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Gold, incentives and meh

Saintly person required as chaperone

Three GPs share their approach to a practice problem

Case history

Mrs Smith rings and asks to speak to you 10 minutes before your half-day closing at 1pm. She is working 10 miles away and is concerned about her six-month-old baby, John, who started with a bit of a cold last night but is currently in a day nursery on the edge of the practice area. The nursery has rung her at work to say John is screaming and very hot ­ they want her to collect him. She is very worried as the baby has never been ill before, and asks you to visit him at the nursery as she won't be able to get back for another hour or so.

You are due to give a lecture on the hospital vocational training scheme half-day release programme at 1.30pm; the hospital is 20 minutes' drive in the opposite direction and the deputising service will not accept calls made before handover time (which is also 1.30pm). No one from the nursery can apparently be spared to bring John to the surgery.

Dr Rodger Charlton

'Life may be less of a hassle by allowing for these extras'

Perhaps life might be less hassle for the doctor if he or she had organised for the lecture to be held later on and so ensured time for such inevitable 'extras' and lunch. It is amazing how many urgent calls seem to come in just before closing time. Perhaps the key to helping this mother is to remember that she is very worried and fears for her baby.

Although the duty of care to the child is with the mother, it has now been transferred to the GP. Having said this, I would advise her to go straight to the nursery and not to delay for an hour and that as part of my duty of care I would telephone the nursery. This would be to make an assessment as to how ill the child was and in particular if there was evidence of a rash or a history suggestive of septicaemia.

Assuming that this conversation supported my impression that this was an acute viral URTI with a fever, I would advise that a single dose 2.5ml of paracetamol suspension 120mg/5ml was administered. I would only visit the nursery if I was worried that there was something seriously wrong with John such as meningococcal septicaemia.

I would arrange a time after my lecture to review John at home or my surgery to reassure his mother and me. Also examination of John will be easier after the paracetamol has had time to work. If John deteriorated for any reason before this consultation, I would advise the mother to ring the deputising service.

Interestingly, if I did feel I needed to visit the child at the nursery and suspected something more serious following my assessment, who would take John to the local hospital? At the end of the day, if I felt I did need to visit the child, my receptionist could easily contact the VTS and say I would be late.

Rodger Charlton is a GP in Solihull and director of undergraduate GP medical education at Warwick medical School

Dr Declan Fox

'Having quickly weighed up the options

I shall spring into action'

My first thought here is for John's safety. Time and locations are all causing difficulties for me but I can sort them out later. I see three serious problems: the first is a sick kid in a nursery; the second one is my practice cover on half-day (closes 1pm, deputising service takes over 1.30pm ­ go figure!); and the third is my own stupidity for booking a lecture involving travel for the same gap.

My departure time for the lecture is now less than 20 minutes away and I need to allow up to 10 minutes to deal with John.

It is physically impossible for Mrs Smith to have John at the surgery before I need to leave. Similarly, the nursery staff are unlikely to make it to the surgery in time, even if they wanted to. Think average speed during urban lunchtimes.

Therefore I cannot physically assess John and make the lecture in time. I cannot do it ­ but perhaps I can ask a partner or local colleague? Or can I change the lecture arrangement?

Having quickly weighed up the options I shall spring into action. I shall assure Mrs Smith that I or a trusted colleague will ensure John gets appropriate assessment and treatment very shortly. And then I shall phone the nursery and make a very rapid telephone assessment of John's condition before doing anything else.

I can talk them through most of the classic Paediatrics Advanced Life Support (PALS) 30-second assessment and make sure he is not about to arrest. General condition? Alert and responsive?

If he sounds seriously ill ­ such as possible meningitis ­ then I shall tell my receptionist to ring 999. I shall make sure I have the basic emergency gear with me (oxygen, Ambu bag and mask, benzylpenicillin would be good) and go. Oh yes, and ask my receptionist to call the VTS centre for me.

If, on the other hand, he sounds quite well then I shall spend the next few minutes calling Mrs Smith back, advising her on management and arranging to see John later that day.

Declan Fox spent seven years as a principal in rural practice in Newtownstewart, Northern Ireland, took ill-health retirement in 1998 and since then has worked part-time in posts ranging from GP/small acute hospital locums in rural Canada to ambulatory paediatrics in Omagh

Dr Zoe Rogers

'I will not collect the baby from the nursery ­

I'm afraid I am not willing to take on this role'

On the face of it this request for a visit to the baby's nursery seems very unreasonable. Mrs Smith is only 10 miles away but is not concerned enough herself to come and collect him straightaway.

However, as a working mother myself, I do have some sympathy for the conflicting demands of work and home, and she is obviously unaware that I have an important appointment in half an hour.

I would explain to her that as she is so concerned about John, his illness must take priority over her job. The nursery obviously wants this sick child collected as soon as possible. Once she has collected him, she will be able to assess how ill he really is and give him paracetamol or ibuprofen if this is appropriate.

I would make sure she is aware of the symptoms that should prompt her to seek urgent medical attention (non-blanching rash, etc).

If she is really unable to collect him herself, she will need to find a husband, relative or friend to collect him. I am afraid I am not willing to take on this role.

I would arrange to ring her later when the lecture is finished. At this time, if I do need to see John, I will ask her to bring him to the surgery. If I do end up doing a visit, it will be to their home address, presumably located within the practice area. Alternatively, if I am really lucky, I may have a GP or nurse practitioner colleague who could ring her sooner and arrange to see John if this is necessary.

If, when she collects him, he is too unwell to wait for my attention, she has the choice either to take him to A&E or to ring the deputising service. If she is unsure in the meantime she can always talk to NHS Direct for advice.

Zoe Rogers qualified at Oxford in 1992 and trained as a GP in the Ealing and Southall area (MRCGP 1999); she has been a principal for four years in Hanwell and recently finished the diploma in teaching in primary care at the University of Westminster

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