Death Before Time

by Andrew Puckett

  “I see. Why wasn’t Ranjid sacked or moved away?”

  “He’d been preoccupied with the custody battle. Also, he had tried to warn the Trust about the place, but no one had taken any notice. Anyway, some of the fallout did stick to him and he’s still rather bitter about it.”

  Fraser said, “I’m surprised Philip wanted him on his team.”

  “Philip’s a rather remarkable man.”

  “I’m beginning to realise that.”

  “You know he’s giving a talk here tomorrow night?”

  “No, I didn’t.”

  “You could do worse than go. It’s at the Postgrad Centre at seven.”

  “Are you going?”

  “I might.”

  *

  That night, Alice Steel died of pneumonia. She’d been 73 and suffering from breast cancer with perhaps only two or three months to live, but she hadn’t been ready to die and was determined to make a fight of it. Fraser had liked her for her gutsiness – it was he who’d put her on ampicillin for a chest infection.

  He found Edwina and told her. “We seem to be having a lot of fatal pneumonia at the moment,” he said.

  “Well, it is a common cause of death in old people.”

  Fraser thought for a moment. “It would have to be either Haemophilius or pneumococcus, wouldn’t it?” he said, naming the two types of bacteria usually responsible.

  “Probably,” she agreed.

  “Well, if it was Haemophilius, it wouldn’t have developed into pneumonia so quickly, and if it was pneumococcus, it would have been sensitive to ampicillin … wouldn’t it?”

  “Haemophilus can be virulent in older people,” she said, “and we do sometimes come across resistant pneumococci.”

  “Is it worth trying to find out which?”

  “Oh, I don’t think so, do you? It wouldn’t have altered anything.”

  *

  There were about forty people in the Postgrad Centre when Fraser got there, mostly housemen and nurses, he thought. He spotted Helen by herself towards the back and went to join her. She was wearing a pink top that heightened her complexion. Armitage was on the platform with a man in an immaculate dark suit and Fraser asked who he was.

  “Patrick Fitzpatrick. He’s Director of Community Medicine.”

  The chatter died away as Fitzpatrick got to his feet and introduced Armitage in a flamboyant Irish brogue. There was polite applause as he came forward.

  “I wonder if it might have been better if you’d waited until I’d finished,” Armitage said, “To see whether you felt I was worth applauding.”

  There was a ripple of laughter.

  “When I was a houseman,” he began, “Geriatrics, as we called it then, was regarded as the fag end of medicine. By the time I retire, I hope that ‘Care of the Older Patient’ will be regarded as one of medicine’s most important as well as most rewarding areas.” His voice was light and intimate and he had a way of looking round that made everyone there feel as though he was addressing them personally.

  People dreaded old age, he told them, which when you thought about it was ridiculous - it ought to be the most pleasant stage of life, the time when you could take stock and take the time to enjoy your family and friends.

  “So why do people dread it so much?” he asked, looking round again.

  Because for some, there was good reason to dread - sickness and incapacity of both mind and body, and as if they weren’t bad enough, a lack of proper care.

  “I’m sure you’ve all heard of the death wards where old people were incarcerated until they died – the irony is that they weren’t only appallingly cruel, but uneconomic as well. By treating older patients humanely, you can actually save money. We’ve proved that here.

  “How? By keeping them out of hospital for as long as possible and, when they do have to be admitted, making their stay as short as possible.“

  He went on to describe the practical means by which they’d achieved this. He finished to solid applause and Fitzpatrick took questions. There were a lot, and by the time the meeting broke up, Fraser was surprised to find that over an hour had gone by.

  “He’s a good speaker,” he said to Helen. “He made it interesting.”

  “Why don’t you tell him that?”

  “I will.” He stood up, paused. “D’you fancy a drink afterwards?”

  She hesitated, then, “All right,” she said.

  They made their way down. Armitage thanked Fraser for his comments, then introduced him to Fitzpatrick.

