Man Who Does Not Believe Cannabis Is Causing His Vomiting — Free SCA Practice Case

Character Overview: You are Elliot Varley, a 30 year old self employed barber who rents a chair and pays the rent every week whether you work or not. You live with your partner Kerys, a teaching assistant, and are saving for a deposit. You do not drive. You have smoked cannabis daily since you were 20, starting as an anxious teenager who could not switch off at night. You now have your first one in the morning, because you wake up queasy and it settles your stomach enough to face breakfast. You have had six attacks of vomiting in fourteen months, closer together now, and only a very hot shower helps. You have been to hospital three times, the last time the week before last, kept in overnight. The doctor said it was the cannabis, told you to stop and gave you a leaflet you binned. You felt written off as a stoner wasting a bed, and you honestly think they have got it wrong: ten years without a problem, cannabis is the one thing that settles your stomach, and ten days off on holiday about three months ago did not stop you being sick. You are friendly and chatty, but tired and defensive about the hospital. If the doctor listens to your side properly, you relax and become curious.

Opening Sentence: "Hi, thanks for this. So I ended up in hospital again the week before last with the sickness, and their letter basically says it's down to me smoking weed. I've smoked for ten years without a single problem, so I honestly think they've got it wrong. I want someone to actually look into it properly."

History if Asked (Data Gathering Phase)

• ●What the attacks are like: "It starts with a day of feeling rough. Queasy, sweaty, right off my food. Then I'm being sick every ten, fifteen minutes, and when there's nothing left I'm just retching. My belly cramps up round the middle. That goes on two, three days, then it stops and I'm back to normal."
• ●How often, and in between: "Six times in fourteen months. Lately every six to eight weeks. I'm fine in between, no pain, just a bit queasy most mornings until my first smoke."
• ●What helps during an attack (if asked about baths or showers): "Only one thing. Standing under the shower, as hot as it'll go, half an hour, forty minutes, then back in an hour later, all night sometimes. It only works while I'm under it." If asked about problems or safety: "Last time my back came up bright red and sore, so I suppose I scalded it. And once I nearly blacked out stepping out of the shower. Kerys found me sat on the bathroom floor. That really frightened her."
• ●The hospital visits: "A&E about seven months ago and again four months ago, a drip and home, and a normal scan the second time. The week before last they kept me in. They said my kidneys had taken a knock and my potassium was low. The doctor just said, it's the cannabis, stop smoking it. It felt like she'd made her mind up the second she saw the word."
• ●How he is today (if asked about being sick, drinking, passing urine or dizziness): "Fine now. Not sick since I came out. Eating, drinking and weeing normally, no dizziness."
• ●How much he smokes (if asked): "Four or five a day, more on a day off. Since the hospital I've cut down to about three a day. But I still need one in the morning or I can't face food." Joints rolled with a bit of tobacco. He smokes at the start of an attack because it settles it, but not once he is properly being sick.
• ●Confidentiality worry (after he has answered the questions about how much he smokes): "This stays between us, yeah? It's not going to the police or anything?"
• ●Ever tried to stop (if asked): "Ten days off about three months ago, my cousin's wedding in Spain. I was a nightmare. Couldn't sleep, sweating all night, snapping at everyone. On day eight I was sick again, two days in the hotel shower. So it can't be the weed, can it? I wasn't even smoking."
• ●Why he smokes (if asked): "It's how I switch off. I was a proper worrier as a teenager, panic attacks before exams. Without a smoke I lie there half the night."

Ideas, Concerns, Expectations

Gating note: Elliot volunteers only that he thinks the hospital got it wrong. Each part below comes out only when the doctor asks what he thinks is going on, what is worrying him, or what he was hoping for.

• ●Ideas: Something in his stomach goes into a spasm and gets stuck, and the heat relaxes it. "The heat relaxes it, like a hot water bottle on a bad back. And the weed's the only thing that calms my stomach, so how can it be making it bad?"
• ●Concerns: He feels written off. "As soon as they hear weed, you're a stoner and nobody looks any further." If the doctor explores further: "What scares me is not having it. It's how I sleep."
• ●Expectations: "I want something stronger than whatever they gave me on the drip, to keep at home for when it starts. And I want to see a proper stomach specialist who'll run every test going."

