Mumps / MMR

I did a shift for Devon Doctors this weekend.
On an admittedly quiet Sunday morning I saw 3 cases of Mumps. 2 from Totnes, 1 from Ivybridge.
We generally have a few Mumps cases coming up now and again, but having seen a couple in the week, then these at the weekend, it makes me wonder whether we are looking at something more like an outbreak.
I can't help but link it in with the few cases of Measles we had a month or two ago. Both things together make me concerned that the degree of immunity we have become used to in the community may be falling. MMR vaccination is clearly key here. We know that rates of vaccination across the country had been falling for a long time.
This of course stemmed back to when the Surgeon Andrew Wakefield decided he had skills as an epidemiologist and paediatrician and whipped up a scare about a link with measles and Crohns disease/autism together. Subsequent studies by people who do this sort of study for a living have showed no such association, but people are still scared off despite all the evidence to the contrary.
This now means that herd immunity has fallen and outbreaks can occur.
Herd immunity is the idea that a disease needs a certain proportion of susceptible people in a population in order to spread. If most people are immune, then if someone coughs out their germs in a room then the majority of people will be fine. If a couple of people get it though and, themselves each pass it on to a couple more people, then it is spreading.
We rely on most people being immune.
This is where those people who have chosen not to have vaccinations fall into a false sense of security. They had been relying on everyone else (the responsible people) getting their children vaccinated in order that their own vulnerable unvaccinated child would be safe in the relatively immune herd. Now that enough people had felt so secure (due to the effectiveness of vaccination) that they felt they didn't need to get their kids jabbed, we are getting outbreaks.
The Department of Health has been pushing an MMR catch-up campaign. At the Surgery we recently invited several hundred unvaccinated children for catch-up jabs. It was good that a few came along. Many still didn't.

Part of the problem is, I think, that because vaccination programmes have been so effective, most people these days have never seen a case of measles.
More have probably seen mumps. Rubella does a little turn occasionally. But by and large, for todays cohort of parents, these diseases are unknown. Diphtheria is another good case. After vaccination was intrduced in 1940 cases reduced dramatically. I've not seen a case at all, ever, after 21 years in healthcare. It still has potential to spread though, and to kill, so we still vaccinate. Smallpox is eradicated entirely worldwide- due solely to vaccination.

I can see that when you are faced with giving your child a vaccination (with its perceived risk) against a disease which is entirely unknown to you, which you have never seen, then there would be a tendency to be reluctant. To some extent that next step relies ultimately on trust. Trust in the health authorities in our country to recommend what is right and beneficial for us. We can't all spend the time needed to educate ourselves in the science of immunology and infection in order to make an informed choice.

So, back to Mumps: The incubation period is 14-21 days and mumps is transmissible from several days before the parotid swelling to several days after it appears. Symptoms begin with a headache and fever for a day or two before the disease which is characterised by swelling of the parotid glands which may be only on one side. At least 30% of cases in children have no symptoms. Complications of mumps include swelling of the ovaries or testes (Orchitis in up to 25% of post-pubertal males), aseptic meningitis (10%) and deafness. Cases may have no salivary gland involvement but develop symptoms elsewhere. There is no firm evidence that orchitis causes sterility. Contagiousness is similar to that of influenza and rubella but not as infectious as chickenpox or measles. Exposed individuals should be considered infectious from 12 to 25 days after exposure.

Dr Morris and the Air Ambulance

Earlier this year I spent some time as the Doctor on board South Devon Air Ambulance.

This was to compliment my work as an emergency Doctor for South West Ambulance Trust. Devon Air Ambulance was first set up in 1986 as a legacy following the tragic Death of Ceri Thomas, who`s mother was told at the hospital if he`d arrived at hospital sooner he`d have likely survived.

The first helicopter went into service in August 1992. I`m used to calling it in or standing it down at the scenes of Accidents, or medical emergencies either where time is paramount, or, with our coast and rolling hills, in inaccessible places.

