To think Dr's are too quick to say "its a virus" go away (sensitive - maybe triggering)

[TheoriginalLEM]

Apologies if there is already a thread.

After listening to the news about the poor baby who died from sepsis last year and the blame being laid at NHS 111 feet, i was struck by the fact that the poor woman had taken her child to two doctors who sent her away with her son saying that it was a virus and would be fine etc.

Of course there were failings on the part of 111 and its a service i really don't have much faith in but surely there must have been some questions over whether this child should have been prescribed anti-biotics at an earlier stage.

It may well have been "just" a virus and non responsive to anti-biotics and Drs are stuck between a rock and a hard place because of anti-biotic resistance. However, Very often bacterial infections are able to take hold because a person is laid low with a virus. Surely if a mother is returning after some weeks with a child that is still unwell, it shouldn't be dismissed as something and nothing.

I think Drs seem to have gone from a default - here have some antibiotics, which was wrong to sending everyone away with a lecture on antibiotic resistance, which can be equally as wrong i feel.

I can think of two examples (at least) where anti-biotics/further investigation were appropraite but that was not the route followed.

I went to an OOH with really bad tonsilitis - man flu (even though im a woman) and felt terrible, im usually pretty stoic and i don't remember ever being so ill. I saw a trainee GP who examined my blistered, pustulating tonsils and proceeded to give me the AB resistance lecture - the experienced GP who was monitoring him, looked at me, raised his eyes to the sky and proceeded to write me up a prescription for big gun antibiotics. I went from feeling like i was about to die to feeling much better within 24 hours. I'm not saying i would have been in any more trouble than having to suffer feeling like shit for a few more days but my illness was clearly bacterial as I responded to the treatment.

The second example - more serious, a friend of mine's child was poorly with flu like symptoms (this may not be that accurate in terms of symptoms), she was due to fly abroad to see relatives in a few weeks, she returned to the Drs a few times during this time, made to feel like paranoid parent, told he would be OK to fly. Come the day before they were due to fly, my friends son was still very poorly, worse even, so she took him back to the Dr, who called an ambulance, suspected meningitis. It turned out to be leukemia and was very nearly, too late. Thankfully this was years back and he is in full remission now, but it could have been very different.

So yes, 90% of the time, it is a virus, and we absolutely should not be giving anti-biotics for viruses, and even some bacterial infections i believe we have perfectly functioning immune systems and we should not rely on anti-biotics but if there is ANY doubt (and not just in the Drs mind - parents are an excellent guage of how poorly their child is) testing for bacterial infection needs to be offered, blood tests, swabs, whatever. Yes AB resistance is a massive problem and ABs should not be handed out like they were, but people should not always be sent away to the chemist for paracetemol either. Sepsis can occur in hours and is easily preventable.

I wonder what the statistics are of the incidents of sepsis with relation to the holding back of anti-biotics and if there is a correlation. Of course i am willing to bet that resistance is probably more of an issue, then surely more testing is the way to go. Yep, its expensive but i think its a fair use of resources.

I actually think the whole system would be better if we had the signs of sepsis in all GP surgery waiting rooms on posters, the signs also on easily accessible websites, 111 should have these signs at the top of their list of questions. We should be and probably will be bombarded with correct information. A tv advert would be a help.
It is sad and bad that it takes a child's death to raise awareness, his poor Mum on the tv trying to keep it together.
Having said that I try to raise awareness of meningitis and try to sway people to vaccinate their babies if circs allow

Sorry if that is garbled and not quite grammatically correct. My head is all over the place today because every time a childs death is news It brings it all back, not that it's ever gone away.

I also had never heard of sepsis when my DD was 2 weeks old.

I had her via section so couldn't drive and called NHSdirect who triaged and I spoke to a nurse who asked lots of questions and said she should be fine, asked me to call back if she got worse.

I walked down to our GP and cried on the receptionist who let us see a doctor, he said it was a virus, keep an eye on her and come back if she got worse so I walked her home.

I waited for the surgery to shut and called out of hours, got a cab to them and they blue lighted DD to the hosp (we passed our house on the way) who immediately diagnosed Sepsis, we very nearly lost her.

