Just One More Question

by Niall Tubridy

  It did not look good. Would he die while I was off in Australia? Was this the last time I would see him? Should I stay? All of these questions were going through my head, but after a few days he asked me when I was going back. I went quiet and said I was supposed to go in a few days, but that I was worried about him.

  ‘Don’t be ridiculous,’ he scolded. ‘You have to get on with your life, and I’ll be fine.’

  He was, if not quite fine, at least OK, within a few weeks, though his heart never entirely recovered. His health was a source of constant low-level anxiety and I feared that the next call from home might bring bad news. If that call were to come, I would be too far away to get back in time to say goodbye. (The fear was mainly about my father; Mum, thankfully, has always had robust good health. I’m mindful of this fear of getting bad news from home when I deal with families in work. Emigration haunts so many of the families I deal with. Is Mum so sick that we call everyone back from America? It can be hard to say. You don’t want to be the boy who cried wolf, but nor do you want to be the one who makes the wrong call, meaning that a mother dies without her children getting home to see her one more time.)

  By the time of my dad’s second heart attack, our parents had been separated for nearly twenty years and Dad had met his future second wife and started a family with her. Myself and my siblings realized that this was giving him another chance at life – one I felt he thoroughly deserved after such a long period of being alone in the world. I think it also gave him the determination to stay as well as he could for his new young family and, to most of the medical people’s amazement (including my own), he lived many more years to see his precious two younger daughters grow up to their late teenage years.

  My father died in 2013. I still miss him. He left more of a legacy than I ever realized and his influence on my career becomes more profound with each passing year.

  22

  * * *

  OFF-BALANCE

  ‘I woke up, turned to my left to ask my husband the time, and my world turned upside down. The whole room flew past my eyes. I sat up, screamed out “help” and promptly threw up all over my husband who was still sleeping. I felt like I was on a ship being tossed about by a stormy sea, or as if I was in the worst aeroplane turbulence of my life. I was sure I was going to die. At best, I was having a stroke.’

  Simone then held her vomit-soaked husband and tried to regain a sense of calm. She sat unmoving and the violent vomiting stopped briefly. When she moved her head again the vomiting became relentless. The photographs of her children flew past her and the bedside books appeared to be spinning on the table. The ambulance arrived within ten minutes and she had worked out by now that moving her head was not an option if she was not going to destroy the bedroom. The paramedics gave her an injection for the nausea and carried her from the bedroom as if they were carrying a fragile glass cabinet.

  I saw her in Casualty that morning and Simone was as white as a ghost. Her vomiting had settled to a desperate retching that was only relieved by sitting stock-still. I coaxed her to stand up and to try to take a few steps. She listed to the left, for all the world like someone who had drunk a few bottles of wine (‘I have not been drinking,’ she managed to whisper). When she stood with her feet close together and her eyes closed she toppled over dramatically. I held my finger up in front of her eyes and when she looked to the left and right her eyes moved like the windscreen wipers on a car window when the rain is drying up. They dragged across from one side to the other, causing her immense discomfort, and this induced further retching.

  She could speak, she could see, her face was symmetrical, and she was moving her arms and legs normally, so a stroke was most improbable. When I got her to walk up and down on the spot, eyes closed, her arms out in front of her like Frankenstein’s monster, she quickly turned almost 180 degrees and ended up facing the opposite wall when she opened her eyes again. I got her to lie back on the trolley and held her head as I gently eased her back over the edge of the bed and turned her head one way and then the other – similar to the position you take to kiss the Blarney Stone, apparently. Turning her head to the left was fine but when I leaned her head over the bottom of the bed on her right side she threw up on the floor and her eyes appeared to be dancing in her head.

  We use our ears to hear, obviously, but many people don’t realize how our ears help us balance. The inner part of our ears has three little canals, called semi-circular canals, which communicate with our eyes to help keep our sense of equilibrium as we move around. This is called our vestibular, or balance, system. These fragile canals are damaged when, say, someone gets a blow to the head. I see concussed sportsmen and women who have an inner sense of unsteadiness long after they appear to have recovered from their injury. It can be hard for them to explain, but usually they agree that it is a non-specific sense of unease that they too liken to being on a ship.

  So Simone had a frighteningly acute form of vertigo, known as benign paroxysmal positional vertigo, or BPPV. This is surprisingly common and quite easy to treat, but when someone develops symptoms, it’s a serious shock to the system.

  Simone was sure she was dying the morning that her BPPV set in. She laughed as she told me that while she lay in the ambulance, she was planning the music to be played at her funeral, and making lists in her head of whom she did and did not want to attend. Simone was very cool.

  ‘I know you think I am being melodramatic,’ – I didn’t – ‘but unless you have experienced that helplessness you can never really appreciate the fear.’

  I have heard comments like this from patients many times and, despite having seen thousands of patients each year for many years, I still wholeheartedly agree. Try as you might, you can never wholly empathize with a sick person unless you have been sick yourself. Even then, each person’s illness is different. How each individual reacts to a diagnosis is equally variable, so what seems like a benign malady to the doctor can be far from benign in its effects on a person’s life, and on those around them. ‘Benign’ to most doctors is cause for celebration. After all, when on a daily basis you are giving some people a death sentence it is no small relief to be able to say you can actually cure someone. So a BPPV diagnosis is a good day for doctor and patient alike because the next person through the door might not be so fortunate.

