When the consultant arrived he was not alone. He had with him a tall plump floppy-haired man wearing a blue blazer, check shirt and—Adam instantly decided—annoying trousers. Walking just behind him, as he laughed at whatever it was the consultant had just said, was the thin blonde psychologist from yesterday.
Dr Walter Peach had been the Consultant Psychiatrist of this and four other wards for over fifteen years. A tall, thin grey haired man with a long nose and an expensive tie, he always arrived last. He had the most authority and therefore his time had the most value. The three fresh-faced medical students sat nervously next to each other, looking at Peach with a youthful mix of awe and terror. Two men and a woman, all young, all white; one of them, a long-faced boy with black hair and a grey crew neck jumper, was playing fretfully with a spot on his chin. Peach sat down and the man with the blazer sat next to him. ‘Adam, good to see you in here. How are you?’
‘I’m well, thank you Walter. How are you?’ Adam spoke softly, politely.
Peach smiled and nodded. ‘I’m well thank you Adam.’ And then he paused, glanced at the floor for a moment before looking at Adam and saying: ‘I had a letter from Graham’s wife yesterday.’
Adam swallowed hard and blinked rapidly three or four times. ‘How is she doing?’
‘OK I think. She mentioned you. She asked how you were.’
‘That is kind of her.’
‘Yes.’ There was a long silence; the medical students looked uncertain. The dark haired boy picked at his spots more nervously. Tim glanced at Phoebe, who looked blankly back at him. Dr Peach looked around and wondered if he should say any more. ‘The child is nearly two now.’
‘Really? Adam raised his eyebrows. ‘Two already…’ He felt a lump in his throat and a burning behind his eyes. Whenever he thought of Graham Cochrane’s son he thought of the day, yet to come, when his mother would tell him how his father died. Peach and Adam looked at each other and, for a moment, met in something like sympathy. A pause, long enough for each of them to acknowledge the other, and then they both looked down and away.
Peach lifted his head and looked around, nodded at Phoebe and pointedly ignored the students. ‘Do you all know Dr Casells?’ He turned his head to the man with the over-ironed trousers. Phoebe shook her head ever so slightly; Adam ignored the question; the students shook their heads vigorously. ‘Dr David Casells has recently joined us from The Bethlem. He will be overseeing the Clinical Psychology department, splitting his time between research and clinical work. About half and half David, is that right?
‘About 50% research, 50% clinical and 50% supervising other staff,’ Dr Casells said loudly, laughing at his own joke to make sure nobody thought he was very poor at sums. Everyone laughed politely except Adam, who yawned.
‘And the young lady?’ Peach said formally.
‘Oh, forgive me,’ said Casells. ‘This is Carla Tandy, she is a trainee. I was hoping that you might help make good use of her.’ He was looking at Adam when he began the sentence but had turned to face Peach by the time he had finished.
‘I’m sure we will find something useful for her to do, won’t we Adam?’ Peach said.
‘It’s already in hand, Walter.’ Adam smiled with a conviviality that was as rare as it was contrived.
‘Good. Right, who do we have first?’ Peach turned to Tim, but before he could speak the ward door opened and closed quickly and they could all hear the sound of rapid footsteps rushing down the corridor.
Anna appeared, breathless and pink. ‘I’m so sorry I am late,’ she said. Adam noticed that she directed her apology to the whole room. ‘Someone on my bus had a heart attack,’ she said, puffing out her cheeks.
‘Oh dear,’ said Tim.
‘He died on the bus, just sitting there in the middle of the top deck. There was nothing we could do.’ Everyone was silent for a moment. Anna looked confused. ‘I mean I didn’t do anything, nobody did, it happened so quickly.’
‘Was he a big man?’ asked one of the students.
‘Pardon?’ Everyone looked at the student, a baby-faced blonde boy with near-invisible eyebrows.
‘I wondered if he was big: bigger people are more prone to heart attacks.’
Peach frowned. ‘Yes, I’m not sure now is the time to be conducting public health research, young man. Our colleague has had a bit of a shock.’ The boy reddened and shrank. He might have tried to apologize but no sound came out.
