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.

Thank you everybody Effelisatrinket yes Daisy had a CT scan but I can't remember much else except an iv anti biotics. She couldn't fight any longer but I know the Drs did everything they could.

PiratePete so sorry to hear about your sister. My experience of being diagnosed with cancer sounds very similar to hers. I had 15 consultations with GP's before being referred and then the hospital sent me packing too - I was told by a hospital doctor they were "glad to see the back of me". After one consultation, I passed out from pain at the wheel of my car and nearly killed a pedestrian. My GP's response was to raise an eyebrow and make a psychiatric referral - the appointment came through the day after I had most of my large bowel removed because of a massive malignancy. I am depressed by the news about poor William but not surprised. GP's are seemingly impervious to criticism because the fobbing off never seems to stop.

Hi.

First of all, as a Mum to 2 young kids, I can't even imagine how his parents are coping with the loss of their son, absolutely awful.

But can I clarify a few details about the case as there are important details left oit by the tabloids and news. He did not attend the gp numerous times about the same thing or even at the same time; he attended in September and October with viral illnesses that we're completely unrelated. Sepsis is an acute event, not a culmination of numerous minor viral illnesses. Also, on the night that he died, the ooh service offered mum an emergency appointment that night but she refused stating she didn't want to disturb him as he was now fast asleep.

None of us know what would have happened or if the outcome would have been different if he had attended that appointment but we know that the viral illnesses that the gp visits diagnosed did not lead to his death.

As a mum and GP, I'm in a privelaged position but I would not have done anything differently for my paediatric patients or my own kids in this situation. As GPs, we are trying to help even if it doesn't always seem like it.

Threads like this make me so depressed. I am a Dr (not a GP, although considering re-specialising for various reasons). I did a rotation in GP as a very junior Dr though. Threads like this remind why I probably shouldn't/won't change to GP. It's a pretty impossible job.

And yes, I do recognise a minority of GPs aren't as good as they should be. Even the best GP can get it wrong. Most do a pretty good job, IMHO.

Ironically, we have a very small number of GPs who send everything in at the drop of a hat. Quite often totally unnecessarily. I know their patients think they are wonderful.

Antibiotic resistance is serious. We are seeing more cases of patients with infections which are multi-antibiotic resistance. There are now antibiotics which are having to be kept in reserve and can only be used with express consent of infectious disease/microbiology consultant because of concerns over potential for antibiotic resistance to most/all antibiotics.

Also, please bear in mind, not everybody who has an bacterial infection should get antibiotics- current advice in some cases of non-severe infections (in patients who are not immunocompromised or frail etc) is not to treat as it is likely that the antibiotics will only shorten the duration of infection by 24-48 hours.

Tests won't usually pick up sepsis on their own- sepsis bundles (used in hospitals) should be started as soon as sepsis suspected and well before blood tests or swabs would be back. Doing bloods/swabs on every single patient a GP sees with an infection would be a massive waste of resources as it's effectiveness would be limited. Swab patients who aren't getting better or who are having recurrent problems, is certainly to be considered.

And to the poster who said if NHS doesn't do it then we should offer private- there are no private labs in our area who would accept routine bloods taken by a GP. And I have no mechanism to get it to that lab. Who would be responsible for acting on the results? A total minefield.

My last thought (and sorry for the length of this) is there are so many times I have done a ward round, where a patient has had a cough or not feeling great in some way (not related to what they are admitted with) but there nothing much on examination and observations are all ok. The impression you get is "this could be viral, could be the start of something. We'll just have to wait and see if something declares itself". Then within hours they have a hospital acquired pneumonia and are septic. To be clear, in most cases I don't think I'd have rushed that patient into hospital on the history and examination earlier on in the day. It is exactly the same for GPs- at the time they see the patient they did not have signs of sepsis (clearly, missing signs of sepsis/not examining is a different matter). The big difference is that as a hospital Dr I have the benefit of the nurses and HCA's monitoring and checking observations and can alert us as soon as something changes. And my patients are generally in hospital for some reason, so less likely to be otherwise fit and well than those the GP sees. So the vast majority of cases that GPs see will be viral and not serious. The GP can only "safety net" with "if it gets worse, look for these signs etc , then come back/phone NHS 24".

How do you know all that Heather?

Questions for those medically trained. This might be a silly question but a lot of the signs for sepsis can occur in many illnesses, like some of the children I saw today. They didn't have sepsis just run of the mill colds or infections but some of their symptoms were the same as the ones you are meant to look out for in sepsis.

Obviously people shouldn't be taking children to A&E every time they get a high temp and become irritable but I'm a little confused myself on when you should take someone in with suspected signs of sepsis. I am an HCA and have came across it a few times in adults but I'm not medically trained.

On the NHS website it says

The symptoms of sepsis usually develop quickly and can include:
a high temperature (fever)
chills and shivering
a fast heartbeat
fast breathing

A lot of these symptoms happened in my children when they were young when they had a virus. So when exactly should you take a child in for any of these symptoms? Today proved to me that people are now scared and reacting to symptoms they otherwise wouldn't have and like I said , I'm quite confused about when these symptoms are A&E worthy. Some symptoms you know are A&E/ OOH worthy but as sepsis can be so easily missed people are now worrying any of these symptoms could be sepsis and I think people are confused about it all.

U2

Sepsis is a systemic response to infection.

It's an overall clinical impression and based on the history + what you find when you examine, the patients past medical history etc. The things you have mentioned are signs and symptoms of sepsis but you can have these signs with a straightforward infection which will resolve by itself. Sometimes it is very obvious, sometimes it isn't.

I have quite recently had a viral infection with temperature well above 38 degrees but feeling cold and was slightly tachycardic (fast heart rate), but was not septic at any point. I felt awful though.

