An Irish Country Practice

by Patrick Taylor

  “Well, Kitty, it’s hardly a diagnostic mystery. Lars is allergic to the animal,” O’Reilly said.

  Kitty squatted, clicked her tongue. “The effects wouldn’t be particularly dangerous, I suppose, but they would be thoroughly unpleasant.” The pup ran to her, lay down, and rolled on his back. She tickled his tummy. “Poor Lars,” said Kitty. “All those years without a dog and now that he has one … Oh, you’re so cute, Kilkenny,” she said, grinning mightily.

  “He’s a cute problem,” O’Reilly said. “I know my brother. He’s worried he’ll upset Myrna if he has to give the dog up, but medically I can’t see any way out.” He scratched his chin.

  “You could explain the medical aspects to Myrna. She’s an intelligent woman. She’ll be disappointed, but she’ll understand, I’m certain.”

  “I agree. I wonder if Lars isn’t being a bit pessimistic about how she’ll react?” Pleased as he always was to see his brother, O’Reilly didn’t quite see why this couldn’t have been discussed over the phone.

  “And if she knows Kenny’s going to a good home? That might please her too. She could see the wee button regularly.” Kitty picked up the pup and held the wriggling bundle in front of her face, to be rewarded with a series of loving licks. There was deep fondness in her voice when she said, “Kinky would call him a wee dote. I think he’s adorable.”

  O’Reilly frowned. What was Kitty hinting? His eyes widened. “No,” he said. “Oooh no.” He backed toward the door. His old friends from medical school used to call him the Wily O’Reilly, but this time it looked like he’d been well and truly outmanoeuvred by his elder brother. Lars had wanted Kitty to see the pup and fall in love—and you can’t do that over the phone. “My love, aren’t Arthur and Lady Macbeth a big enough menagerie at Number One? And what with Barry and Nonie, Kinky, and possibly a student in the house, the place will be a circus. And I thought,” O’Reilly said, arching an eyebrow, “you wanted more privacy.”

  “Don’t be silly,” Kitty said, “one little puppy won’t make that much difference, and Arthur Guinness will be delighted with the company. Probably make him feel five years younger. Probably make us feel ten years younger.”

  “I’m not worried about old Arthur,” O’Reilly said, “but what about Lady Macbeth?”

  A faint cry of “Finn” came from the direction of the hall.

  “Hang on to the pup, Kitty,” said O’Reilly, and opened the kitchen door. There was no sign of Lars. “Lars? Lars?” No reply, but O’Reilly could hear a faint rapid wheezing coming from the lounge. An allergy to dog dandruff or hair could bring on an asthmatic attack. “Quick, Kitty,” O’Reilly called. “Shut Kenny in, then go get my bag from the car and give me a hand.”

  “Right.” She left at the run.

  He found Lars slumped in an armchair, head thrown back, eyes watering. His lips were a slatey blue. Cyanosis from oxygen deprivation. There was pleading in his eyes as he looked into O’Reilly’s and gasped, “Can’t—” wheeze, “can’t breathe.” He was having more difficulty exhaling than inhaling, typical of the partial obstruction caused by a bronchial muscle spasm. O’Reilly began undoing the top buttons of his brother’s shirt, then took his pulse. Rapid at one hundred per minute, but not a serious tachycardia. O’Reilly knew his brother had no previous history of asthma, nor was there any reason to suspect this attack had been brought on by infection. He said, perfectly confident in his diagnosis without any need for auscultating Lars’s chest with a stethoscope, “You’re having an asthmatic attack brought on by your allergy. I’ll have you right as rain in a few minutes.”

  Lars nodded.

  Kitty arrived, clutching the worn leather medical bag in her arms. “Adrenaline one to one thousand for subcutaneous injection?”

  “Please.”

  Kitty opened the bag and began her preparations. “I’m going to give you a slow injection, brother. It may make your heart rate even faster. If you feel palpitations, tell me and I’ll stop at once.”

  Lars nodded and wheezed on.

  “Here.” Kitty handed O’Reilly a syringe and a cotton-wool ball soaked in methylated spirits. “Point five millilitres.”

  “Thanks.” O’Reilly rolled up Lars’s shirtsleeve, swabbed the skin on the inside of his arm, pinched up a fold, and slid the needle in. He began to increase the pressure on the plunger. To reduce the risk of severe tachycardia, he was going to use Hurst’s method of injecting: 1 minim, of which there were 8.5 in the syringe, per minute until the attack ceased.