  “A fellow Celt, if I’m not mistaken,” Fitzpatrick said, shaking him heartily by the hand. “Patrick Fitzpatrick. I’m the original Irish joke.”

  “Fraser Callan,” said Fraser, not quite knowing how to take him. He was about five feet nine, an inch shorter than Fraser, with a round face, very blue eyes and dark hair beginning to go grey.

  “So what brings you to the land of the Sassenachs, Fraser?”

  “Er - gainful employment, I suppose.”

  “Ah,” he said sonorously. “Another who has had to leave the land of his fathers in order to live.”

  Helen and Armitage, who were standing together, exchanged resigned looks.

  “Aye,” Fraser agreed, “I’ve sold my birthright to the mighty pound.”

  Fitzpatrick laughed, then said, “Well, you couldn’t ask for a better colleague than Philip – or indeed the fair Helen here.”

  “Shut up Patrick,” she said. “Or I’ll go.”

  “Are you coming next week, my love?”

  “I’ll try.”

  “Oh, do, please, my heart of hearts. And why don’t you bring Fraser with you?” He turned to Fraser before she could answer. “I’ve become a father and I’m welcoming the fruit of my loins into the world with an orgy. Tomorrow week, my house. Do come.”

  “I’ll – er – do my best,” said Fraser. He thanked Armitage again and they left.

  “Is he real?” he asked Helen in a low voice.

  “I’m afraid so.” After a pause, she said, “I can never make up my mind whether he really is a fool, or whether he’s fooling the rest of us.”

  She led the way to a lift. As it rose, he said, “You don’t have to take me to his party, Helen.”

  “I know. I haven’t decided whether I want to go or not to go, anyway.”

  “Why don’t I take you?”

  She smiled. “Because I might want to leave earlier than you.”

  The lift stopped and the door opened.

  “I’ll be going back to Bristol, so I’ll have to leave pretty early.”

  “I’ll think about it.”

  The Doctors’ Bar was crowded. He bought her a glass of wine and himself a beer.

  “How old is Patrick?” he asked.

  “About fifty, I think. Why?”

  “Is this his first child?”

  “Oh, I see … no, he’s got four daughters by his first wife. He only plucked up the courage to leave her when his girlfriend got pregnant. He’s Catholic,” she added, as though this explained everything.

  And so it did, to an extent, he thought - also perhaps the slightly desperate edge to all the badinage, he put the thought to her.

  “You could be right,” she said with a shrug.

  He wondered if her sudden coolness was due to Fitzpatrick’s clumsy attempt at pushing them together, so he turned to neutral topics while they finished their drinks, then went with her to the entrance.

  Strange how she blew hot and cold, he thought as he walked back to his flat. Why had she come to the talk? She must have heard Armitage speak on this before …

  He wondered about their relationship – she clearly admired Philip Armitage and he’d felt their closeness earlier, even though they weren’t obviously in each other’s pockets … close, yes, but platonic.

  Not that it concerned him. It wasn’t as if he fancied her or anything.

  Chapter 4

  He got back after the weekend to find that Olive Spencer had died of pneumonia on
Sunday. She’d been another “faller”, admitted with a broken hip. She was 73 and had MS, but it was under control and she’d been an intelligent woman, alert and impatient with herself for being so clumsy.

  Fraser checked her notes. Chest infection Friday night, ampicillin prescribed by Becca Lake. It had developed into pneumonia on Saturday and by the time anyone thought to add another antibiotic, it was too late.

  Exactly the same pattern as the others. He drummed his fingers on his desk for a moment, then started going through the patient files on the computer.

  In the four weeks he’d been there, six patients had died from pneumonia despite treatment. Six had been treated and survived. He went through Singh’s patients and found a further five deaths.

  Eleven patients in a month. A lot.

  Sure, pneumonia was common in older people, but this common? With this high a death rate?

  He took down David’s Principles of Medicine from the shelf and leafed through it, but could find nothing about epidemics of pneumonia.

