To jab or not to jab?

A patient came to see me the other week and asked me about the swine flu jab for her children. Should she get her children vaccinated?

She had two healthy children under five with no pre-existing illnesses. The media had helpfully pointed out that the children who had died from swine flu had pre-existing illnesses, although rather more unhelpfully no one was saying what these illnesses were.

Being a locum, I thought I had missed the official information to give to parents about the jab. I checked in with Dr Google but couldn’t find a thing. A few papers here and there, but nothing that had meaningful numbers in it. I was surprised as there is a wealth of very good information for parents about other vaccines but nothing that I could find for swine flu.

Eventually she decided that she wasn’t going to bother as she thought it was all rubbish. Not exactly the informed choice I was hoping for, but it’s her choice nonetheless.

Then the invite came through for our children, I was faced with the same choice: to jab or not to jab? I won’t bore you with medical papers that I read to see if was really necessary to vaccinate an otherwise healthy child for a mild illness (in most) that she may have already had or may not even catch.
Click here to find out more!

But what I wasn’t prepared for was the amount of hand wringing and floor pacing about the decision to potentially stick a needle in my child’s arm. Previously the wife had taken the children to their jabs so she had to endure the sight of a needle piercing their flesh, the looks of betrayal on their cherub-like faces and the inevitable ear piercing shriek that followed.

The daughter was sick the other day, and three weeks later she is still harping on about how she puked – God knows who taught her that word. Would I be prepared for her constant whining about how Daddy let the nurse hurt her and the years of counselling she would no doubt need afterwards? Not to mention the fact that it’s not nice to see your child in pain. Would I get emotional? I couldn’t blame it on the hayfever as it was winter. Perhaps blaming the dusty environment might help.

It made me realise that what we might regard as trivial – a quick jab, or a blood test - can be very upsetting for the child and parent and that might discourage them from attending or going along with the management plan. How do you explain to a 3-year-old what is about to happen? It's no wonder children bawl their eyes out when they attend the doctors.

I’ve asked colleagues and friends about the swine flu jab and it's been more or less a 50:50 split over whether their children have had it or not. The uptake is poor in the otherwise healthy, which has got me wondering whether it was worth offering in the first place?

The government wasted million on Tamiflu, which was largely useless. Have they done the same for the swine flu vaccine?

Why not just put Tamiflu in the water..?

Hello again dear reader,

Been getting loads of feedback via twitter (@GPforhire) about my last posting. Apparently you didn't realise that Tamiflu isn't all its cracked up to be. Not surprising really as the negative side of tamiflu has had very little coverage. I could be paranoid and think that the government is suppressing reports of its lack of efficacy and side effects but is Labour capable of that?

Things are changing a little, there was this report in the Guardian today, and a previous one in May. I saw a young child last week that got a nasty rash from the drug. We've had multiple patients that couldn't tolerate the tamiflu due to vomiting and then phone us in a panic worried that they'd succumb to Swine Flu without their magic bullet drug.

Just so you know that I'm not making this up heres a few links that have looked at various bits of data.
You might have to be a BMA member to see the full articles

Tamiflu and anti-inflammatories (aspirin, ibuprofen or diclofenac) might be a nasty combo
GPs seeing lots of patients with side effects from Tamiflu
Tamiflu and neuropyschiatric side effects in teenagers - case not proven, caution recommended
Use of Tamiflu in children not supported by the evidence

So for the record, I wouldn't take Tamiflu, and neither would anyone in my family. Not for Swine flu anyway. For Avian flu I'd probably take it but resistance to it is growing.

Another worrying development:

Misdiagnosis.

I know of 3 deaths that have happened recently because they were thought to have Swine Flu but sadly had something much more serious which was missed until it was too late. This number will increase as the number of people assuming they have Swine Flu when they have something else will no doubt increase.

We run a simple problem clinic at our practice (see my earlier blog entry). Its been nearly empty this week. Summer holiday don't make that much difference to the numbers. I think its because these patients are confusing their symptoms with Swine Flu and using the Pandemic Line to get their tamiflu. These patients will probably turn up next week complaining of side effects from their treatment for their non-existent Swine Flu. I know some docs who have been swabbing patients still. Roughly 10% of the patients they thought had Swine flu actually had it on swabs. Thats experienced GPs seeing patients face to face and are still getting it wrong 90% of the time. God knows what the general public numbers would be like. Its madness frankly. Countless thousands of people taking Tamiflu (via the Pandemic line) for a mild self-limiting illness which they haven't even got!!