There are defined criteria for sepsis- 2 or more of the SIRS (systemic inflammatory response syndrome) criteria + the cause is thought likely to be an infection. The SIRS criteria are:

• Temperature >38 or 38.3°C or 100 bpm in adults (heart rate greater than 100 beats per minute- some criteria use 90bpm)
• Tachypnoea (in adults this >20 breaths/minute (respiratory rate greater than 20 breaths per min)
• PCO2 10% immature forms.
• Hyperglycaemia in absence of diabetes mellitus

obviously PCO2 and WBC count are results which may not be available initially, so you rely on the other criteria and your examination.

Heather it is very strange that you are privy to all that information.
Surely confidentiality should be paramount

The sepsis trust has a check list for sepsis and a seperate guidance for indentifying sepsis in children, sepsistrust.org/ .If your child or loved one has symptoms of sepsis, dial 999 and make sure to say that you think they have sepsis and what the syptoms they are exhibiting are.

That list on the sepsis website is much more helpful than the NHS one!

Thank you jacks for explaining all that. Very helpful.

sugar many details of this case have been published in the press - for example William's mother declining an emergency appointment is described here:

m.westbriton.co.uk/Mother-tells-inquest-doctors-missed-chances-save/story-26674881-detail/story.html

Thanks for that parrallax I'm actually in the same county but I haven't read that piece until now. Very interesting and goes to show that there are always 2 sides to every story.
Apologies Heather

One of the many problems with accurately diagnosing sepsis is that even the best algorithm will not apply in every case.
Algorithms and check-lists are v useful, but they are not the be all and end all.
There is much to understood about why and how some infections go on to cause catastrophic sepsis in some individuals and some don't, even when the same microorganism is involved. Many people are totally asymptomatic carriers of meningococcus, yet it can also cause devastating illness and death.

People with sepsis look ill, properly ill, frighteningly so.
I am less concerned about a child with a high temperature who is running about my consultation room, exploring the toys and chatting away as I am about a lethargic, 'limp' child. Clinical examination, experience and 'Spidey' senses all come in to it. And good safety netting and reassessment is vital, including an awareness that sepsis can move spookily fast.

All the swabs and tests and antibiotics in the world will not prevent every case of sepsis; good clinical examination and judgement will hopefully pick up those who need urgent and intensive treatment with subjecting the vast majority of people with self-limiting illnesses to unnecessary and potentially unpleasant and not risk-free treatments.
There will always be some tragic cases, even when everything was done perfectly.

And to expect that health economics don't come in to the management of most conditions needs to inform themselves about what a service that is funded as the NHS is can and cannot afford.

I just read the piece that parallax linked to and the scenario as described is exactly what makes me break out in a cold sweat at night: a fairly bog-standard infection (strep A is the most common cause of bacterial throat infection - the most common cause of sore throat being viral by about a factor of 10 to 1, and the evidence rising that most strep throat infection in healthy individuals should NOT be treated with antibiotics) leading to complications that end up in devastating loss .

I have no idea how bereaved parents keep on going; equally I know that if this happened to me as the treating doctor, it would affect me forever.

PD I have the greatest respect for GPs and appreciate how difficult the job must be with 10 min slots and reams of paperwork.
I just want to say that the day I took my dd to my GP he was marvellous and although Daisy died my he diagnosed meningitis correctly. He sent me straight to hospital but Daisy couldn't fight the sepsis which had developed
I just phoned for an appt as the surgery didn't have a triage system at the time.
I'm going into what ifs here but point remains I know you all do your best so wanted to reply to you
Sorry if this doesn't make sense but you get the gist.

Oh, sugar

You have no idea how much it means that somebody in your shoes can post in such a measured way. Sincere thanks.

At the risk of the sin of bringing up a TAAT, I'm going to do it.

Less than a week ago someone was asking whether the nursery was at fault in their handling of an incident when her child suffered a head injury involving unconciousness.

The nursery called 111 for advice and was told to get the patient to A&E within the hour. Good.

But they didn't dispatch an ambulance and the nursery, who should have known what to do without advice, called the mum.

All was fine. The mum got there in time. The head injury was benign. But she was uneasy about the way it had been handled, primarily by the nursery.

However, many people told her she was making a fuss, people treat ambulances like taxis, blah, blah, blah. One of them claimed to be a doctor.

I agreed with her concerns as did a few others. Yay us.

At least one person demanded to know whether I thought I knew better than the noble call operators at 111.

I said no, but I still believed the nursery had acted badly.

After hearing what happened to William Mead and the fact that 111 is a money-saving multiple choice exercise for amateurs I am horrified that I didn't have a go back at that naive poster.

It's not that I want to say that I'm right and aren't I so wonderful. It's more that I wonder where the people on that thread are tonight.

People are too trusting and it's a MN thing to berate people for panicking and wasting precious NHS resources.

!imited I refer you to the link on parrallax s post.
People are too trusting, yes we probably are, we trust the media to give us the whole story.
I had a child die from sepsis and meningitis. Because the ambulance service is overstretched and under funded I was given the option by my GP of an ambulance or take my dd myself. I took her myself which with hindsight was the wrong decision and I have to live with that. I got stuck in traffic without the benefit of blue lights.A few hours later Daisy died

It was my decision not the NHS

Please can i say to all the GPs on this thread that i absolutely didn't start this thread to slate doctors, maybe i should have worded it better as i was questioning the guidlines of not prescribing antibiotics wch doctors have to adhere to rather than Drs decision making. I have every respect for GPs who do a demanding and responsible jobs and 99.9% of them do it bloody well.

sugar, you must know that your decision wouldn't have made any difference even if she was blue lighted in an instance :(