  Kitty and Lars said nothing as they watched O’Reilly slowly and steadily push the needle’s plunger. There was no sound in the house. Even Kenny’s whimpers and yips had subsided. Five minutes later, with less than half the amount left in the syringe, Lars’s wheezing eased and stopped.

  O’Reilly withdrew the needle. “There,” he said. “Feeling better?”

  Lars drew in a slow, even breath. “I don’t think I ever truly appreciated breathing until I couldn’t,” said Lars. “Thank you very much, you two.” He swallowed and managed a weak smile. “Sometimes it comes in handy to have medics in the family.”

  “And for once,” O’Reilly said, hiding his concern for his brother, “the old saw ‘doctors who treat their own family have idiots for patients’ is not true. I’m going to give you a prescription for isoprenaline sulphate, twenty milligrams. If you ever get another attack, pop half a tablet under your tongue.”

  “I hope I never have to use it, but thanks.” Lars buttoned his shirt sleeve and began to do up his collar.

  “But we don’t think you will have to use it, do we, Fingal?” Kitty said. “I’m sure you’d agree that Myrna can hardly be upset with Lars now. Asthmatic attacks are a serious condition.” Her smile was beatific. “The source of the problem must be removed, and I honestly think—”

  You clever minx, O’Reilly thought.

  “I honestly think we could have little Kenny in our family. Don’t you? We can take him with us when we go.”

  O’Reilly grinned. Game, set, and match to Lars and Kitty O’Reilly. “If that’s all right with Lars?”

  “All right? I should be eternally grateful,” Lars said, “and I’m sure Myrna will be relieved too, that the little lad will still be in the family, so to speak.” He laughed as he did up the buttons of his shirt. “Now, I’m feeling much better. Perhaps we should finish our pre-luncheon drinks and head on down to the Arms?”

  “That,” said O’Reilly with an innocent smile, “is a splendid idea, but you’ve just had adrenaline, big brother. I’d suggest we finish ours, but that you heel tap until we get to the pub.” Lars was by no means a bowsey, but it still gave O’Reilly a little secret pleasure to get one back at the big brother who had just pulled a fast one with an allergenic pup.

  5

  The Weaker Vessel

  Barry was driving as fast as he dared along the rutted lane to Lewis and Gracie Miller’s seaside bungalow. Gracie’s panicked words had come tumbling over the phone not fifteen minutes before. “It’s my Lewis. He’s slumped over the kitchen table and he won’t wake up.” A muffled sob. “For God’s sake, come as quick as you can. Please.” The line had gone dead.

  Had he had a heart attack? A stroke? Internal bleeding? For a man in his early eighties, all were possible and all very urgent.

  O’Reilly, no slouch when it came to breaking speed limits, would have been proud of how fast Barry had raced out to his patient. He would assess Lewis and then decide if an ambulance was needed. If he’d had a heart attack then he’d need the newly introduced cardiac flying squad with its portable defibrillator. But Barry knew it would be irresponsible to tie it up if Lewis had some other condition.

  He parked outside the low back wall, grabbed his doctor’s bag from the passenger’s seat, and hurried through the back garden to the door.

  It opened. “Thank God you’ve come, sir.” Gracie was a small woman but she grabbed Barry by the arm with surprising strength and hurried him into her cosy kitchen redolent
of roasting chicken before slamming the door. She wrung her reddened hands. A single tear trickled under her tortoiseshell-framed spectacles and down her wrinkled cheek. Wisps of iron-grey hair straggled from her bun. “He’s still out like a light, Doctor, but he’s breathing.”

  “Good. That’s good, Gracie.” Barry gently detached her hand from his arm, then tore off his overcoat and duncher and flung them on a chair beside the kitchen table, where Lewis had his head cradled between a plate of biscuits and a side plate that lay overturned on a rumpled red tablecloth. The retired postman’s head was turned to one side, his spectacles half-dislodged from the bridge of his nose. His sandy hair was tousled and Barry saw beads of sweat on pink patches of scalp.

  “I’m terrible sorry, sir. I should’ve tidied up, but I was too scared to do nothing, so I was. All I wanted was for you til get here.” She sniffled, wrung her hands. “I didn’t know what til do.”

  “It’s all right, Gracie,” Barry said. “There was nothing you could do, but send for me.”

