A recurrent feature of general practice is that we let our patients decide what is urgent and what is not. When you’re on the front line, there’s not really any other way. The punters triage themselves, to a certain extent.
A colleague told me she saw a patient who had requested an emergency appointment because he was constipated. For one day. For 40-odd years he’d had a daily dump, but one day he didn’t. So he demanded an appointment on that day to see his GP. I imagine there was not a great deal that she could do at the time, other than waiting until the next day to see if his arse could deliver the goods. It’s not the sort of scenario where you’d rush in with a total body MRI scan.
At the other end of the spectrum, today I met a lady with recurrent hidradenitis suppurativa (abscesses in the armpits) and I’ve literally never met anyone with such a horrible ongoing disease. She had suppurating, discharging, lumpy abscesses in both axillae and both inguinal areas and had pus running down four limbs.
‘You could have come earlier,’ I commented.
‘I don’t usually bother the doctor with them. The last time I came here, you just stuck a knife in it, so I thought I could do that at home.’
I had a look at her records, and this was indeed true. I’d incised an abscess in 2005. ‘So you stick knives in your own armpits?’ I asked her.
‘Yeah, I usually do it in the bath so there’s less mess. But this one is too hard; I can’t get the knife in.’
‘What sort of knife?’
‘Just a normal kitchen knife. But don’t worry doctor; I keep it separate from the other knives. It doesn’t get used for food as well.’
‘That wasn’t my main concern,’ I told her.
Auto-surgery is rare, but not unknown. In fact, I’m guilty of it myself. Many years ago on holiday, a feral child (not one of mine, I hasten to add) smashed me on the wrist with an iron bar, and I developed a synovial cyst.
I would occasionally stick a green needle into it and squeeze the jelly out while watching The Sopranos with my wife. This seemed to irritate and distract her, for some reason. ‘Why can’t you just pick your toenails like a normal man?’ was one thing I remember her barking at me. But at least
I used to use a sterile needle, most of the time.
Also, I have a GP friend who incised and drained his own external haemorrhoid in the bath, with a mirror, with his legs up round his neck. If he’d mentioned it to me in advance, I would have probably tried to dissuade him. But I suppose it’s not the sort of thing you’d bring up over a pint in the pub.
I explained to my patient about this thing called the subclavian artery, which was within a few millimetres of the bit of her body that she habitually stuck a bread knife into, and politely, but emphatically, asked her not to do it again until she’d seen the surgeon I was keen to acquaint her with. She looked a bit doubtful, but said she would comply with my advice. I believe her, I think.
But I still marked her referral ‘URGENT’.
Dr Phil Peverley is a GP in Sunderland