  The lining of one of Simone’s semi-circular canals in her inner ear had come loose. The exquisitely finely tuned ebb and flow of inner-ear fluid traversing these canals now carried in it minute stones (otoconia) causing small eddy currents to the flow. This change in flow disrupted the nerve signals from her inner ears to the control centre for her eye movements when her head was held in certain positions, but not in others. It was as if the wallpaper lining the canals had peeled off and dropped into the slow-flowing water, and the disrupted flow was causing her acute vertiginous symptoms.

  The solution was the weird-looking ‘Epley manoeuvre’, whereby the patient lies on one side and is gradually turned over, quite like a rotisserie chicken – not a very pleasant analogy, I admit, but most people get the gist. By rotating the person’s head slowly, the loose ‘stones’ are emptied internally from the canals, restoring the normal flow of fluid.

  For Simone it was just a few days before she was back to her usual self with no lingering physical or psychological effects. For others, the symptoms can grumble on for months or years, changing their entire lives. Most people have a single acute episode, get the right treatment, and get on with their lives, making it hugely satisfying to treat as a neurologist, and a massive relief to patients.

  Carried away with the romance of his daughter’s wedding, and a few too many celebratory drinks, Eddie decided that at sixty-eight years of age he was still able to jive the way he and his wife used to in the 1960s and he swung the light of his life enthusiastically to Bill Haley. As the ‘clock struck two’ he fluffed his dance move and let go of his wife, toppling backwards into a dessert trolley and finally coming to rest with a thump to t
he back of his head on the dance floor’s edge. He jumped up quickly, profoundly embarrassed, of course, but with just a small cut to the back of his head and a massive bruise to his paternal pride.

  Eddie felt fine, he insisted, but drank no more and an hour or so later made his excuses and went to his hotel room. The next morning his world too was turning upside down, as he cursed his decision to pay for the cheaper wine the wedding planner had offered. Surely it was to blame. He vomited once or twice, and after a few minutes the spinning settled into a low-grade pulsating headache with a disconcertingly persistent sense of nausea. He soldiered on through the barbeque that day, but was unable to eat the food he had paid for, and his daughter was raging with him for making a fool of himself the night before, which didn’t help matters.

  Over the next few weeks the symptoms settled and he put his unpleasant experience, sensibly, down to concussion rather than a prolonged hangover. But he continued to feel vaguely out of sorts for months, and decided he needed to do something about it. He had become temperamental and was acting strangely; he was starting to snap at his wife and work colleagues over minor issues that ordinarily would not have bothered him.

  It is always interesting to watch how physical symptoms can affect a patient’s mood and how this in turn affects their relationships. They will attribute all of their problems to, say, that fall on the dance floor, and tell anyone who will listen how it has ruined their lives. After a while, family and friends will get bored of the complaining; after all, he looks fine – no blood, no stitches, no cast; he can’t be that sick. He’s probably turning into a grumpy old man. (Oh, how we love our stereotypes!) As life with the sick person becomes progressively more unpleasant, people start to distance themselves, and the patient becomes isolated and depressed.

  Eddie came to see me about a year after his daughter’s wedding. I was his last hope, he said forlornly. He had seen any number of doctors and had at least two brain scans, but the scans were clear and he was told he had suffered a mild concussion, about which he was now understandably depressed.

  I agreed with these interpretations of his symptoms but, in addition, it turned out that he had injured at least one of the semi-circular canals of the vestibular system in his ears, which explained his unease and ongoing nausea. When he was reading a book or scrolling through his phone, he felt wretched. I reproduced the symptoms he got when reading by making him move his eyes left to right, which in turn revealed the same dry-windshield-wiper effect that Simone had shown.

  I arranged for him to see a physiotherapist who specialized in helping people retrain their damaged vestibular systems through a series of exercises. I reminded him that his symptoms had been present for a year, and that he should expect a slow recovery. When a rugby player breaks a leg, he does not take off the cast and run out into the Aviva stadium. He has to slowly rebuild the atrophied muscles and rehabilitate in a gradual manner to regain his former physical ability. Almost as important, a player has to regain his psychological strength after losing his sense of invincibility.

  A simple injury like that having such catastrophic results enthrals me. Eddie himself marvelled at how quickly his health and self-confidence were taken away from him. It took a few months, but he gradually recovered his sense of physical and mental equilibrium. He was embarrassed by how he had reacted to what he now saw as a minor injury and apologized to everyone he had been short with. Eddie later told me that the physiotherapist had restored his sense of hope – though he swore that his jiving days were over. I wasn’t convinced and I had a feeling he’d be back out there ‘Dad dancing’ again the next time a wedding band struck up ‘Rock around the Clock’.

