Clinical Views
Watch this space for (hopefully) useful advice on dealing with common medical conditions, and possibly some opinion pieces on pertinent clinical topics of the day. Of course if you are unwell and unsure of this advice in anyway, or if you do not fit into the category of patient described under each subject heading it is important that you give us a call and ask for tailored advice.
Half million deaths from flu!
July 21st, 2009 by Dr Wheeler.Scary isn’t it? Everywhere you look there are tales about killer flu. Get your Tamiflu now! It’s your only hope! We’re doomed!
Some of the journalism I have seen on the subject has been truly horrific, even from reputable sources such as the BBC – though perhaps the media shouldn’t be singled out for our opprobrium when the government can be seen to be egging them on at every opportunity!
One headline you probably haven’t seen is the ‘half a million deaths’ one posted above… but it’s actually true. Not in respect of swine flu of course… but plain old seasonal flu that comes round every winter and kills off thousands of old people in the UK annually. The figures from the Centre for Disease Prevention and Control in the USA state that probably 250,000-500,000 people die from the flu every year around the world. By contrast the figure for worldwide confirmed swine flu deaths from the start of the outbreak is…. wait for it… 700! (Source.) Not quite so scary when taken in context is it?
But Swine flu is much more dangerous isn’t it? Well…. that might turn out to be true – but not based on what we know so far. The rate of deaths per confirmed case serious enough to need medical attention is currently estimated to be about 0.5% – very similar to the case fatality rate of seasonal flu as reported (here.) Don’t take this to mean that there will be 1 death for every 200 people with swine flu however… there would be many thousands of cases of mild infection that wouldn’t even be reported to medical services and so wouldn’t be included in the figures. The actual death rate will in reality be much lower than 0.5%.
So it might not be that dangerous… and if we do get it Tamiflu will save us anyway wont it?
Erm… no. This is the most shocking aspect of this whole mess in my opinion. Tamiflu has been around since 1999. But up till now has not exactly covered itself in glory. The limited research that exists suggests that it’s effect on flu is to reduce its duration by three quarters of a day to one full day at best. It may reduce the chance of developing pneumonia in flu patients… but it has never been established exactly how good it would be at preventing death in affected individuals. Figures (based on incomplete evidence) suggest that you would need to treat 1800-3200 patients to save just one life – though some doctors think you would have to treat many many more times those numbers to do so. As is so often the case in medicine we just don’t have all the facts…. but my gut feeling (for what it’s worth) is that Tamiflu probably isn’t all that much use. An interesting debate is linked here – though it isn’t geared towards the layperson you may find it interesting. That’s not to say that Tamiflu doesn’t have a role. In vulnerable patients it might just make the difference between life and death… but that’s not how it is being used under current UK policy.
But are there any downsides to using it? Well there are some side effects – nausea and vomiting being the most common, and some people wonder if there may be serious psychiatric reactions in a very few cases (link.) Of more concern is the fact that widespread use of this drug (which is after all the best antiviral we have got) will most probably lead to widespread anti-viral resistance within a short period of time. Basically – if you give it to a whole load of people with mild symptoms who would have got better anyway… by the time someone really sick comes along they might not have much of a chance because the drug has started to become useless!
So – what should you do?
Well – you could start with this video… quite a nice FAQ from the BBC website that goes through the basics.
You could read this BBC blog which gives a pretty reasoned outlook on how the flu is going (unlike some parts of the BBC!)
You could use the online symptom checker at NHS direct or phone NHS 24 on 08454242424. Both of these routes can help tell you if you are in one of the at risk groups who needs to consider using Tamiflu / seeing a doctor for your symptoms – or if you could just deal with it yourself with paracetamol and fluids like a normal cold.
If you are not in a high risk group and you do have the flu you need to make a decision about whether you would want to take Tamiflu or not. We would be happy to discuss this decision over the phone and give advice. Please don’t book an appointment or turn up at the surgery – one thing we can ALL do is to try and prevent the bug spreading as much as possible by keeping our infections to ourselves. being careful who we meet up with if we feel unwell and taking basic hygiene measures seriously (like washing our hands frequently.)
Unfortunately people will die from this virus – just as people die from viruses every year. Some of them will be children, and some will be healthy adults who you would have expected to pull through. Tamiflu isn’t going to change that basic fact – and telling the public that it is some sort of wonder drug that will somehow make you safe from harm is disingenuous to say the least.
The best thing to have by your side heading into a pandemic situation is a fair bit of luck. Luck in not catching it, or luck in having a mild illness when you do. The next best thing would be to have good life support if you became seriously unwell – so the intensive care departments in big city hospitals will be an important factor in saving lives for the worst affected amongst us. Tamiflu has its place as well, but some common sense is needed in analysing exactly what it can do for us – both as an individual and as a society.
