I have an interesting relationship with Karvol. It is no longer produced in the UK but I found some old capsules in my medicine cupboard. So, of course, I decided to imprison them. Using embroidery thread ranging from oranges and reds to browns and beiges. Following the project see my story (Carly has an ambiguous relationship with Karvol) to see how it all began.
Carly has an ambiguous relationship with Karvol
Carly has an ambiguous relationship with all sorts of things and all manner of people. That is the nature of someone who is contrary at times. She is reminded of Mary, who might have really been called Mary-Mary, who sat on something in the garden and is not to be confused with Little Miss Muppet. As a paediatrician, Carly has had to prescribe a lot of medication for children over the years. This isn’t really an ambiguous relationship (Carly and prescribing). It is just what she and all her colleagues do. If she was a surgeon she could perform operations, and if she was a radiologist, she could take various images of patients. But she is a physician and really there isn’t much in the way of treatment that she can administer. There is talking and there are drugs. When she was a medical student, she would practise saying complicated drug names in front of a mirror. Even now she finds it difficult to remember the name of the new drug she wrote a guideline for in the last year (dextropropoxyphene). She has become a teensy bit lazy with learning this sort of name. It is so long and unwieldy. But it does work. The drug that is. Not the learning of the name. She tries hard not to overly prescribe medication. Most children’s ailments get better all by themselves. And it is important to heed guidelines about not prescribing antibiotics unnecessarily. This is because they are often used to treat viral infections and so, by definition, don’t work. But also, the bacteria get resistant to the drug and so when they are needed for a bacterial infection, they don’t actually work anymore. Unsurprisingly, there is pressure to resist prescribing unnecessary antibiotics and for some utterly bizarre reason this has been termed “antibiotic stewardship”. Who on earth coined this phrase was on a mission to mask understanding and make things unseemingly complicated. But Carly has taken advantage of this by getting involved in a virtual reality scenario to see which sorts of GPs are able to resist prescribing antibiotics for an elderly woman by her very demanding daughter. It had certainly been a fun project. And the results. More senior doctors were better than junior ones!
Carly has often been involved with prescribing projects. She helped launch an online teaching tool to encourage safer prescribing of medicines for children. This group was headed up by a colleague at a tertiary hospital. He was lovely and kind, but Carly always felt he was about to drop dead by self-explosion, as he looked like he was always about to blow a gasket. He seemed very highly strung which meant Carly had to really reign herself in when they were working on this project. She didn’t want to be responsible for him self-detonating because of her exuberant nature.
Carly felt that the Medicines-for-Children’s website was really helpful and when she found out there was a restricted number of parent information leaflets on commonly used medicines, she set about resolving that. She involved a whole team of doctors in training. This was the easy part. The bureaucracy was the hard part! It always was when dealing with large organisations. In the end, many years later, this website covers far more drugs. Carly feels she has had to learn from her prescribing mistakes. Over the years she has made a number. Luckily no one came to any harm. Phew, muses Carly. And she has put her energies from feeling guilty about these prescribing misdemeanours to use.
Early on in her career, a toddler came into the Emergency Department in extremis. The family only spoke French, so it was difficult to elicit a history. Essentially, the child had a blocked nose and the family had squirted Karvol up his nostrils causing him to struggle even more with his breathing. Things calmed down but Carly couldn’t really understand why they had done this. Then she looked at the packaging and realised that the photos showing how you were supposed to apply this decongestant liquid to the pillow could be misinterpreted. The pillow or handkerchief looked quite like a nose. And the fact they couldn’t understand the written information meant Carly now really did understand. So, she took it upon herself to contact the manufacturers. But they seemed very uninterested. Carly was rather bemused, but as one who is serendipitous by nature, instead she wrote it up as a journal article. Being very junior in her team, she sought help from a more experienced colleague. Let’s call her Kathleen Bumble. The initials (KB) are the same. Clearly there was going to be an issue, as she would normally just use the real ones!