  He wondered about discussing it with Ranjid since both Philip and Edwina were away that day, but his attitude to Fraser had been so offhand since the incident in the canteen that he decided not to. Instead, he went over to the hospital library, but couldn’t find anything there either, except that the speed of the infections meant they were almost certainly pneumococcal.

  On the way back, he found himself passing Pathology and on impulse, went in and asked to speak to the microbiologist. The receptionist phoned through and, after a couple of minutes, took him up.

  “Dr Callan? I’m Roderick Stones.” He was a small, slender man with thinning grey hair and a rather abrupt manner. “Have a seat. How can I help?”

  Fraser explained. “What I wanted to ask you is whether this could be some kind of epidemic?”

  “Is this something Dr Tate has asked you to look into?”

  “Well, not as such, no – she’s away today. To tell you the truth, I came in more or less on a whim because I couldn’t find anything in the library.” As he said this, he was aware of Stones’ pale blue eyes watching him.

  “I see. I have to say I’m rather surprised you should have come here without telling her.”

  Thinking this more than a little pedantic, but not wanting trouble, Fraser said, “I take your point, Dr Stones. Edwina’s due back tomorrow, so I’ll raise it with her then.” He made to get up.

  “Oh, sit down – now that you’re here. D’you have any names?”

  Fraser sat down again and showed him the list he’d made. “Only one actually had samples sent to the lab.”

  “But they’re all patients of Dr Tate?”

  “Er - no, five of them are Dr Singh’s.”

  “I see. So he’s away too, is he?”

  Resisting the urge to squirm, Fraser said, “No, he isn’t. As I explained just now, I came in on a whim. But you’re right, perhaps I should have spoken to them first.”

  “Eleven in four weeks,” Stones mused. “It may seem like a lot, but it’s not what I’d call exceptional, bearing in mind their ages and the time of year.”

  Fraser swallowed, said, “I accept that, Dr Stones, but what about the fact that they’re resistant to ampicillin? I didn’t think that was common in pneumococci.”

  “Oh, we don’t use so passe a term as resistance with pneumococci anymore. True resistance is rare, but not insensitivity. Let me show you …”

  He turned to the computer terminal on his desk and rattled the keys.

  “Here’s your patient, and look – the organism isn’t sensitive to ampicillin, but nor is it truly resistant. By the time you started treatment, the infection was consolidated. He was an old man, the organism was insensitive … I’m afraid it happens. Let’s see go back a little and find one who recovered …”

  Fraser watched, feeling more foolish by the minute.

  “Ah, here we are - this one, you see, has a completely different sensitivity pattern, which knocks any idea of an epidemic on the head.” He swivelled round in his chair. “Let me tell you something about the pneumococcus. Did you know it used to be called ‘The Old Man’s Friend’?”

  “No, I didn’t.”

  “It’s a term not used so much now. It acquired the name before the widespread use of antibiotics, because it was probably the most common cause of death in the elderly then.”

  “Why ‘Friend’?”

  “I was just coming to that,” he said testily. “Because it seemed to target those people whose life had come to a natural end, and also because, before diamorphine, it was probably the kindest way to die there was. The patient becomes drowsy, then slips easily into a deep sleep followed by coma. There’s no pain or discomfort, just peace and rest. In some cases, it’s positively cruel to treat with antibiotics.”

  Fraser apologised for bothering him and saw himself out.

  *

  Ranjid summoned him to his office immediately after lunch.

  “Shut the door, please and sit down. How dare you go behind my back, discussing my patients with Dr Stones?” He was actually shaking with rage.

  Fraser tried to explain how it had come about ... “And when I noticed how you seemed to have as many cases as Edwina, I thought – “

  “You told him we have an epidemic … “

  “I asked him, Rancid. It seemed to me – “

  “What did you call me?”

  “I – “

  “You just called me Rancid – I heard you. You find that amusing, a racist pun on my name?”

