Ten Miles for a Glass of Water

With such a title it would be very tempting to turn this into a post about yet another abuse of the Out Of Hours Service. Certainly I did travel 10 miles last night to visit a patient and it's true, that all I really did for him in the end was fetch him a glass of water; but that's not whole story although the water was at the root of why the call occurred.

It was an extremely quiet night last night and this call was to an area outside my usual patch. It came via 'Careline', those disembodied voices that appear when people 'pull their cord' or 'press their button'. It was to an elderly gentleman with a 3 day history of productive cough, high temperature and generally feeling unwell. Query a chest infection, the doctor wondered "would I mind popping round and having a quick look?"

Well, like most of these calls it wasn't quite as straight forward as that. As with many elderly people the gentleman seemed unsure of the 'history' surrounding his present condition and didn't know what medication he was on or why the doctor had 'put him on it'. As far as I could gather, after about 15 minutes of questioning, he'd been to see his GP about 3 weeks ago because "I wasn't feeling myself". I'm guessing a chest infection was diagnosed as the patient was prescribed a course of antibiotics – "penicillin, I always have penicillin" – and sent for a chest X-ray at one of the local hospitals.
"So what did the X-ray show?"
"That one lung was not so good but the other was fine – I think."
Turns out the gentleman had also been sent for a second X-ray, about a week or so ago, as a follow up after the course of antibiotics had been completed. He said that 2 days previously he had spoken to the GP but the results were still not through.

I had a listen to his chest. Not too resonant and definite 'crackles' to the bases of both lungs. Now it would be easy just to say "Yep. Chest infection" dole out some more antibiotics and exit, but I'm not one for dishing out medication (despite being the Candy Man the other day). Was this a new infection or the remnants of the earlier one? Did he have some kind of heart failure that was producing 'fluid on the lungs'? The lung sounds would be evidence enough for a doctor I'm sure; but I'm only an ECP and still struggle with the finer points of 'lung sounds'. Or was it something more sinister and could that be why the GP had requested the X-rays?

I had a hunt about for details of his medication. There was the ubiquitous 'weekly dispensing box' but no medication details. Eventually I was directed to a drawer in a cupboard where "the carers put my pills". It was the usual stuff: a diuretic, a statin, an anti-hypertensive, aspirin, GTN spray, etc. So nothing definitive then. All the differential diagnoses were still possible.

In the end I passed the buck. It was 3 a.m. The GP surgery would be open in 6 hours and any antibiotics I could have administered would have taken a few days to 'kick in'. I persuaded the gentleman that, as he was not in any great distress and had been sleeping peacefully when I arrived, it would make more sense for him to visit his GP in the morning and let him follow up on the X-ray and any appropriate medication. I know this GP mostly by reputation; well liked by his patients and I'm sure he would be accommodating for this gentleman.

So where did the water come in? Well the gentleman had woken up a few hours earlier. He was a little breathless; it was dark; he got anxious; he had a dry mouth from having a blocked up nose and wanted a drink of water; but he felt too weak and was frightened to get out of bed for a glass of water in case he fell. He'd had a couple of falls over the preceding few weeks and had twice had an ambulance out to 'pick him up and dust him down'. He didn't want it to happened again. In his anxiety he'd 'pulled his cord' and Careline had set the wheels in motion. In the end all I did for him was fetch that glass of water and provide him with some company. I wonder what his GP will say.

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