Further Confessions of a GP (The Confessions Series)

by Benjamin Daniels

  At times like this, each new patient being brought in feels like an extra mouth to feed when there is already not enough food to go round. The doctors and nurses collectively groan as they witness each new admission being wheeled in. The poor patient sitting on the ambulance trolley needs help, time and care, but this can often be lost when the staff are in such a flap simply trying to manage the impossible task of fitting 50 patients into a department with 30 beds.

  ‘There’s a bed crisis,’ one of the nurses mouthed to me as if to try to explain the madness that I was walking into. There was a time when a bed crisis was considered to be a rare, traumatic event, but now we just seemed to run on the assumption that there was always a bed crisis, which makes the phrase meaningless.

  Fortunately for me, I wasn’t responsible for managing the bed issue. I was simply there as a foot soldier. My job was to see and treat the patients as effectively and efficiently as I could. I blanked out the noise and chaos and picked up the medical notes of the next patient to be seen. To my surprise it was a patient I knew very well and, if I’m honest, was probably my favourite patient at my practice. One of the odd perks of being both a GP and an occasional A&E doctor is that I sometimes meet my primary care regulars when they have an emergency and end up in casualty.

  Betty was a great character, well known to all the staff at my practice. She had a loud cackling laugh and called everyone ‘darling’. She made sure to buy the practice a bottle of sherry every Christmas and would flirt outrageously with any man aged between 16 and 100. Betty had worked the boards as a cabaret performer for years and I loved visiting her flat and seeing the old black-and-white photos of her from the late 1940s looking glamorous. Her stage persona was Betty Ferrari, which sounds like the name of a drag act now, but back in the late 40s, she assures me, it was alluring and exotic. ‘I was married to the stage and I was monogamous!’ That was her way of telling me that she never settled down or had children. With no family, Betty was lonely. I visited as often as I could. If we had medical students attached to the surgery I would bring them to meet her. I told them she had an interesting medical history but the real reason for the visit was because she loved the company and revelled in performing a few of the ‘old numbers’ for a new audience. Unfortunately, these days her bad lungs mean she rarely finishes a song without being interrupted by a coughing fit.

  Back in those original photos the cause of her current suffering could be clearly seen. In each picture she was holding a cigarette holder with the cigarette itself shrouding her in a swathe of smoke.

  ‘We used to think we were so sophisticated,’ Betty told me, ‘and I loved the sexy husky voice the smoke gave me.’

  ‘You could still give up,’ I often told her.

  ‘Too late now, darling,’ she would reply with her husky laugh.

  It was no real surprise that Betty was here in hospital. She had been in and out of the emergency department seven times in the last six months. Each admission was for the same complaint. Her lungs just couldn’t get enough oxygen into her blood stream. On each occasion she was admitted for a few weeks, given oxygen, steroids and antibiotics and then sent home. She had all sorts of inhalers, but despite everyone’s best efforts, an infection would cause her lungs to deteriorate again and she would be back in hospital. We couldn’t give her oxygen in her flat as she still smoked and so the risk of her accidentally igniting the oxygen supply and blowing herself up was too high.

  Betty was sitting up on the trolley leaning forwards. She was struggling to breathe and had an oxygen mask tight round her face. She was in a hospital gown that covered her front but was left open at the back displaying her ribs and shoulder blades protruding through tired pale skin. Betty was so short of breath that she couldn’t really answer my questions. She had been sitting in this cubicle for the last two hours waiting for a doctor to come and see her. As the mayhem increased around her, Betty’s breathing had become steadily worse. All alone, unable to shout or call for help, she was simply focusing all her attention on trying to get enough air into her lungs to stay alive. When I walked in I saw the recognition on her face. She tried to tell me something but the effort was too much and instead she gently shook her head and grasped my hand.

  Betty had been short of breath ever since I’d known her, but I had never seen her look this bad. Watching someone unable to breathe is horrendous. How it must feel for the poor sufferer I can’t imagine and I was finding it difficult to watch Betty suffer so terribly in front of my eyes.

  The department was chaotic, but Betty was sick and needed expert help. I started her on a BiPAP, a machine that helps the patient to breathe more easily, and called the doctors from intensive care. Betty was too sick to go to a ward. She needed to go to intensive care where they had all the equipment and expertise to get to grips with her breathing and possibly even put her on a ventilation machine. The specialist intensive care doctor clip-clopped into the department in her high heels. She was South African and looked impossibly young and elegant. Tall and slim, with perfect hair and make-up, she was a stark contrast to us dishevelled A&E staff wearing faded scrubs and grubby trainers. I carefully told her Betty’s history and observations.

  ‘I don’t think she’s really appropriate for the intensive care unit,’ she said curtly after listening to my referral.

  ‘What do you mean “not appropriate”? How sick does she have to be?’

  ‘It’s not that she’s not sick; it’s just that I think her outlook is poor. She has end-stage lung disease and everything points to there not being much room for improvement.’

  I was fuming. ‘You’ve barely even waved your nose in front of her and you’re condemning her to death. How bloody dare you …’

  Slightly taken aback by my response, the impossibly elegant doctor looked down at me in surprise. ‘I think you might have got too attached to your patient,’ she retorted. ‘I’ll have a chat with my consultant and get back to you, but I’m fairly sure he’ll back me up on this one. I think she needs palliative care rather than intensive care.’