  Oh God, how could he have … “No, of course not, I – “

  “Get out. Get out of my sight. There is no place for you here.”

  “Ranjid, I – “

  “I’m not interested in your excuses - save them for Dr Armitage.”

  *

  Fraser agonised through the afternoon whether to try ringing Philip in the evening; in the end he left a note on his desk explaining what had happened.

  The next morning, after clinic, Philip called him to his office.

  “You know what this is about, of course?”

  “Yes, and I’m very sorry it should have occurred.”

  “So am I, Fraser.” He sighed. “What possessed you to call him Rancid?”

  “I don’t know, Philip, it just slipped out. It was quite unintentional.”

  “I’m sure it was. Unfortunate, though.” He paused for a moment, then continued, “Ranjid is in rather a fragile emotional state at the moment, and these days, any charge of racism has to be taken seriously.”

  “It wasn’t meant to be racist. I’m not racist.”

  “I’m sure you’re not. However, taken with the other business … “

  “D’you want my resignation?”

  “Oh, hopefully it shouldn’t come to that.” He looked at him. “Unless it’s what you want. Is it?”

  “No.”

  “Well, let’s look for a way round it. What made you go to Roderick Stones in the first place?”

  Fraser explained and Philip let out a sigh.

  “If you’d come to me with this, I’d have praised your observation and initiative. However, going to Dr Stones was a mistake.”

  “I do see that.”

  “Not entirely, you don’t – he and Ranjid go back a long way and it was inevitable Dr Stones would tell him.”

  Fraser groaned.

  “Why didn’t you go to Ranjid first, since he was here?”

  Fraser hesitated. “To be honest, because I didn’t think our relationship was very good.”

  “Professionalism should come before personal feelings, Fraser.”

  “Yes, it should.”

  Another pause. “Are you still worried about the number of pneumonia cases here?”

  “Aye, I am, a bit.”

  Philip steepled his fingers, pressed them against his lips. “Pneumonia’s probably the most common causes of death here, especially at this time of year – April isn’t called the cruellest month for nothing.”<
br />
  Fraser nodded. “I realise that, but what’s bothering me is that so many of them seem to be resistant to ampicillin – or insensitive, perhaps I should say. Is there not a case for using a different antibiotic?”

  “Which would you suggest?”

  “Well …” Fraser hesitated, realising he’d been put on the spot.

  “Tetracycline?”

  “A lot of pneumococci and Haemophilus are resistant to it now.”

  “Erythromycin, then?”

  “Same problem, besides which, it’s not as efficacious as ampicillin.”

  “How about cefataxin?”

  “Fine for pneumococci, not so good for Haemophilus.”

  “Vancomycin? Gentamycin? Chloramphenicol?”

  “All rather toxic. The fact is, ampicillin does remain the drug of choice, even though we are seeing some insensitivity to it. It’s good that you’re thinking about these things though, which is why I don’t want to lose you. Unfortunately,” he continued, “Ranjid wants his pound of flesh. I suggest we try and get him to accept an ounce. Would you be prepared to apologise to him in front of me and assure him it won’t happen again. After which, so far as I’m concerned, it would be forgotten.”

  What had he to lose? “All right,” he said.

  “Good. I’ll go and put it to him now.”

  But as they shook hands on it shortly afterwards, it was obvious to Fraser that Ranjid was neither going to forget nor forgive.

  He went and found Edwina to apologise to her as well, but she gazed at him blankly and said she didn’t know what he was talking about. He explained.

  She said, “So you’re happy now with what Philip told you about the pneumonia cases?”

  “Yes.”

  She shrugged. “OK then, fine. You’ve apologised and it’s over. Forget it.”

  He’d been expecting worse. She must live her life in compartments, he thought as he walked away; if something didn’t directly concern her, she wasn’t interested. OK then, fine.

  Chapter 5

  “Wow,” Fraser said. He was looking down the face of a scarp that dropped 500 feet into a broad valley below.