There are 2 helicopters in Devon One based in North Devon at Eagleswell. The one I crewed is based with the police helicopter at Exeter police HQ at Middlemoor. It flies at 150 mph and has a 2 hr flight time. It can carry 4 crew the pilot, 2 paramedics, and my case a Dr ( but not usually). Not forgetting one normally carries the pilot, 2 paramedics and one other person- in my case me as doctor, and then of course the most important person there- the patient.

It can reach 50% of Devon in 5 mins; the rest of Devon within 20 mins. The 2 helicopters fly 1500 missions a year in Devon, and (like the charity I work for ) is purely charity funded , needing 4 million a year to be operational.

The website for daat is http://www.daat.org/site/

Dr Morris

10 Steps to Making the Most Out of Your Doctor's Visit

(This is lifted from a google knol page. It is American in origin but still summarises pretty well some of the main points to consider when going to your GP. I particularly like point 10. I, as a GP, am your health advisor, and only that. It is your health and you may choose to take my advice)

1. Identify your Agenda

There is nothing doctors dread more than to hear "Oh, by the way..." from a patient as their hand is on the doorknob at the end of the visit. As you can imagine, when the visit is over and the doctor is already thinking about the next patient, it is not the best time to bring up a serious concern.
Most of the time, the doctor has an idea of what he or she wants to accomplish during the office visit based on the "reason for visit" noted at the time you make your appointment. So, if you have more you want to discuss, make sure that everyone from the receptionist to the nurse to the doctor knows what is on your agenda.

2. Make a List

Write down the top 3 things you want to discuss plus any others (if there is extra time). Make sure to think about the things you want to discuss before you get to the exam room. This way you will have all the information you need at the time of your visit. Maybe you have a question about something you read in the paper - bring the article along. If you want to know something specific about your medication - bring the bottle along. You get the idea. It is kind of like going grocery shopping. If you don't write down everything you need, you will inevitably forget the milk or eggs.

3. Ask for the Time you Need

Expecting too much from the limited amount of time allotted for your office visit is another way to sabotage a successful doctor's appointment. In general, a 15 minute visit is about enough time to address one or at the most two concerns. Make sure to let the receptionist know everything you want to discuss at the visit. This way, enough time can be scheduled to make sure you get a chance to get to everything on your list.

4. Be Honest

Let's be honest...some of the things you talk about in the doctor's office are downright embarrassing. Sexual dysfunction, hemorrhoids, vaginal discharge, a rash "down there" are all things that can be hard to discuss with your doctor. However, and let me be very clear here, there is nothing we haven't heard as doctors. And I do mean, nothing. So, feel free to spill all the gory details about whatever it is that is concerning you. It is the best and fastest way to get better.

5. Be Patient

It is understandable that after you have suffered with some type of ailment for weeks, months, or even years, you want an answer today. Usually it will take some time for the doctor to make a diagnosis (maybe after getting a lab, xray, or other test) and to formulate a treatment plan. In fact, you may want to be wary of any doctor who jumps to a diagnosis and treatment before giving your adequate time to share your history, do a careful exam, and get other needed information. It is also important to give the treatment (whether that is physical therapy or a medication) time to work.

6. Be Nice to the Office Staff

I am amazed sometimes to find out that a patient who was perfectly nice to me was yelling at my receptionist just minutes before. Most of the time, the people who are working in your doctor's office actually like people and want to help you. They understand that nobody is at their best when they are sick, but the receptionist, nurse, lab people, and administrative staff do want to be treated just like you do - politely. In my clinic, I have a very low tolerance for any patient yelling at or cussing at my staff. So, if you can't be nice, you may be looking for a different doctor.

