Just One More Question

by Niall Tubridy

  At twenty-eight I was in London, working as a junior registrar. I recall walking home with a takeaway McDonald’s one evening when a flash car beeped at me. The car pulled over and out popped an old schoolmate from Dublin. I remember how self-conscious I felt, hiding the McDonald’s bag beneath my coat as he regaled me with tales of the buckets of money he was making in ‘the City’. I shouldn’t have cared, but I did. I was hardly on skid row, but he had bought a house and car, and, most important to me, seemed so much more grown up than I was, as I headed back to my shared flat in Lilley Road with my cold Big Mac. I was bemused that ten years after we had left school I was working ridiculous hours, albeit in a job I loved, but with little or nothing tangible to show for it. Yet, even as a junior doctor, I felt I was needed. I had a purpose that money could not buy.

  27

  * * *

  THE PRICE OF SAYING ‘YES’ TO THE DRESS

  Janine had not been sleeping well. She would wake in her West London flat at 3, 4 and 5 a.m., as if an alarm clock was going off on the hour. Her recurring dream was of a small elephant walking slowly in front of her family and friends, a forlorn look on their faces, as the sounds of a Durban school band echoed in her ears.

  Her wedding was in three months’ time and she was worried. Not about her decision to get married – Giles was definitely The One. Nor was she concerned about having the ceremony in her native South Africa, the ongoing long-distance rows with the wedding planner notwithstanding. What was really causing her sleeplessness was the fact that she was three stone heavier now than when she and Giles had met two years earlier. Domino’s pizzas and nightly video rentals had turned her into what she referred to as ‘the blob’. She had been so sure she would lose weight she had persuaded the bridal shop to order a dress two sizes smaller than she then was. They told her that of course she would lose the weight; every bride did. Now they were making noises about letting out the seams and sewing in extra panels.

  She had tried various diets, each one more extreme than the last. Her net weight loss: a miserly four pounds. In desperation she joined a local gym and signed up with a prohibitively expensive personal trainer. Finally, the weight started to shift. She ate hardly anything, walked to work instead of taking the Tube, and gave up alcohol. Life was miserable but at least she was getting thinner. Four weeks into this desperation regime and she had shed a stone. She decided to up her game by taking laxatives. In two weeks she had lost another half-stone. She felt tired and wretched, but at least everyone was telling her she looked great and it looked like she’d get into her wedding dress after all.

  On her way to her next punishing gym session, she tripped over her gym bag as she tried to haul it out of the car. Both of her legs suddenly felt numb and, as she made her way inside, she tripped again, this time falling flat on to the tarmac. She picked herself up hurriedly, took two further steps and realized that her feet were not doing what they should. To propel herself forward she had to lift her legs high off the ground. Her walk reminded her of the images of astronauts walking on the moon; she knew that if she did not imitate their high-stepping movements her feet would remain stuck to the earth and she would go over once again.

  Janine came to visit the Central London hospital where I was working about six weeks before the big day. The loud slapping of her feet on the hospital linoleum made the diagnosis more acoustic than visual. She just could not lift her feet off the ground. When she walked it was with great effort from her upper thigh muscles. The noisy slapping of her feet accentuated her embarrassment and prompted a torrent of anxious tears.

  Although it was clear she had foot drop, I did not know why and thus could not adequately comfort her. It did not take long to explain how this had happened – she had damaged both of the nerves that controlled her ability to lift her feet off the ground. It took longer, however, to find out why. I asked the usual questions about changes in medication, family history and whether she had had any previous medical problems, but to no avail. It was the trip over the gym bag that was key. And so I got the whole story of her mad bid to lose over two stone in three months.

  As a result of dieting and exercising like a woman possessed Janine had lost the fat protecting the nerves near her knee joints so they had been inadvertently exposed. These nerves run down to our feet and control dorsiflexion of the foot – the movement we produce when we walk on our heels. Being more exposed, the nerves were easily compressed; for example, by crossing her legs when sitting at meetings at work. Eventually, the nerves controlling the muscles of her ankles and feet were damaged to the point where they could no longer transmit the electric current required and ceased working altogether, leading to Janine’s pre-nuptial ‘dropped’ feet. It is a common problem in people who lose weight precipitously either by design or through illness. It is a fairly common sight in patients with cancer or in some who have spent prolonged periods in intensive care.

  The nerves would recover slowly over the next month or two, and Janine’s fears of a wheelchair-bound future were put to rest. But the wedding had to be postponed. I later learned that she recovered full function of her legs and went on to marry Giles later that year. She walked up the aisle the same size she was before the nightmares of elephants had started.

  Younger doctors, who lack experience in medicine and in life, can sometimes seize upon the vices of their patients to chastise them. Contrary to their deserved reputation for prolific drinking, young doctors may seem very mean, lecturing already anxious patients many years their seniors. Over time I realized this was a small defence mechanism to manage their own (my own, in my early years) ignorance. After all, it is easier to blame a patient for their illness, and thus exacerbate their shame and misery, than think through the problem in depth and admit how little you actually know.