  “Right enough.” He heard relief in her voice. “I’ve been talking to him, like. I don’t think he can hear me, but I keep asking him to wake up.”

  Barry ignored the cold tea dribbling from a smashed teacup on the tiled floor at Lewis’s carpet-slippered feet. The man’s trousers were soaked too. Thank the Lord he was still breathing and it was deep and regular. The tongue of a patient who had passed out could block the airway and cause suffocation, but was not a risk here. Barry held Lewis’s wrist to take his pulse. His skin was clammy. Barry counted a steady ninety-two firm beats per minute. It would be racing and thready if there were major internal bleeding, and irregular if there were atrial fibrillation associated with a heart attack. Barry felt a little less concerned.

  It would be better if the patient could be moved to a couch or bed, but Barry doubted if he and Gracie could carry Lewis between them so decided to leave the man where he was.

  “Can you tell me what happened, Gracie?”

  “Him and me was having a wee cup of tea in our hands. He kind of moaned, then he says, ‘Holy Mother, I can’t see nothing from my left eye’ and fell forward. He dropped his teacup. I screamed and I asked him what was wrong, but he never said nothing. I shook him, but he wouldn’t wake up, so I ran til the phone…”

  “You did exactly the right thing,” Barry said. And what she had told him had given him enough to formulate a working diagnosis. A heart attack was unlikely. No crushing chest pain or pain radiating up into the jaw or down an arm. Nor was the pulse rate irregular. It was possible that Lewis Miller had had a bleed from a brain blood vessel or a thrombosis of one, either referred to colloquially as a “stroke,” but the loss of sight in one eye was more suggestive of disease of the left internal carotid artery, the great vessel which with its partner on the right were the major suppliers of oxygenated blood to the brain. If it were narrowed by fatty plaques of atheroma, blood flow would be impeded and an early sign of that was loss of sight on the same side as the vessel. It was a condition from which quite a few sufferers survived the first attack without permanent nerve damage.

  No matter the exact diagnosis, there was little any doctor could do in the home for any of the potential causes. Lewis Miller would need to be admitted to hospital to establish a firm diagnosis and receive expert nursing. “Gracie,” he said, “I think Lewis may have had a thing like a wee stroke.”

  “Dear God, that’s desperate.” She bit her knuckles. “Oh, Doctor, will he die?”

  I don’t know. He might, Barry thought, but he couldn’t bring himself to give an honest answer. Not yet anyway. The truth was he simply didn’t know. He put his hands on Gracie’s shoulders and looked into her eyes, seeing the pleading in their depths. “I think the big artery, here”—he put two fingers on the side of Lewis’s neck—“may be a bit narrow, but I don’t think he’ll die.”

  She took a deep breath. “Thank you, Doctor.”

  Sometimes comfort was kinder than the truth. “But we’ll need to get him up to the Royal Victoria Hospital in Belfast. I’ll arrange that right away.”

  “Phone’s in the hall, sir.”

  Barry rang the Royal. “Come on, come on.” Hospital switchboards were notorious for their slowness in answering. As he waited, he looked out through the glass panels of the front door of the bungalow, a house he’d started thinking of as his own. He and Sue were hoping to buy it once the Millers finally decided to sell. The lough was powder blue with ranks of white etchings and the Antrim Hills, purple in the distance, blended with a baby blue sky. Sue was going to love it here.

  “Get a move on,” he muttered, and for a second wondered if he were talking to the switchboard or most uncharitably encouraging the Millers to sell. He knew Gracie had had some hesitations and now with Lewis … Stop it, he told himself. Trying to predict the future is a waste of time and energy. Concentrate on your patient.

  “Royal Victoria Hospital switchboard.”

  Barry soon learned that wards 5 and 6 were on “take in” today, accepting emergencies on a twenty-four-hour rotational basis with other medical wards. He asked to speak with the duty registrar, explained the situation, and was told an ambulance would be dispatched and a neurologist consulted, if need be, after the patient had been assessed. “Just keep his airway clear. There’s not much more GPs can do.” That last with a touch of condescension. “Thank you, gotta go, it’s Bedlam here. Good-bye.”

  Not much more I can do? Barry blew out a deep breath as he replaced the receiver none too gently. Some of these self-satisfied specialist trainees, who only had to be knowledgeable in their own narrow field, should spend a bit of time in general practice. Might help them understand the difficulties of practising without access to all the sophisticated equipment in a hospital.

