An Irish Country Practice

by Patrick Taylor

  “Medication? Poor wee lamb,” Daphne said.

  “She’ll have to go to the Royal. I’ll go and phone if you’ll keep an eye to her.”

  “Her phone’s in the hall.”

  “Thanks.”

  As Barry went downstairs, he set to remembering all he knew about the rare side effect of barbiturates called porphyria. It was a disturbance in the metabolism of a family of chemicals from which haem was derived. Haem combined with iron to form haemoglobin, so vital in red cells for carrying oxygen. One in every 25,000 people was genetically predisposed to the disorder. In some, it appeared in childhood. In others, the defect lay dormant until provoked by some external stimulus. One of the possible external stimuli was barbiturates, and last Friday Barry had prescribed Nembutal 0.1 gram to be taken half an hour before Eileen’s bedtime. He remembered how he’d rushed out the door because Hester Dolan and her broken wrist were waiting in the outer office. Barry had not warned Eileen of any potential side effects of the medicine he’d prescribed. Damnation. This was a classic case of iatrogenic, or doctor-caused, disease.

  He dialled and waited. Damn, damn, damn. He spoke through gritted teeth to the necessary people, made the arrangements, and went back upstairs. Wasn’t the unwritten law of medicine primum non nocere, first do no harm? And yet in fairness to himself, his well-meant prescription would not have affected 24,999 other people. And he was a mature enough physician to recognise that.

  “I think she’s calming down a bit, sir,” Daphne said when she saw him in the doorway.

  Eileen was lying on her pillows, eyes closed, her breathing regular and deep, but by the time he had crossed the small room to her bedside she was sitting up, grabbing her belly, and sobbing, “Oh God, it hurts. It hurts.”

  His textbook had said that the pain of porphyria could be excruciating. And yet it had been drummed into them as students never to give painkillers until a firm diagnosis had been made. An absolute diagnosis could only be made by chemical analysis of her blood and urine.

  He rummaged in his bag as he convinced himself that giving a painkiller would not interfere with the diagnostic process at the Royal.

  Eileen moaned and Daphne murmured, “There, there, love.”

  “I’m going to give her a jag in just a minute.” He drew 100 mgm of pethidine into a syringe. “This will only sting for a second,” he said, rolling up the sleeve of her nightgown and giving the drug intramuscularly.

  It took several minutes for an obvious effect to be noticeable, but soon her breathing was deep and regular again.

  Barry knew he was halfway to solving one of Eileen Lindsay’s problems—the medical one. But what to do about her children? “Daphne,” he said, “I know you and Tom have a shop to run—”

  “Never you worry about it. Me and him’ll see to them the day, get them their brekky and off til school, and—” She frowned.

  The Jacksons worked as a team. He understood that while they could afford to help out today, they would not be able to provide a long-term solution. He said, “When Sammy was sick Maggie Houston came and babysat. I’ll ask her if she’d help out again.”

  While he waited for the ambulance, he’d fill out the forms to make sure she got her sickness benefit and that her employer understood her absence from work. The Lord knew money was tight enough for Eileen, poor creature. As if coping with the desertion by her husband, raising three kiddies, and working full time wasn’t enough to cope with, his attempt to let her get a decent night’s sleep had made her sick enough to end up in hospital. He just hoped they could do more for Eileen Lindsay than a country GP.

  12

  Of Some Distressful Stroke

  Barry let himself into the warm kitchen at eleven the next morning. And a good thing it was warm too. Rain was rattling off the kitchen window, staccato, never-ending drum beats to underscore something bubbling in a pot on the stovetop.

  “You’re up?” Kinky said, turning from the stove.

  “I am,” he said, and inhaled. Whatever she was cooking was a delight to the nose. “That smells delicious.”

  “For himself and Kitty’s dinner,” she said. “Parsnip and apple soup. Kitty will only have to heat it up, so, and there’ll be beef and dumplings to follow.”

  “Pity you’re married to Archie,” Barry said with a grin. “The way you feed us I might just forgo Sue if you’d marry me.”

  She laughed. “Go away, Barry Laverty. You’re quite astray in the head about Miss Nolan.”

  “I am,” said Barry, “but you are a marvellous cook, Kinky.”

