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Fun with flowcharts

There isn’t a huge learning point to be made here. I doubt I’m going to cause any readers to reel back from their desks and clutch at the doorframe for support. But I’m going to do it anyway, and assert that the bone-headed application of flowcharts makes for bad clinical medicine. Whistle incredulously and slap your thigh all you want, but it’s true.

My previous favourite example in the genre was a lady who presented with what looked like a cherry tomato where her eye had been.

She had been woken from sleep by the pain. In her life she had given birth four times, had peritonitis, and fractured a neck of femur. She reckoned the pain in her eye was worse than any of those. She could just about count the fingers that I waved in front of her eye, for the few seconds that she could bear to keep it open.

So I phoned the ophthalmology department, and before being allowed to talk to the doctor on call, I was forcibly guided through a triage flowchart. This came to the conclusion that GPs probably hadn’t come across conjunctivitis before, and cheerily suggested that I pack her off with a few days of chloramphenicol.

For sheer inventiveness though, there is a new champion. This was another lady, who had phoned a well-known medical helpline for advice. On a Sunday night at home she had stood up in the kitchen, and bumped her head on a cupboard door. For some reason this had prompted a phone call rather than a bit of mild to moderate swearing, and she had been whisked into the vortex of a head injury pathway.

I spoke to her the next day, when she anxiously told me that she was fulfilling two of the criteria for a severe head injury. Excessively drowsy, and with a change in personality that was making her snap at everybody, did I think she needed a CT? This being a Monday on call, I’d have been next in the queue, but I did the decent thing and took a history.

The mystery of her tiredness and irritability quickly melted away. She had been advised that she needed regular neurological observations so her husband, clearly something of a go-getter, had fetched a torch from the car and set to work. Every two hours, without fail, he had woken her throughout the night to check her pupils were still reacting nicely. She could hardly stand up and was thinking of taking the day off work. Come to think of it, he was feeling a bit peaky too.

One-size-fits-all defensive medicine. You can’t beat it.

Dr Nick Ramscar is a GP in Bracknell, Berkshire