It's all about the bag..

Marilyn Monroe once said, 'Give the girl the right shoes and she can conquer the world'. Well, I say, give the doctor the right bag ...

The Hoy doctor's bag is the stuff of dreams; soft, wrinkled with age and experience and large enough to carry..not much more than a small notepad and pencil (which is really all you needed in the days of listening to a patient's chest with your ears alone)

Three days into my placement at the health centre I was trusted with not only 'the bag' but also the doctor's jeep; a wily creature famous for it's love of stopping mid hill climb and it's abundant exhaust fumes. Set loose on a home visit to a patient we'd been reviewing daily I faced my transport with trepidation..frankly, a case of severe pneumonia on a background of obstructive lung disease was the least of my concerns.

I hadn't driven a manual car for about..ten years (I'll argue with anyone who says they're better than an automatic), but took to the wheel with that trustworthy thought 'what's the worst that can happen?'... It was only during the first gear change that I realised the front seat, carefully re positioned about five inches away from the pedals to accommodate my diminutive stature, was not fixed in place and in fact would not be fixed in place at any distance other than around two metres back. Thus followed a rather disjointed journey as the jeep lurched along at ten miles an hour spewing out black smoke as it went, with me flying back and forth along the seat runners on a funfair ride I had no desire to be on. At least it's not a small place where nothing goes unnoticed..

I arrived at my patient's door feeling in desperate need of a stiff drink. Sadly the bag of dreams offered only a grimy stick of chewing gum..better than nothing.

My patient was not well at all. Like many residents, they were as adamant about not leaving the island for hospital as they were breathless. Their protests came in bursts that became weaker as time went on. We had been treating the patient at home for 5 days with observations that had shocked me on the first day and would have, in a London practice, had me calling for an ambulance. The case illustrated the challenge of managing serious illness on the island; the transfer of people to the mainland of Orkney, or further afield, for hospital treatment is both logistically difficult and often unwanted.

Whilst consideration is put into making referrals or ordering investigations universally, in a place where an emergency transfer to hospital can involve two ambulances and the waking of a ferry master or helicopter pilot; where outpatient appointments often require travelling over 250 miles and where blood tests are done only once a week, really thinking about every decision is crucial.

The reluctance of patients to leave the island as well as the practicalities involved understandably plays a part in their management. The pros of an environment where illness ,at a more severe stage, is managed at home are perhaps being able to deliver care more in tune with the patient's wishes as well as the relief of pressure on hospital beds, however it also requires a larger skill set for the doctor caring in this environment.

After assessing my patient and making a plan for us to review them later with the likely outcome a hospital transfer, I made to leave. As I got to the door they called out ,' could you please check the lady next door? I am worried about her as she's not been around'. I said I would and preceded to the next bungalow where I spent the next half hour politely refusing tea and trying to get to the bottom of whether there was indeed a problem. On leaving the second house I was asked again, could I please pop into the gentleman next door? He had not looked well on passing the window earlier. Thus began my unplanned ward round of what seemed to be the whole street...just me and my bag taking on the world.

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