Just a R&R on Allergies

allergies

Humour me – I need to do a R&R (Rant and Rave) on patient’s allergies.

I am sick of people with ridiculous allergies.

My anaesthetist once told me, that if a person put down more than three drug allergies, then he/she is most likely crazy. I have had patients who ran out of space on their pre-consultation questionnaire for their allergies that they started to list them on the back of the form. I understand that there may genuinely be people who have multiple allergies, but these people are extremely rare. Their allergies are often proven with forma allergy-testing.

I have had patients who have listed every class of antibiotics under their allergies, so I have had to tell them that I couldn’t operate on them, because if they got an infection, I won’t be able to treat it.

Then there are the patients who put down ‘allergic to general anaesthetics’ when they check into hospital for their operation. Really? Would you prefer a sledgehammer instead? You can’t be allergic to general anaesthetics – to put someone to sleep it requires a finely-balanced cocktail of different intravenous drugs and inhalable gases. Sure, there are known idiopathic reactions to specific anaesthetic drugs, but these are rare – often the specific agent can be identified and the patients are informed in detail. The generalisation of being allergic to general anaesthetics just shows patient’s complete ignorance to their true allergies. Nausea and vomiting or a mild rash after a GA is common – it doesn’t mean you are allergic to it.

Patients who are allergic to multiple pain killers are a complete headache to surgeons. When patients put down that they are allergic to all narcotics except Pethidine, they shouldn’t be surprised that medical and nursing staff treats them like Pethidine addicts. Pethidine is a narcotic, it’s hard to fathom that someone could be allergic to all narcotics but not Pethidine. Most often, people who get a high on Pethidine prefer Pethidine injections to any other narcotic as their pain relief. There are also patient who claim they are allergic to simple analgesia like paracetamol/acetaminophen, or anti-inflammatories, but can only take narcotics. That to me, also sounds pretty suss.

Then there are patients who think they are hilarious. When I ask them what they are allergic to, the response is, ‘doctors’, or ‘pain’, or ‘hospitals’. If only I had a penny for each time I get the funny patient, I’d be a millionaire by now. What about patients who write ‘hay fever’ or ‘eczema’ in the box next to ‘Drug Allergies’. Really?! Do they know of any doctors who prescribe ‘hay fever’?

Food allergies, however, are important to disclose, as some people who are allergic to seafood or crustaceans can also be allergic to iodine. One of the intravenous anaesthetic (propofol) also has egg protein in it, so can cause severe allergic reactions in those who are allergic to egg. As for being allergic to cat? Well, we don’t normally prescribe cat, and the well known cat-gut sutures are actually made out of sheep gut.

People need to understand the difference between side effects and allergy. Nausea, indigestion or even itch sometimes, is not an allergy; it is just a common side effect. These side effects can be avoided if advice or treatment is sought. Being sensitive to something is not an allergy. Patients love telling me they are allergic to all tapes.  When tested, they are usually not allergic to any, because the ‘red rash’ they describe are just irritation from the sweat which has accumulated under the tape on their sensitive skin. Some people are also quite ‘sensitive’ to medications, and although understandable, is still not a true allergy. All that is needed is a dose or timing adjustment or even treatment to prevent these sensitivities.

Sometimes I have to admit, it can be the doctor’s fault that patients think they are allergic to numerous things. When a patient reports a side effect, the doctor is often quick to blame the drug and put it down in the allergies column, instead of explaining to the patient that it is not a true allergy, and find out if the drugs were taken correctly.

Why is it so annoying to a doctor when patients put down allergies which are not true allergies? Because once you have written it down as an allergy, medicolegally, we find it very hard to give that particular drug to you, even if you need it desperately. So if you put down that you are allergic to an antibiotic when all you get is a bit of nausea, we have to give you a second-line antibiotic choice to treat your infection because we don’t want to be sued for drug reactions. If, instead of putting it down as an allergy, you tell us that you get a bit of nausea with the antibiotic, we will dose it so that you can take it with food and maybe some antacids to treat the side effect, but you will now get the best antibiotic for your infection.

So next time you write down your allergies, think twice before you start listing them.

What about the patient who told me that she was allergic to light?

I told her that it was ok. I can operate in the dark.

 

Diagnosis: I Don’t Give a S#@% about myself

One of the most frustrating things I encounter at work is trying to help people who doesn’t want to help themselves.

Here are the 10 top clinical signs (for the novice):

1. The beautifully tanned patient who is sunburnt all over, (looking like he/she has just spent their weekend on the beach), and is about to go into the operating theatre to have a melanoma excised.

2. An obsession with blenders. The lap band is tight to maximise weight loss, the patient is supposed to be on a portioned healthy vitamised liquid diet. Instead, he lives on a  ‘vitamised diet’ of Big Mac and French Fries, liquified via a blender. ‘I just don’t understand why I am not losing weight…

3. The dangerous oxygen tank. The patient who just had 1/2 of his right lung removed for cancer – so now he is dependent on oxygen – lighting up a cigarette in the hospital courtyard. Taking a drag on their cigarette in between inhaling a whiff of oxygen from their mask. Honestly – if you want to kill yourself, that’s ok, but to blow up the hospital???

4. An X-ray that shows a new fresh hand fracture through plates and screws over an old fracture. Excuse: ‘Well, punching my fridge is better than punch my Dad in the face, rght?’

5. The MIA patient. The patient was called for the operating room, but he couldn’t be found anywhere. Because he was outside for his ‘last smoke’ before having half f his lip removed for  lip cancer. ‘You only told me that I couldn’t eat or drink before my anaesthetic, you didn’t say I couldn’t smoke.’