Thankfully however. the odds are in our favour…. the vast majority of people who catch swine flu will be unwell for a few days and then get on with the rest of their lives. We don’t need to live in fear of this bug, despite of what the newspapers say!
Mens health
July 17th, 2009 by Dr Wheeler.http://news.bbc.co.uk/1/hi/magazine/8154200.stm
Nice article from the BBC website about mens reluctance to come to the doctors for advice. We often find that guys turn up after weeks or months of illness… sometimes too late for us to help them if it turns out to be something serious.
As well as coming in for specific problems – if you are male and over 40 you could book an appointment for a general health check. We can find out what your cholesterol level is, do your blood pressure, and make sure you dont have underlying problems like kidney or liver disease through some simple blood tests. If you are a smoker we could also refer you to our smoking cessation clinic and give a prescription for nicotine replacement therapy.
Call 01876 500333 to book an appointment.
Colds and Flu’s
July 12th, 2009 by Dr Wheeler.Snuffly nose? Bit of a cough? Coming to the doctors is for many people an immediate response to this scenario…. but are they doing the right thing?
Figures vary – but it is probably fair to say that about 90% of sore throats are caused by viruses. These are organisms which (unlike bacterial infections) are not amenable to treatment with antibiotics. Sore ears in children, acute bronchitis (a chesty cough that doesen’t make you especially unwell and can last for weeks), runny noses and sinusitis are all in the same rough grouping. In short – with the best will in the world your GP won’t be able to do anything for these conditions, but they will eventually get better by themselves.
Doctors however are human beings; they like to think that they can help… even if they have a sneaky suspicion that they can’t. They are also susceptible to pressure, and have been known to accede to patients demands even if it wasn’t technically the right thing to do!
On the other hand – several studies have shown that Doctors greatly over-estimate how much their patients actually want antibiotic treatment, leading to inappropriate prescriptions that might have been avoided if better communication had taken place. The onus is on the doctor to make sure that this doesn’t happen, but the patient has a responsibility too… as a demanding patient can often lead to bad medicine.
GP’s and their patients aren’t the only problem however – Possibly 70% or antibiotic prescribing is for animal use, and in countries that allow the public to self medicate without a prescription antibiotic overuse at incorrect doses and for inadequate time periods compounds the problems of overzealous use of these drugs.
These problems unfortunately are not minor – apart from medicalising self limiting conditions, causing diarrhoea and the occasional serious allergic reaction; antibiotic over prescribing is causing massive issues with Drug resistance. There has been little advance in antibiotic research since the 70’s – and we are already seeing potentially very dangerous strains of bacteria emerging around the world (MRSA probably being the most well known at the moment.) There is an interesting article on the subject here.
So what should we do? Well, GP’s can start having more meaningful conversations about treatment decisions with their patients for one. Patients in turn will need to take on board this kind of advice and trust that their doctors are acting in their best interests.
Life is complicated however – and some people will need treatment – so who needs to see the Doctor, and who should deal with it themselves and save an appointment slot for someone who really needs it?
I can’t give you a precise answer – though the common sense approach is usually pretty good in my experience. If you are usually fit and healthy, have a sore throat, cough or cold, but are able to drink plenty of water and dont feel really terrible, then you won’t be needing treatment other than the usual rest, fluids and possibly some paracetamol. If on the other hand there is something unusual going on: a funny rash, hallucinations, inability to drink, neck stiffness / severe headache or confusion (i.e. what we would class as ‘septic’ symptoms.) Then you certainly need to see a doctor ASAP – phone and get advice! I would normally say the same for flu as well… but of course with swine flu about you should really speak to NHS24 / your GP about flu like symptoms at present (see the upcoming ‘swine flu’ post for more info!)
Kids who look fine can usually be left to cope at home with their parents – though we would have a much lower threshold for worrying about children, so don’t be afraid to bring them in if there is any doubt in your mind (a mums gut instinct is usually better than a doctors medical school training!) If patients are below the age of 2 or above the age of 65 it is probably best to come in, or at least chat to the doctor on the phone about the case just to be on the safe side.
NICE have come out with some more formalised guidance here, though it is not aimed at the layperson specifically, you may find it interesting to see how your doctor is thinking things through for you.
So – in summary. Viral infections are common and are very rarely dangerous. If you are between 2 and 65, fit and healthy but have come down with a bug then you could probably deal with it yourself at home – unless you have one of the serious symptoms outlined above, or think it might be ‘the flu.’ If in doubt then phone and ask for advice.
