Sophie Cook: Home visits in the snow

sophieEven in the most auspicious weather conditions, urgent home visits are time consuming and on days when snow falls this creates another obstacle to negotiate in an already stressful on-call day.

I’ve become irrationally fearful of the snow. Children love it, but adults tend to be less welcoming of snow due to the disruption to day to day life we’ve come to expect from it. Even in central London snow has the potential to grind transport to a halt and in more rural locations this disruption is ever more severe. Remote working isn’t an option for healthcare providers in a way it might be for other professions when weather conditions are bad. People still fall ill and need assessment and treatment, and asking them to wait until the weather improves is not an option.  In my experience most doctors are very committed to delivering care. I’ve known colleagues take extreme measures to get into work, some even walking for miles in the snow to avoid letting colleagues down and disrupting service.

Provision of home visits in the snow can cause problems. If someone requests a visit and you don’t think you can reach them, what should you do? If they cannot get to you, the likelihood is that you won’t be able to reach them.  And what is the medico legal position of an on-call GP who cannot perform a visit? It’s an interesting dilemma, but yet another problem to consider when you already have a surgery full of extras and several visit requests to triage. Decisions will probably depend on your local practice protocol (if you are organised enough to have one). You might be lucky enough to have a colleague with a 4 wheel drive car who is more equipped to take on visits in the snow. But ownership of a 4 wheel drive car is not a requirement to become a GP, and you might not have this luxury. For a single handed GP this situation is even more difficult as there is nobody to share this burden and decision with. I’m always happy to visit patients, and I’ve never declined a visit if someone feels it necessary, but in poor driving conditions, one has to consider the risk of getting stuck in the snow and the further disruption to service this might cause if the on-call doctor is stranded and out of action.

The MDDUS issued a press release this week regarding how to deal with home visits in the snow following a number of calls from GPs for advice on this matter. The MDDUS says “doctors should make every reasonable effort to visit ill patients at home, but only if it is the safe and sensible option.” Dr Jim Rodger, Head of Professional Services at MDDUS, says: “It is essentially the application of common sense rather than any legal or service requirements,” and “the general advice is to gather as much information as possible, decide on urgency, act in the patient’s best interests, and apply common sense.”

Dr Claire Macaulay, Medical Defence Union medico-legal adviser says, “It is important that each patient is offered an appropriate consultation which may be at the surgery. It may be necessary to offer some patients a home visit if it is not possible for them to safely make their way to the surgery, for example, if their mobility is poor, and every effort should be made to reach them safely.”

Dr Richard Stacey, medicolegal adviser at the Medical Protection Society (MPS) says, “we advise doctors to gain full information on the patient’s symptoms, past history, and the weather conditions in their area before making a clinical decision on how to proceed. Any decision should be in the patient’s best interest, whilst ensuring the doctor’s own safety.”

This does all seem like common sense, and while it’s comforting to know that we should only do what is safe, it doesn’t ease the burden of these decisions. I continue to keep my wellington boots in the car and look forward to the spring.

Sophie Cook is an assistant editor, BMJ, and a general practitioner in North London.

  • Michael Hall

    Dear Sophie

    Your blog reminds me of the great snow of 1977 when as a single handed GP in Shebbear in rural North Devon we were “cut off” for eight days by snow drifts of 10-20 feet. The lanes were of course completely blocked but we were also without telephone lines. One of the snow drifts by my surgery went right across the road from roof top to roof top.

    My visits were on foot around the village, tractor rides courtesy of local farmers for nearby hamlets and helicopter for further afield.

    Fortunately the village exchange was nearby and someone gained access so that I could contact the emergency control centre for
    helicopter support and even get put through to the hospital in Barnstaple if I needed consultant advice. The connection was difficult and intermittent.

    In fact we needed a helicopter on two occasions, the first when there were three distant emergency visits, two of which were for children with acute abdominal pain and one for a woman in early labour. We had difficulty identifying one of houses but the pilot landed near a cross roads and we checked the road sign!

    After picking up the third patient the pilot reported running low on fuel and offered either to take me onto the hospital in Barnstaple, some thirty miles away, with the likelihood of staying away overnight or being dropped off with a 3 mile walk home across the snow filled fields; I choose the latter as I had taken skis with me I was able to get back to the village before dark.

    The second helicopter call out was for another young child with severe abdominal pain. I diagnosed a perforated appendix. It was 2.00 a.m. We collected a team from the village and built bonfires around a possible landing area. The helicopter successfully landed with the help of the fires and torches and picked up the patient.

    All this was accomplished with a little help from a very poor telephone link and bonfires and torches. There were no mobile phones!

    All three of the children required appendicectomy. In forty years of general practice, I can’t ever remember having diagnosed three patients with acute appendicitis in a single week.

    My wife, a nurse, helped out with district nursing duties as the community nurses could not get to us. Amongst her visits was one to a visually impaired patient with diabetes who needed a daily insulin injection, my wife was able to ski downhill to her but of course had to trudge back up to the village. This activity made headlines in one of the national newspapers!

    All this before 4x4s or mobile phones, but the local community swung into action and made sure that the “medical service” got to those in need.

    Good wishes

    Michael Hall (Retired GP)