Tom Goodfellow

Tom Goodfellow is a consultant radiologist at University Hospitals Coventry and Warwickshire NHS Trust

It’s Friday, it’s five to five, and it’s a horrendogram

By Tom Goodfellow - 8th March 2010 6:04 pm

I do the nightmare Friday afternoon interventional ultrasound list, infamous because we end up having to sort out all sorts of complex problems which have mysteriously just appeared during the pre-weekend ward round.

At about 4pm, before doing ‘a poets’, the team send down the most junior HO they can find to request a horrendogram on some poor sod who has been festering in the corner, unnoticed all week.

This particular Friday, some years ago, was no exception. The patient, admitted with a UTI, was now profoundly septic with a possible pyonephrosis and could I drain it please?

What they didn’t tell me is that she had a severe toxic confusional state and weighed well over 20st. To make it worse she was sent to the department at 5pm in a bed in which the hoist mechanism had failed, so it was virtually at ground level. The ultrasound images were comparable to driving a Morris Minor through a snow storm with no windscreen wipers.

This is the first and hopefully the only time that I have performed a nephrostomy on my knees, in bed with a patient who was completely doolally.

I prayed and plunged in the needle with little idea of where it was going, but when I removed the trochar was rewarded with a gush of laudable pus. 

I met her the following week to do the nephrostogram. She was now completely recovered, sane and proved to be a delightful erudite lady, a professor I think, and embarrassingly grateful for my ministrations.

Another Friday I remember also a lady of similar girth, referred from St. Elsewhere’s, presenting with severe dyspnoea related to a probable retro-sternal goitre. She was unable to lie flat; consequently a CT was not possible. I was asked to ultrasound her thyroid immediately prior to surgery, which would include a sternal split. The scan demonstrated an anechoic lesion just poking above the manubrium.

I popped in a needle, aspirated crystal clear fluid and after only 20ccs she exclaimed, “I can breathe!” In total I drained 130ccs of fluid from her simple thyroid cyst (quite rare in my experience) and returned her to the ward with a report stating triumphantly, “I have cured your patient.”

An hour later she appeared in the department on her way home. Like a Spanish galleon in full flow she bore down on me and pressing me to her ample bosom kissed me passionately on both cheeks, in full view of the waiting room. I was a bit concerned that she might give the same idea to the other patients! (Please don’t tell the GMC).

Despite the multitude of frustrations working in the NHS, the practice of our trade can still be deeply rewarding, even at 5.30pm on a Friday…

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My pet hatred of texts and answerphone messages

By Tom Goodfellow - 15th February 2010 11:14 am

One Saturday afternoon a number of years ago, when my children were still young and innocent, a message was left on our answerphone.

One of my children listened to the message and attempted to relay it to me. “Dad” they said, “a man from the hospital has called wanting you do some special test on Mr Smith of 47 Acacia Avenue, Little Sodbury. He has got a dysfunctional reptile. What’s that?”

Sure enough, I replayed the message and listened to one of my colleagues give comprehensive details of Mr Smith’s erectile dysfunction problems, and could I do a private bonking dongogram on him (well I would hardly do it in public), a test still not made entirely redundant by Viagra.

I told the kids that Mr Smith’s problem made it difficult for him to get up in the morning (almost correct, only one word missing).

Over the years I have had a number of similar messages (although with differing clinical scenarios - I am not that specialised), more generally from junior doctors who believed it was perfectly reasonable to leave confidential clinical and personal details on an open domestic answerphone.

I have always hated answer-phones which I rate alongside texting. I do not deny that both may occasionally be a convenient method of imparting information, (loudly, “I’m on the train”), but as forms of communication they are little better than semaphore. However, despite this clear clinical misuse, my strongest objection is that by their very impersonality they allow the sender to transfer responsibility for the message onto the recipient; that they have done their job and are no longer accountable for the outcome.

Why didn’t you tell me the meeting was cancelled? “I left a message on your answerphone” (so it is clearly your fault for not picking up).

“We need an urgent specialised procedure on Mrs Smith; we know you are not on call but can we leave it to you to sort out?” (And now that we have dumped the responsibility onto you, we can put our feet up and watch the rugby).

“Ur dumped, its ovr. Dnt try 2 call me.” (I know that I am behaving like a complete tosser, but it is easier on me to do it this way than actually to have to face you).

“Sorry to phone so late. My GP has just signed me off for another two weeks so I will not be in on Monday. I will keep you updated.” (I have deliberately phoned when I knew that there would be no one in the office to take my call so that I would not have to try to explain my extended absence on the vague grounds of ’stress’. I also know that you cannot telephone me back otherwise I would be able to claim harassment should I need to take you to an employment tribunal).

