This was basically what was happening to Adam; the tiny tear was allowing the cerebrospinal fluid to leak out, like a dripping tap. When he lay flat, the fluid in the system attained a sort of equilibrium, like a builder’s level. But when he stood up, gravity made the fluid flow downwards and seep out of the hole. This ‘dehydrated’ the brain, causing Adam’s severe headaches. The meninges lit up after the dye was injected because of the low pressure in the fluid between the meninges and the brain. This confirmed the low pressure in the fluid protecting Adam’s brain.
Fixing an unhealed hole after a lumbar puncture, or a tear like Adam’s, requires taking some of the patient’s own blood and injecting it into the region where the leak is happening. The patient’s blood then does what blood will, and clots. The clot serves to cover over the hole or tear, sealing off the leak. This is known as a blood patch. It can all seem like plumbing, and that’s basically what it comes down to.
I called the anaesthetist. Anaesthetists are the best doctors for this kind of thing (they perform epidurals for women in labour and blood-patching is a not dissimilar process). She arrived quickly and took a small sample of blood from Adam and then proceeded to re-inject the blood into his lower back area, which has been shown to help heal any leak in the system. It was not pleasant, but Adam bore the pain stoically. I left him to lie on his back for a few hours while I got on with seeing patients on trolleys around him.
When I returned, Adam was sitting up, smiling. ‘The pain is gone,’ he said. ‘Can I go home?’
From our point of view it was a job well done. A quick diagnosis, nothing too serious, and an expertly executed treatment, all within the space of a few hours.
As is often the case, especially with young healthy people like Adam and Anne, after successful treatment patients quickly consign their fears to the far reaches of their memory and want to get back to their lives. The Senior Cup rugby tournament was starting in a few weeks. Adam was cured – but would you let your son run back on to a rugby pitch after an event like that? I certainly wouldn’t, and told him and his father so. They were dismayed.
‘Are you sure?’ his father asked.
‘No, I’m not sure,’ was the only honest answer I could give, ‘but he is at risk of another tear. I’d recommend that he sit it out this year.’
Adam started to cry and his father looked at me grimly.
‘But you cannot say for sure that he will get this again if he plays?’ he asked.
I knew where this was going.
‘I really think he should not play,’ I said. I pointed out that, were it to happen again, he might not be so lucky, and that I had seen people who have had to have multiple blood patches that didn’t work this well, so I felt he had been pretty fortunate.
One Sunday afternoon a few weeks later I was watching the schools rugby on TV and saw Adam receiving the ball on the halfway line. He took off, beat his opposite number at a canter and offloaded in a tackle to his teammate, who ran in for a try. I watched Adam jump to his feet and run around with his friends in celebration. So, my advice about the danger of him playing again had not been enough to convince them that he should miss his big chance to emulate his dad’s achievements.
I’m always perplexed when a doctor’s advice is wilfully ignored. If he had been injured, would Adam and his father have lived with regret for years to come? Or would they blame me for not being more insistent? But if I had been, would they have listened? I followed Adam’s team’s progress and was relieved when they lost in the semi-final. His dream was over, but at least he was out of harm’s way – for the rest of that season at least.
16
* * *
HEAL THYSELF
I fractured my collarbone in my last failed attempt to play rugby at school. I was far too skinny compared with the other boys and, although I loved the game, I was no match for their ever-increasing size. I got hand-tripped as I ran with the ball and fell awkwardly on my outstretched hand causing a searing pain in my neck. I had no idea what had happened, but was taken off the pitch and sent home. I was unable to cut my dinner that evening and complained to my father about the pain. He used my scarf to put my arm in a makeshift sling, cut my food into small pieces and gave me a spoon to use with my left hand. And that was it for the next few days.
After much complaining on my part, he eventually acquiesced and took me for an x-ray; it confirmed I had fractured my collarbone. It had already started to heal imperfectly, however, and there was little to be done at that point, leaving me with a disfigured right collarbone ever since.
It is funny how many of my friends whose parents were doctors had similar experiences. In our early days we would laugh at how dismissive our doctor parents were about the childhood ailments or injuries we may have incurred. It was not a lack of empathy, but when you see genuinely sick people every day, sniffles, cuts, bruises and even fractures – even those of your own children – tend to pale into insignificance. And now we are the case-hardened ones, we will dismiss medical complaints in those closest to us either through denial that there could be something seriously wrong or reminding them that we see far worse things on a daily basis. When any of my siblings complains of a pain it has to be pretty persistent and causing real distress before I will try to help them out medically.
My father had his first heart attack when I had just finished my first year at medical school (pre-med as it was then called). I had found the year extremely arduous, especially having spent so much time the previous two years studying to get into medicine, and I was on the cusp of giving up. I just about scraped through my exams. I might easily have dropped out had I been forced to do repeat exams in the autumn – I just could not have faced further hours of isolated study through the summer.
