A nice furry white blood cell (not Dr Genesis')

At Dr Genesis' GP practice there are a number of nurses. Some of them run minor illness clinics. The sort of nonsense that doesn't require a busy doctor to lend their expertise to. Coughs and colds, earaches, sore joints etc. There is a list on the wall. Make an appointment with the minor illness nurse if you have: earache, a sore throat, dizziness, fatigue, lethargy, a rash, a nosebleed, a headache. The list covers at least 30 conditions. If Dr Genesis knew how to deal with all of them he would be a very proficient GP indeed.

When is a sore throat laryngeal cancer? When is a headache a brain tumour? When is a rash meningitis, or a vasculitis? When is a nosebleed a nasopharnyngeal tumour? When is lethargy a haematological malignancy like leukaemia? Wait a second, did you say leukaemia?

The nurses are actually pretty good. They know their limitations, on the whole. And they have a lot of respect for the GPs. Unlike hospitals nurses, who on the whole view doctors with disregard.

But one slipped through the net.

A 16 year old boy. Who hadn't been himself for a few weeks. He was pale, tired and hadn't been playing with his buddies like he normally does. The nurse had looked at his throat, his ears and taken his temperature. All were normal. But she didn't examine his abdomen.

If she had, she would have detected his massive hepatosplenomegaly.

The boy had acute lymphoblastic leukaemia.

Thankfully the parents took him to hospital within the next few days and he was administered the appropriate chemotherapy at a specialist centre. He is making a good recovery.

It wasn't the nurse's fault. She hadn't been trained to palpate abdomens. Doctors used to see patients exclusively, 20 years ago. But now they're too busy seeing the dozens of healthy people coming in each day, eager to have their risk factors assessed.

A life of solitude

I went on a home visit yesterday to an old lady. The district nurse had asked a doctor to see the scar from a vascular operation. ?keyloid, the referral had said. I drove round and rang the bell. The lovely old lady let me in. She lived alone. Her lay-about son, who sponges off the state for benefits, lives a while away and isn't much help. Her husband died 12 years ago.

She underwent an extensive vascular operation to open up the arteries in her leg a few months ago. The scar was well healed. Not keyloid, but slightly hypertrophied I do agree. She was exquisitely painful around the scar, even to a gentle wisp of a hand over the skin. This was neuropathic pain, I explained, probably from the nerves knitting together after the op. It should settle on its own, if not we can use some medicines (amitriptyline/gabapentin for the medics among you). No thank you doctor, I'm not much of a pill taker. Sensible woman.

While in hospital, practically immobile, she had developed a terrible pressure sore on her heel. She told me how she had asked the nurses to move her leg around, to relieve the pressure but she was ignored.

Dr Genesis can easily believe this. It's not that the nurses are malicious. But they are tied up in paperwork and spend most of their time at the nurses' station, data gathering and ticking boxes. They would almost certainly have asked this old lady her religion, her marital status and her dietary requirements. But they could not stretch to simple nursing care like washing and moving a patient. There is no form for that.

The pressure sore went black and needed debridement. The helpful district nurse has attended to it very well. It has nearly healed, three months after the operation.

Dr Genesis enjoys home visits as a GP registrar. It is a real privilege to be allowed into people's homes, when it is truly necessary of course. As we said goodbye, we exchanged some pleasantries about the area and had a little chat. Then Dr Genesis swooped out the maisonette and back to his busy life.

I did feel a little sad that this nice old lady spends most of her days alone.

Walking among the snoring classes

A&E on a typical Saturday night

Believe it or not, Dr Genesis is back on nights. Thank goodness it is his last night shifts before he becomes a GP registrar. You know, that's the one where they write your name in pen above the other GPs and you think "I hope I don't have to see that useless junior". That's me.

Dr Genesis worked from 9pm until 10am yesterday. Despite not getting a wink of sleep and drawing back an old man from the abyss of a diabetic coma, he didn't receive a single word of thanks from the consultant on the ward round. In fact, there is barely an utterance of appreciation from the powers that be in medicine. There seems to be a culture to studiously avoid positive feedback. It takes a great senior to say thank you to his junior.

A&E was packed last night. Most of them were degenerate scumbags who just got too drunk, hit someone/something inanimate, broke/cut/squashed some part of their body then got their free slice of the NHS cake. Dr Genesis has worked in A&E. On his first shift, a drunk teenager came in practically comatose. "What shall we do?" a fresh faced Dr Genesis asked the charge nurse. "Fill them up till they piss themselves, then chuck them out". With a few years of experience, Dr Genesis thinks that is too good for them. Why does intoxication necessitate a trip to A&E? These people have barely paid any tax in their lives. When something is free, it tends to be abused.

Bear in mind, in Australia you have to pay $30 to see your GP. Pay on the day and receive a discount to $27. Use the other $3 to buy a "tinnie".