 

And, of course, “U R fired”. (Don’t bother coming in; we’ve changed the security codes. Your personal things will be sent on to you).

 

Sigh!

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Would the advances of yesteryear happen today?

By Tom Goodfellow - 3rd February 2010 10:50 am

There is little of humour to be found in the furore surrounding the GMC panel report into the conduct of Dr Andrew Wakefield, which described him as dishonest and irresponsible.

The only exception was when one of his supporters branded the inquiry into the conduct of his MMR research “a kangaroo court”. Now it seems to me that a process which has taken 197 days, found more than 30 charges proven and which has cost several million pounds might be termed many things, but kangaroo ain’t one of them! This is a bit like saying, “the lack of bureaucracy in the NHS is a disgrace”. But reason does not seem to characterise Dr Wakefield’s supporters or indeed the doctor himself.

He did not attend the hearing in person preferring to air his views, surrounded by his suporters, at a noisy press conference outside the front door. What stood out was his defiance towards both the GMC and the medical profession at large, and his utter refusal to accept that he could be wrong in any way despite the considered views of his peers and many independent researchers.

The whole inquiry was clearly a conspiracy by the establishment and the drug companies to silence him. Wakefield contra mundum!

However, this brings to mind a conversation I had back in the seventies with a venerable cardiothoracic surgeon over an open chest. I was spending a very unhappy 12 months as a surgical registrar at a London Center of Arrogance (as it was in those days) and was assisting with a closed mitral valvotomy, a technique pioneered in Britain by Baron Brock of Wimbledon in the late 1940s. “Of course he killed the first ninteen,” confided the venerable surgeon who had trained under Brock, “but the twentieth survived!”

Now I have no way of confirming the veracity of this and I do not wish to malign the great man’s reputation. However if true and, if the standards which apply today were applicable then, Brock would undoubtedly have been suspended long before he reached case number 20.

There would have been a full inquiry and questions in The House. He would likely have been arraigned before the GMC and even worse in the gutter press. I can see him now, flash-bulbs popping, waving his fists while he defiantly challenged the profession to prove him wrong (he was by all accounts a Lancelot Spratt type of surgeon, not one of your shy retiring sorts).

But the difference between him and Wakefield is that he was proved right, and his work led to the transformation of the lives of many of his patients and the advancement of the speciality. But would he have been allowed to achieve this today?

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Learning points from Obama’s bloody nose

By Tom Goodfellow - 22nd January 2010 11:01 am

Many of us in the UK, although admitting the manifold weaknesses of the NHS, are totally bemused by the violence of the opposition to President Obama’s healthcare reforms.

The good folk of Massachusetts have just delivered him a severe bloody nose by electing a largely unknown (other than for his nude pose in Cosmopolitan) Republican senator. This is sad, but if the majority of Americans chose to have a system which provides phenomenally good healthcare for those who can afford it while providing Third World medicine for those who cannot, then surely that is their issue! After all in the land of the free you should be free to chose, even though your choice effectively deprives millions of others of any choice at all.

Medical bills are the highest cause of bankruptcy in the US. But hey, if they cannot afford to support themselves or their family then they must be the undeserving poor for “The greatest of evils and the worst of crimes is poverty” (G B Shaw, Major Barbara). So why should this bother me?

But in some strange way it does! It is not the ludicrous comments made by the likes of Sarah Palin (pit-bull in lipstick) on the NHS “death panels” that upset me, or the assertion by the Republican right that Prof. Stephen Hawking would long since have died had his care been left to the NHS. We all know that Middle America, fed on a diet of Fox News (an oxymoron if ever there was one), is largely unaware of the world beyond its own back yard (it is said that many Americans only learn world geography through the countries they invade).

However it is too easy to ridicule Palin, and the views she represents. Many millions of Americans regard her as a cross between Princess Diana and Joan of Arc (although thinking about it most of them are unlikely to have heard of St. Joan - she never appeared on Oprah).

What really troubles me is the fact that to some extent I agree with them! The Republicans hate what they term “big government” and they profoundly resent the interference of politicians in healthcare matters. Does this ring a bell?

When Blair came to power, recognising that the NHS was chronically broke, he significantly increased funding (a good thing). But then he could not leave it alone and imposed his top-down, command and control, micro-management culture. Thatcher was almost as bad!