In the end they wrote the case up as a letter for the Lancet. This is a very prestigious journal and Carly was so excited. The very start of her academic career. But when the letter was published it only had KB’s name on it. Carly was bemused and contacted the journal. They said that KB was unsure of how to spell Carly’s surname and so left it off. Normally they would contact all the authors but only in the States where this journal is published. Now Carly was actually furious. Totally, hopping mad. It was her work and her case, and she had merely asked for some help. After lots of phone calls and letters, as the internet and emails were only in their infancy then, eventually, Carly managed to sort this out. But it was a very important lesson. One she has NEVER, EVER forgotten. It must be really significant, as Carly so very rarely uses SHOUTY CAPITALS.
Since then, Carly has written many peer review papers and published abstracts. Right from the get-go, even if the project may fold and get nowhere, Carly ensures that the author list and order is clearly laid out. As her senior mentor and colleague, Ben Lloyd (of course this is his real name as this is complementary) said “the goal is always clarity”. Carly did a number of presentations on this Karvol case – she called it the Karvol Kid – and images of a child with a Stetson riding around in the Wild West, on a horse with packets of Karvol in his pockets would pop up in her head and she would smile quietly. She even made slides of her then niece Harriet who was a toddler taking the Karvol and putting it up her nose. Carly and Harriet’s mother had to keep warning her this was just for the camera, and she must never do it in real life. She never did and also became a doctor. Maybe this early, formative experience influenced her career choice.
Karvol was something Carly used often for her children when they were blocked up with colds. Of course, she put it on their pillows. Or on handkerchiefs. By this stage the packaging has miraculously changed, so it was clear you didn’t squirt it up your child’s nostrils. In fact, she still has some, mostly as a memento. The company no longer makes Karvol, as it folded in 2013. Carly dares not look at the expiry date on the packaging. She believes anyway that medicines probably just get a bit weaker over time. Actually, she couldn’t resist. She took a look at the packaging. It is now October 2023. The expiry date was March 2010. What’s 13 years between friends?
Later on in her training, Carly went to work at Guy’s Poisons Unit. This was a rather sideways move. She wanted to take a regular 9-5 job with no nights or weekends as she thought it might help her fertility treatment to work. Oh, and it did! She was there, on the phone lines, dealing with all sorts of queries. Both accidental and deliberate poisonings. And strangely it was also for pets. One man was upset that a mouse was getting into Fluffy, his rabbit’s hutch. So, he put down warfarin as poison for the mouse, not realising the deleterious effect it would have on Fluffy. Carly was flabbergasted that people really could be that dense! This job culminated in Carly presenting a series of paediatric accidental methadone overdoses at a national conference. And being pregnant. Double whammy!
When she was pregnant, Carly did yoga at the Active Birth Centre in North London. She was keen to have as natural a birth as possible and felt yoga might help her on that quest. They had one weekend for couples to explore birth with other pregnant women and their partners. Ades, her then husband, was excited to come along. The first exercise was to crawl around the floor, like a toddler, and collect an article from a newspaper or a magazine from the floor that seemed to be of interest. He chose one about having no sleep. He suggested to the group that he thought paracetamol would help and he would be keen to give this to his baby. Whenever he himself cannot sleep, this is what he takes. Carly tries to explain about the placebo effect, but he shrugs and says he doesn’t want to know as it works. Okey dokey, says Carly. That’s ok. But doling out Calpol to a baby who won’t sleep, didn’t really go down too well with this rather politically correct and baby-front-and-centred group. Carly and Ades decided this was a last resort strategy. Their kids are now adults. They usually had medicines when they needed them and seemed healthy and not currently addicted to any drugs. Phew! Job well done feels Carly as a mother.
