Author Archives: Dr M Kittel

Position Paper for Primary Care in Bracknell

Please read the 5 point paper and then click on the link below to comment and improve the paper and vote on it.

With 500000 people dying a year in England alone there is a danger of increasing morbidity and mortality when focussing on Coronavirus alone. Unless and until the situation becomes so overwhelmingly difficult that all community resources are also required to focus on Coronavirus Care Bracknell GPs would like to propose the following ways of working to support our secondary care colleagues in their fight for saving lives.

  • Unless the system is collapsing and all clinicians are needed in COVID-19 care, Minor Illness Community Care should be delivered mostly by Nurse Practitioners and Paramedics. This part of healthcare is mostly about delivering observations, pulse oximetry, BPs, tempatures etc. It is fairly pathway driven.
  • COVID -19 centres should be set up to allow a separation of potentially infected patients from patients with chronic conditions. Consider pre-admission scoring and community triage of patients prior to hospital admission according to new NICE guidelines
  • Practice nurses should focus on optimising health outcomes, diabetes, COPD and asthma care and self care and self isolation education. A lot of this type of care can be done on the phone.
  • GPs should focus on complex case management, mental health and all other conditions that need to be seen. To support secondary care GPs should also do follow ups and reviews for overwhelmed hospital trusts. GPs with special interest in Cardiology, dermatology, diabetology and respiratory medicine and MSK management should support the hospital system in the community. Current QOF, DES and LES reviews, particularly chronic disease reviews for diabetes, asthma, COPD and older peoples care should be accelerated while possible. GPs should also focus on public education and motivate people for good and responsible self care and behaviours.

Now click here, make your own additions, changes and comments and vote on the paper.

 

Coronavirus – Practical Advice

Updated Version – 20/03/2020

NEW: Going to the supermarket

New evidence emerging on Coronavirus survival on surfaces. This was actually sent to me by one of my patients!

Be careful when you go to the supermarket. The shopping trollies, self check outs, cash, pushing in pin numbers etc, all potentially dangerous. And there are no handwashing or disinfecting facilities at the entrance / exit. Then you touch your car keys, steering wheel and gear shift. Consider washing goods, fruit etc with soapy water. You dont know who has touched it before. And all the Coronavirus infected people have to shop, too. Most of them are mildly sick. We really need supermarkets to provide disinfection or handwashing facilities at their entrances / exits because we cannot stop food shopping during the crisis.

Self isolation advice: Read here if you have symptoms and here if you don’t.

Introduction

The article below is for my subscribers to my website www.nhsevent.info. I wanted to put some information together that may help you in your journey in these uncertain times. Please be aware that this article is not written by a Coronavirus expert, but by a GP. Some of the messages may be soon out of date, others may be valuable for a long time.

Why is Coronavirus important?

Coronavirus is a new virus. There is no immunity in our population. Therefore potentially up to 80% of us can get it (but its likely to be much lower). Most people just have a cough and a fever or a fever alone. But some patients, particularly the elderly, patients with chronic conditions or an impaired immune system are more at risk of serious illness or even death. Many of us think it is like a flu / viral pneumonia, but we still have a lot to learn and don’t know everything. And crucially, unlike the flu, we do not have a vaccination available to us.

I am having a hip replacement in a hospital, tomorrow, should I cancel?

You should talk to your hospital if you are high risk or if you have any signs of a viral infection including symptoms of Coronavirus. All hospitals are required to put their patients safety first. They will cancel your operation if necessary. You really only should go ahead with a procedure if you are low risk. If you are very worried about not getting your procedure done, because you are in a lot of pain and most routine procedures will soon be stopped, try to call your consultants secretary and get put into a slot as soon as possible.

I cannot get any Hand Gel, what should I do to disinfect my hands?

Regular handwashing will remove 99.9% of all virus and bacteria on your hands. You do need to keep your skin moisturised, though. There is usually the principle of “viral load”. To get infected by any virus you need a good number of the virus into your system, usually about 1000. Few conditions, like Hepatitis, require less virus to become infected and people with reduced immunity also may need less virus. We don’t know what the viral load for Coronavirus is, but as handwashing with soap binds the virus it is a good strategy.

How about sending my kids to school?

While the schools have not closed yet, you should be careful if your child is on immunosuppressant drugs, is severely obese, has severe asthma or needs a flu jab for any other reason. You should also now separate vulnerable adults living in the same household as your children. Children are vectors (transmitters) of this disease, but healthy children seem to very rarely get seriously sick with this. They also will provide “herd immunity” for society in the future.