So it was with great relief that I set off with my father and siblings to Connemara. The car packed up – my dad, five children, aged nine to twenty-two, Ruskin, the red setter, and enough food and clothing for a small army (such was the isolation of our destination) – we set off one Saturday morning for our annual two-week holiday in a tiny cottage that my grandfather owned in the back of nowhere. We were halfway through the six-hour journey (slowed to a crawl by the need for regular pit stops for food and toileting and occasionally to clear the car of canine flatulence, or worse) when my father developed pains in his chest. He pulled the car over in a hotel car park in Athlone.
Though supposedly an expert in biology, chemistry and physics, I was of absolutely no use medically or otherwise; I couldn’t even drive. He sent the three younger kids for a walk (on their own!) around the town and my older sister and I tried to persuade him to go to the local hospital. He wouldn’t hear of it and, after an hour’s rest, he lit up a smoke and off we went again.
By Galway the chest pains had recurred and, despite my youth, even I could tell something was seriously wrong and I insisted that he go to Casualty. He had an electrocardiogram (ECG) to assess what was going on with his heart. I had no idea how to read an ECG at that point and didn’t know enough to fake asking intelligent questions. In my eyes, the young senior house officer on duty might as well have been the heart transplant pioneer Christiaan Barnard himself – I regarded him as the man who could save the situation. I attempted to talk him into keeping my dad in hospital. My older sister and I told Dad we would sort out accommodation for ourselves and the younger kids. Although he wavered for a few moments, he thought better of it and discharged himself against the advice of his younger colleague. Perhaps it was a typical older doctor’s scepticism about the judgement of a novice, or perhaps he was being stoic for the sake of his children.
Whatever it was, he drove on to our grandfather’s cottage perched on the edge of the Atlantic – miles from a telephone. The nearest shop or pub was at least a half-hour’s walk, and the nearest hospital was the one we left behind in Galway, over an hour’s drive away. For the next three days I fretted as my normally active father lay in bed in the back room. Gradually the chest pains subsided. He never
complained. He must have been worried beyond belief. We crept around the house as quietly as possible but, given there were six people in three rooms and a dog convinced he could consume the entire local flock of sheep, it was not quite the ideal coronary care unit.
A few days later he was up and about again and, keen to keep the holiday going, started taking us out on the local lake for our customary fishing expeditions. These took place in a leaky boat that had a small pot to bail out the brown water that gathered at our feet. With all six of us piled in, no life jackets and an excitable dog on board too, it was a miracle that any of us survived those health and safety-free summers.
Though he appeared to recover quickly, years later tests would confirm that my father had had a potentially life-threatening cardiac arrest that summer. It haunts me still to think how easily the second Doctor Tubridy could have died in Galway that weekend.
When we got back to Dublin, I tried to persuade him to go to see someone about his heart but I don’t know if he did. He was, at that point, rather fatalistic about life as the separation made him a little melancholic for a few years, and he had a lot to deal with at work too.
He never complained once about being unwell. At the time I thought this admirable but in retrospect his inability to accept himself as a patient seems foolish. Indeed, whenever I brought up the events of the summer he would almost get irritated and mutter something about it all being fine and that there was no need to worry. Doctors are said to make the worst patients and he was living proof of this. We ate our usual diet and we both drank to excess at times. He smoked away for many more years and never seemed to have another problem until years later, although it is more likely he just never told me.
After my first year of medical school, I seemed to settle into the routine and the study more. Midway through medical school, doubts about the path I was on resurfaced. I was working as a waiter in Melbourne for the summer and having the time of my life. I was making good money on tips and saving to pay back the loans I had taken to travel abroad. The sense of independence while earning my own money was exhilarating because at home most of each year was spent studying and I was reliant on the generosity of my father for any sort of social life. Having spent three years as a student, I had three more to go. And even after qualifying as a doctor, I would then be going back to the bottom of the medical food chain once again. I would not be progressing with my life, as I saw it, until I was in my late twenties, which seemed so far off when I had just turned twenty-one. I resolved to stop studying medicine and join the real world, hoping to run a restaurant of my own in due course.
Fuelled by too much Australian beer, I called my father in Dublin to tell him of my decision. Far from shouting and screaming down the phone he quietly suggested I come back to Dublin in September and see how I felt after a few more months before changing course. Thank God he did.
17
* * *
THE CHOKER
Joanne was celebrating her fortieth wedding anniversary with her husband, Neil, in a posh restaurant just off the Boulevard Saint-Germain when the third piece of her bœuf bourguignon got stuck in her throat. She coughed, and reached for her water glass, but very quickly a wave of panic hit her as she struggled to catch her breath. Her usually attentive husband seemed distracted by the waiters in their white shirts and black aprons busily ignoring the guests. Joanne felt the blood drain from her face and dropped her glass. She tried to stand, but was now in full fight-or-flight mode and flight was winning.
