Sunday, 23 October 2011

Knee injury and the NHS

tl;dr: NHS can be great but you'll be lucky if you do get great care at all times.

I'll talk about my physio at some point now that I'm seeing a private physiotherapist, but first I'll sum up my thoughts on the NHS. Note that this is purely anecdotal from my experience and those around me that I've spoken to. Perhaps half of NHS staff are brilliant, maybe even more of them, with good intention, good experience and all round high quality of care. Seeking to solve medical problems through the NHS however, especially those that present themselves after an accident of some kind, is very hit and miss. If you're lucky and you go through A&E with an accident that occured because of some unknown-but-existing problem then it's almost certain that it will be treated as a regular injury without examining further to identify exactly where the problem is, regardless of reason.

I injured my wrist some time ago and was told it would "heal up by itself in a few days, maybe a few weeks" and after a few weeks passed I went to see them again and got exactly the same story. It was only after a referral to a private specialist, by my request, that the idea of it not healing by itself was entertained.

Now that I've injured my knee (patellar dislocation due to a maltracking knee cap, which happened due to an excessive twisting motion during a mis-stepped landing doing parkour: a running precision (~10ft) to step-through on a low flowerbed) I've encountered similar delays in healing due to the way the NHS have dealt with this.

After the initial injury I was unable to move even slightly without extreme pain so was lying on the ground with my leg propped up for over an hour before the ambulance arrived, which was an annoyance but I'm certainly not kidding myself that it's anywhere close to an emergency on the level of heart attacks, shooting, etc. The ambulance took me to hospital, at which point I had to sit and wait, which is fine as of course other patients have as much need as me, but then they made me walk (!) through to see the nurse despite my obvious agony, thankfully after walking a bit one of the more helpful members of staff had spotted this and came across the room to help halfway through my hobble-hop-pain-journey!

The nurse was pretty helpful and did many of the movement tests to check that the ligaments were fine but as soon as she saw that they were okay, I was given crutches and sent away having had no x-ray and told to see an orthopaedic/orthopedic doctor at the end of the following week. The notes from that encounter mentioned potential medial mensicus damage, but the orthopedic doctor suspected ligament damage before even touching my knee and didn't check for that using the McMurray test, though was thankfully very insistent on getting an x-ray done that should have been done at the time (the form that the nurse filled in had a box of things to check and do on "all knee injuries" and that included x-ray). I got an MRI and saw the orthopedic doctor for a second session but his suspicion of it being ligament damage and having not read the report of potential cartilage damage meant that was all he looked at, and he sent me away saying that the ligaments were fine and it will heal up by itself with the only pain being due to a couple of bruised bones that he spotted.

I had a follow up appointment the following week to see if the radiologist's report of the MRI scan would agree with the diagnosis. I only did this because of having an MRI earlier in the year for my wrist and the helpful private doctor gave me a diagnosis and then explained that after any medical imaging the radiologist also reviews the images and reports potential problems with the scanned body part, so this report acts as a second opinion. My follow up appointment was then very insightful thanks to this, far from the "it'll heal up by itself" story I'd heard the previous week that would have been my end diagnosis and thoughts had I not arranged a second appointment. A deeper look into the MRI revealed that my knee cap (patellar) has a predisposition to dislocate, something apparently more common in women than men thought I wouldn't consider my legs feminine!, due to various things including the groove upon which the kneecap sits being slightly shallower than normal and it being slightly off centre.

This second time I saw a much more informed and useful doctor. The first doctor I saw the previous week was very friendly and I'm sure if it was ligament damage he'd have been able to help just fine but due to his focus there didn't pay enough attention elsewhere on the knee so the second doctor, especially armed with the more open minded (I mean not to insult the closed-mindedness of the first glance look the doctor had, but it is was it is) analysis of the MRI, was able to give a much better explanation and diagnosis, as well as potential options, the end goal of which was a referral to physiotherapy.

This was great! I'd gone into the second session knowing that were I not to get a satisfactory diagnosis that I'd be seeing a private specialist but it wasn't needed, the NHS had done a fine enough job despite it requiring a second appointment, pretty much summing up the hit and miss nature of a successful diagnosis beyond "rest and it'll heal itself". How naive I was to think that it was now going to be problem free by going with the NHS; I then went to arrange physio. The physio request was faxed to a hospital more local to me, upon which I was told the new hospital was contact me soon to arrange my appointments and there was nothing else for me to do.

I waited a few days.

A week later, I was surprised to have not heard anything but knowing that the request went out on the Friday of the previous week I decided the weekend would have affected both the work there and the mail.

I waited another week.

Two weeks after the request, remembering that the physio itself was only supposed to last four weeks, I decided to call the new hospital. In my excitement at the time I'd not even taken the details of which hospital it was so got in touch with the original physio department that faxed my request over, reconfirmed that they had sent it over, and they resent the request just in case. I got in touch with the new hospital, they'd received it at the time and the second request sent that day but told me that "we were arranging prioritisation and as your request was non-urgent it was put on the waiting list". The waiting list turns out to be NINE weeks long, over twice the length of time I'm supposed to have been taking physio and healing up anyway, but the worst part of all is that they weren't going to tell me this and instead were going to get in contact with me at the end of the waiting list period to THEN arrange when my first appointment was.

I understand that the service is for many people in worse situations than me, but that doesn't excuse poor quality of care. That I wasn't informed of this wait and had been informed by the referring physio department to expect a letter in the "next few days" instead of "in about 9 or 10 weeks" is a huge problem, because I'd at least like the option to heal up sooner and without complications of healing without suitable physio that may cause further problems. A simple bit of contact that there was going to be a delay would mean I'd at least know what's going on. The NHS is huge so I imagine this sort of miscommunication happens very often, and the only was to get quality care is to chase things up yourself. In future if anything happens I'll be doing precisely that, getting estimates of times that I should be hearing from people or getting new appointments, and unfortunately I'll also be researching whatever problem it is online to see the range of problems and the sort of diagnostic methods that should be taking place.

The problem with researching problems yourself is that the internet is full of either useful information listing symptoms of given problems, which is terrible as many different problems have similar symptoms and it's easy to convince yourself you have a completely different problem (which is why doctors are required to learn a wide a range as possible of potential situations that could cause said symptoms) or one much worse than you think, or it's full of people complaining on forums and blogs (yes, like this one!) about a problem that should have been diagnosed and was much worse than the doctor said, so look out for . I'm not going to talk about my knee in particular and say that it a doctor says it is one thing then get him to check the patellar tracking or anything but make sure it's as verifiable as possible. If a diagnosis is from imaging, get him to explain the image to you and why (s)he thinks it's that problem- bones breaks are great because there isn't really any doubt that the gap between those two bits of bone shouldn't be there, small lumps or fractures are less obvious so get him to explain; but also get that second appointment to see if the radiologist agreed if he says that nothing is wrong.

I hope for no more injuries or sickness, but I foresee private healthcare something to consider much sooner than I used to.

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