  “Thank you.” She made a little bow. “It does be nice to be appreciated, bye.” She sipped a taste from a spoon. “Coming on a treat.”

  “I’m off—”

  “For your bath, I imagine, and to make a phone call about last night’s case. You must be famished, bye.”

  Barry opened his mouth but no words came out. Kinky’s powers of deduction were especially keen this morning. “How—how did—? Never mind.” He smiled.

  “I do have a fresh batch of soda farls. I’ll make you my Kinky’s eggs Benedict.”

  Barry grinned. Her soda farl topped with a rasher and a lightly poached egg and smothered in Hollandaise sauce was a thing of beauty. “That would be wonderful.”

  And fifteen minutes later it was. Oh it was. He mopped dark orange-yellow egg yolk and creamy sauce Hollandaise up with a piece of fried soda farl.

  “That,” she said, “will do you for breakfast and lunch, seeing it’s eleven thirty now.”

  “It will,” Barry said, “and keep me full until this evening. I’m taking Sue to the Culloden for dinner.” He sliced off a piece of rasher and popped it in his mouth. Delicious. And decent of Kinky to make it for him.

  “Busy night last night,” Kinky said. It wasn’t a question.

  “Yes. I’m afraid Eileen Lindsay was taken poorly.”

  “She went off by ambulance,” Kinky said, then paused dramatically. “Aggie Arbuthnot popped in to bring me a dozen eggs, so. You’re eating one of them now.”

  Barry grinned, mopped up more yolk, and shook his head. He had long since stopped marvelling at the speed of Ballybucklebo’s jungle—no, that was the wrong word—its rustic telegraph.

  “And will Eileen be all right?”

  “It was the Royal I was phoning just now. She’s more comfortable this morning. She’s got a thing called porphyria. There’s no cure.”

  Kinky tutted. “The poor wee soul.”

  He heard the deep sympathy in her voice. “But if she avoids things that bring it on, she’ll be all right once she’s got over this attack.”

  Kinky folded her arms. “It will be difficult for her to manage with three kiddies and her the only breadwinner.”

  “Aye. It will.” Was this perhaps the “need” Kinky had foreseen for her four-hundred-pound winnings on Foinavon? He popped in the last slice of tomato, then carried his plate to the sink. “I’m going out, but I’ll wash my things first.”

  “Leave that. I’ll see to it,” Kinky said.

  “Kinky, cooking breakfast for late-sleeping doctors is not exactly in your job description. You were kind enough to make me breakfast, the least I can do—”

  “It’s your day off, and besides, I can’t have you underfoot while I’m finishing up this soup. Now run along and get dressed like a good doctor.”

  And Barry did as he was bid.

  * * *

  He was back in the kitchen ten minutes later, putting on his Burberry raincoat and cramming a paddy hat on his head. He listened to the rain still rattling off the windows. The late Al Jolson may have waxed lyrical about “April Showers.” Clearly the man hadn’t experienced what Ulster could offer. More like a blooming monsoon.

  “And where might you be going to on an afternoon like this? And why aren’t you tucked up in the lounge with a cup of tea and your book. That John D. MacDonald one about a Mister McGee that you’ve been talking about?”

  “Eileen’s going to need help.
She’ll be in hospital at least until Saturday.”

  “Och, the dear.”

  “The Jacksons can hold the fort today, but they’ve got their shop to look after. I thought maybe Sonny and Maggie might help out the way they did when Sammy was sick.”

  Kinky nodded. “Hearts of corn, those two. I’m sure they will.”

  A gust shook the kitchen windows.

  “Keep yourself well wrapped up, Barry Laverty. I’ll make some beef tea for when you come home.”

  “Thanks, Kinky,” Barry said. “I’m off.” And having a distinct image of Scott’s South Polar Party straining into the Antarctic blast, he let himself out and hunched his shoulders against the storm.

  * * *

  “Come in out of that, Doctor,” Sonny Houston said. “And let me take your hat and coat.”

  As always, barks and yips came from the kitchen where the Houston dogs were penned when visitors called.

  “Come into the parlour.” He led the way. “Look who’s come to call, Maggie,” Sonny said.