Anna rescued him. ‘Someone on the bus, while we waiting for the ambulance, said we should carry him off the bus so the rest of us could get to work. He said the bloke was dead so what was the point of everyone just sitting there staring at him. A woman started crying and called him heartless and the man said if rigor mortis sets in they’ll have to cut him out.’ Everyone made noises that conveyed outrage. Only Adam’s sounded like a laugh. Anna caught his eye and laughed out loud.
‘Perfectly natural response,’ said Casells. ‘To laugh, I mean.’
Anna smiled politely. ‘Comes to something when arriving at work feels like I am getting away from the madness. Anyway, I am sorry for being late, Dr Peach.’ She turned to Casells. ‘I am Anna Newton, Community Psychiatric Nurse.’
Casells stood up, walked over and took her hand. ‘David Casells, Specialist Consultant Clinical Psychologist.’
‘Well,’ said Dr Peach, who may not have forgiven Anna for arriving after he did. ‘I am sorry for your awful morning, Ms Newton. We are all glad you are here. Now I think if we may we should press on. Tim? Who is first please?
Tim was momentarily thrown. He was still looking at Anna and appeared deep in thought. ‘Right! Sorry!’ He swung his whole body round in his chair as if he was unable to turn at either the neck or the hips and as he did so he lifted both legs off the ground. ‘Right,’ he added as he stopped moving. He picked up a set of notes from the top of his pile. ‘First up, Michael Wells, he has had a very difficult week. He became overwhelmed by his voices on Tuesday and in his frustration broke a few things in the day room. I upped his medication but to no avail: two days ago he extracted four of his own teeth with pliers. He felt they were antennae attracting the voices. Yesterday I understand he took a snooker cue to an armchair. He slept OK, I think?’
Tim glanced at Adam, who lifted his hand and moved it from side to side. ‘Not well, I don’t think,’ he said quietly
‘Right, well he appears distracted this morning; he says the voices are getting worse. They are telling him he is worthless and is the son of Satan. He says the voices are mocking him. And they are incessant. More recently he says that one of the voices belongs to his father.’ Tim glanced at Adam again. ‘I am aware that he is at the top of his dosage. I wonder if we might need to rethink his drugs?’
Peach sat quietly, his fingers on his lips. ‘What is he on’?
‘1200mg of chlorpromazine. 40mg haloperidol. 5mg procyclidine. And last night I gave him some temazepam to help him sleep,’ Tim said.
‘Drug-resistant psychosis, ladies and gentlemen. What might we try next? Alex?’ Peach was looking directly at the spot-twiddling medical student.
‘ECT?’ the boy suggested.
‘Not for psychosis, no,’ said Peach dismissively. ‘Miss Ray?’
The young lady reddened and stuttered but answered nonetheless. ‘A different anti-psychotic perhaps? Er, sulpiride?’
‘Good,’ Peach said. ‘I am not a big believer in sulpiride but we work our way systematically through the treatment options until we find one that works. Tim, start him on sulpiride 200mg three times a day.’
‘And cut back on the chlorpromazine?’
‘We’ll wait a week or so and then look at that, shall we?’
Tim looked at Peach waiting for a rationale. Far too many drugs all trying to do the same thing. It wasn’t quite illegal but it was wrong, and unscientific. Peach stared him down.
Tim bit his lip and wrote down the new prescription. Without looking at his boss he said: ‘Would you like to see him?’
Peach looked at Adam, who pursed his lips. Adam knew that he possessed a certain goodwill with Walter Peach. In part this was because they had both worked with Graham Cochrane and his death had bound them in shock and in very different ways a sense of failure. In part because, as the charge nurse, Adam was supposed to have some authority and if Dr Peach did not enact that rule he would ultimately be undermining his own status. It was, Adam knew, a pantomime but he had learned that it presented him with tiny flakes of power and that he should use them wisely. Michael Wells would no more benefit from being in here than Adam did.
‘No, I think it is OK Tim, thank you. Perhaps you will talk to him later and explain that we think the new drug will help with the voices but that it may take a few days to start working and during that time he might want to use the temazepam to calm him.’
