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CHRISTMAS NIGHT ON CALL

By Hamish Maclaren
Contact the author by e-mail at christopher.johnstone@ntlworld.com

I drew the short straw: on call from 18:00 Christmas Day to 08:30 Boxing Day. I got ten calls, and I would like to describe them to you, concentrating not so much on the clinical material, but rather on my personal reactions to each consultation or, as some would have it, each “client/care-giver contact episode.” I have a suspicion that the reason why most general practitioners are choosing to opt out of after-hours work (at least under the terms of the new contract) is that their reaction to the work, at an emotional level, is not unlike my reaction. But see what you think.

Some demographics: The area: 500 square miles of rural/semi-rural Scotland extending from the penumbra of a large conurbation to some of the most beautiful countryside in the world. The population: 25,000 patients covered by half a dozen practices and broadly representative of “Middle Scotland” (if there is such an entity); a population as disparate as the characters in Chaucer’s Canterbury Tales. Me: male, aged 52, likes music, literature, aviation, running; good at anger management; bad at long-term relationships; naturally full of health and probity.

I registered with the call centre (in New Delhi... I’m only joking) at 17:55 and I could tell the telephonist was wearing a funny hat.

“Busy?”

“Dunno. I’ve just come in from my real job. I’m here till midnight. Never again.”

“You’ll just have to make a New Year Resolution.”

“Yeah. Get a life!”

And I got my first call at one minute to six. I’ll dwell on this a little, because it was by far the most interesting call. The others will be quicker. The call was from a young woman, the neighbour of an elderly lady, who had a sore throat. She’d had it for a month. Two courses of antibiotic had made no difference. It all sounded a bit nebulous. I asked, “Does she look ill?”

“Yes. She looks ill.”

So I arranged to see her at the surgery, midway between my home and her home. And my construct was: young person visits old person next door once a year; finds her looking not very crisp, feels guilty, and reaches for the deus ex machina, the doctor. Well, put your money where your mouth is and bring her along.

But as soon as I saw her I knew I’d got it all wrong. She was ill; pale, clammy, distressed. Was she having an infarct? Is a sore throat ischaemic jaw pain?

Oxygen, iv access, morphine, blue light ambulance. It just shows you!

19:45: Call 2. Two year old child with a fever. I distrust telephone consultations. I have a very low threshold for visiting. I worked for 13 years in Auckland, New Zealand, the meningococcal capital of the world. I have sat in an NHS Direct call centre in London and watched the nurses scroll through the endless algorithms. You can’t beat a real live doctor-patient consultation. Anything else is second best. The problem is that this child lived in a village 15 miles away in a street where the houses were unnumbered. Get out the map; drive to the destination; wander aimlessly up and down the street; call the family on the mobile and get them to wave out of the window... The child was fine.

21:00: Call 3. 10 month old child with cough and fever. Another 30 mile round trip to see a child with a croupy cough who was fundamentally well.

21:20: Calls 4 and 5 taken en route to Call 3. I’m using a hands-free mobile in the car and am grateful that it is still legal so to do. Two adult patients in a hotel at the other end of the locality, one a lady with “severe” abdominal pain and vomiting, the other a lady who has fallen on the dance floor and split her scalp open. I can’t see either of them for at least an hour and have to do some telephone triage. I organise an ambulance, conscious of a vague sense of dissatisfaction. Later I get over to the hotel, largely as a public relations exercise. Both patients have been transported to hospital.

23:00: Call 6. A 46 year old man has just squirted superglue in his eye. Fancy doing late night DIY on Xmas. I take a comprehensive history. He needs a slit lamp exam and I suggest he take himself along to a nearby Emergency Department. I am very careful not to use the appalling expression “A & E.” There is no such thing as an accident.

00:30. I go to bed and whisper a mantra to myself. “You never know your luck.”

01:00: Call 7. A 35 year old lady has gone into labour. First baby. I speak to her husband and make sure transport is available, and I call the labour suite, and I call the patient back and send her every good wish.

02:00: Call 8. 5 year old child distressed with earache. They haven’t got any analgesia in the house. 25 mile round trip to an obscure location, and inadequate directions. I adopt a professional demeanour and ensure that the child is fundamentally well, and organise some symptomatic relief.

04:00: Call 9. Eighteen monther with cough and distress on lying flat. Near neighbour of patient 8. It’s croup. If the child gets agitated I can just persuade myself that I can detect some stridor. I seem to be handing out a lot of advice and patting a lot of people on the head tonight.

06:00: Call 10. 60 year old lady with acute asthma requesting nebulised salbutamol. Actually she’s not that bad. She’s anxious and I think she’s a bit lonely. She paints water-colours; they are all over the house. I spend some time admiring them and this seems to be very therapeutic.

08:00 I’m wide eyed and bushy tailed and repair to the surgery to do the paperwork. Before I know it it’s 08:30 and I’m off the hook. Time for a black coffee and a large fry-up.

10:00 I crash.

It took me 14.5 hours to see six patients. We run 10 minute appointments at the surgery. I can comfortably see six patients in an hour. I started with half a tank of petrol and nearly ran dry. Most of my time was taken up with non-clinical activities - fielding telephone calls, map-reading, writing up notes and, most of all, driving.

Nobody in their right mind enjoys getting up in the middle of the night to go to work, but that apart, I’ve always enjoyed doing house calls, especially to engage with an acute problem. To drive down an unknown private road to a hitherto undiscovered country house and briefly to enter people’s lives in a unique way can be an extremely satisfying professional experience. Still, there are aspects of undertaking night call that are profoundly dispiriting. Three things come to mind; first there is the inordinate investment of time, effort, resource and even emotional capital with very little palpable end-product, all undertaken in an atmosphere of mild angst and with the possibility that you might, albeit rarely, have to deal with a real emergency. Second is the communal complacency borne of the long tradition of domiciliary care in general practice in this country. That the GP should travel 30 miles at 2 am in midwinter to pat a child on the head is regarded as de rigueur. Third and most oppressive of all is the intense solitude. Unlike the hospital doctor, you can’t filch chocolates from the nurses’ station, and indulge in a little ribaldry.

hoolet is the magazine of RCGP Scotland. It is supported intellectually, financially and emotionally by RCGP Scotland.

This issue maintained by Robert Hallam.