Happy just to relax

Dr Genesis has wanted to be a doctor since watching Sam. I suppose he wanted to be a hero. And to be well versed in human physiology. I suppose I am now, although sometimes my knowledge of the human body seems too simple. But then compared to the average Joe in the street, Dr Genesis' knowledge is vast. Most people don't even know where their liver is. I thought at medical school that once I qualified I would know a lot about the body and have a zest for knowledge. But now I find that I'm not that interested in esoteric diagnostic medicine. Most of it isn't thought-provoking. A lot of it is just running dozens of tests and hoping one will come up positive.

So when an elderly lady came in, having fallen over, with a few cuts and bruises on her legs, Dr Genesis didn't take blood. The lady was in her 90s, with advanced dementia and had been bed bound for two years. What would the bloods show? Mildly impaired renal function, a slightly high CRP, a mild anaemia? I knew it was cheeky. How would I explain myself at the ward round the next day?

As it was, in the morning I found that Mad Female Medical Registrar (every hospital has them: they are single, irate, not that attractive, totally obsessed by detail and unlikely to ever settle down with a husband and children, even though that is actually what they really want...) had taken blood from the old lady at 1am. Guess what they showed?

Life: as fragile as a petal blowing in the wind

Difficult day. Emotional day.

An unfortunate, previously well, late middle aged gentleman had a brainstem haemorrhage. Just doing what middle aged men do...a bit of DIY. Then his voice went slurred, he fell to the ground and started fitting. A quick scan showed a burst blood vessel in the most important part of his brain: the brainstem. This is why Dr Genesis doesn't do DIY.

Unable to talk, swallow, see or move, he lay there breathing through the tracheostomy that the ITU doctors had put in before he came to the ward. To a side room.

Three weeks later, he was still breathing. And was being fed through a nasogastric tube.

The wife and family were in agreement: Dad wouldn't want to be like this. He was such a fun-loving guy, always doing things in the garden, always active. He wouldn't want to be a vegetable. Dr Genesis always finds it a coincidence that people who are seriously incapacitated used to be remarkably active beforehand. The family never say "Dad was actually a bit lazy, he probably would quite like being grossly neurologically impaired."

We decided to pull out all treatment avenues...and allow him to die. It fell to Dr Genesis to do this, it was too much to ask of the nurses. He took out the NG tube easily enough. But removing the tracheostomy. That was tough. That was an active removal of the route of breathing for this man. Even Dr Genesis' confidence buckled and he administered some sedation to the patient. Why sedate a man with a Glasgow Coma Score of 3? To calm the doctor of course.

He continued to breathe for the next 36 hours. The family were very grateful for Dr Genesis' help. They knew there was no hope. They knew as soon as he came into hospital.

New role for the Isle of Wight

The average appearance of Dr Genesis' patients

Dr Genesis has had two weeks off work. He slept for the first two days. Then he remembered what it is like to be human again. Any junior doctor knows how he feels. You forget there is a normal world outside the hospital walls. A world where people aren't continually abrupt.

Dr Genesis came back to work today. Within 15 minutes of the ward round, Dr Genesis was despairing. There were a couple of middle aged people with acute medical problems which we could actually treat. The rest were over the age of 85. And this isn't even an elderly care team. Most of them had minor medical problems, consistent with old age. Normal. In any other country they would be tucked up in bed by their family and fed porridge. Then they would die in a few months, peacefully, with their family around them.

But in the UK, death is an avoidable pathology. It must be delayed as long as possible. No stone must be unturned to discover why a patient's sodium level of slightly lower than it should be. Or why their CRP (a marker of inflammation/infection) is slightly higher than it should be. The patient must be cannulated, catheterised, fed with intravenous fluid and antibiotics, bombarded with radiation and "coded".

Then and only then can they be allowed to die. With their dignity strippped from them.

Flogging a dead horse

Heart failure. For the laymen amongst you, when the heart gets weak (usually after a heart attack, or just old age). Too weak to pump adequate blood to vital organs, like the brain and kidneys. Initially you can try medications to off load the heart of strain. Things like diuretics and sometimes beta blockers to help slow the heart down. But the heart is just like any muscle. My muscles ache after I run up to the 10th floor for a cardiac arrest. So too does the heart get tired after many years of strain.

Eventually, no matter how many medications they try you are past the point of no return.

So it is with our man on one of the wards. We could call the ward "Sunrise". Many wards have silly names designed to lift the spirits slightly and help diminish the overwhelming stench of urine as you approach. Most nurses are well meaning and would clean up said urine, were it not for their constant need to fill out "care bundles" and other meaningless forms that serve not to care, but to audit.

Our man is past the point of no return. The 8 different medicines are serving only to perpetuate his renal failure. He is drowsy. His wife, herself in her late eighties, asks for him "to be kept comfortable". She doesn't want him to suffer. I agree.

But his team of highly trained professionals are still pushing him full of diuretics, carefully timed iv fluids and performing daily blood tests.

They should let him go in peace. It's what his wife wants.