Not that I blame anyone during that time (over 10 years ago now) I only first realised the real seriousness of what the diagnosis meant by the poster "sepsis can kill" posted on the door in the parents room.

Its not just babies and young children, adults too, especially the elderly.

Sugar - it must have been a difficult day for you today I was thinking of you when i was listening to the lady on the radio. Maybe time for bed with a book for a bit of escapism? It must be very raw for you xxx I hope this thread hasn't upset you, just say and I'll have it taken down

No Lem Your thread hasn't upset me. I dunno about a book and bed, sleep eludes me and I can't concentrate.
I am writing poems as a sort of diary and I have quite a lot. You've seen examples on my thread although they're not very good.
For some reason it helps me to write, I suppose that's something.
Oh and thank you for thinking of me.

Actually, and im not just being kind, your poems are pretty amazing, very evocative and maybe one day, you should think of getting them published. At the very least they will help other parents in your situation. x

Sepsis can be hard to diagnose, particularly in infants and older people. There has been a massive push in hospitals recently to be more vigilant, GPs also have guidance. At this time of year every other person coming to the GP has an infection, most of these will get better on their own. Imagine how terrible it would be if all these people were sent to A&E 'just in case' - after all, A&E is generally run by more junior doctors who have the advantage of full observations, instant blood tests/imaging and much more time than the GP. They are not better doctors, and they over treat many people

There clearly are GPs around who could do better, but most are very competent and will listen to a parent or family member's concerns. The advice should always be 'if you are no better or worse in the next 48 hours, please come back' or similar, assuming there are no concerning or dangerous clinical signs present

It isn't really possible to 'just send a child for blood tests' - who will do this? Taking blood from children is a specialist skill, if they need blood tests today then they need to see a paediatric doctor who will take the blood and make a clinical assessment

Don't get me started on 111, I would never advocate any friend or relative of mine uses it. They are qualified nurses with a checklist who don't/can't use clinical judgement

Big hugs to those who have lost children or relatives through illness x I cried for days when a baby I was (loosely) involved with died fairly recently - even though I knew the medical condition was a terminal one and not curable

Disclaimer: I am a doctor. I try to be a good one, but it's not easy. That's why it takes so many years to train. Googling symptoms and guidelines does not make a lay person an expert, but telling me your child or parent is not themselves or is more unwell is very valuable information

The problem is generally one of money. In 99.9% of cases it's a virus. If we were to start blood testing, swabbing everyone the cost implication would be huge. Simply we can't afford to.

This is not to say the doctors don't make mistakes, they are after all over stretch humans. And especially trainee doctors (which is exactly why they have the senior doc is there to check) but in the main, doctors do a fantastic job, diagnosing correctly the vast majority of people. We all make mistakes at work, we are just very lucky that for most of us, those mistakes aren't life and death, and we are very lucky that the vast majority of doctors make very very very few mistakes.

Problem is we can't ring OOH directly in our area now, and there's no walk in centre
I'm neutropenic and a temperature can be serious but it doesn't trigger on 111 as such
I need something in between a&e and Google!

I normally hide any threads on MN about GPs doing stuff wrong as I am a GP & it's too stressful. However there are a couple of things particularly wanted to say in response to this thread.

1. I don't think the case of antibiotic resistance is being overstated. I am starting to see patients in the community with multi-drug resistant urine infections that only very strong intra-venous antibiotics will treat. It is very scary.
2. I don't think more antibiotic prescribing is the answer, better awareness of sepsis and the need to intervene earlier is. As said up thread you can be septic & die from a virus. I have recently had training on this & there is lots of training going for primary care staff (eg the people we phone our admissions through to now have a special pathway they activate if you say the patient has sepsis)
3. tests aren't necessarily the answer either. A patient could deteriorate & die in the time it takes to get tests back. There is no blood test that confirms the patient has a bacterial infection rather than virus anyway. Even swabs might not give the answer- a good example being if a see a patient with cellulitis (skin infection) but their skin is dry with no wound if I swab the skin I might not grow any bacteria, it doesn't mean they don't have an infection. Finally I am very sad to hear about all those who have lost loved ones. This story made me cuddle my own babies a little tighter. It also made me worry about work. Have I done everything right today? Have I missed a case like this? I know lots of GPs and other doctors. We know we aren't perfect but we are all trying our best & would be devastated if we were involved in something like this.