Carly gives a number of talks about medicines at this stage in her career. She has several on her Dr Carly YouTube channel. One of her big bugbears is to promote shutting bathroom doors and keeping medicines in locked cabinets. Carly is perturbed by how many of her paediatric colleagues with young children don’t abide by these simple guidelines. But Carly cannot be too smug. When Boo was two, she went for a sleepover with her friend Johnny. One of them had a sore finger and so they went off exploring to find some analgesia. They found paracetamol tablets in the bathroom and popped them out of the packet. They told Carly that they had posted them down the bath plug hole but it wasn’t easy to see if this was true. Off they went to the Emergency Department to have levels checked. She should have believed them as these levels were indeed negative. But the treatment is simple, and the consequence of liver damage is severe.
So, for all Carly’s expert knowledge about drugs and poisons, one must always be vigilant…..
October 2023
Prescribing – a Personal and Professional Journey (for the Annual European Conference on Assessment in Education in Holland 2017)
I like to teach about journeys – usually patient journeys (1). They are a good source of how to teach about professionalism. And this is my personal journey. My prescribing journey. I realise it defines who I am and how I practise. I prescribed Valproate for constipation (instead of Docusate) – whoops picked up by pharmacy – we are fallible. My first publication was about Karvol. It appeared in The Lancet without my name initially as the senior colleague helping ‘forget’ how to spell Fertleman (2).
I am hyper-vigilant about author recognition and order because of this experience. I was involved with a number of studies about medications. One to speed-up pain relief in sickle cell disease (3) and another about paediatric methadone toxicity (4). These were simple studies for a jobbing clinician. Then, as a lecturer, I led undergraduate
prescribing assessments (UCL) where they produced a drug poster. But it didn’t really teach them about therapeutics or prescribing. Rather how to make posters! So I led an award-winning multidisciplinary team that produced an innovative prescribing teaching programme using drug charts and a summative OSCE. This developed further into integrated teaching combining medical and pharmacy students who held preconceived views of each other. This joint teaching dispelled such myths (5). This led to provision of training materials nationally to enhance paediatric prescribing skills and assessment (6). As prescribing became electronic we delivered bespoke sessions to students before they qualified (7). Recently I delivered a quality improvement project to substantially increase the number of drugs listed (medicinesforchildren) (8). For the paediatric exit assessment I have co-written most of the extremely complicated and realistic prescribing scenarios. This formative assessment compels candidates to remediate against poor outcomes before completing training. As candidates perform the prescribing station poorly, I have decommissioned a live question with concomitant explanations to incentivise future trainees to improve their prescribing.
References
- Chloe Macaulay, Polly Hirons, Caroline Fertleman. Learning from Paediatric Patient Journeys:
What Children and Their Families Can Tell Us. CRC press (2016). - Blake, K. D., Fertleman, C. R., & Meates, M. A. (1993). Dangers of common cold treatments in children.
Lancet, 341(8845), 640. - Fertleman, C. R., Gallagher, A., & Rossiter, M. A. (1997). Evaluation of fast track admission policy for children with sickle cell crises: questionnaire survey of parents’ preferences. BMJ, 315(7109), 650.
- Fertleman, C. R., Eastwood, J. A., & Dawling, S. (1999). Methadone poisoning in children. Proceedings of the Royal College of Paediatrics & Child Health Spring Meeting. In Archives of Disease in Childhood Vol. 80 S1 (pp. A6).
- Birley, K. J., Moreiras, J., Fertleman, C. R., & Bates, I. (2014). Integrated pharmacy and medical student practical prescribing teaching. Medical Education, 48(5), 530-531.
- www.rcpch.ac.uk/training-examinations-professional-development/quality-training/paediatric-prescribing-tool/paediatr
- www.researchgate.net/profile/David_Gamble4/publication/303518448_Teaching_prescribing_to_MBBS_medical_students_using_an_electronic_prescribing_computer_system/links/5745d01808aea45ee8560dbf.pdf?origin=publication_list
- www.medicinesforchildren.org.uk