  Silvia was fifty-six years old, right-handed and originally from Croatia. The pressure of a late-in-life course to become a reiki instructor was getting her down. Her two children had left home a few years previously. The ‘Is that it?’ of the empty nester was a cliché she tried to stave off by devoting herself to her studies, but it wasn’t helping. She was drinking more than she used to, but denied it was a crutch until she woke up in a blur one Monday afternoon and was unable to move her right arm.

  She tried to convince herself that she had had a stroke, as this was far more palatable to her than having to face the truth of her descent into alcohol dependence. Her wine o’clock drinking had escalated to gin and tonics for lunch, and things deteriorated from there. She had downed a half-litre of Hendricks on her own that Monday while watching daytime television instead of writing up her assignment.

  Silvia had already searched for possible causes for her weak arm on the internet and quickly came up with ‘Saturday night palsy’. This pejorative phrase was coined by doctors many years ago for drunks who fall asleep with their arms draped over the back of a chair, compressing the radial nerve in the spiral groove of the humerus. It results in a ‘dropped wrist’ (like Janine’s dropped foot) and usually recovers within four to six weeks – although the sense of shame probably lasts a lot longer than the hangover. (In fact, the term is thought to have been used to describe wrist drop in young men courting on park benches in more chaste times in London, a much more romantic image but, I imagine, rather difficult to explain to partners if the romances were of an illicit nature.)

  Silvia was initially reluctant to engage with me, but softened when she realized she was not being judged. I was able to agree with her own diagnosis, which made her feel better – not only was it a temporary state of affairs but she had managed to do a sensible bit of research about it too. I didn’t have to say anything about her drinking because she knew well herself that she had had a wake-up call. Silvia’s arm recovered within a few days and, of course, she swore off alcohol for ever.

  28

  * * *

  DR GOOGLE

  My first job as a schoolboy was picking strawberries with friends. We were paid two pence for each pun
net and, to a ten-year-old boy, this was a fortune. I was always a fairly competitive soul with a decent work ethic so I would arrive early each summer’s day to the local strawberry field owned by the parish priests in our area, and try and out-pick my friends. After hours of kneeling in the dry soil I would stand to find one or other of my feet was numb. Sometimes it would be more severe and for a brief few moments my foot would be weak (dropped foot – there it is again). I would massage the leg and run it off before getting back to competitive strawberry picking.

  I would later discover that ‘strawberry picker’s foot drop’ was a well-described phenomenon in neurology. Being a skinny fellow, this transient foot drop could occur over the subsequent years whenever I even sat with my legs crossed for prolonged periods. Like most people, from time to time I would also wake up with a numb hand having slept in an awkward position. I would shake my numb hand briskly, leading to return of full feeling, and get on with my day.

  As I began to learn about all things neurological, I started to understand the mechanics of nerve compression. What, to me, was a simple transient compression of the median or ulnar nerves to my hands, I soon became aware represented the first signs of multiple sclerosis or motor neuron disease to those who were not as fortunate and who had turned to Dr Google for enlightenment.

  Professor Jean-Martin Charcot is regarded as the father of modern neurology. He worked in the famous Pitié-Salpêtrière Hospital in Paris in the late nineteenth century. (I was fortunate enough to spend almost a year there during my training. I did not speak much French but the people there could not have been more welcoming, and I immersed myself in the history of the subject that I love.) Charcot was a brilliant clinician and teacher and took a particular interest in what he called hysterical behaviour. At public lectures he would demonstrate what was known at that time about all things neurological and bring in subjects whom he felt were feigning their illnesses (of course, these being sexist times, they were nearly always women). Charcot is believed to have spoken, over 130 years ago, about ‘la maladie du petit papier’ (roughly translated as ‘disease of the small piece of paper’). Patients would arrive at the clinic with scraps of paper on which they detailed all of their symptoms. The longer the list, the less likely he felt that he was dealing with a serious neurological illness. Sir William Osler, another giant of medical history, known as one of the fathers of modern medicine, termed the condition ‘neurasthenia’.

  Far from labelling it ‘la maladie du petit papier’, I think the use of lists and diaries detailing neurological illnesses can be extremely helpful. I encourage patients to write down their symptoms, the timelines, any variations, and things that provoke or alleviate these symptoms. I believe it helps people to focus on what they truly want out of a consultation. And it can give them back a much-needed sense of control. For someone with migraine, for example, tracking what makes their headaches better or worse makes the patient an active participant in figuring out a treatment plan.

  However, like most things in life, problems arise when the behaviour is taken to extremes. We are now in the age, as it has been called elsewhere, of ‘la maladie du grand printout’. Today we have not just plain lists but pages of printed-out notes, spreadsheets of symptoms and even timelines stretching back decades – all to be covered in a thirty-minute consultation while the queues of patients build up outside.