I do also agree though that 111 is total crap. You have to phone it in our area to get the out of ours GP. I needed it for my son & knew what was wrong & what was required but the woman had to ask me millions of questions about travel to east Africa to see if he had Ebola. And to correct up thread they are not nurses they are just called centre workers with a tick box programme.

Sometimes you can't help the over prescribed though. It's taken me 8 YEARS and 50 plus blood tests to finally be told I've been severely neutropenic all that time
In and out with infection after infection that I couldn't shift and kept being told "bloods all fine"
Every infection needed 2 courses of antibiotics, often more. Dread to think how many I've had

I work at the 111 call centre, well one of them. What isn't always made clear in the papers etc, is that the outcome to the assessment is based on the answers given to the questions. We have no idea if your kid's crying isn't right. We aren't there.

What we do usually do, when someone disagrees with the advice we give about where to go next, is to pass the details onto one of the clinicians to talk with the patient. It doesn't look like it happened this time, if the ooh Dr called the mother back.

I don't know exactly what happened here and I'm in no way putting the blame on anyone but reading the reports it says it was a failing of a lot of people, not the person on the end of the telephone at the 111 service who, according to the reports, did their job properly.

I started working there because the 111 person I spoke with saved my son's life. He explained why an emergency ambulance would be needed when I just thought ds2 was a little peaky. He was very sick.

I know that if ever I'm unsure at work there's clinicians to speak with who will take the call.

As I said upthread we need a universal checklist if that is possible. Something that 111 operators have to ask and patients can be aware of easily. Many of us cannot get GP appt for days (not blaming them) so 111 or a&e are our options.
I wouldn't want to be a GP today.

Lem Thanks for your kind words about my poems, as I said I find writing then cathartic

www.nice.org.uk/guidance/cg160/chapter/1-recommendations#management-by-remote-assessment-2

There are already guidelines but they are not failsafe. Personally I don't think assessing children over the phone is very safe in general. The examination counts for a lot in this situation.

And even a thorough history and examination can still draw the wrong conclusion. Patients present as mixed pictures usually so clinical judgement is nearly always required. Spider sense. Obviously the extreme cases are unlikely to be missed but diseases can be more indolent with confusing contradictory symptoms than the textbooks describe.

The thought of missing a diagnosis of any sort is awful to most GPs.

I am with lem completely - if I am worried I always take my kids to doctor. I feel that as a taxpayer I am entitled to do this and I am also entitled to a proper service and appropriate testing if I need it. It's depressing going to GP - I'm just not convinced they are interested or care that much.

< Serious Zombie >

I worry about AB resistance. I have to take 500mg of Ciprofloxacin 2 times a day on days 5 - 12 of each 3 weekly chemo cycle. I was also in hospital for 5 weeks last year with pneumonia and numerous complications and was on IV ABs for almost all of that time.

I don't have to deal with 111 because as an oncology patient I have to ring a specialist oncology help line if there is a potential problem. If hospital admission is required I also bypass A&E and am admitted directly to AMU / CDU for assessment before being transferred to the oncology ward.

One thing I have learned from this thread is about a low temperature being a potential danger sign for sepsis. My 'normal' temperature is between 36.5 and 37.0. I've had a cold for the last couple of weeks and my temp dropped to 35.4 for a couple of days. I wasn't worried but perhaps I should have been.

My 20 year old sister went to her GP over 15 times in 2 years about a persistent cough. Each time she was made to feel stupid. It was only when she saw a locum that she was sent for a chest X-ray and a tumour the size of a rugby ball was found in her chest. She was then diagnosed with terminal lung cancer and given less than 3 months to live, oh and she was told this at an appointment she went to alone. After a few weeks of devastation my mum refused to accept it and sought a second opinion. Lo and behold it was rediagnosed as very advanced Hodgkin's lymphoma which was treatable. She started chemo 3 weeks later after being refused egg collection on the NHS as they 'didn't have time to do it and she was too fat for it to work). She was a size 16. Luckily a private clinic did a rushed egg collection and ended up with 12.

