It was around 11 am, a message appeared on the computer, ‘Mrs M has asked for Dr Kersh to call her. She is very worried about Mr M, she feels he needs a visit’
Mr M is one of my favourite patients.
I am not sure if it is OK for a doctor to have favourites.
I am sure all doctors and nurses gravitate towards certain people more than others, whether because they remind them of a parent or relative or it is just that their manner, demeanour or smile resonates.
I am quite certain were another relative to have called, perhaps someone who was not on my favoured list, given the urgency of the message I would have done the same; phoned straight away.
Mrs M sounded worried; she described that her husband wasn’t walking as well as normal, he had back pain, she was concerned he wasn’t drinking enough.
For most doctors, when the suggestion of a home visit is proposed, from the start of the conversation we often run calculations as to the necessity of going to see the patient against other potentially mitigating strategies that might enable us to get away with either advice or a prescription sent direct to the chemist, ‘Sounds like a water infection,’ for example, is easier than going out and prodding the patient’s tummy.
With Covid adding an element of risk to a visit which previously was just an inconvenience, we have found new ways to estimate risk – visiting a patient at home and the potential added information available versus the risk of a remote consultation.
For older people, like most of my patients, using iPhones or iPads to run online consultations is fraught; I have written before about all the difficulties of WiFi, understanding where to point the device, combined with visual and hearing impairment.
Sometimes visits are necessary.
‘I’ll be along in 15 minutes.’
I could tell from Mrs M’s voice that it was not only her husband but she who needed support.
When I arrived, donning the requisite PPE, I sat with my patient’s wife for a few minutes in order to get a more detailed picture of recent events; what had passed since I had last visited in October.
She was concerned about his reduced mobility, diminished diet and fluid intake, he had become delirious, confusing where he was and the location of his bathroom.
Lying in bed I was surprised at how well Mr M looked.
He was pretty much his usual friendly, affable self, wearing PJ’s rather than his normal shirt and tie.
He related his symptoms, I examined, checking his pulse, blood pressure and oxygen levels.
Everything seemed fine.
At some point he had stopped taking the diuretics I had previously prescribed – he wasn’t sure when or why and my diagnosis was a degree of heart failure.
I asked him to re-start the water tablets, said I would arrange a district nurse assessment, booked some blood tests for Monday and would call the following week.
My patient and his wife were reassured.
I went home (the centre of my operations during Covid where I work from our front room).
I was surprised when later that afternoon I received an email from his son thanking me for visiting and relating how grateful he and his family were for my support.
As any doctor or nurse will know, when a patient says, ‘thank you,’ that is appreciated; when someone goes a little further and either sends a card or in this case an email, it is enough to both make your day and a blog!
I replied thanking his son and adding that I would be happy to do anything to support his dad.
I later reflected as to whether my assessment had been accurate; were the crackles I heard in his chest an infection rather than fluid? Should I have prescribed antibiotics? Maybe getting the rapid response nurse to assess on the same day would have been more appropriate?
It is hard to know and this is just one of the many actions and decisions doctors and nurses take every day when assessing and treating patients.
With older people the stakes tend to be higher – a miss-step can be the difference between recovery or deterioration, admission to hospital with all the associated risks to an older person’s independence and function.
There is a fine line between working and treating your patients professionally and caring for them, with the latter, becoming a more substantial risk as we gain greater insight into their lives, increasing our understanding of who they are, where they live, meeting and talking with their children or relatives.
The thickening patchwork of relationships that functions at the centre of life as a community doctor is what compensates from the intensity of hospital business; the richness of experience provides succour.
I did my best.