  23

  * * *

  A HIDDEN SIDE OF CANCER

  Tom was a twenty-year-old Gaelic footballer. His father had played before him and loved the fact that his son was following in his footsteps by playing on the Under-21 team at their local club. Tom was popular and had a wide circle of friends both in real life and online, as is the way of things these days. One November morning, he arrived downstairs to the kitchen in a state of distress. ‘My phone has been hacked,’ he said to his mother.

  ‘What do you mean?’ she asked.

  ‘My Facebook page, my Twitter feed; everything has been hacked,’ he said.

  He was apoplectic with rage and his mother tried to calm him down. She knew things had not been quite right for the previous few weeks, but small events suddenly took on new significance. He had been involved in a row with a college mate, which was most out of character, and he had started to question his tutors aggressively during lectures. His mother had heard of these events and asked Tom whether anything was wrong. He had side-stepped her questions by explaining that he felt under pressure at college and was finding it difficult to keep up with some of his course work.

  Tom was convinced now that he was the victim of an online campaign to discredit him socially, and hence his belief that his phone had been hacked. He cancelled his Facebook, Twitter and Instagram accounts. By the end of the day he seemed less agitated but the following morning his mother knew something was seriously awry when a friend of his called to ask whether he had made it home. Tom had gone with friends to the college bar, but at some point had walked out without saying where he was going. The friends had also been worried about changes in his behaviour and had gone looking for him. They found him wandering alone on the football pitch ranting about the mountains collapsing around him. They thought perhaps his drink had been spiked (he had only had two pints) and talked him out of his fugue-like state to the point where he said he was fine and was going to get a taxi home. They let him head off but remained concerned enough to call his mother the following morning.

  I saw his distraught parents and his sister outside the small cubicle in Casualty later that morning. By now Tom was asleep on a trolley but he had seemingly been nonplussed earlier about why he was in hospital and why his family was so upset. A psychiatrist had been called, and had spoken with Tom and quickly concluded it was more a neurological than a psychiatric issue.

  Although Tom could walk and talk he seemed to be detached from his surroundings. He answered my questions slowly and, like a phone call to Hong Kong, there seemed to be a delay between my questions and his responses. He followed my request to walk in a straight line and was able to enunciate various complex phrases I asked him to say. He was oddly incurious about what was going on. The rest of his physical examination was fine so we arranged a brain scan, which revealed a bright spot in his temporal lobes (memory centres). We also performed a lumbar puncture.

  The tests confirmed he had an unusual autoimmune condition called limbic encephalitis. This is yet another condition whereby the immune system becomes over-zealous and the antibodies it produces to protect us start attacking normal tissue. These autoimmune conditions can arise spontaneously or following an infection, but they can also herald an occult cancer elsewhere in the body. That means a cancer that is already causing harmful effects, without our yet knowing where the primary tumour is. In these cases the first symptoms a person develops may be neurological – changes in personality or even seizures – arising from the antibodies attacking areas of the brain.

  We checked Tom for such a cancer and found he had a small lump in his testicle that subsequently proved cancerous. Once the cancer was removed, the stimulus for the rogue antibodies that were attacking his brain would be halted. However, Tom still needed ‘good antibodies’ – immunoglobulins – to defeat his own ‘bad antibodies’ to allow the attack on his memory centres to cease.

  Thankfully, Tom responded brilliantly to the treatment and within weeks he was back home and had reopened all of his social media accounts. When I met him again he had little recall of his stay in hospital or of any of our conversations during his time with us. His parents could not believe what had happened. I wondered how long it would take them to stop looking over their shoulders whenever their son behaved in any way out of the ordinary – in other word
s, like a typical college student.

  Ophelia, better known as Hamlet’s love interest in Shakespeare’s play, is forced to choose between her father and brother, who warn her against the liaison and her love for the Danish prince. Slowly she descends into madness.

  I had never heard of Ophelia syndrome until I met Jack when I worked in Melbourne. He was forty-three years old. When I was called to see him in the hospital’s emergency department his wife described how her quiet and studious husband had changed over the preceding seven or eight months. He paid his rent several times in one day and got lost in familiar places, and this, coupled with increasingly obvious problems with his day-to-day memory, caused her to seek medical help. He was sent to see a psychiatrist, and with some anti-psychotic medication he appeared more settled for a few weeks.

  This loving husband, who had rarely so much as raised his voice to his wife or children, then began to display increasingly aggressive tendencies. He was brought into the hospital by the police when they were called following an assault on his brother. How could this man who had never harmed anyone in his life suddenly undergo such an extreme change in personality?

  Jack was calm when I met him but, like Tom in the previous story, bizarrely indifferent to the chaos around him. He seemed uninterested in why he was in hospital and unconcerned about the distress he was causing his family. There was no loss of muscle strength in his arms or legs and he could walk and move his eyes normally. But his speech was slurred and he found it troublesome drinking from a glass of water.

  Jack also had clear-cut memory problems. We tested his cognitive abilities using the Montreal Cognitive Assessment Score. This assesses a number of cognitive abilities, including short-term memory and basic questions about the day, date and year. Jack scored fifteen out of a possible thirty.