Neil jumped up in fright, realized what was wrong, but was unsure what to do. He had seen this in movies and in countless medical dramas and, he would tell me afterwards, had even seen someone have their throat cut to relieve a blocked airway. He didn’t fancy doing that, so he stood behind her as he had seen Dr House do once on the television, and tried to perform what he called ‘the Heimfeld test’. The other diners rushed over to help as he clearly had no idea what he was doing – ‘it’s not like it is on television when you’re trying to save your wife’s life’ – and pandemonium ensued.
Finally, the waiter casually took over, grabbing her firmly from behind and briskly jerking her body upwards two or three times, whereupon the offensive piece of bœuf flew out of her mouth and on to the floor. Joanne gasped in relief and sat down quickly, embarrassed at the scene she had caused. ‘It’s OK,’ she said to the waiter in a bad French accent, ‘the food just went down the wrong way.’ She drank some water from Neil’s glass, composed herself and tentatively went back to her meal. The waiter was insisting on calling an ambulance, but she brushed him off, too mortified to consider it. He shrugged as only a French waiter can, and left them alone until dessert. Joanne finished her meal slowly, carefully cutting her food into child-sized bites, but was keen to finish so that they could leave.
Over the next few days, they walked many miles around Paris. She was exhausted each evening, but put it down to too much shopping and too much wine. Still, she had a niggling feeling something was wrong. Back in Dublin, all the following week she was drained by eight o’clock each evening and, although she did not choke again, she felt as if there was something stuck in her throat whenever she tried to eat. She put it down to anxiety after the episode in Paris.
A few days later Joanne Skyped her daughter, Alison, a trainee nephrologist, in Sydney. Alison laughed at her story of ‘the Heimfeld test’ and her mother’s humiliation in front of the cool Parisians. She said, ‘I can see you’ve not stopped celebrating yet.’
‘What do you mean?’ Joanne asked, mildly offended.
‘You’ve hit the wine early this evening!’ Alison said with a smile.
‘I’ll have you know I have not had a drink since we got back.’
‘But you’re slurring your words,’ Alison said innocently.
‘No, I am not!’ Joanne replied, enunciating in an exaggerated manner – and with some effort, she quickly realized.
‘OK, Mum, whatever,’ Alison said, and they moved on to other events.
Their Skype calls always upset Joanne. She missed Alison terribly, and regularly ranted at Neil as to why they had brought up their children, and worked hard to educate them, and now Alison was living on the other side of the world. Joanne had come to expect feeling sad as they said goodbye, but felt a shiver of worry when Alison signed off with, ‘You know I love you, Mum.’ Alison wasn’t given to professions of love, and Joanne could see the concern in her daughter’s face.
Later that evening, she was chatting to Neil about the call. Unprompted, he asked, ‘Well, can I have some of that wine, or did you finish the bottle on your own?’
Furious at this second accusation of solitary drinking, Joanne said, ‘What do you mean? I haven’t had a drink since Paris. Do I seem drunk?’
‘A little,’ he replied. ‘Your voice sounds a bit slurred, but maybe you’re just tired.’
The next morning, after a sleepless night, Joanne found herself looking in the bathroom mirror and attempting to recite the alphabet in as distinct and articulate a way as she could. When she got to ‘S’, she started to slur.
‘I do sound drunk!’ she thought. ‘Oh my God, I’m having a stroke.’ She called Neil and asked him to drive her to Casualty. That’s where I saw her a few hours later.
Her CT brain scan was thankfully clear, so there was no evidence of stroke, but her slurred speech was becoming more persistent. She looked forlorn on the uncomfortable trolley, and when she tried to put on a brave face she seemed as expressionless as someone with Parkinson’s (in that condition the facial muscles can appear unmoving). I listened to her story and it turned out I had known her daughter when she was one of our medical students.
‘Do you want me to call her?’ I asked. ‘She might be able to help as she was the one to point out there was something wrong.’
Alison laughed when I asked whether she remembered me. ‘Jesus, Prof, how could I ever forget? You are one of the main reasons I did nephrology and not neurology!’
I wa
s rueful but you can’t win them all; I made a mental note to be nicer in lectures and tutorials in future. I asked Alison what she’d thought after the Skype call with her mum the previous evening.
‘I remember a lady in clinic with you who spoke like Mum spoke last night. She had myasthenia gravis and it was the only case of myasthenia I saw when I worked with the neurology team. It stayed with me, though, as she made a great recovery, having sounded like a wino when she came in.’
Alison certainly didn’t hold back – her Australian adventure had given her a new confidence since her student days, and I couldn’t have been happier for her. In addition, I agreed with her diagnosis, the only time I have seen such brilliant long-distance clinical acumen.
Joanne indeed had a condition called myasthenia gravis (MG) that explained her difficulty articulating words and problems swallowing. There are many different kinds of autoimmune disorders in neurology. MG is a chronic autoimmune neuromuscular disease that causes weakness in the muscles which are responsible for breathing and moving most parts of the body, including the eyelids, arms and legs.
Just One More Question Page 11