The results are MTAS, MMC, WTD, revalidation, endless standards and regulations, the Care Quality Commission (and its predecessors), process and outcome measures, a legally binding NHS constitution, Lord Darzi and, of course, targets.

Don’t get me wrong. I think the American healthcare system is vile and a disgrace to a supposedly fair and democratic society. But I do wish our politicians would back off the NHS for a bit and let us get on with the job.

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Repressed or vulgar patients? Take your pick

By Tom Goodfellow - 10th January 2010 5:04 pm

I had a ‘tumpty-tum’ patient in ultrasound today, the sort who whistle or hum tunelessly to themselves while you are scanning them.

They are very much of a type, almost always men over 60 wearing brand new gleaming white underwear, clearly purchased by the wife for the trip to the hospital (for what man will go into M&S to buy white pants).

They are over co-operative in a generally unhelpful way, insisting on removing their shoes because they “don’t want to dirty the sheets”. Ask them to lie down they will climb on at the foot of the couch and somehow worm their way half way up then come to rest with their head not yet on the pillow and feet dangling off the end. Others will climb onto their hands and knees and lie on their belly. When asked to loosen their clothing they pull their knickers down to their knees, baring all. Put them in a hospital gown and all they want to do is take it off. And then starts the subliminal ‘tumpty-tumpty-tum’ while you do the business.

Don’t misunderstand me, I have great affection for these patients who are invariably polite and jovial. Their odd behaviour is because they are trying to compensate for their acute embarrassment. They are from a generation of men among whom bodily parts and functions were simply not discussed (other than by doctors who have a special dispensation).

My own late father was of that type. I have a vivid memory of many years ago while travelling with him in the car. I farted (as young lads are occasionally inclined to do). “What’s that?” he exclaimed. Then after an excruciatingly embarrassing silence lasting aeons he simply remarked: “Oh!” And that was it, no further conversation.

Throughout my childhood and adolescence the word “penis” never once crossed his lips, at least not in my presence. 

What a contrast to the 18-year-old lad whose scrotal hydrocoele I scanned the other day. He was completely uninhibited about getting his kit off, and discussed with me in great detail the differing size of his bollocks (his words) and the effect on his performance. He was also completely frank about discussing his girlfriend’s views on his endowments. He had a disarmingly complete lack of modesty.

So which extreme do I prefer? While the obsessive avoidance of anything remotely bodily speaks of a rather unhealthy repressed view on life, the total frankness of the other on all matters physical and sexual borders, to my thinking, on the vulgar.

I am going to have to think about this one…tumpty-tumpty-tum!

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Watch out all ‘data controllers’ - they’re after us

By Tom Goodfellow - 30th December 2009 1:56 pm

Now that the “Bah, humbug!” season is over, there is no more pleasurable way to embrace the New Year than with a good rant.

Without claiming sainthood, by and large, I have been a good and upright human being over the last six decades. I have not committed adultery or coveted my neighbour’s ass, and I do try to honour the Sabbath Day (easier now that I have dropped off the on-call rota). I have managed to avoid difficult dealings with the GMC and have never yet troubled my defence body. I now have a licence to practice and my CRB status is unblemished.

So, how is it that last week I was confronted with an official letter stating that I was liable to prosecution and, if convicted, I could be fined up to £5,000 in the Magistrates’ Court or receive an unlimited fine in the Crown Court!

The reason is because I had failed to respond to an earlier letter informing me that, as a doctor who sees private patients, I was required to register under the Data Protection Act with the Information Commissioner’s Office (ICO). I was deemed by the Commissioner to be, de facto, a ‘Data Controller’ under the terms of the Act and that failure to register was a criminal offence. Ignorance was not an excuse!

I rarely go the Golden Nugget these days. Consequently the reason I did not receive the earlier letter is that it was addressed to the local BMI Hospital, which I had not visited for weeks. I asked the ICO why they had not written to me at my GMC-registered address and was told, rather lamely, that they had found my name on a website listing doctors who did private practice and they were picking us off one by one (my interpretation).

The annual registration fee is not huge, currently £35, but the whole episode still leaves me hopping mad. The only electronic patient data I ‘control’ is the reporting module on a PACS system, and I naively assumed that this would be covered by the registration of the hospital, NHS or otherwise.

Apparently not! So despite the fact that I remain completely unclear as to the purpose or benefits of registration I have bitten the bullet, retracted my testicles and paid up (also the wife was not too keen on marriage with a convicted criminal).

What will be the next assault? Since I work with children, it will be registration with the Independent Safeguarding Authority to prove that I am not and never have been a paedophile. I wonder how much that will cost me?

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