  “How’s about ye?” Maggie asked. “Take the weight off your feet.” She sat by a roaring fire with what looked like a large atlas open to a map of Australia and the one-eyed, one-eared General Sir Bernard Law Montgomery purring on top of it. “Very well, thanks, Maggie,” he said. “And all the better for seeing you and Sonny.”

  “And what can we do for you, Doctor,” said Sonny. “As much as we’re delighted by your visit, I imagine this is more than just a social call.”

  “I’ve come to ask for another favour for Eileen Lindsay. She’s had to be admitted to the Royal. She’s okay, but she’s probably going to be in there until at least Saturday.”

  “Gracious me,” said Maggie. “As if the poor soul doesn’t have enough to contend with. That deadbeat wastrel of a husband of hers taking himself off to England—”

  “Now Maggie dear, no one can know what happens inside a marriage except those involved.”

  Maggie sniffed. “For a man who spent his life sifting through people’s rubbish, Sonny has no interest in gossip.”

  “It’s not rubbish. It’s called a midden and it’s important to archaeologists. But you’re quite right about gossip and rumour. Now, how can we help?” Sonny asked.

  Typical of the man, Barry thought. “Her weans, Sammy, Mary, and Willie, need looking after until Eileen’s back on her feet.”

  “What do you think, Maggie?” Sonny asked.

  “They’re a bunch of wee dotes, so they are.” She frowned. “But we’ve the dogs and the General til look after.” She hesitated then smiled her toothless-as-an-oyster smile. “But don’t we have two spare rooms and couldn’t you run them to school and pick them up, Sonny?”

  “With no difficulty. It is a bit of a walk from here.” He beamed. “And do you know what, Doctor? Tom Duffy’s Circus will be in Bangor on Saturday. A trip there might help cheer them up. We’ll do it.”

  Before Barry could say thank you, Maggie had stood up, decanting the General and the atlas onto the floor. “You and Sonny work out the details. I’ll make us a wee cup of tea in our hands. The kettle’s on and I’ve some new plum cake.”

  Barry’s heart sank. Even Arthur Guinness turned his nose up at the indigestible stuff.

  “But I’ve fresh scones too, Kinky’s recipe, if you’d prefer.”

  “That would be lovely, Maggie,” Barry said, swallowing down the acid taste that always developed in his mouth when he thought of Maggie’s tea. The stuff could tan rawhide, but trapped as he was by courtesy, he’d choke down a cup before leaving.

  “Maggie and I’ll go over after school today and work things out with the Jacksons, but the little ones will be perfectly fine with us. Maggie and I didn’t have kiddies so we’ve no grandchildren. It’ll be a kind of being granny and grampa, and I know Maggie will really enjoy that.”

  “I will, too,” Maggie said, depositing her tray on a table. “And I’ll tell you a thing, young Doctor Barry Laverty. We all know yis and Miss Nolan’s getting wed in July. Make sure the pair of youse has lots of weans or youse’ll end up like me and my ould goat.” Her voice was honeyed with affection. “Mammy and daddy to a clatter of daft dogs and a belligerent pussycat. Now,” she picked up the teapot, “I’ll pour.”

  Barry sighed. He remembered that walk along the banks of the Braid River with Sue in February, when they’d discussed starting a family. He’d confessed he was torn then, and he still was. He wished to hell he could be enthusiastic, but, unlike Sue, deep down he found the prospect of parenthood daunting.

  “Here’s your tea, sir.” Maggie gave Barry a cup. “Help yourself til—”

  The phone rang in the hall.

  “I’ll answer it,” Sonny said, and rose.

  Barry was on the verge of accepting a scone when Sonny reappeared. “It’s Kinky for you, Doctor, and she says it’s urgent.”

  “Right.” Barry ran to the hall and grabbed the phone. “Kinky?”

  “It’s Gracie Miller. She says Lewis has taken another turn. Doctor O’Reilly’s in the surgery sewing up a bad cut and Nonie’s just left to see someone in Helen’s Bay.”

  “I’m on my way.” Barry stuck his head into the lounge. “Thanks for helping with the Lindsay kids, you two. I’ve got an emergency. Gotta go.” He grabbed his coat and hat and without bothering to put them on tore into the pelting rain and down the path.