Many times she was almost given the wrong chemo which luckily we spotted. We were nervous wrecks and never left her alone. One night she developed an infection in her chemo line. A&E were a bit underwhelmed with it, gave her oral antibiotics and sent her home despite have a temp of 34, being sweaty yet cold and clammy and fairly blue. Luckily her consultant was private and we had his phone number. He went absolutely mad, blue lighted her in and she spent days on IV antibiotics. Amazingly she survived, went into remission and now has 2 children on her own but it could easily have been very different.

This experience has left me with PTSD as I was her carer for a year. I have 2 children now and I have been fobbed off by them a few times when it was something serious (severe sleep apnea resulting in turning blue and severe milk allergy)

Now, I trust my own instincts. If I know something is not right I go to A&E until I am taken seriously. If I had to sit in the waiting room for days I would. Sadly, I have found that people who shout the loudest and know their rights get taken much more seriously than those who meekly scurry away.

Sugar so sorry for your devastating loss.

I disagree money is the issue as I've lived overseas where money for the health services has been just as difficult as here. It's a management and attitude issue.

I'm generally very supportive of the NHS but have also had experience of people who should not be working in it. With direct relation to this thread my sister had sepsis as a result of chicken pox. My mum was fobbed off several times as being 'neurotic' (that was actually written in the notes!) Even though my sister was her 2nd child and the 6th child she had raised (eldest of a large family where both parents worked long hours) and it should have been obvious from the notes she rarely took us to the Dr.

Sister ended up in hospital very ill on iv abs, sight and hearing permanently damaged.

Most gp's are good conscientious people, some are dismissive idiots.

Sorry I will clarify my earlier comment. I know tests can help and I would often use tests if a patient isn't improving. If we are talking about sepsis though then the criteria for diagnosing this are almost exclusively based on examination findings. If the patient is in A&e being treated for sepsis then the various aspects of the sepsis bundle should be instituted prior to any blood investigations being back.
I think the general population think that tests are more definitive than they are. This is completely understandable as it is only through my medical training that I have learnt about the false positives and false negatives various tests can give.

The problem is generally one of money. In 99.9% of cases it's a virus. If we were to start blood testing, swabbing everyone the cost implication would be huge. Simply we can't afford to.

How do you know what I can afford?

If a GP based his actions/advice on what the NHS can afford, I would be fucking livid. I am seeing him for his medical expertise, economics shouldn't come into it. If some treatment/test might be beneficial, but the NHS can't afford, it's his job to tell me that, and he's negligent if he doesn't.

(Calming down a bit, I can see how difficult it would be for GPs if they had to do that with virtually every patient, probably sparking a patient tantrum in many cases. This one of many intrinsic flaws of the NHS.)

The only way to diagnose meningitis with certainty is with a CT scan followed by a lumbar puncture.

The only way to pick up sepsis in its early stages is with serial blood tests and observation in a clinical environment probably over 2-3 days at least.

Throat swabs can be positive for streptococcus in carriers who have a viral infection. Plus they take 48 hrs to grow anything, assess sensitivities and put together a report. By which time it may be too late - hopefully because the patient is recovering, but also possibly because a significant bacterial infection could have taken hold while results are awaited. Which is why the face-to-face clinical assessment is so important IMO.

There may come a time when we do admit children with tonsillitis, ear and chest infections, viruses to wards for observation. It would require a massive increase in beds. It would also make the febrile illness a much safer event for any child.

In the meantime I think antibiotic prescribing will go up as sepsis awareness is raised. And OOH shift medical cover will become less and less as the risks feel simply too great. I'd be embarrassed to post the hourly rate they are offering GPs here to cover shifts and still they lie unfilled.

Sugar - I cannot imagine what you have been through - your strength to come on here and discuss it is humbling.

I was working in A&E this morning and a few parents brought their children in due to having a high temperature. Because of the news of the poor little boy dying it seems like there is going to be a big increase of parents panicking and taking their child to A&E for what is actually just a virus.

I was looking at the symptoms of sepsis and a high temp, slight lethargy and being irritable is also common in many non serious illnesses, so I can see why parents are panicking today when they otherwise might not have done.

Sugar