about three to my one. He says I have to stop saying: "Is there anything else you need?" and that I need to just deal with what they're complaining about and bring them back if I want to "play at nurses". I, on the other hand, believe that he's only doing half a job if he sends patients to see a nurse for blood tests, urinalysis, ECGs and dressings. I take his point, and I'm quite capable of working very quickly when we're busy, but given the time I prefer to offer a full service.
It was a fairly quiet morning when I saw John. He'd come in with back pain - he hadn't slept for the previous five nights and was at desperation point, which was why he had finally come to the surgery. Before this he hadn't been to the GP for eight years and hardly ever before that.
John was 55, a Scot with an accent probably more Edinburgh than Glasgow, although I'm no expert and I didn't ask. His body language openly displayed his pain. He walked in slowly, holding his back, and was sweating profusely with high colour on his cheeks as though it was a warm day. He was not overweight but he was mildly exophthalmic and looked exhausted. He readily admitted that he didn't like coming to "these places", saying he was probably just being "a Jessie", but could he please have something for his back.
He admitted to smoking and liking the "odd bevvy", but said he was usually "fit as flea" and could I be quick because he was due at work. Because of his lack of recent observations I started with his blood pressure. It was normal, but there was marked tachycardia and I couldn't help noticing his bulging feet as he was wearing slippers that looked as though they had been newly cut to accommodate the swelling. The slippers looked incongruous with his white shirt and black trousers, which obviously constituted his workwear. He rationalised that his feet had only swollen because of the hot weather, and that he had slept only fitfully in his armchair the past five nights. He had smoked because he couldn't sleep and had never been very good in the heat - therefore no wonder his pulse was fast and feet were swollen. Anyone's would be. And could I "give him something for the back so he could be on his way?"
Well no, I couldn't. Not now, as I had to investigate. I persuaded him that an ECG and blood tests were in order. I wondered whether he had supraventricular tachycardia (SVT), possibly from thyrotoxicosis, which could lead to heart failure, although I only told him that I wanted to investigate the fast pulse and swollen feet, since I am capable of overestimation.1
I took blood for a full blood count, urea and electrolytes with glomerular filtration rate to check kidney function because of the oedema and back pain, and a lipid profile for cardiovascular health. I took a liver function test in case he needed statins, and checked thyroid function because of the tachycardia, exophthalmos and inability to sleep. I had considered his rationalisation, but the analgesics and alcohol should have helped him sleep. I suspected that both had been used in generous doses since it was only their lack of effect after repeated use that brought him to me.
The ECG confirmed SVT, his heart rate showing an average of 181 beats per minute. That in itself requires hospital admission. I told John that we'd need specialist help at the hospital to deal with the heart rate, and that I needed to speak to the doctor, amid his protests that he'd be fine with a dose of painkillers. He asked if the hospital would keep him very long, as he had to "be somewhere" that night. I said he'd probably have to rearrange his plans for that night, and left him on my desk phone while I spoke to the GP.
On seeing me with an ECG the doctor started with the usual banter, but once he realised what I wanted he quickly said: "Well done. You get the ambulance, I'll ring the hospital." I rang 999. John was just finishing his call saying: "No really I'm fine, it's nothing. I'll ring you. Aye, I promise. Look, I've just got a bad back, anyone's pulse would be fast. I said I'll ring you. I will. Bye!" I told him the ambulance was on its way, at which he said he'd drive there, or failing that he'd take his car home and the ambulance could pick him up there. But he couldn't contemplate leaving his car in the surgery car park, it was his pride and joy. By then the doctor had joined us and confirmed it wasn't safe to drive. John began again saying he had backache, that was all, and that it was no wonder he never came to the doctors - look at the trouble it caused when he did - he was needed at work, his girlfriend thought he was stringing her along and now his car was going to get vandalised. John's address was only about half a mile from the surgery so I offered to drive his car to his address at lunchtime and leave his keys with someone. He hesitated, obviously estimating the damage I could cause in half a mile, then reluctantly agreed, handed over the keys and asked me to put them through the letterbox as he lived alone. He'd get a taxi home from the hospital. The ambulance crew arrived, saw John's ECG, ankle oedema and degree of perspiration, gave him oxygen and quickly wheeled him out. He said, sheepishly: "Thanks, I know you're doing a good job, you will be careful with the car though?" I joked that I'd just take it for a spin to the coast to get the engine warmed up before dropping it off.
I took his car, left it in the street outside his flat, then dropped the keys through the letterbox, having checked the number several times, fearing the reprisals if I'd got it wrong. It amused me, sitting in John's car, since it was clearly his private domain. The stereo started with the ignition - Dire Straits, full blast. The three giant packets of crisps and bottle of Coke on the passenger seat were probably going to have been his lunch. The smart jacket, to match his trousers, hung from the rail in the back.
I rang the hospital that evening. John was on the medical ward. His liver function tests had been grossly abnormal, suggesting infection, a myocardial infarction or carcinoma. He was due for a scan the next day, but he developed ascites, and then collapsed with multiple organ failure. Two days later John was dead. The postmortem read: "Metastatic carcinoma, sepsis, multiple organ failure."
It all seemed terribly incomplete. His last fragment of normal life had been in my room when he was supposed to be on his way to work, where he would have eaten crisps and drunk Coke, and then had a date that evening with his girlfriend. I wondered whether he had rung her as planned, whether she had been to visit him. I didn't think I'd done him much of a favour, but then perhaps he would have collapsed at the wheel of his car and involved an innocent bystander.
Either way, I think I'll keep on with the investigations. Hopefully next time I might be in time.

Reference
1. Clinical Knowledge Summaries. 2007. Available from: http://www.cks.library.nhs.uk

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"Just how do you manage all that in 10 mins? My minor illness clinic times are tomorrow being reduced from 15 mins to 10mins. I also try to complete care where possible, doing my own investigations rather than delegate to another nurse. I know I will find this more difficult with less time. Maybe this article can be of use if I need to negotiate a return to 15 mins." - Lynne Weastell, Sutton in Ashfield