Just One More Question

by Niall Tubridy

  ‘How did you know?’ she replied with a quizzical smile. ‘I got a GHD for Christmas last year but over the last few months I have been unable to use it, as my arms get tired when I am using it before a night out – it’s ruining my social life!’

  It is not uncommon to see a case such as Aishling’s, hear about GHDs and the like for the first time, and then, like buses, see similar cases in quick succession. I am sure there is a certain bias in this non-scientific method and, of course, I always fear I have missed many such cases before by not being alert enough to ask the right questions.

  I went through the same examination with Siobhán as I had with Aishling. Once again the strength of her pulse diminished rapidly when I held her arms above her head for a few minutes. Feeling smug, I ordered the x-ray to confirm the cervical ribs and was deflated when they confirmed nothing of the kind. I requested an MRI scan of her neck and of the forest of nerves around the armpit regions, and here we found a narrowing of the blood vessels to her arms.

  With some further blood tests and scans we were able to determine that Siobhán had a rare inflammation of the blood vessels throughout her body, though only those to her arms were causing any symptoms, but intermittently and particularly when using her hair straightener.

  With medications to reduce the inflammation she was eventually back to herself and her straight hair, although by now she had grown used to her ‘new look’ and abandoned the GHD anyway.

  Both of these young women had similar symptoms and similar signs on examination and both blamed their GHD. Yet the cause for each was very different, and for Siobhán it meant heavy-duty medication for over two years to alleviate her pain. These are good examples, I think, when trying to illustrate how self-diagnosis via Google can be unreliable. Many conditions can match someone’s complaints and cause either panic (‘Oh my God, I have a vasculitis and will need steroids for ever’) or undue reassurance (‘Ah sure, it is only a little extra rib’).

  One of the great secrets of modern medicine is that doctors are training to treat the sick but are in fact frequently treating the well. It is fairly basic pop psychology to understand the worried well. People with headaches brought on by the stresses of their jobs are convinced they have a brain tumour. Our minds are so cluttered we cannot store all of the information we are exposed to, so inevitably we start to forget things and then worry that we are developing dementia. The hand that is numb in the morning because we slept awkwardly provokes concerns about MS. And, again, Dr Google is not always the friend of the worried well.

  Raising awareness of chronic illness is a goal of many charitable organizations. I greatly admire their endeavours, as the people who suffer from as yet incurable illnesses appear to regain a sense of control when they get involved in such drives to raise awareness, and millions of euros are raised to help researchers better understand difficult conditions and work towards an eventual cure.

  The Ice Bucket challenge was devised by someone with an iPhone and an interest in raising money for motor neuron disease and was performed as a wheeze. It raised millions, and fast, and was quickly seen as the go-to route to raise money for relatively rare illnesses.

  What happened next was unprecedented though. What became apparent in my clinics – and I presume those of other neurologists – was that awareness, now raised, had led to hyper-awareness and, in many cases, to borderline hypochondriasis. Around the time of ‘the Challenge’, I encountered numerous young men at their wits’ end asking whether they were dying of this terrible disease. It was difficult to reassure them on clinical or statistical grounds. And when all of the tests proved normal or negative, I would hear from neurology colleagues that they had been asked for second or third opinions.

  At the root of their anxieties the social history appeared critical – middle-class (usually) white males who had recently become fathers for the first time. The men were worried that they would not be around to see their newborns grow to adulthood.

  This cannot be the only generation of young fathers who have experienced such angst, but this highly specific manifestation of their worries in the wake of a social-media-led awareness campaign was new to me. I did not diagnose a single case of motor neuron disease among this worried group. But I wonder if they ever recovered their full peace of mind.

  Likewise, for many years I have seen young mothers present with numb hands or feet or pins and needles in their extremities, and they are generally worried about multiple sclerosis. It seems particular to young Irish mothers who are aware that they are in the most frequent demographic category affected by MS – young, white and female. All they can see ahead is a future with wheelchairs.

  While occasionally I have diagnosed MS, most of the women who presented have turned out not to have it. It is curious to me that men seem to worry more about developing motor neuron disease and women about developing MS, but both groups seem, at heart, to be worried about not being there for their children. Giving patients the ‘all clear’ is one of the great joys of my working life. After all, it is pretty easy, as a doctor, to look after those who are well.

  29

  * * *

  HIMSELF

  After leaving Ireland in 1995 I spent many happy years in various hospitals throughout central London before moving to Paris for a year and to Melbourne in 2000. I had brilliant fun as a peripatetic neurologist, but I missed Ireland and was keen to get home. And that’s why, almost ten years after leaving Dublin, I found myself sitting in front of what seemed to me like a huge panel of senior colleagues in St Vincent’s Hospital feeling like an eighteen-year-old first-year medical student once more, being interviewed for a consultant-neurologist post.

  I worked very hard at my interview preparation as there were at least ten other suitable (possibly more suitable) candidates for the job, so there was much excitement among the small but loosely knit community of Dublin neurology. This was to be only the twelfth or thirteenth consultant neurologist appointed in Ireland at that time.

