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Hello guidelines, meet the real world

I love a good guideline. They can be a useful tool for advancing treatment plans and avoiding referrals, much to the delight of CCGs countrywide. Imagine my excitement then, to receive an email asking if I wanted to attend a teaching evening on the updated guidelines on COPD – thrilled doesn’t cut it.

The night itself was perfectly pleasant. A catch up with some old friends, a chance to put names to faces hitherto seen on letters alone, even a free pack of incontinence pads from the drugs rep for my troubles. The topic for the evening was an update on the GOLD guidelines for COPD. In a nutshell, this moves us away from inhaled corticosteroids and towards dual bronchodilator therapy. ‘It’s simple’, we were told, ‘Find your stable COPD patients who are on an inhaled corticosteroid, and so long as they aren’t too symptomatic or at risk of exacerbation, take them off the steroid component.’

I love a good guideline

So far, so good. Taking people off steroids sounds like a good idea, if only so I don’t have to figure out who gets bone protection/ calcium supplementation/ a vertebral fracture.

Fast forward to today, and the first opportunity for putting learning into practice arose (I’m sorry, I’ve not long finished VTS, writing this stuff is the only thing I know).

‘Good morning Mrs Jones. It’s lovely to see you today and… are those for me? That’s very kind… please put it with the rest of them. Now, let’s talk about your breathing. I went to a talk with the specialists yesterday and I think we can stop those nasty steroids you have to inhale.’

‘Oh good doctor,’ she replied, ‘I need some more of my inhalers anyway. What do we need to do?’

‘All I need to know, Mrs Jones, is whether or not you’ve had any symptoms with your COPD over the last three months, breathlessness and coughing for example?’

She paused.

‘Well doctor, you see I’ve always had a bit of a cough since Arthur cleaned the shower curtain and spread mould everywhere. Oh and I was reading that coughing is one of the side effects about that statin you’ve put me on and that’s making me feel a little chesty. My breathing isn’t so bad though, although I have been feeling a bit out of puff of late, but I am 83 you know. But no, no symptoms of my COPD at all.’

‘I see’, I said. ‘Your COPD is fine except for the cough and breathlessness you’ve been experiencing?’

‘Yes’ she exclaimed, ‘Oh Dr Chapman, you’re always so on the ball.’

‘Ok then, let’s… er… it looks like things have been well controlled so far. So all we need to do is stop this inhaler which has the steroids in and start you on a new one which doesn’t.’

She looked crestfallen: ‘I don’t like the sound of that, doctor. Beryl down the road had her inhalers changed and now look at her. First of all she couldn’t figure out how to use it and now she can barely walk.’

‘That’s because Beryl has had her hips replaced, Mrs Jones. The inhalers must have been a coincidence,’ I mused.

‘I don’t want to take any chances, doctor,’ She looked at me with her aged eyes, eyes which suggested that presently, life is well.

I sighed, crumpled up the piece of paper with my guidelines on, and met her hopeful gaze with defeat.

‘Let’s talk about bone protection…’

Dr Danny Chapman is a locum GP in east and south Devon