Angry as #$%# tonight.

[Loose rivets]

It seems that the medical profession likes to swing with the trends as much as any other business. The Rivetess was plucked from the gurney by an anesthetist today because she had a lung infection. Just a post-cold bug, and I think the specialist doctor was right to do this. But...

Days ago, she went to a hospital clinic in North London, they said no lung infection, just wait to get better. She went back with all the symptoms of a secondary infection, but not at the gurgling stage by any means. Following strong counciling by me, she explained that she was soon to have a general anesthetic, and really wanted to be well for this procedure (that was costing us a fortune)

It was refused.

My argument is, that GPs have for decades, given antibiotics by the lorry-load based on nothing more than the high probability of a secondary infection. The conscientious GPs seem to bias towards the elderly, and households with young children. This seems about right, but now, perhaps because of MRSA or perhaps because of cost, they are in a knee jerk reaction phase.

Here we have a grandmother that is about to undergo surgery, albeit, minor. She has been caring for children that are generating snot by the bucketful. A usual scenario with kids either side of two. Wasn't this a case for giving that drug on a basis of probability, where the consequences of not doing so would be extremely upsetting?

[gingernut]

Hi LR, hope the mrs is recovering well.

As you say, the choice to give, or not to give antibiotics, is usually made on the basis of probability. (It's not an ideal situation).

Even NICE recognise the uncertainty http://www.nice.org.uk/nicemedia/pdf/CG69QRG.pdf and allow us some licence to use our clinical acumen (guess).

On the facts you supplied, it does seem a tad mean on the Mrs, although in all honesty, it's likely that her symptoms are viral, so antibiotics wouldn't affect the outcome, and may even delay things further.

[Loose rivets]

Thanks gingernut. I felt fairly sure that the viral stage was well behind her. Despite being a passionate non smoker, she nearly always coughs her little heart out for days - weeks even - after a cold. "I'm not taking drugs" is one of her mantras. Then we have one of those "well go and cough over there then" type of conversations.

This time however, I felt she was showing classical secondary infections symptoms, lungs a bit wet, and the produce starting to thicken. It's just the common sense bit about the impending surgery. This 20 min lady's type procedure costs as much as an hysterectomy, so to have it messed up by hitting the moment where doctors dig their heels in about anti-biotics really does seem unfortunate.

She's going to have to change her airline ticket for our son's reception, as well. Three friends involved in the logistics to get her to and from, daughter spent 12 hours away from her two infants driving or waiting - it goes on and on. I think doctors need to think about how far reaching some of the affects can be. In my wife's case in affected a charming surgeon, and no doubt someone that he could have done instead. ( She did phone the day before to warn them, but they said come in and we'll take a look at you)

If some needy person had wanted her place, she'd have given one of her huge smiles and said okay. But all this for the want of a short coarse of pills...:hmm:

In the latter stages of my flying ooop north, I was with a young chap all one night that coughed his lungs out. ' I'm getting better' says he. I ended up with double pneumonia. 36 hours - a hot burning in the lungs, 40 hours - feeling really unwell, but now away from base. 45 hours, lungs on fire and feeling like hell. From going off duty, I hadn't seen a single soul in between then and getting back from my very lonely digs - so I'm pretty sure where it came from - I had never been so ill in my life. A second f/o stood behind me to monitor, upon landing, the flight was canceled, pax stranded, doctor called - I even considered calling an ambulance to the airfield it was that bad. All so avoidable.

I was talking yesterday about having to fly with a stinker of a cold. That or send our regular and dependent pax home. F/O said he wasn't happy, but could see that half the airline was sneezing, so bit of a fait accompli. I proved that you could share a flightdeck with someone with a heavy cold...and not catch it. Every sneeze, I grabbed for a small hand towel instead of a handkerchief, and wiped the power levers etc., with something strong every few moments. Kept the contagious route to a minimum and the airborne into the towel. It worked. After hours with me he didn't get a tickle.

[Bob the Doc]

There are two issues here. One is the management of 'chest infections' generally and the other is anaesthesia.

Chest infections are usually viral and settle on their own. Antibiotics do nothing to change the course of the condition and unnecessary prescription of them causes antibiotic resistance. Those that are productive of nasty green sputum may need antibiotics if there are signs to hear on chest examination but this is a small minority of cases. GP surgeries are full of people with a cold who want antibiotics because they think it will make their cold better or because they are going on holiday tomorrow and think that the antibiotics will somehow change the course of their viral illness. It is entirely appropriate not to prescribe antibiotics for these patients. Often the diagnosis of pneumonia (a bacterial infection of the chest) is made after a likely viral illness has failed to resolve after a week or so.

Anaesthesia is a different case entirely. There is evidence that a viral illness makes the lungs more sensitive to irritants for as many as six weeks after resolution. Most inhaled anaesthetic agents (the ones we use to maintain anaesthesia, even if we use the magic milk to drift you off to sleep) are irritant to the lungs in some way or other. This irritation can lead to increased mucus production, leading to coughing. In worse cases, it can lead to bronchospasm (an asthma-like condition which can be life threatening if not managed quickly and well). There are numerous other effects of this but these two make the point well enough to avoid labouring it.

Therefore, in elective (as opposed to emergency) surgery, it seems silly to take a chance that the patient will become severely unwell under anaesthesia when postponing surgery by 6 weeks makes the risk much smaller. General anaesthesia has a very low risk associated with it (about one death in every 100-200,000 fit and well patients). This is partly because anaesthetists understand the risks associated with anaesthesia and act to reduce them as much as possible. To do anything else is a disservice to the patient and difficult to defend professionally.

I hope this doesn't sound like an anaesthetist defending his speciality against a reasonable complaint but sometimes you have to understand that we make our decisions based on different criteria to the GP seeing the patient with a cough.

Hope that helps. If you want any more information, please feel free to ask.

Yours

Bob

A flying anaesthetist

[Loose rivets]

Bob, thank you for you comprehensive reply.

As mentioned, the surgeon was very pleasant, and the lady anesthetist was very professional indeed. She gave my wife a good briefing on the logic. My grouse, is squarely with the north London hospital outpatients doctor that my wife saw - twice - where she outlined the impending surgery and her predisposition to coughing. She's never smoked, and reacts to cigarette smoke at a hundred yards.

I felt the danger of a small increment of AB resistance would be insignificant compared to what might - and did - happen.

I once had a GP that could trust me to carry an antibiotic following a nasty cold, because he knew that I would, most lightly, be able to tell when the secondary infection had set in. I got great comfort from that 'Linus Blanket' and don't ever recall actually taking them - under those circumstances. However, I can see that most patients, would probably start swallowing them as they left the chemist.

To this day, I'm astonished at how, even some quite well educated people, believe they can 'kill' a virus with this or that product.