  I went back into Betty’s cubicle and grabbed her hand. ‘I’m having some trouble with the specialist team but I’ll get you to ICU, don’t worry.’

  Betty shook her head and gestured for me to turn the noisy BiPAP oxygen machine off.

  With the machine quiet, she mustered up all her energy to say, ‘No, darling. Thank you but let me go. This really is my final curtain call.’ With that she attempted a smile and held my hand. I was surprised to find a tear running down my cheek and to my annoyance realised that the intensive care doctor was right.

  ‘Is there anyone you’d like me to call?’

  Betty shook her head and now it was her turn to shed a tear.

  With the noise and chaos of the busy department engulfing us, I managed to sit quietly with Betty for 10 minutes holding her hand. Our little cubicle, with the curtains drawn, was like a tiny oasis of reflection, and although Betty had her eyes closed, I’m sure she knew I was there. When I couldn’t justify leaving my colleagues to face the constant onslaught any longer without my help, I gave Betty a kiss on the cheek and said goodbye. She was admitted to the respiratory ward and slipped away that night.

  Smelly bum

  John was absolutely convinced that his bum smelled. So much so that this was his fourth or fifth visit to see me with the same problem.

  ‘You’ve got to help me, Doctor, the smell is repulsive. It’s repugnant. It follows me everywhere.’

  ‘Do you wash it regularly?’

  ‘Yes, Doctor, of course I wash it. I scrub it every morning and evening. Nothing I do makes any difference. I’m sure everyone can smell it: the woman who sits next to me at work, people sitting behind me on the bus. I just can’t go on like this any more.’

  ‘And it’s not a flatulence issue here? I mean, you don’t just need to cut down on the cabbage and beans?’

  John looked at me as if I was a complete idiot. ‘No, Doctor! It smells all the time. Not bec
ause I fart or haven’t washed. Every minute of every hour of every day I can smell it and it stinks!’

  I was at a bit of a loss. I had sent samples of his poo to the lab to be tested and ordered all sorts of blood tests. I even put my finger up his behind to make sure that there wasn’t some sort of anal tumour that was giving off the smell. The last time he was in I even tried a Google search of ‘smelly bum’, but other than getting a list of some very odd and unsavoury sites not appropriate for workplace internet browsing, I was still at a complete loss.

  ‘So has anyone else actually ever commented on the smell?’

  ‘No, but it’s not the sort of thing that you actually ask someone is it. “Can you smell my bum?” I’m sure they can all smell it but are just being too polite to say. I’ve not had a girlfriend for years because I’m terrified she’d just dump me because of it and then tag a photo of me as “smelly bum” on Facebook.’

  Although John had seen me on numerous occasions about this problem, on each occasion I had simply ordered another test and sent him on his way. This time I had run out of tests and really I needed to do what I should have done the first time he came in.

  ‘John, I need to smell your bottom.’

  ‘Excuse me?’

  ‘If you really feel that your bum smells this bad, but only you have smelled it, you need me to smell it and tell you if this really is a problem or not.’

  This is how I found myself in a scenario I never imagined I would have to face. Some of you may feel that doctors are overpaid and perhaps you’re right, but how many of you reading this have a job that involves placing your nose in the close vicinity of a naked man’s bottom? John was leaning over the couch with his trousers and pants around his ankles. He was holding apart his bum cheeks and as I kneeled down on the floor, I wondered how close I would actually have to place my nose to his anus to satisfactorily complete the examination. I was doing my very best to suppress my oversensitive gag reflex and feeling bitter that of all the doctors working at this practice, John had chosen to come to see me. As I got closer to John’s anus, I realised I was instinctively holding my breath, so had to consciously make an effort to open my nostrils and take a big whiff.

  I was prepared for the worst but to my surprise, John’s bum smelled fine. It didn’t smell like spring meadows or an ocean breeze, but there was certainly not the horrendous reek that he had been describing. Having never actively smelled any other man’s behind, I was lacking a benchmark for comparison, but to my part relief and part annoyance, there was absolutely no reason why I needed to have my nostrils in such close proximity to his anus.

  John was overjoyed when I told him his bum didn’t smell. He did need some convincing and at one point seemed to be suggesting that I check again, but fortunately he did eventually take my word for it. Having managed to belatedly resolve the dilemma of the phantom smelly-bum syndrome, I had two options: I could of course simply wave John on his way having cured him of his complaint, or I could take the professional and appropriate option, which was to sit John back down and delve deeply into his inner psyche, to try to establish what previous trauma had culminated in his long-lasting and deeply disturbing delusional paranoia about his bottom.

  I thought about it for a millisecond …

  ‘Bye, John. Glad we’ve sorted this all out for you. All the best.’

  As far as I’m concerned, smelling John’s bum was already beyond the call of duty that afternoon. His 10 minutes were up and the opportunity to explore his inner psyche would have to wait for another day.