  I remember the ill-fitting suit I wore and the nervous attempts at raising a smile from the forbidding panel of my future peers – how not to do an interview, according to all of the advice I have read on the subject since. That evening I was catching up with friends with whom I had shared many of the ups and downs of medical student life, expressing resignation about how badly it had gone and anticipating the long flight back to Melbourne, when I got the call offering me the post. Quite overwhelmed and very much out of character, I shed a tear. I was ecstatic. I guess my somewhat naïve authenticity had somehow won the day.

  Having packed my life up once again, and said goodbye to Australia, I was very excited to arrive in St Vincent’s some months later. While I felt ready for it, I was still extremely nervous. My senior colleague Michael (known to one and all as ‘Hutch’) had worked single-handedly as the hospital neurologist for over twenty years and appeared pleased to finally have a colleague, albeit a much younger and greener one. The relationship between colleagues in medicine is described as more difficult than a marriage as you can always divorce your spouse but you are stuck with colleagues – and they with you – for life.

  When I arrived Hutch said, ‘Great, you’re here at last, you can take over!’

  He was joking – but he promptly left the ward and I like to think he went out that evening and got gently drunk with relief after all of the years he had carried neurology in the hospital on his own.

  One of my first tasks, and one that will remain with me for ever, was to explain to a family of six adult children that their mother, who was in the end stages of motor neuron disease, was dying. It was impossible to be precise about when, but I was qualified thirteen years by this stage, and experience told me that she had no more than a few months to live.

  I explained the eighty-year-old woman’s circumstances confidently – and, I hope, sympathetically – to her children, who ranged in age, I estimated, between about forty and fifty-five. They knew she would soon be dead, and had come to term
s with it as best they could, but were keen to have greater clarity as to when and how the end would come. I told them that I believed she had between three and six months to live, with the usual caveats of ‘it could be less, it could be more’, and that we would do all we could to avoid her suffering any further.

  I often wonder what goes through the minds of patients and family when a relatively fresh-faced doctor explains a sad case like this. You can see them glazing over as you explain the more complex medical details, but you assume they will remember for ever some of the words you use. Indeed, this family was probably going to remember even the peeling wallpaper in the ‘relatives’ rooms’ we then used for breaking such sad news.

  I finished my monologue and asked whether they had any questions. After a brief silence, the eldest son piped up. ‘Well, Doctor, how long has she got?’ I was disappointed with myself that, in spite of my best efforts, I had obviously not been clear.

  ‘About three to six months,’ I repeated. ‘It could be more, it could be less.’

  He received this seemingly new information with a grim but accepting shake of his head.

  The room once again went silent and I edged forward in my seat before asking, ‘Does anyone else have any questions?’

  His sister spoke next. ‘I want to know, Doctor, how long you think she has?’

  I got slightly flustered. Here was my first task on my first day, and I was falling at the first hurdle. I appreciated the intense nature of the conversation. I had done this many times before while working abroad: this grieving family was not taking in a word I was saying.

  ‘Three to six months; could be more, could be less. One can never be sure about these things. I am really sorry you are all going through this awful ordeal.’

  I waited. Silence again. Had the terrible news finally begun to sink in … perhaps?

  I thanked them for listening – what else could I say? – and got up to give them some privacy for a while. I said I would come back later in case they had any further questions. As I reached for the door handle, the youngest of the six siblings let out a yelp.

  ‘I have just one more question!’

  I was dumbfounded. I spun around and started to repeat myself.

  ‘About three to six months; could be more, could be less –’

  ‘No, it’s a different question,’ she cut across me. I was relieved, if a little embarrassed at my display of exasperation.

  ‘Are you anything to Himself?’

  The trials of having a famous brother had begun.

  What had never occurred to me when returning to Ireland was that having a brother who worked in television would have any impact on me. Of course, during my long sojourn abroad Ryan’s career had developed, but before coming home I had no idea how high his profile was. I was soon to learn.

  A decade later and an oncology colleague asked me to look at one of her patients. Mrs O’Reilly was about sixty-two years old and had been well until a few months previously. A niggling but persistent pain in her right flank eventually persuaded her to see her GP. Within a few weeks she was undergoing her first round of chemotherapy. The chemotherapy was not working and she had developed a weak right hand.

  I walked into her room. Her distraught husband was sitting beside this frail lady who now looked many years older than him. I thought he was her son initially. The brief few months of her illness and her treatment had aged the poor woman terribly. Her emaciated frame was topped with her beanie hat (‘the new bandana’, her daughter told me with a smile). I introduced myself and explained why I had been asked to see her – to investigate her weak right hand.

  Her left eye was closed and, when I asked her why, she casually mentioned some double vision for the previous few weeks that she attributed to an allergy to some new eye make-up.

  As we chatted she started to giggle. It was undoubtedly a pleasant interaction but the humour in it eluded me. From the neurological perspective she had a third-nerve palsy (paralysis of one of the nerves to the muscles that move your eyeballs and keep your eyelids open) of her left eye, no feeling on the left side of her face and a decidedly weak and clumsy right arm and leg.

