I know an excellent and experienced GP who sent home a child who then went on to develop meningitis. It is a horrible diagnosis to miss but only rarely is it a ‘blunder’. The only thing we GPs can really do for the thousands of snotty feverish children we see every day is educate the parents as to what danger signs to look out for and when to bring them back to see us.
I’ve only seen meningitis a handful of times and thank goodness never as a GP. The first time I saw it was the most memorable. I was working in casualty and a dad carried his four-year-old child into the waiting room. I took one glance at the child and went straight to the drugs cupboard, whacked some penicillin into his vein and called the paediatric registrar instantly. Despite the fact that I had never seen meningitis before, the diagnosis was obvious. The child looked really bloody sick. He was floppy and completely disinterested in anything around him. This was not a clever diagnosis. No doctor in the world would have sent this child home. Several hours earlier when the child was just a bit hot and bothered but still happily watching Disney videos and playing with his brother, the diagnosis would have been much more tricky. If I’d seen the child at this stage, I could easily have sent him home and become the next day’s ‘blunder doctor’ newspaper headline.
I am always happy to see children and babies in my surgery and will do my best to fit them into a full surgery if Mum or Dad is worried. In fact, seeing kids is one of my favourite parts of being a GP. The main difference between children and adults is that kids are very rarely unwell. The truth is since I’ve been a GP, I’ve probably seen well over a thousand children and babies, but I am yet to see one that was unwell enough for me to be really worried. Meningitis is really scary but also pretty rare. I understand that this might not be that reassuring if it is your own child that is hot and miserable and that is why I’m always happy to see kids and to reassure parents. As a parent myself, I do realise that it is hugely anxiety-provoking to have this small person for whom you are solely responsible and whom you love overwhelmingly and unconditionally. We doctors are equally anxious when our kids are unwell and I once heard of a GP rushing her infant to see an ear, nose and throat specialist as she was convinced her child had a nasal tumour. She was understandably very embarrassed when the specialist then removed an impressively big but definitely benign bogey from her child’s nostril.
A few kids need a good check-over before I’ve reassured myself that they can go home, but the vast majority are obviously fine as soon as they walk through the door. This may seem a bold statement to make when I’ve previously talked about how easy it is to miss meningitis early on. However, these borderline kids are the minority of children we see. If a child skips into my consulting room and gives me a smile, they haven’t got meningitis. I can’t say that they won’t develop meningitis in 12 hours’ time but then I couldn’t say that any well child wouldn’t develop meningitis in 12 hours’ time. Unfortunately, that is the nature of the disease. In the same way that it took me about one second to decide that the child with meningitis was really sick, it takes me about one second to decide that 99 per cent of the children I see are completely fine.
When I say that the vast majority of the children I see are ‘fine’, I don’t mean that they are not unwell. What I mean is that they don’t have meningitis or any life-threatening condition that needs hospital admission right then. They also almost certainly don’t need antibiotics as they invariably have a viral infection. It’s important that I don’t use the word ‘fine’ to Mum and Dad as they have been up half the night with a miserable crying infant. These children are ill but not ill in a way that I can do anything about. It is just part of being a child.
Kids get ill because they haven’t been exposed to lots of the bugs that we have. They are going to be snotty for much of their early years and often spend the vast majority of their first couple of winters going from one viral infection to another. Children need to build up their immune systems and, unfortunately, the only way they can do this is to be unwell. I often think that new parents are a bit unprepared for this part of parenthood. Children will have recurrent ear infections, coughs that last for weeks, sore throats that are really sore and funny spotty rashes that don’t quite look like anything in my dermatology textbook. All these things are just part of being a kid and staying up all night comforting them is part of being a parent. It’s not much fun at the time but it’s normal. I would love to be able to give an instant cure for these childhood illnesses but, unfortunately, I can’t. My job is simply to listen to the parents, do a quick examination, offer encouragement and reassurance and make sure that Mum and Dad come back if they are worried. A generation or two ago when big extended families lived together, this reassurance was given by Grandmother or Auntie, but nowadays parents can be quite isolated, hence it is often the GP that fills this role.
Soothing anxious parents is definitely one of the hardest parts of my job. Many are very happy with some sensible reassurance. Others are looking for antibiotics and won’t be happy unless they leave with them. We all want the best for our child and seeing them unwell is hard to bear. I think some parents feel that they are letting their child down if their snotty and coughing infant doesn’t get antibiotics. In direct contrast, as I strive to be a good doctor, I am trying to hold back from giving antibiotics. It can be a difficult battle that can go either way.
To try to swing the encounter in my favour, I have developed a battle plan. The first thing that I do is try to empathise and say how the child definitely does have a very bad infection – be it a cough or ear infection or sore throat, etc. I sympathise about how hard it is for the whole family when a child is up all night coughing and crying, etc. Vital is me then telling the parents what a great job they are doing with regular paracetamol and lots of cuddles. My aim is to make them feel that I am on their side and that I realise how exhausted they are with no sleep and a miserable child. Then I explain why antibiotics aren’t appropriate to treat viruses, but still offer them as an option. If I’ve done my job well, they say no, but feel that it is their decision. Finally, I make sure that they will come back and see me if they are concerned and tell them about the worrying symptoms of meningitis to look out for.
If I’ve succeeded, they don’t come back, as the parent feels more confident and the natural course of these viruses is that the child gets better. Ideally, they also feel a bit more confident about managing the child at home next time they are poorly. When these consultations go well, they are great. When they go badly, they are a disaster and usually either end up with the child getting an inappropriate prescription for antibiotics or an anxious parent getting very upset and dragging their child to A&E.
Uzma
It’s 6.30 p.m. and my last patient has just walked in. I’m running on time and I’m due to meet a few friends for a drink after work. Working in offices, they have been in the pub for ages and have a pint waiting for me. If I can just get through this last patient quickly, whizz through some paperwork, I’ll be in the pub by seven.
Uzma comes in. ‘I need the repeat of my pill, Doctor.’
Happy days! Contraceptive pill checks are a boring part of general practice but quick and easy. I do a speedy blood pressure reading, ask if there are any problems, which invariably there aren’t, and then the patient is out of the door within a few minutes.
Just as I’m generating the prescription, Uzma seems to be welling up. I’m torn now. I am a nice sympathetic doctor. Honest! It’s just that I’m tired and drained and I can practically taste my pint. I really don’t fancy spending the next half-hour listening to a weeping 16-year-old. I contemplate pretending not to have noticed, but it’s too late. The tears have arrived. They are unmistakable, especially as they are now dripping on to my blood pressure machine. I sink into my seat and prepare myself for a long evening.
‘So Uzma, you seem a bit upset?’ Not exactly reading between the lines, given her quiet sobs have now turned into loud wailing.
‘I can’t go home tonight, Doctor; they all hate me. Everyone hates me.’ More wailing and tears. ‘They blame me for everything and always take my brother’s side.’ Wail wail. ‘My parents don’t understand