Quick link before I go. Heres a website run by the Medicines and Healthcare products Regulatory Agency MHRA. You can report any side effects from Tamiflu here. Tamiflu is a black triangle drug and so all side effects (even minor ones) should be reported. Its how we get to know if a drug is doing something odd. Anyone can report a side effect, doctor or patient.

Stay Healthy and see you again soon!

The Week that Was

So its the end of my first week back at work and the Swine Flu panic, er, I mean pandemic is in full swing. We are getting 30-40 patients a day worried they have it. Some do, some don't. Should we be giving them all Tamiflu? Well that depends on what guidelines you read and whether you are bothered by something called evidence-based medicine.

You're no doubt aware of the mountainous piles of Tamiflu the government has stockpiled. Let's get one thing straight. Tamiflu is an antiviral but this doesn't mean its a cure. Its not like taking an antibiotic for pneumonia. At best it will shorten the duration of symptoms by a day. The evidence so far has shown it has no impact on mortality (i.e taking it won't stop you from dying if thats your fate). Its use in a pandemic is unproven.

Lets not forget all the side effects. We are already seeing children who get quite nasty vomiting from it (1 in 10). Trouble is you tell the parents to stop the drug and they shit themselves, convinced that Tamiflu is the only thing stopping their child from knocking on heavens door. So the child vomits themself into dehydration and ends up needing admission.

Interestingly a large study of Tamiflu's potential neuropyschiatric side effects showed a possible increase in seriously abnormal behaviour (such as self-harm) in the under 19s. Its not meant to be used in Japan for this age group such is the number of cases they have had. Of course in this country we have no such qualms in giving it to our children. Tamiflu is classed as a black triangle drug in the UK- this means its a new drug, not all the side effects (or frequency of) are known, or the potential interactions.

One of the high risk groups for complications of Swine Flu is the under ones. The UK has a limited supply of liquid Tamiflu for this group. Guidelines state that all under 1's should be offered the drug. Trouble is is that it doesn't work, no evidence it works and I've been informed via a consultant Neonatologist that the under 1's lack the enzyme to activate it. Also the blood brain barrier hasn't fully formed yet meaning the drug that is known to cause hallucinations and confusion can easily pass into their developing brain. Brilliant. Is that in the press? Hell no, its not even in the Daily Mail which hates all things medical.

Now don't get me wrong. I'm not trying to scaremonger. I'm just letting you know that Tamiflu might make you quite sick, or worse. It lacks evidence of effectiveness and I'd think twice about giving it to anyone under 18.

One flu over the Swine nest

Good evening dear Reader,

I write this as I am watching Bear Grylls eat frozen squirrel brains in a Siberian forest. Still, if its a choice between that and Kendal Mint cake I know what I'll go for.

Work is vaguely interesting at the moment. We are all going to die from Swine Flu.

Or maybe not. In January of this year the RCGP published its Pandemic Flu guidelines which gave information about what do in the event of a new global flu pandemic. It was based on models from previous flu pandemics last century (that makes me feel old) with mortality rates etc... from Avian Flu. That was assumed to be the Big One. Its nasty, it kills a lot of people. Much to everyones surprise it was actually Swine Flu (H1N1) that swept the planet.

So far its killed a few hundred people and infected many tens of thousands (at least). Although these deaths are tragic, things should be put into perspective. Seasonal Flu (normal flu) kills 12000 per year in the UK. Does it get the same kind of hysterical coverage in the media? Not a chance. Mind you I can't be too tough on the media and the government (for once) as their projections were based on the far more deadly Avian flu.

How's things panning out now? Well I'm sure you are aware that Swine Flu is a lot milder than everyone was expecting. True it has killed people but the majority of these had other significant illness (not sure what exactly as no-one will tell us). One person died today of Swine Flu who was otherwise healthy. I am assuming they died from viral Pneumonia - v.nasty but rare, 40% mortality rate.

