Lurking 'coming out'

[pinksha]

I have been a bit of a lurker only occasionally posting, but a specific post this week, about the mum and her daughter not being treated correctly by her GP made me want to comment.

I was asked several years ago by my GP if I would talk to 1st year students regarding my Type 1 diabetes and living with it, which I gladly did and still do. Even in Year 1 they know the basic symptoms to look for, such as thirst, lots of urination, tiredness, weight loss.

This progressed when I went on my pump and for the last 3 years I speak to Year 3 students at the hospital, for my pump Doctor, again about Type 1 and how it is looked after, and they know much more, including DKA etc etc. The Doctors try to have different types of diabetics, Like Type 1 on a pump, Type 1 on MDI, Type 2 on medication, Type 2 on diet, and very occasionally people who have the more unusual types such as Lada, therefore covering as wide a range of diabetic as possible, so,the students get a good picture of all diabetes types.

This is of course all voluntary and I feel just maybe if they remember one small thing, these could be our GPs or even consultants of the future.

This leads me to wonder where on earth the GP that missed such obvious symptoms had actually been for his/her GP life.

Isn't it scary that GP's are still missing such glaringly obvious signs!

 

[Northerner]

Hi pinksha 🙂 Yes, I agree. Whilst it's a relatively rare condition, it's really something that GPs and nurses should be more aware of as a potentially life-threatening situation. Just do some simple tests, for goodness sake! Blood glucose and ketone tests are as easy to conduct as urine tests (possibly easier), and expense really doesn't come into it - a repeat appointment would cost far more. Well done you for trying to spread the word, we can only hope that it gets through to more and more as time goes on, and that parents also feel able to challenge their GP if it is dismissed as a urine infection - yes, they quite probably will have a urine infection if their sugar levels are high, test their blood as well! 🙄

My understanding is that medical students get about a week of training on all types of diabetes, so understandable if not everything sinks in, and they may hardly ever encounter a case in practice, but simple checks should be part of their 'checklist' when someone presents with the symptoms.

 

[Sally71]

Well it was similar for us, as you probably read in that thread. Luckily for us the fasting test result came back just in time and the GP then must have realised that I wasn't a neurotic mum and that he needed to act fast, and he then did what he probably should have done in the first place, i.e. Finger prick test and then referral straight to hospital. When we went for that second consultation he looked visibly uncomfortable as if he'd just had the shock of his life and realised that he'd only narrowly avoided making a very serious mistake (he could hardly believe how far my daughter had deteriorated in the intervening few days either). So we got to hospital just in the nick of time, daughter was already drowsy by then and going into DKA. (I'm just sorry that I didn't have the brains to do what the other mum did, and seek a second opinion in the meantime )

I remember our diabetes team discussing this just after my daughter was diagnosed. They said that most GPs rarely see any type 1s, they base all their diabetes knowledge on type 2 which they see a lot of. So they all seem to remember that to diagnose T2 you need to do a fasting glucose test (2 in fact for a correct diagnosis, luckily our GP had the sense not to bother with the second one as he could see how sick my daughter was by then). What they don't seem to remember is that T1 is not the same and you don't have the luxury of time!

I know that GPs can't possibly be expected to remember everything about everything, but surely they should be able to spot potentially life threatening symptoms! What I would like all GPs to learn is the following:

To diagnose T2 do what you are used to and do fasting tests and take as long as you like over a diagnosis.
HOWEVER, when you are faced with glaring symptoms of T1, especially in a child, then it is an EMERGENCY and you do not have time to faff about waiting for fasting tests - do a finger prick glucose test, which is a lot more useful than a urine test, and if it shows anything even slightly abnormal,then REFER THEM STRAIGHT TO HOSPITAL!!!
Oh and you don't need to wait until they are actually in DKA before you send them to hospital, would be better for them to get treatment before they get that sick!

How can we get this message across? Couldn't DUK do some sort of campaign?

 

[Copepod]

GP wasn't completely unaware, as they were treating urinary tract infection. Doctors are also taught to consider the most common / likely explanation for symptoms, as T1D can look like a UTI, just an menigitis can look like many other more minor virus infections. It's essential to preserve life, but also not to give out antibiotics inappropriately, which leads to antibiotic resistance. Similarly, blood tests should be minimised / restricted to essential ones only, to lessen distress to child and reduce pressures on labs, NHS resourced etc. 24/7 NHS isn't just about doctors - lab staff are rarely mentioned.
Okam's razor (not sure about spelling, and no time to check online just now) gives rise to advice that when you hear hooves in the street, it makes more sense to look for horses than zebras.

 

[Flower]

Diabetes UK has got an awareness campaign with the 4 T's, reading through it suggests putting posters up to raise awareness in various places including in doctors surgeries - presumably the waiting room but maybe it should be the consulting room! It is appalling to think a life threatening condition is not checked for immediately with simple finger stick tests for blood glucose and ketones.
https://www.diabetes.org.uk/the4TS

 

[Sally71]

You have a point Copepod, but the child also had glucose in her urine which surely isn't a normal symptom of an infection?
And yes the GP was doing all sorts of blood tests, but by the time the lady got her daughter to hospital the child was "struggling to walk and her breathing was laboured" which sounds like DKA and is very similar to the condition my daughter was in by the time we got to hospital. Which means she probably had 48 hours tops before lapsing into unconsciousness, and the way the GP was carrying on he didn't seem confident that his test results would be back by then!