  Tarig II

  It had been a few months since I had last seen Tarig and failed yet again to persuade him to agree to take HIV medication. Unexpectedly, I had a request to urgently phone his wife. I didn’t know Tarig’s wife well as she rarely came in to see me, but I often wondered what she made of his decision to not treat his HIV. She herself had tested negative to the disease and had, on the surface at least, stuck loyally by her husband’s side. She must have known that his decision not to have treatment was effectively a choice to commit suicide.

  ‘Doctor, please come. Tarig is confused and unwell.’

  As I arrived, his wife greeted me at the door.

  ‘Doctor, please don’t mention the HIV in front of the children. They don’t know,’ she whispered.

  Tarig was in bed looking pale and unwell. He was saying some words in a language that I took to be Arabic, but his wife assured me that he was confused and making no sense. It was clear that Tarig was really sick. Once the immune system becomes very weak, numerous types of infection can take hold and I wasn’t sure which one was making Tarig so unwell. Severe forms of pneumonia and meningitis are common, but regardless of which infection had taken hold, he clearly needed to go to hospital. In any other circumstances, I wouldn’t have thought twice about calling an ambulance for such a severely unwell man in his 40s. With Tarig, though, we had spoken on numerous occasions about his specific wishes not to be treated for his HIV. In hindsight I wish we had put together some sort of living will or something in writing to prepare for this very situation. We hadn’t, so I had to make a decision. Tarig’s wife and two teenage children were in floods of tears. There was no way that I could leave him at home to die. He was now too confused and unwell to refuse hospital admission, so I went against my patient’s previously expressed wishes and dialled 999.

  These decisions are really tricky. If a person is actively suicidal and threatening to jump off the nearest building, they can be ‘sectioned’ (compulsorily detained in a psychiatric hospital) and incarcerated against their will for their own safety. Tarig’s refusal to take medication to treat his HIV was equally suicidal in its nature, but he wasn’t mentally unwell. He fully understood the implications of his actions and although most people would feel that this decision was wrong, there is no law against being wrong. The alternative to leaving him to die would be to lock up Tarig against his will and to hold him down and force him to take medication every day. I’ve seen this done in psychiatric units and it is frightening and brutal to watch. Severely mentally ill patients are only forced to take medication for a short period of time because they are so unwell that in their psychotic state they have no concept of what is real and what isn’t. They don’t have the ability to weigh up decisions rationally. The same couldn’t be said for Tarig. He had been calm and rational during our previous conversations and well aware of the implications of the decision he was making. Right now, though, he wasn’t well and as he had lost the ability to make a rational decision, I made one for him.

  I worried about the ethics of that decision for some time afterwards. However, after spending some time in hospital, Tarig was discharged home and to my amazement he was voluntarily taking HIV medication. ‘I had a lot of time to think in hospital and I decided that God wasn’t ready for me to die just yet,’ he explained.

  ‘Good,’ was all I decided to say in response. He neither thanked me nor criticised me for my decision to send him to hospital that day and so we never discussed it.

  Over the previous year I had engaged Tarig in numerous theological debates and completely failed to persuade him that God didn’t want him to die. Clearly it took his own near-death experience for him to come to this conclusion himself. I’m just relieved that he did.

  Should we know how much health care costs?

  The NHS is running out of money. We are told this on an almost daily basis, but what you may not be aware of is that GPs like me have been told that we are now going to be the people in charge of balancing the books. One of the reasons that GPs have been given this large responsibility is that we generally run our own surgeries fairly efficiently and it would appear that, at the time of writing, the coalition feel that this effective management can be extended to the entire NHS. The truth is, I don’t really know much about accountancy. My surgery runs efficiently enough, but only due to my heavy reliance on our practice manager. She steadfastly makes sure that there is enough money for everyone to get pai
d and that we get the best deal on our toilet roll order. I get on with trying to make the patients get better and as a business plan it works well enough.

  I was against the new health legislation, but am not totally against both doctors and patients actually knowing how much things cost. Each day I sit with a metaphorical book of blank cheques of taxpayers’ money and I write up prescriptions, order tests and make hospital referrals. All of these have a price and therefore cost money to the NHS and hence all of us who pay tax. Up until recently I was blissfully ignorant as to how much these all cost, but GPs are now being put in charge of the local health budgets and as a result of these changes, I am now beginning to get an idea.

  Many doctors and patients are scared of thinking of health care in terms of money. The fear is that we medics will no longer see you all as real people in need of medical support, but instead as pricey leeches draining away our budgets. I would like to think I am capable of considering the financial value of what I do without it automatically having a detrimental effect on my clinical decisions.

  If it were up to me, I would make up for the NHS shortfall by scrapping the recommissioning of Trident nuclear submarines – £20 billion would make our budgeting meetings considerably easier to bear. With that sort of injection of cash, the improvements we could make to patient care would be staggering. Of course, the whole point of the coalition’s new health act is to make do with less money rather than more and therefore the only places we’ll find any cash will be through reducing our own inefficiencies. Anyone who works within the NHS could list several ways in which we could work more efficiently. Traditionally, doctors have thought of these shortcomings in terms of wasted time for us, and poor service for patients, but now we will be encouraged to think of them from a more financial perspective.