  And, damn it, there was more he could do, Barry thought as he headed back to the kitchen. Make Lewis comfortable, examine him in greater detail. It might be professional pride, but GPs weren’t mere signposts to direct the sick to the right specialist. Barry took satisfaction from making accurate diagnoses with the limited resources at his disposal. And he could support Gracie until the ambulance arrived.

  “Doctor. Come quick.” Had the man taken a turn for the worse?

  Barry entered the kitchen at a trot to find Lewis sitting upright and Gracie resettling his spectacles over his grey eyes. “Glory be, he’s woke up there now, Doctor, but I can’t make out what he’s saying.”

  Spittle ran from the drooping right corner of Lewis’s mouth.

  Gracie wiped it off with a hanky.

  His face lacked all expression and he said in a monotone, “I muh ha fawn aheep,” which Barry interpreted as “I must have fallen asleep.” Dysphasia, difficulty in speaking, could be associated with a stroke caused by either a clot in a blood vessel in the brain or bleeding into the brain or disease of the carotid artery. Following a stroke, it never fully recovered. It might, though, if the artery were the cause.

  “You had a wee turn, Lewis,” Barry said, “but you’re on the mend.”

  “Ank oo.”

  “Is Lewis right-or left-handed, Gracie?”

  “Right,” she said, “I’m the cack-handed one.” Her giggle was one of nervousness. She held up her left hand. “I had it tied behind me back at school when I was wee, so I did, so I could learn til write with my right hand. I do, so I do, but I’m still a leftie for the rest.”

  “Poor you,” Barry said. “It’s important for me to know about Lewis. Thank you.” The information of his right-sided dominance would help Barry piece the puzzle together. He knelt beside the man’s chair. “Lewis, I’m going to ask you to do a few things. All right?”

  “Awight.”

  Barry grasped his patient’s left hand. “Squeeze my hand.” The grip was firm, but the same request was met by a feeble response when the right hand was tested. At least this was only paresis, weakness of voluntary movement, rather than paralysis, complete loss of activity. “How does your left side feel?” />
  “Fine.”

  “And your right?”

  “I’ve tebbil pins a eedles.” Although slurred, his speech was improving and there was no sign of the intellectual impairment that often accompanied such an episode. That was a good sign. Paraesthesiae, heightened sensations, on the one side was also typical of cerebral damage or at least temporary oxygen deprivation. Whatever was afflicting Lewis was doing so on the left side of his brain, which received nerve signals directly from the left eye and in a right-handed patient controlled speech, interpreted sensations from the right side of the body, and sent control messages along the nerves to make the right limbs move. The key to deciding if the underlying cause was a stroke or narrowing of the left carotid artery would be the speed of recovery of function.

  Barry felt optimistic that the root cause lay in the artery and that there was the possibility of a full recovery in the short term. “I’m sure,” he said, “that the worst is over.”

  “Thank God for that,” Gracie said, and began to cry softly. “I don’t know what I’d do without the oul’ fellah.” She put a trembling hand on her husband’s shoulder and he reached up to grasp it with his left hand.

  Barry knew the Millers had been married for sixty years. Although he and Sue were only on the threshold of their marriage, he couldn’t bear the thought of life without her either. What Gracie was going through he could only imagine. His heart ached for the Millers. Recovery from a stroke would be slow and was never complete. Even if his diagnosis was right and full recovery was possible, there was at least a 10 percent risk of a full-blown lethal interruption of blood supply to the brain within the next forty-eight hours. Once again he decided to keep that information to himself. Let Gracie have her bit of comfort.

  Modern medicine could diagnose carotid narrowing by angiography, injecting radio opaque material into the artery and taking a series of X-rays. He had heard that an American surgeon, Doctor Michael DeBakey, had operated successfully on such a patient in 1953, but here in Ulster in 1967 no one was doing such procedures. He sighed. In fairness, he supposed Lewis was already ahead of the odds. Average life expectancy for a man was about seventy years, but Barry knew that Gracie Miller was not thinking about actuarial tables. She was thinking about the prospect of life without her husband of sixty years, and the thought must be terrifying. Barry sighed. He did not have much more comfort to offer, but he could keep her occupied and get Lewis tucked up warm and comfortable while they waited another half hour for the ambulance. “Gracie, have you a wheen of pillows and a rug?”