plik

Confessions of a GP

Meningitis

Every six months or so, a newspaper will print an article with a headline something like: ‘GP

MENINGITIS BLUNDER – My GP diagnosed my child as having a cold, ten hours later she was

in intensive care with meningitis.’ This is the sort of story that terrifies every parent and every

doctor. For GPs who are also parents, it is a double-fear whammy. Meningitis is a frightening

condition for GPs because it tends to affect children and young people and if we miss it, the

patient can be dead within hours. The difficult truth behind the scaremongering headlines is that

any child who is seen by their GP in the first few hours of meningitis will probably be sent home

with some paracetamol having been told that they have a viral infection. Early meningitis

symptoms are generally a fever, feeling a bit lethargic and not being very well. We see bucket

loads of children like this every week. The symptoms of a rash and neck stiffness that give away

the diagnosis are only seen much later on, by which time the child is already quite sick. I know

an excellent and experienced GP who sent home a child who then went on to develop

meningitis. It is a horrible diagnosis to miss but only rarely is it a ‘blunder’. The only thing we

GPs can really do for the thousands of snotty feverish children we see every day is educate the

parents as to what danger signs to look out for and when to bring them back to see us. I’ve only

seen meningitis a handful of times and thank goodness never as a GP. The first time I saw it

was the most memorable. I was working in casualty and a dad carried his four-year-old child

into the waiting room. I took one glance at the child and went straight to the drugs cupboard,

whacked some penicillin into his vein and called the paediatric registrar instantly. Despite the

fact that I had never seen meningitis before, the diagnosis was obvious. The child looked really

bloody sick. He was floppy and completely disinterested in anything around him. This was not a

clever diagnosis. No doctor in the world would have sent this child home. Several hours earlier

when the child was just a bit hot and bothered but still happily watching Disney videos and

playing with his brother, the diagnosis would have been much more tricky. If I’d seen the child at

this stage, I could easily have sent him home and become the next day’s ‘blunder doctor’

newspaper headline. I am always happy to see children and babies in my surgery and will do

my best to fit them into a full surgery if Mum or Dad is worried. In fact, seeing kids is one of my

favourite parts of being a GP. The main difference between children and adults is that kids are

very rarely unwell. The truth is since I’ve been a GP, I’ve probably seen well over a thousand

children and babies, but I am yet to see one that was unwell enough for me to be really worried.

Meningitis is really scary but also pretty rare. I understand that this might not be that reassuring

if it is your own child that is hot and miserable and that is why I’m always happy to see kids and

to reassure parents. As a parent myself, I do realise that it is hugely anxiety-provoking to have

this small person for whom you are solely responsible and whom you love overwhelmingly and

unconditionally. We doctors are equally anxious when our kids are unwell and I once heard of a

GP rushing her infant to see an ear, nose and throat specialist as she was convinced her child

had a nasal tumour. She was understandably very embarrassed when the specialist then

removed an impressively big but definitely benign bogey from her child’s nostril. A few kids need

a good check-over before I’ve reassured myself that they can go home, but the vast majority are

obviously fine as soon as they walk through the door. This may seem a bold statement to make

when I’ve previously talked about how easy it is to miss meningitis early on. However, these

borderline kids are the minority of children we see. If a child skips into my consulting room and

gives me a smile, they haven’t got meningitis. I can’t say that they won’t develop meningitis in

12 hours’ time but then I couldn’t say that any well child wouldn’t develop meningitis in 12 hours’

time. Unfortunately, that is the nature of the disease. In the same way that it took me about one

second to decide that the child with meningitis was really sick, it takes me about one second to

decide that 99 per cent of the children I see are completely fine. When I say that the vast

majority of the children I see are ‘fine’, I don’t mean that they are not unwell. What I mean is that

they don’t have meningitis or any life-threatening condition that needs hospital admission right

then. They also almost certainly don’t need antibiotics as they invariably have a viral infection.

It’s important that I don’t use the word ‘fine’ to Mum and Dad as they have been up half the

night with a miserable crying infant. These children are ill but not ill in a way that I can do

anything about. It is just part of being a child. Kids get ill because they haven’t been exposed to

lots of the bugs that we have. They are going to be snotty for much of their early years and

often spend the vast majority of their first couple of winters going from one viral infection to

another. Children need to build up their immune systems and, unfortunately, the only way they

can do this is to be unwell. I often think that new parents are a bit unprepared for this part of

parenthood. Children will have recurrent ear infections, coughs that last for weeks, sore throats

that are really sore and funny spotty rashes that don’t quite look like anything in my dermatology

textbook. All these things are just part of being a kid and staying up all night comforting them is

part of being a parent. It’s not much fun at the time but it’s normal. I would love to be able to

give an instant cure for these childhood illnesses but, unfortunately, I can’t. My job is simply to

listen to the parents, do a quick examination, offer encouragement and reassurance and make

sure that Mum and Dad come back if they are worried. A generation or two ago when big

extended families lived together, this reassurance was given by Grandmother or Auntie, but

nowadays parents can be quite isolated, hence it is often the GP that fills this role. Soothing

anxious parents is definitely one of the hardest parts of my job. Many are very happy with some

sensible reassurance. Others are looking for antibiotics and won’t be happy unless they leave

with them. We all want the best for our child and seeing them unwell is hard to bear. I think

some parents feel that they are letting their child down if their snotty and coughing infant doesn’t

get antibiotics. In direct contrast, as I strive to be a good doctor, I am trying to hold back from

giving antibiotics. It can be a difficult battle that can go either way. To try to swing the encounter

in my favour, I have developed a battle plan. The first thing that I do is try to empathise and say

how the child definitely does have a very bad infection – be it a cough or ear infection or sore

throat, etc. I sympathise about how hard it is for the whole family when a child is up all night

coughing and crying, etc. Vital is me then telling the parents what a great job they are doing with

regular paracetamol and lots of cuddles. My aim is to make them feel that I am on their side and

that I realise how exhausted they are with no sleep and a miserable child. Then I explain why

antibiotics aren’t appropriate to treat viruses, but still offer them as an option. If I’ve done my job

well, they say no, but feel that it is their decision. Finally, I make sure that they will come back

and see me if they are concerned and tell them about the worrying symptoms of meningitis to

look out for. If I’ve succeeded, they don’t come back, as the parent feels more confident and the

natural course of these viruses is that the child gets better. Ideally, they also feel a bit more

confident about managing the child at home next time they are poorly. When these

consultations go well, they are great. When they go badly, they are a disaster and usually either

end up with the child getting an inappropriate prescription for antibiotics or an anxious parent

getting very upset and dragging their child to A& E.

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