We've had a few cases through the doors where I work - despite advice to stay at home. I think currently the Staff are more scared then the patients. The difficulty is the guidance coming out from the PCT is mixed, frequent and far too wordy. I get 2-3 emails per day with 4-5 attachments. Each email supersedes the previous one - usually. Its a fucking mess. The Swine flu packs never turned up - not that they are needed now. Tamiflu guidance seems to change every few days. I'm still unsure if its for people presenting within 48hrs of symptoms, just the high risk groups, or everyone. Not that its any good. Government seems to think its a silver bullet but the evidence behind its use is not brilliant. Shortens the illness by hours, reduced viral load but its not without its side effects - including making all your skin fall off (rare but if everyone uses it we might see a case or two)!

Don't get me started on NHS Direct. Fucking waste of space that is. Masks are pointless too but good for scaring patients. I think a lot of the problems come from the original guidance which was based on Avian flu. Which is nasty and kills a lot of people. Where as Swine flu just makes you feel a bit poorly (usually). The guidance is slowly changing to take account of the fact that its not the End of humanity as we know it.

How you diagnose Swine flu? You guess. Thats right. We've been given a few symptoms that people will have but the trouble is is that the vast majority of viral infections we see in GP-land present with this. Even worse with children. Its only a matter of time before we miss a serious illness (meningitis, cancer, etc...) as we are so focused on believing everyone who is unwell has Swine Flu. And then the Daily Mail will have a field day. Whoop-de-fucking-doo.

Of course come winter the shit will hit the fan when Swine flu grows some balls and becomes the killer that we are all worried about. Oh well, such is life.

My first entry

Woohoo. So here it is, my blog. To be honest I'll be amazed if anyone reads this. I think the main reason why I am writing this is so I can offload about how shitty work is and how GPs (especially salaried ones are getting crapped on). I might do a bit on Swine Flu as well as it seems to be the topic of the moment. This is all new to me, I guess I should post links to various bits and bobs but frankly I can't be arsed and everyone knows how to use google nowadays anyway.

I've taken a peek at various other blogs - my 2 favourites are Dr Rant and NHS Blog Doctor . Hey fancy that, I've made a couple of links. Anyway, I doubt this blog will be anywhere near as good as them as I have a sneaky suspicion that work has blocked access to blogs - the bastards. Thankfully I still have access to Twitter.

Ok, lets take a peek at BBC News health section and see whats going on there...

Hmm, mild swine flu? Its quite amusing that people seem to be miffed that its not fatal like avian flu has been or like SARS. Give it time. Influenza viruses mutate at a fair rate. Who knows, come winter it might be a bad-ass and people will be dropping like flies (or should that be pigs?). Frankly I'm glad its mild (so far), people at my practice tend to turn up literally hours after a sniffle or cough starts so even if its mild the increase workload will be a real pain in the ass.

This is rather worrying . Its hard enough to get anyone to do Child Protection. Its terrible that the GP involved who referred the child twice to A+E with suspected Non-accidental injuries has been suspended by the GMC. Not sure I understand why - does anyone? Politics I guess. Lets see, Prof Southall got suspended by the GMC and then reinstated for false accusations re child abuse. This other GP gets suspended for correct accusations re child abuse. Damned if you do, damned if you don't.

Doing Rapid Access Clinic tomorrow. Brain-child of one of the partners. Originally conceived as a rapid, simple, drop-in clinic for things like coughs, sore throat, ear ache etc. The idea was that these problems only take 2-3 mins to sort out and so don't need a 10min appointment. Trouble is is that people are coming in with stuff that really doesn't need to a GP - like waking up that morning with a sore throat. As a result the clinic is full (30+) of minor crap that could be self treated or waiting for it to settle. The clinic should really be done by a nurse with appropriate training. Complete waste of bloody time but alas, as a simple salaried GP I am unable to sway the partners. I can't even get them to change the name of the clinic - its no longer rapid access (drop-in) its now pre booked appointment slots. Completely fucking stupid.

When I get a moment I'll go through whats wrong with the practice where I am working. Mainly so I have a note of what not to do if I ever become a partner (GP partner jobs are rare as rocking-horse shit). Will save that for another day.