Areas of risk

Anything you have touched with dirty hands or others have touched is an area at risk, so wash or wipe it. Supermarkets are so full of people, they are like viral kettles, now. So what is high risk? The list is endless, but start here: Supermarket trolleys, supermarket self check outs, your steering wheel and gearshift, your mobile phone, not washing hands before eating. Public door knobs and door handles. Anything your kids touch unawares.  Wash your hands before you eat. Don’t eat finger food from buffets where others eat, too. Again, the list is endless.

NEW: How can I disinfect my toilet seat / doorhandles etc with what is still available in supermarkets?

Household bleach is a powerful disinfectant. Use small amounts, as advised on the label, in water and use to disinfect all surfaces that are resistant to it (dont blame me for a bleached surface, try a small area first in an invisible place). Always read the label. Also ensure to wear gloves and don’t bring into your eyes. After you have disinfected areas, wash away bleach with water. Alternatively, you may find disinfectant washing up liquid or other household disinfectants. The list is long.

I can’t get any facemasks

Most facemasks are only bits of tissue that cannot filter the virus. Virus filter masks are not easily available and currently quite expensive. But not to worry. What usually carries the virus are little droplets, that you cough or sneeze out when you first get a virus (in fact a recently published small article published on Sunday March 8th by a group of German scientists (not peer reviewed, not yet confirmed) suggests it is most infectious in the early stages and mild cases. And these droplets can be filtered by tissue. May this be the reason why the government has reduced the viral symptoms isolation period to 7 days, because the virus is not as contagious once the sneezing / early symptoms stop (pure speculation!)? But what does this mean if it is true?: Even a scarf, a pullover with high collar or a couple of pieces of normal kitchen roll secured with 2 rubber rings in front of your face provide good protection against the droplets and can help with some basic protection against any virus in caCatch it bin it kill itse somebody coughs or sneezes at you. Just replace it frequently.

My relative is on Chemotherapy / Radiotherapy for cancer, can I visit them?

No, you shouldnt. If you (have to) visit older or sick or vulnerable relatives or they are dependent on you, ensure they and you frequently wash their hands, door-handles and everything you or they touch. Keep a 2m distance whenever possible. Cover your face with tissue when you sneeze, cough or speak loudly (your relative may be hard of hearing). Ask them to cover their faces with a handkerchief or any other fabrics while you are around.

I am worried about getting my prescription medication

There is no worry, supplies are reasonably good at the moment. Try not to stockpile, order as you usually would.

I am worried about Paracetamol being completely sold out

The problem is that people are stockpiling. If everybody only buys what they need we will be fine. I am sure Paracetamol manufacturers will try to increase output in the next few weeks as long as supplies are not hampered by other factors. Remember, Paracetamol is a comfort drug, it isn’t really curing anything. If you have an illness, it makes you feel better, but by lowering your temparature you also decrease your metabolism and your temperature is increased to be able to make antibodies quicker. Use your current supplies sparingly.

What is better, handgel or handwashing?

It depends. But if you use handgel you leave a film on your hands that can in some gels later provide a breeding ground for germs. So frequent handwashing is vital.

I am vulnerable myself because of Type II diabetes .

You now need to self isolate. At the same time try to improve your self care and reduce your sugar levels if possible. Even lowering your weight by a stone may reduce your sugars so much that your immune system can kick in again. Patients with high sugar levels paralyse their immune system. If you are overweight: By acting now and going onto the 800 calorie diet immediately you may be able to build up your immunity in time for Coronavirus.

I have another condition that reduces my immune system

You should now self isolate. Read here for more information

What else can I do to reduce my risk of severe illness or death with Coronavirus?

  1. Stop smoking. Within 3 days of stopping, all the Carbon Monoxide in your blood is gone and the oxygenation of your blood will improve. Within 6 weeks the little hair in your bronchi will grow back to naturally get rid of debris, bacteria and germs. This gives you a better chance with Coronavirus as it causes breathing problems in severe cases.
  1. Ensure you eat a balanced diet not deficient of any nutrients you need
    • Increase your vegetable intake massively (at least 5-a-day, better 9-a-day!)
    • Reduce salt in your diet (to reduce your blood pressure)
    • Reduce fats and sugar in your diet (general drivers of obesity, pre-diabetes and diabetes)
    • Eat fresh food, cook yourself (avoid additives and bad fats, know what goes into your dinner!)
    • Avoid food additives, the list is endless.
    • Alcohol in moderation (also driver of obesity and impairing the natural defences of your liver)
  1. Loose weight (obese people have a higher risk of pre-diabetes and diabetes and many other conditions that can affect your immune system and resilience
  2. Keep well hydrated
  3. Be active, do plenty of exercise (not in a crowded gym, outdoors is better at the moment or at home with your own equipment or indeed without equipment like Pilates or Yoga.