Phoebe spoke up: ‘He’s making a pot in the craft group.’
Everyone nodded. Peach related an anecdote about a patient he once had. ‘I’m sure you remember him.’ He was looking at Adam. ‘This young man spent the whole time he was here making pots. Some of them were really rather lovely. When he was discharged he opened a little shop called Gone Potty.’ Everyone laughed. Adam chose not to tell them that the shop went bust after a few weeks because the mad sod refused to sell any of them.
‘Now, who is next?’ smiled Peach.
‘Forgive me, sir.’ Carla Tandy the trainee psychologist glanced at Adam before smiling almost flirtatiously at Dr Peach. ‘Can I ask a question please?’
‘Of course, my dear.’
‘Can I ask the charge nurse: is this the patient you thought I ought to try to do some work with?’ she asked with a sarcastic curiosity. ‘Or am I mistaken?’
Peach glanced at Adam who pursed his lips and then smiled. ‘No, that’s right. I’m pleasantly surprised that you remember, as you seemed to suggest that people with a diagnosis like his were not of any interest to you?’
Carla reddened. ‘I certainly didn’t mean to suggest—’
Adam interrupted. ‘You see, I understand that Michael Wells is not unique in his presentation, and of course I understand that therapy tends toward the more articulate and dare I say middle class patients, but my sense is that Michael would benefit from some thoughtful, specialized therapeutic time. I think at the very least distraction helps him and at best a different type of assessment, a psychological ongoing assessment might serve to accompany the medical team’s efforts to contain his symptoms. A team approach if you like.’
At no point did Adam look at the woman as he spoke, instead he looked at Casells and smiled. Now he had finished he did not take his eyes off of him. To Casells’ credit he held his gaze and did not speak immediately.
Peach, however, did. ‘I have to say I think Adam has a point. What do you think, David?’
Casells nodded slowly. ‘Well, I wouldn’t want to think that someone trains for five years in order to simply distract a patient in distress. We could after all probably do that with a cap gun and some sparklers. However, I do agree that we need to be integrating psychological therapies more routinely into a wider client group than we do currently and it is of course the intention of our team to work with nursing staff. Indeed, as you know, Walter, one of my hopes in coming here is to extend my own research specifically in combined therapy. That is,’ he looked around the room, comfortable with the attention, ‘designing specific psychological therapies that integrate with the altered mental state created by medication. Why work in parallel with medicine when we could, perhaps with more success, work in unison? What say Miss Tandy does some exploratory work with Mr Wells? Shall we say six weeks? It may be that Michael would prove to be an ideal candidate for our sort of specialist therapy.’ Peach looked at Adam.
‘How about we review after six weeks, rather than assume it will finish?’ Adam said. ‘It may be that the process benefits Michael and we certainly wouldn’t want to write off that possibility before your trainee even starts, would we?’
Peach nodded and Casells looked away. ‘Of course. Who knows, she may cure him,’ he said with just a hint of sarcasm, before looking at Adam and saying ‘We’re delivering a teaching session in the school of nursing next week that outlines the combined therapies programme. You might be interested, Mr Sands?’
‘I doubt it,’ thought Adam. ‘Who knows?’ he said with a shrug.
‘Good,’ said Peach ignoring them both. ‘I look forward to hearing your views, Miss Tandy, and thank you, Dr Casells, for your help.’
Adam nodded at Peach but did not look at Tandy. It was, he felt, important that whatever it was she was feeling was accompanied by his contempt.
‘Next we have Libby Hoffman,’ said Tim.
Adam, who was just beginning to wonder what concession he would have to offer as payment for Peach’s support—a support he had negotiated the day before in Peach’s office—was to find out more quickly than he had expected. Libby had not been discussed in the ward round for over a year. He raised his eyebrows at Peach.
‘My idea, Adam,’ the consultant said.
Peach, as he always did on such occasions, offered a history for the students. Adam listened, choosing not to fill in the gaps to a past he had no reason to know so very well.