6. Patients with bags of ‘unfilled’ medication scripts. One is really unsure as whether these patient don’t take their prescribed medications (for their heart disease, cholesterol, diabetes, infections etc), because they can’t be bothered, they don’t want to or they just ‘don’t believe in taking medications.’

7. DNA’s (did not attend). Patients who have appointments for their cancers to be assessed and removed do not turn up to their appointments despite multiple phone calls, or simply, they have important work-commitments or holidays and need to move their appointment to 6 months later when things are quiet (and the cancer will be inoperable.)

8. The broken plaster on a broken arm. Sometimes, the non-existent plaster on a broken arm. ‘I know my arm is broken, but it got so itchy I had to take the plaster off’.

9. The gigantic fungating cancers. It takes time for cancers to grow. When I see a very very large cancer, I wonder why patients don’t come in when it was the size of a coin. Once I had a patient with a skin cancer on his chest. It was the size of a dinner plate, and it had already eaten into his breast bone. I asked him why he left it until now to come, he said that he only came in because it was growing into his neck and he couldn’t hide it behind his business shirt and tie at work anymore. Did he know it was a cancer? Yes, but he was too busy at work to take time off for an operation.

10. The smoker with a cigarette dangling out of his neck. The throat cancer patient who had his throat removed now has to breathe out of his tracheostomy. He was found lighting up with a cigarette taped to his tracheostomy. A short-cut highway of delivering poisons directly into his lungs. Well, I guess he won’t get oral cancers from smoking this way.

The Differential Diagnoses:
1. I have a severe case of NFI (No F&%$* Idea)
2. I am so f$%#@ scared that I’d rather bury my head in the sand
3. My health is my doctor’s responsibility because that’s their job to fix it

But sometimes we just have to face the harsh diagnosis of: I don’t Give a Shit about Myself.

 

An Impossible Letter to the Health Minister

This is an open email distributed by the doctors working in the public health system of Queensland Australia.
The Queensland state government has presented new contracts consisting of ‘improved’ work conditions for its doctors.
These conditions include:
1. If a doctor resigns, 6 months’ notice is required, or paymentf 6 months salary to the hospital is required for leaving
2. On dismissal, there is no process for appeal
3. Doctors can be rostered to do any shift, with no specification on having available junior staff support
4. Work conditions (pay, allowances etc) can be changed without notice by adminstrators
5. Work hours, duties, locations can be changed by discussion, not agreement
 
It is a contract which several independent industrial lawyers have advised against signing.
It s a contract where the government will own the doctors’ livelihood. Doctors will be held hostage by their contracts, which may come in conflict with patient care, as they may have to make decisions to appease the administrators, rather than what’s best for the patient.
 
*Please note, I didn’t write this email, but I wish I did.
 
 
Date: 7 March 2014 10:48:17 PM AEST
 
Subject: Nothing here is impossible Mr Springborg

Dear Minister Springborg and Premier Newman,

We have been told that your legislative changes are irreversible, and the train carrying these individual contracts has already pulled out of the station, and cannot be stopped.

We sincerely hope that your talks with the SMO representatives around the concerning issues in the contracts result in a successful outcome for all.

If SMOs are not convinced that our ability to continue to practice public health medicine with safety is secured, then the state will be in grave danger of losing its’ brightest and best.

Please listen:    We say to you that nothing in your legislation, and the individual contracts, is irreversible. This train wreck can most certainly be stopped.

You are dealing with a group of people who understand what is truly irreversible and impossible, as they have stood in the face of death and tried to stare death down, bargained against time with their knowledge, skills, equipment and courage, and sometimes failed, and often times not.

When you have to tell parents that their child has autism and intellectual impairment and that their lives will forever be filled with difficulty and challenge, and watch their grief unfold – that is irreversible.

When you watch a child bleed to death before your eyes as you pump blood in their arm only to see it pour out of the gaping hole in their skull, where it has been sheared off from a motor vehicle accident – that is irreversible.

When you tell parents that their baby has cerebral palsy and will never walk or talk, or even eat independently, because their brain is malformed or damaged beyond repair   –  that is irreversible.

Nothing here with your individual contract legislation is impossible to change – we’ll tell you what is impossible.

When parents beg you to save a child’s life after a second failed bone marrow transplant for leukaemia, as you’re watching them die from an infection they have no white blood cells left to fight  –  that is impossible.

When you’re trying to bring back a heart beat in a child who has been pulled from the bottom of a pool, an hour after its heart beat stopped  –  that is impossible.

Don’t you dare sit there and tell us that this legislation is irreversible and that stopping this contract roll out is impossible. Because we know that all it takes is a show of hands in a parliamentary room, and the swipe of a pen across a piece of paper.

No fancy machines, no million dollar drugs, no transplanted tissues, no 12 hour operations, and no miracles of fate.

Just understanding and good will from your colleagues and yourselves. And if you’re up all night to achieve that, then welcome to our lives.

We have each others’ backs, us medicos  –  we always have and always will.

Because we have all stood there with the sick and the dying, and we know how lonely that journey is without colleagues at our shoulders, and support and resources at our backs.

So we will stand together, even if we have to walk away, together  – until you listen, and pull on the brakes, and stop this train wreck from playing out to its end.

Please enter the discussions with good will, and open minds and hearts, and leave your egos on the coat rack outside.

The health of the state is in your hands – please don’t throw it away.

Sincerely, Senior Medical Officers of Queensland Health.