If Asked: Medical History and Medications

Gating note: Elliot answers each of these plainly when the doctor asks about it.

• ●Health, medicines, allergies, operations: "Just the anxiety when I was younger, leaflets from a GP at nineteen, no tablets. No operations, no medicines, no allergies, no diabetes or thyroid that I know of."
• ●Alcohol, other drugs, family: "Two or three pints on a Saturday. No other drugs. Nobody in the family has had anything like this."

Social History and Lifestyle Impact

• ●Work: Self employed, no sick pay. "Three Saturdays I've lost in the last few months, and Saturday's my best day. A couple of weeks ago I had to cancel a stag party. No haircuts, no money, and the chair rent still comes out every Monday."
• ●Home: Together with Kerys four years. She does not smoke. "She's been on at me to pack it in for ages. After she found me on the bathroom floor she was in bits."
• ●Routine, sleep, mood: "First one before work, one at lunch, a couple in the evening to switch off. Fed up with being ill, not low."

If Asked: Associated Symptoms

• ●If asked about vomiting blood or coffee grounds, black stools, trouble swallowing, yellow skin or eyes: "No blood, just watery, bitter stuff once there's nothing left. Bowels normal. Nothing sticks. No yellow."
• ●If asked about pain or sickness between attacks, weight, fever, thirst or passing a lot of urine: "No pain, just the morning queasiness. Weight's about the same. No temperature. Not thirsty."
• ●If asked about headaches, vision, weakness, numbness, heartburn, chest pain, thoughts of harming himself, paranoia or hearing things: "No, nothing like that."

Responses to Management (The Negotiation Phase)

• ●If the doctor agrees with the hospital before hearing his side, or asks why he thinks they got it wrong:
  • ●Reaction: If the doctor sides with the hospital first, flat and irritated: "So you've read the letter and that's it. Same as them." If asked, he relaxes: "Thank you. That's all I wanted, someone to actually listen." He then gives his three reasons: ten years with no problem, the weed settling his stomach, Spain.
• ●If the doctor explains how cannabis can cause the sickness, or why hot showers help:
  • ●Reaction: Sceptical. "Ten years and nothing, and then all of a sudden it turns on me? How does that work? A smoke first thing is the only thing that lets me eat breakfast." He settles if told the morning smoke may be masking the queasiness. If told most people with this find hot showers help: "Other people do the shower thing? I thought that was just me."
• ●If the doctor recommends stopping cannabis completely, or has not explained the ten days off:
  • ●Reaction: "I've already cut down. Isn't about three a day enough?" If told it will not stop the attacks he is unhappy. If the break is not explained: "I was sick on day eight in Spain. Explain that one." He accepts it if told attacks can carry on for weeks or months after stopping. If stopping is offered as a test, with a review and further tests if attacks carry on: "Alright. If I do it properly and I'm still being sick, you'll send me to the specialist? Deal."
• ●If the doctor explains what stopping feels like, suggests a gradual stop to a set date, mentions tobacco, or suggests the drug and alcohol service or help with anxiety and sleep:
  • ●Reaction: Worried. "When I stopped in Spain I was a nightmare. How am I meant to cut hair on no sleep?" Relieved by a short reduction to a set date, and open to patches or gum. On a drug service he bristles: "I'm not some addict. Do they tell anyone?" He agrees to self refer if told it is free and confidential. On anxiety help: "I'm not depressed, I just can't switch off." Interested if it is put as help with sleeping without a smoke.
• ●If the doctor declines or limits anti sickness tablets, does not refer him to a specialist for now, or gives vague safety netting:
  • ●Reaction: Frustrated. "So I go home with nothing again? What am I meant to do when it kicks off in the middle of the night?" He settles with a clear plan. "What if it's something else and everyone's just blaming the weed?" Vague safety netting: "Bad how? At what point is it a hospital job?"
• ●If the doctor asks for a blood test, asks him to press on his tummy on camera, or explains what happens if he stops for good:
  • ●Reaction: "Not a Saturday. Can I come in first thing, before the shop opens?" He declines to press his tummy: "I wouldn't know what I was feeling for. I can come in." If told he can recover: "Does it all go back to normal? No lasting damage?"