7. Make Sure You Understand

It is hard to remember what the doctor said even 15 minutes after you have left the office. A lot of doctors are great at explaining things and writing them down for patients, but a lot of doctors go too quickly through complex information. This really struck me when I had eye surgery. Even though I am a doctor and should know all this stuff (yeah right!), I was given 4 different eye drops to use and couldn't remember which one was just to use "as needed" and which one I was supposed to take every day. If you need to remember more than one thing, it is usually best to write everything down. Ask Me 3 is one approach to making sure patients understand what is going on at a doctor's visit. It recommends that patients ask (and write down the answers to) 3 questions:

1. What is my main problem?
2. What do I need to do?
3. Why is it important for me to do this?

8. Tell the Doctor about Barriers

This is a super-important, often over-looked part of the visit. If you can't read or can't read well (this is actually very common), let your doctor know. You may do better by watching a video or getting one-on-one nursing teaching than by reading a pamphlet. If you can't afford your medication, let your doctor know. What is the point to getting a prescription you can't fill? If you are not willing to engage in lifestyle change (losing weight, quitting smoking, etc), let your doctor know. That way he/she can come up with Plan B to get your chronic diseases under better control.

9. Follow Up as Directed

If your doctor asks you to come back in 3 months to get that little spot on your arm checked, make sure to do it. If you are not any better after one month on the medication the doctor started, follow up. This is the only way to make sure that you get the care you need, that things don't get worse, and that if the first remedy doesn't work, you move quickly to the next.

10. Be the Coach

You are in charge of your health care team. Make sure that you act as the coach. Get input from and advice from your doctor, but take an active role in managing your health care. This incorporates steps 1-9 listed above. Do not be a passive bench-warmer as your health care is decided for you.

Leatside and Swine Flu

You'll be glad to hear that we have been making plans at Leatside just in case Swine Flu really takes a hold.
I don't think anyone at the moment is really expecting an epidemic of it, but we had better be prepared in case.
For us that means planning for many patients being ill. Possibly many of us doctors and our staff being ill as well.
Also that if people are getting ill with flu that we have ways that we can check over the worst cases for possible complications.
No-one expects that everyone with flu would need to be seen by a doctor. In fact I've been surprised by how many people the experts say get the flu virus but no real symptoms. Most people however will get a typical flu illness.

Our local John Huxham described the symptoms during an epidemic in 1733 here in Devon:

"[It] began with a slight shivering, which was soon succeeded by an uncertain erratic heat, a

heaviness and stoppage of the head, great and very troublesome sneezings, wandering pains
of the limbs, but especially in the back, and often in the breast, but not fixed, though on account of the violent cough frequently very troublesome. By cough and sneezing a vast quantity of thick acrid mucous was thrown off-these seemed only to be the symptoms of a fresh cold as they call it: however soon after some degree of fever came on; sometimes indeed not a small one, and the pulse grew very quick, but by no means hard and tense, as that of pleuritics; nor was the urine very high-coloured, but thick, and for the most part whitish and turbid. The tongue was not dry but daubed over as it were with a great deal of whitish mucus. All complained of want of sleep; a giddiness, or sharp pain in the head, afflicted very many and sometimes a slight delirium; a noise in the ears was troublesome to a vast many, and not a few had an acute pain in the meatus auditorius, which sometimes ended in an imposthume, but a soreness and abcess of the fauces were much more common. All were very apt to sweat; which being plentiful, easy, and continued, within two or three days, carried off the fever entirely ..."

Not much has changed since then actually. We generally expect most people to get a high temperature, marked sweating and muscle aches. Sore throat and headache are common too.
If people are getting flu then coming to the surgery probably only serves to spread it more, so we are expecting to need to provide for a lot of house-calls if it does break out to check on those who might have complications.
Pneumonia is one of the more common and more serious complications of influenza.
People will, of course, come to the surgery anyway, so we have a sort of plan to segregate off an area of the surgery for those with flu to sit and be seen.
Straightforward flu does not need a doctor to assess it. It may be helpful though to consider getting tamiflu for other people in the house if someone does get it. Arrangements to do that should become clearer as time passes, but this will doubtless be done on the phone.
To reduce the risk of flu spreading in the home the American CDC have a helpful page of advice as well as advice on looking after someone with flu.

Hopefully the current scare won't come to anything, but rest assured that we have been planning for the worst case scenario. If it comes to it of course some of our usual services may suffer, but we hope to be able to manage a flu outbreak tolerably well.