‘Libby, full name Elizabeth Hoffman, is eighty-two or eighty-three?’ He looked across the room for confirmation. Adam shrugged petulantly. She was eighty-five.
‘Anyway, she is, I’m afraid, something of a product of the hospital. She was admitted in the early 1920s with a diagnosis of melancholia. She was brought in by her parents, who were disturbed to find that she had become tearful and neglectful around the house. It appears that she had developed something of an infatuation with the local post boy, only to discover that he was rather toying with her affections. Libby was treated, when she got here, quite… extensively. A lot of the old notes make no sense and others have been destroyed. However, we can safely assume that she has experienced many things.’
Anna looked at Adam, who avoided her gaze. Peach continued. ‘Her present, and I have to say, intractable condition, is a deep-rooted nihilistic delusional state. In short she believes she has no body. She is also a diabetic, the result one suspects, of rather extensive insulin therapy in the forties.’
‘Has ECT been considered?’ the spot-twiddler asked.
‘Do you have shares in the electricity company?’ Peach said impatiently. ‘She undoubtedly had extensive ECT many years ago. Such treatment now would of course be absurd. There would be unnecessary risk of memory impairment and very little chance that it would have any effect on her ideation. ECT is, as you most certainly should know, a treatment for depression, not psychosis. Indeed, I have to say that I do not feel her beliefs alter her quality of life to such an extent that hospitalization remains necessary. That is why I would like to propose discharge.’
Anna was still looking directly at Adam, which lent him a self-consciousness he could do without at the moment. ‘Michael Wells getting a bit of therapy was just a softener for this,’ he thought. He raised his eyebrows to exaggerate a show of interest. ‘Interesting idea,’ he said. ‘Do we have any sense yet of where she might go?’ Impassive, engaged. He felt his stomach tighten. He chose not to ask himself why.
‘There is a new project opening on Delia Road,’ Peach said. ‘A house for six elderly patients. It is well staffed and well equipped. I’ve seen the house, indeed I will be the named consultant. I don’t imagine funding will be a problem.’ Both Anna and Tim shook their heads. ‘So you know her best, Adam, before we ask her to come in what do you think?’
Adam nodded slowly, pantomiming thought even though he knew that his thinking wasn’t working very well. It could only go so far before it bumped into something: a fog or some chemicals or something. He breathed i
n slowly and tried to ignore his stomach. He said: ‘Well, given the history you outlined, Walter, I certainly think she deserves some comfort in her dotage, don’t you?’ Peach smiled politely. ‘But from a nursing point of view I suppose my concern would be about the impact of change. At her age, consistency and familiarity are important. She has been on this ward for fourteen years. I am not suggesting that that is in itself a good thing, but I am wary of what change might do to her.’
‘In assessment she shows no significant deterioration in cognitive functioning,’ said Casells. ‘Which suggests she is capable of change.’ Casells looked from Adam to Peach as he spoke.
‘When was she last assessed?’ Adam asked.
‘I assessed her yesterday at Dr Peach’s request. You weren’t on shift.’
Adam reddened slightly. Embarrassed and annoyed that something had happened on his ward that he didn’t know about. He felt a pang of paranoia too. Someone knew, one of his nurses, and they hadn’t told him. He turned to Anna. ‘What do you think?’ He knew what she would say, what she would have to say, but he preferred the idea of having to concede what would soon become an overwhelming case to a nurse rather than to the pompous sod in the perma-pleat trousers.
‘Well, I think you are right about change, obviously. The evidence suggests that significant change for older people accelerates disorientation and physical deterioration.’ She directed this at Casells, who nodded and went to speak, but before he could Anna turned to Adam and continued: ‘However, I know the Delia Road house and the staff who are setting it up and I think they are good nurses who would be sensitive to that. I also think that we could do some useful work over a reasonable length of time to prepare her for the move. Most importantly, I think that she isn’t getting any younger and this ward, even though it is supposed to be a rehabilitation ward, is getting more acute. Michael has been unwell, Kaz, Colin… I don’t believe that is the best environment we can offer an eighty-five year old woman.’
Stranger Than Kindness Page 7