  Extensive Google searches will yield multiple possible diagnoses and, human nature being as it is, we will invariably latch on to the worst-case scenario that fits with our symptoms. As often as not, the doctor is forced to exclude the patient’s diagnosis and, when they do, the disbelieving patient may go elsewhere and the process begins all over again.

  One of my rules in the internet age is to tell young doctors never to trust the findings of someone who comes with a Google diagnosis, and never to trust anyone who says they have not googled their symptoms. We all do it, neurologists included, so we might as well at least start the conversation as honestly as we can.

  Imelda was eighty-five and accompanied by her three grown children, who had spent the summer months watching their mother list drunkenly around the house, dizzy spells interspersed with episodic vomiting, and then she would take to her bed. Imelda looked great and had a fine sense of humour, but had lost her self-confidence. This can happen with people who are lucky enough to have been pretty healthy well into old age and finally experience ill-health.

  Her previous scans were all clear, her children assured me, but they had done their research, and each had come to their own conclusion. Her son was sure she had Parkinson’s; her two daughters thought that she was having recurrent strokes. Imelda sat there petrified as they made their diagnostic pronouncements.

  Imelda told me that she had been having dizzy spells for well over thirty years. As usual, I wanted her to recall when this had first happened. It was striking how, with only the slightest prompting, she was able to do this. Imelda had gone on holiday to Italy with four friends around the time of her fiftieth birthday. She had been very excited about it, and looked forward to the trip away with ‘the girls’ for months. She felt she had overdone the wine on the first night and wanted to sit by the pool the next day to recover, but as she walked from the lift to the sun loungers she noticed she was listing to the left.

  ‘Oh my God,’ she recalled. ‘I really had overdone it, and I thought I was still drunk.’ Imelda was very lady-like and you could see this was not her form at all. Even thirty-five years later, she blushed just retelling the story.

  The dizzy spells settled for a while and she got on with things, but intermittently over the next thirty-five years Imelda would experience these horrendous spells when she would walk ‘drunkenly’. She gave up alcohol altogether, just in case it was the cause. She would sometimes be confined to her bed for a week or more, her world turned upside down whenever she moved her head. She felt her head was constantly ‘muzzy’ for all of those years.

  From time to time she had sought help, but only got the occasional period of respite from the medications her GP prescribed. She stood in front of me, and when asked to close her eyes she started to sway as if caught in a strong wind. Her eyes would stutter when she looked from left to right, and she couldn’t walk easily in a straight line on the clinic room floor. ‘You do think I’m drunk!’ she laughed.

  Happily, Imelda just had chronic vertigo, due to an imbalance in the fluid of her inner ear, and totally unrelated to her alcohol intake. With a lot of physiotherapy, her balance problems could at least be significantly improved and possibly cured entirely. In this case Dr Google, and Imelda’s children, had got it wrong.

  Aishling had beautiful red hair, but it had a tendency to curl which was ‘not cool’, she explained. ‘I have been straightening my hair since I was fifteen,’ she said, ‘and never had any problems until the last few months. Now, I can only straighten one side of my hair and then my arms are too tired to finish the job, so unless Mum helps me I am left with one side straight and the other side curly and my brother now calls me “Sideshow Bob” [a character from The Simpsons].’

  As my long-haired registrar stifled her mirth at my ignorance, Aishling produced her GHD. Given my follicularly challenged state she had to explain what it was. GHD stands for ‘Good Hair Day’ and it is the brand name of one of the bestselling electrical hair straighteners. It looks like a pair of tongs, but when plugged in it heats up to become a clamping iron in which the long hair is gripped and slowly straightened. To straighten Aishling’s luxuriant locks took about twenty minutes on each side.

  The neurological examination of Aishling’s arms was normal. She had good power, no loss of muscle bulk, and all her arm reflexes were present. When she held her arms up above her head for a few minutes they appeared to go a shade paler. I took her pulse in both arms with her arms down by her sides and then with her hands held above her head. After a minute or so the strength of the pulse to both hands diminished appreciably and Aishling reported that her arms wer
e too tired to hold up any longer. It was clear that something was interrupting the blood flow to her hands but only when they were held above shoulder level for a few minutes.

  An x-ray of Aishling’s neck revealed an extra rib in the neck area, known as a cervical rib, that would have been there from birth. Sometimes fibrous bands associated with the extra rib can compress the blood vessels coming from the heart to the arms and so the symptoms would come on only when her arms were raised above her head. A relatively simple surgical procedure cuts these bands and relieves the pressure on the circulatory defect. Aishling underwent such a procedure and was soon back to her good hair days.

  Within three weeks of seeing Aishling I met Siobhán. She was twenty-two years old and complained of pain in her arms for the previous year.

  ‘Do you have a GHD?’ I asked.