 

[everydayupsanddowns]

I found this post really interesting in relation to GPs and diagnosis of T1D, particularly the bits about how long you are likely to practise before coming across a case: https://medium.com/@k_d85/time-to-give-hcps-a-break-forgive-but-don-t-forget-f1ff5f421007#.4gnaas6kk

 

[everydayupsanddowns]

Diabetes UK has got an awareness campaign with the 4 T's, reading through it suggests putting posters up to raise awareness in various places including in doctors surgeries - presumably the waiting room but maybe it should be the consulting room! It is appalling to think a life threatening condition is not checked for immediately with simple finger stick tests for blood glucose and ketones.
https://www.diabetes.org.uk/the4TS

I have tried to get this poster put up in my surgery, but without success (so far!). Reminds me that I must try again.

 

[Northerner]

I found this post really interesting in relation to GPs and diagnosis of T1D, particularly the bits about how long you are likely to practise before coming across a case: https://medium.com/@k_d85/time-to-give-hcps-a-break-forgive-but-don-t-forget-f1ff5f421007#.4gnaas6kk

Good to see things in perspective Mike. I have to say, I pretty much ignored the symptoms that were screaming at me for about 18 months until everything became critical - drinking 30-40 pints of milk a week is not normal, yet I never even went to my GP. Still, would adding a fingerprick and ketone test really be that hard? I can see that some symptoms might be assumed to be caused by something else, but when they are extreme, saying 'come back in 2-3 weeks' is surely not acceptable

 

[Copepod]

Another principle that most health care professionals live by is that if a parent thinks there's something seriously wrong with their child, especially if the child is deteriorating, the parent is usually right. Often, when sending urine or blood to lab, they also say to seek help if child worsens eg phone back or head to A&E if "out of hours". That bit of advice isn't usually mentioned when retelling "near misses" but that doesn't necessarily mean it wasn't given.

 

[Matt Cycle]

I agree with the fact that with T1 being relatively rare a GP will not see many cases. This is no excuse for mis-diagnosis though. The T1 symptoms are relatively straightforward when presented.

I think one of the issues is pressure on GP's with workloads. I thankfully don't need to see them that often but if I do need to go it's not easy getting to see one. I know they should treat the symptoms but when fantasists, hypochondriacs and google symptom searchers probably take up a lot of their time when someone with genuine medical issues turns up you can see why these things happen.

 

[SB2015]

The 4Ts campaign is such a simple message. There was a pack sent out to every school last year, Making the Grade, when the law changed regarding their responsibilities for making adjustments for pupils with T1. However the packs sometimes just end up with one teacher and the message was not shared.

Perhaps a similar pack is needed for GPs.

 

[Northerner]

The 4Ts campaign is such a simple message. There was a pack sent out to every school last year, Making the Grade, when the law changed regarding their responsibilities for making adjustments for pupils with T1. However the packs sometimes just end up with one teacher and the message was not shared.

Perhaps a similar pack is needed for GPs.

I think the problem with GPs is that they receive so much from so many different health charities etc. that things may often get overlooked even if provided.

 

[SB2015]

Good point Northerner.

I went in for one of the training sessions at our GP Practice to talk to them about management of T1 on a pump which none of them were familiar with. They said that they learnt a lot more from that, than the theoretical stuff that they had done, of many so long ago, which was now so out of date.

Well worth it.

 

[Diabeticliberty]

When I was first diagnosed I went and saw my previous GP. I had been through a very long period of lethargy, general sickness, excess urination, very excessive thirst and generally feeling pretty bloody awful. My doctor, God bless him suggested that I was suffering from, wait for it: over active nerves in my stomach for which he wrote a prescription. I duly took this to my pharmacist who had known me pretty much since I was able to crawl. The pharmacists assistant took my prescription and the pharmacist eventually came out of the back room he asked about my symptoms and flatly refused to supply the medication on the prescription because he felt that it was completely wrong for my condition which was what he correctly felt was diabetes mellitus. He referred me back to my GP and gave me a carefully worded script to memorise. He insisted that I did not tell my doctor that he had prompted me to recite word for word this script. 40 minutes after seeing my doctor a second time I was in hospital on an insulin drip. I never got to thank my chemist because he became very ill while I was in hospital and never returned to his pharmacy. I will never forget the 'hand up' that he gave me and will never forgive myself for not being able to thank him properly. I would have to say that if I did my own job as poorly as my previous GP sometimes did his I would be unemployed after about 20 minutes work. My previous GP however is still practicing medicine.

 

[robert@fm]

The experiences I have read about on here remind me of my own incompetent-GP horror story, in autumn 2007 (a GP whom I fortunately saw only the once -- after the first time I made sure I never saw her again). I'm aware, from the excellent ebook Sick Notes by Tony Copperfield, that complaining of constant tiredness is often (if not usually) a symptom of hypochondria; but that doesn't mean that it's always a symptom of hypochondria, it can also indicate other problems, some of them quite dangerous, so other symptoms need to be taken into account as well. How the silly cow managed to overlook the fact (as I told her) that I was ceasing to breathe in my sleep, and dismiss that as nothing serious, is beyond me to this day. 😡😱

 

[Sally71]

The GP we saw thought I was neurotic when I took daughter in and said I was worried that she was showing signs of diabetes. Luckily he realised that he wouldn't be doing his job properly if he didn't investigate such symptoms and sent her off for all the (fasting!) blood tests. I could tell he thought that there wasn't really much wrong with her. He had a bigger shock than I did when the result came back... 😱