  Brunhilde, as Volkswagens were reputed to do, started at once. As Barry accelerated, he recalled that an angiogram had confirmed a narrowing of the left internal carotid artery in Lewis’s neck. Over the years a build-up developed, called atheroma, of fat—he guiltily thought of the fry he’d just enjoyed in Kinky’s kitchen—white blood cells and calcium under the inner wall of the vessel. Lewis had been discharged on the fifteenth, twelve days ago, and the low dose of Coumadin he’d been prescribed, an oral anticoagulant, had stabilised. The senior consultant who had looked after Lewis—Doctor Harold Millar—had said in his letter to Barry that it was unclear if anticoagulants really helped, but it was the best he could do.

  Barry wished his specialist colleague could do more. Ultimately nothing was going to prevent the inevitable: either more attacks like the last one or, perish the thought, some of the atheroma breaking free, travelling to the brain, and causing death of brain tissue. That outcome would be categorized as a stroke and the severity of the residual damage would depend upon how much brain function was lost—if Lewis survived.

  The sooner Barry got to their bungalow, the better.

  * * *

  Gracie met him at the back door. She was in floods of tears, fragile and pale. “You have to do something, sir. Come quick.” She ran back into the kitchen. “It’s not like the last time. Lewis never said nothing. He just collapsed in a heap.”

  Barry slammed the door against the gale and gave silent thanks that the kitchen was toasty. He’d got himself soaked for a second time on his way from the car.

  Gracie stood wringing her hands over her husband, who lay crumpled on his right side on the floor. He wore a shirt under a sleeveless pullover, trousers, slippers, and socks. His spectacles had skidded across the tiles.

  Barry knelt beside the fallen man and set his bag on the floor. He made sure Lewis was breathing regularly and deeply. His pulse was slow, but there was no evidence of any arrhythmia. “Lewis?” Barry said into the man’s ear. “Lewis?” But there was no sign he had heard. Barry pushed the patient gently so he lay on his back. His eyelids were closed. Barry opened the right eye. He pulled a pencil torch from his inside jacket pocket and shone the beam into the eye. The pupil constricted. He repeated the process on the left. No response. It was the left carotid that was damaged. It supplied the left part of the brain that received visual signals from the left eye.

  “Is he—Is he dead, Doctor?” Gracie asked. Her voice quavered.

  “No,” Barry said, “but he’s unconscious. I just need to do a quick examination.” Loss of consciousness wasn’t always a sign of a stroke, but B
arry was seriously worried. He lifted Lewis’s right arm, bent it at the elbow, and supported it by cupping it in his own left palm. He pulled a patella hammer from his bag. The instrument looked like a tomahawk with a steel handle and triangular red rubber head. He tapped it against the tendon of the biceps. No response. He moved to kneel beside Lewis’s left knee, flexed it, and tested the patellar tendon reflex between the kneecap and the shin bone. Nothing. Barry took off the man’s right shoe and sock. His toenails were yellow and horny and the ball of the foot and heel callused. All those years as a postman had left their mark. Barry found his keys and rubbed the tip of one along from the heel to the front of the big toe side of the sole. The toe bent upward into what was known as a positive Babinski reflex, named for the French physician who had described it in 1896. This, along with the loss of reflexes, was indicating left-sided cerebral damage. Barry inhaled deeply, then said, “Pillows and blankets, please, Gracie.”

  “Yes, Doctor.”

  It was going to be back to the Royal for Lewis Miller, and this time whether or not he’d be coming out was unclear. And if he did survive, how damaged would he be? That was the job of the specialist to assess if Lewis recovered consciousness.

  “Here y’are.” Gracie gave Barry a pillow that he slipped under Lewis’s head and a pink blanket to cover the man.

  Barry rose. “You stay with him, Gracie. I’ll need to phone.”

  “Will he live, sir?” The pleading in her voice was heartbreaking.

  “I hope so,” Barry said, “but I must phone.”

  There was a bed for Lewis on ward 22, the neurology ward. The ambulance would arrive in about twenty minutes.

  Barry looked down at the man, feeling helpless and knowing he could easily slip into feelings of guilt if he didn’t recognise that doctors were only human and could not cure everything. And certainly not cerebral damage. His care now must be for Gracie. He took her by the elbow and led her to a kitchen chair. “Sit down, Gracie,” he said, helping her to do so. “Can I make you a cup of tea?”