  Her quiet giggling continued as, apologetically, I scratched her feet to elicit the plantar response. Her right big toe went up (a bad sign) and she laughed again. As I started to tell her that I was concerned, but not absolutely sure yet, that her cancer might have spread to her brain, she interrupted me.

  ‘I feel like I am meeting Himself.’

  By now, after years of getting a similar response to my apparent resemblance – in manner and voice, if not appearance – to my younger brother, I was well used to this happening. Having had a long and intense conversation with a patient about a life-changing, or even life-ending, diagnosis, I usually finish by asking if the patient has any further questions. Frequently there is a question about Ryan, or a joke about getting tickets for his show. It took me quite a while to stop being surprised at how many times a week this would happen. It was comedy of the blackest nature. As I got older I realized that my sense of disbelief was in poor spirit. If it was a distraction for people at a difficult moment what harm was it doing? As I keep reminding myself – ‘Whatever works.’

  30

  * * *

  A SHAKING PALSY

  Conor was writing a cheque in the bank and the queue was building behind him. He could feel the Friday afternoon crowd’s impatience when he dropped his chequebook on the floor and fumbled as he tried to pick it up. He felt sweat trickling down his back and his face start to burn. The bank clerk smiled and asked him to sign on the line. He paused. He couldn’t do it. He reddened further and asked her to take the cheque unsigned but she said she couldn’t. He tried again. The pen felt like a lead weight in his shaking hand. He tried to scrawl his signature but the result was unrecognizable. His usually neat handwriting was indecipherable. He could hardly read the tiny, spidery writing himself. The bank clerk reluctantly accepted the cheque. Conor hurried out of the bank past the glaring customers. ‘They thought I was drunk, I’m sure,’ he told me later. He felt both humiliated and frightened, and his embarrassment finally convinced him to seek help.

  He was sixty-three and had worked in marketing for years. He was happily married and financially comfortable. His children were grown up and he was a proud grandfather twice over. Friday nights were spent with his old school mates, and he had a season ticket for the Leinster rugby matches. On the face of it, life was pretty good.

  But Conor had known something was wrong for about a year. Everything had felt terribly non-specific, but anxiety was creeping into every part of his life. He realized that he was increasingly hampered buttoning his shirt for work in the mornings. Then in the office he felt he was constantly rushing, though he was clearly slowing down. He noted that his colleagues would walk ahead of him when heading out for lunch and it was tiring for him to keep up with them. He sighed at what he thought were the vicissitudes of age.

  Now and again, when he was watching television, his right hand would tremble a little, and he would hide it from Gráinne. He hadn’t shared his worries with her, but he was tossing and turning a lot at night and she complained about him kicking her in his sleep. He put it down to nightmares. So now she was sleeping badly, too.

  He did not feel old but he began to think that the man looking back at him in the mirror was ageing rapidly. His granddaughter started to imitate him one Sunday as they walked Dun Laoghaire pier. She mimicked a hunched-over old man. He laughed, but was secretly horrified. ‘Is this how she sees me? Is this how she’ll remember me when I’m gone?’

  Retirement loomed and he fretted from time to time about what he would do with his days. He loved his job and didn’t want to retire, so, he reasoned, the worry was probably distracting him as he got ready in the morning. He laughed at the irony of all the young people who complained about stress at work; here he was, heading into retirement, stressing about not working.

  Try as he might to ignore t
he gathering storm, it was the little things that slowly but surely broke his self-confidence. He held the bannister of the stairs more firmly. He took the lift at work when previously he would have bounded up the stairs. The shake in his right hand became more persistent, and eventually he began to eat lunch alone, telling colleagues he had too much to do and couldn’t go out for the usual soup and sandwiches. He knew full well he couldn’t manage soup, as the spoon had started to sway on its way to his lips. He isolated himself for fear of being found out, though he didn’t know what he was trying to hide.

  Gráinne had noticed the change in Conor’s walk, and felt awful nagging him to stand up straight when she saw him turning into an old man before her eyes. She had also noticed that during their evening walks by the sea Conor seemed to swing one arm and hold his right arm rigidly by his side. ‘It reminded me of the scene in Catch 22, when the troops took to walking with their arms straight down,’ she said later.

  Yet she joined in the lie that the changes were due to her husband’s anxiety about his imminent retirement. She was nervous about the retirement herself – what would all that time together do to their relationship? She hadn’t gone out to work since they’d married over thirty years earlier, and since the kids had left home, she had settled in to the slower pace of her life without them. She was used to having the house to herself each day.

  Their eldest daughter got engaged and they held a party in the family home. People reflect on their lives and relationships at times like this; it’s a time to see everyone together, observe how things have changed since the last big celebration. As Gráinne looked fondly on her family celebrating this latest good news, she caught a glimpse of Conor, unsmiling in the corner and avoiding the throng while pretending to busy himself mixing drinks. This wasn’t like him at all. She was used to gently upbraiding her husband for his excesses and ‘any excuse for a party’ attitude. Thank God she hadn’t married a boring man, she had always thought.