When I am sick or worried with a cough or fever, I need to see my GP, right?

No, please dont come into the surgery, call NHS 111 or 999, depending on the severity of your symptoms. If they advise to call your GP, then contact the surgery via telephone or online (where available).

“I never get the flu, I don’t even have the flu vaccine, even if the surgery texts me. Therefore I won’t get Coronavirus”

You may be of ruddy good health and never get any problems, but you also may be relying on a phenomenon called “herd immunity”. It depends on the virus, but generally, if 70-90% of a population are immune to a virus, the rest won’t get it, because a virus cannot spread sufficiently. Therefore turning down vaccinations that are offered to you is usually unwise, because 1) you don’t protect yourself and 2) you don’t contribute to the greater good of “herd immunity”. Again, a person with health problems is more at risk and that is the reason, why they are the first patients we contact for the annual flu vaccine.

Important Links on self isolation:

Self Isolation with symptoms: https://www.nhs.uk/conditions/coronavirus-covid-19/self-isolation-advice/

Self isolation without symptoms: https://www.gov.uk/government/publications/covid-19-guidance-on-social-distancing-and-for-vulnerable-people/guidance-on-social-distancing-for-everyone-in-the-uk-and-protecting-older-people-and-vulnerable-adults

Dr M Kittel, March 12th 2020, updated March 14th

 

Viral Gastroenteritis Diet

Self-care for adults:

BRAT diet

For vomiting, follow these instructions in order:

  1. Do not eat or drink anything for several hours after vomiting.
  2. Sip small amounts of water or suck ice chips every 15 minutes for 3-4 hours.
  3. Next, sip clear liquids every 15 minutes for 3-4 hours. Examples include water, sports drinks, flat soda, clear broth, gelatin, flavored ice, popsicles or apple juice. Do not drink citrus juices or milk. Increase fluids as tolerated.
  4. When you can tolerate clear liquids or diluted apple juice for several hours without vomiting and if you’re hungry, try eating small amounts of bland foods. Try foods such as bananas, rice, applesauce, dry toast, soda crackers (these foods are called BRAT diet). For 24-48 hours after the last episode of vomiting, avoid foods that can irritate or may be difficult to digest such alcohol, caffeine, fats/oils, spicy food, milk or cheese.
  5. When you can tolerate bland food, you can resume your normal diet.

Retake medications if vomiting occurs within 30 minutes of taking usual medication. If you vomited after taking oral contraceptive pills, use a back-up contraception method for the rest of the month.

If diarrhea is the only symptom, try Imodium, a non-prescription (over-the-counter) medication available at any pharmacy according to package directions. Follow a bland diet (see 4 above). After the passage of a soft, formed stool, you can resume a normal diet. Call for medical advice if you have no improvement within 48 hours after starting Imodium.

 

Warts and Verrucas

Topical treatment for warts and verrucas

Topical treatment includes wart paints containing salicylic acid or similar compounds, which work by removing the dead surface skin cells. I recommend Salactol Paint.
The paint is applied once daily. Treatment with wart paint usually makes the wart smaller and less uncomfortable; 70% of warts resolve within twelve weeks of daily applications.
• Soften the wart by soaking in a bath or bowl of hot soapy water.
• Rub the wart surface with a piece of pumice stone or emery board.
• Apply wart paint or gel accurately, allowing it to dry.
• Cover with plaster or duct tape.
If the wart paint makes the skin sore, stop treatment until the discomfort has settled, then recommence as above. Take care to keep the chemical off normal skin.

How about other methods?

Other methods have scientifically not proven more successful and are often not available on the NHS

Pitfalls

  • Not trying for long enough
  • Not being persistent with the treatment

 

Dr Kittel’s Mental Health Resources – Bracknell

Adult Mental Health

Image result for mental health

Find below a list of Mental Health Resources that you may find useful for your own Mental Health journey. You may also wish to register on this website (see registration section on the right hand side) for occasional non-promotional local NHS information emails by Dr Kittel and Forest Health PPG.

  1. A list of Mental Health Self Support Messages by Dr M Kittel
  2. A list of counselling and other support organisations in and around Bracknell
  3. The excellent “Books on Prescription” service by Bracknell Library
    1. A prescription form
    2. A synopsis for every book
  4. A PHQ 9 and GAD 7 form for self assessment of Anxiety and Depression. Please take a completed form to your GP

Child Mental Health

Click here for a self help leaflet on Child Anxiety

 

Back Pain – Tips and tricks

Introduction

Low back pain and Sciatica are incredibly common conditions in highly developed, civilised societies. According to some reports, more indiginous societies (i.e. tribes in the Amazon etc.) rarely suffer back pain. This is probably due to better core strength in less civilised peoples.

Summary

What should I do with acute back pain in a nutshell: 5-point plan:

  1. Initially, take painkillers that you are not allergic to i.e Ibuprofen (beware indigestion) and / or Co-codamol (beware constipation) over the counter and take them regularly for a few days. Always read the drug information sheet in the pack. Don’t take them long term.
  2. Read the NHS write up on back pain, it contains lots of good information.
  3. Buy Robin McKenzie “Treat your own back” (see below)
  4. Ask your doctor  to refer you for physio if your backpain hasnt improved after 2 weeks or see your practice physiotherapist.
  5. Contact your doctor, should you have any “red flag symptoms” described in the NHS leaflet.
  6. If you suffer chronic back pain, improve your core strength with Pilates. There are many free courses, I am using “Trifecta Pilates” for my own back pain successfully. There are many sessions online.

More on Low back pain and Sciatica

These 2 conditions are the most common ones causing patients pain and disability. There is a really good overview on the NHS website . However, there are a few additional resources that I  would like to share.

  1. The Book: Robin McKenzie, “Treat Your Own Back” for a quick fix.
    • This is a 30 year old book based on a 60 year old method that my own doctor recommended to me and truly, with a few stretches, a lot of people are able to improve their back pain quite significantly. Thus, I believe it is the best £10 I ever spent on my own back.
  2. StartBack Tool
    • The StartBack Tool is a good tool to assess the chance of Chronification in Low Back Pain. Click here to download and complete it. The scoring method is explained on the second page. If you score highly, seek help early, as you are much more likely to suffer this condition for a long time.
  3. The Back Pain Booklet
    • Almost 20 years old, this booklet is still very relevant and helpful. Click here to download this file. It is double sided A5 and a bit tricky to print, but the content is very good

Why an MRI scan is commonly a useless investigation

An MRI scan is a tool to get a good 3D photograph of our spine. It is very sensitive to abnormalities like disc bulges, slippage etc. However, many people with disc bulges lead completely normal lives without any symptoms. Equally, people with entirely normal MRI scans suffer severe back pain. Click here for MRI scan results of the spine for normal people without back pain.

Should I see my GP with Low Back Pain?

Most GPs are not well placed to treat Low Back Pain. Apart from painkillers, with a various degree of side effects and health hazards attached to them, they often can do little to help back pain. However, many practices now employ senior physiotherapists (First Contact Physiotherapists), who can be helpful in the assessment and treatment co-ordination of Back Pain.

Of course there are exceptions where Low Back Pain has more serious causes and there is a good summary on the NHS website quoted above. If you think your symptoms may be more serious, you should see a health professional quickly.

Dr M Kittel, March 2019

 

 

Extended Hours GP Services in Bracknell – Phone Number Change

Phone number changes for cancelling ‘Extended Hours Clinics’ appointments- Bracknell and Ascot

A telephone number for residents to call when cancelling evening or weekend GP appointments, as part of Bracknell and Ascot’s ‘Extended Hours Clinics’ service, has changed.

The new number is 01344 233 300 and is available Monday to Friday 8.30am -6.30pm and during clinic opening times, Monday – Sunday inclusive of Bank Holidays.  Please note that the old number – 01344 637 808 – is no longer in use.

The change coincides with Berkshire Primary Care Ltd, who is commissioned by East Berkshire Clinical Commissioning Group (CCG) to provide the service, moving offices.

The clinics continue to run from Boundary House Surgery as usual.

The ‘Extended Hours Clinics’ are available for people who find it difficult to take time off work or have other commitments during daytime hours. The service offers a range of appointments with GPs, nurses, healthcare assistants and phlebotomists (blood tests).

People must be registered with a GP surgery locally to access the ‘Extended Hours Clinics’ and appointments can only be made in advance through their own GP practice, as the service cannot accept walk-in patients.

Appointments are for routine general practice issues only and not for urgent care. If urgent care is required, please call NHS 111 for advice.

Although residents need to book appointments through their individual GP practices, they are urged to call the cancellations line if they are no longer able to make the appointment.

The ‘Extended Hours Clinics’ in Bracknell and Ascot are part of a national initiative to improve access to general practice.