Confessions of a GP (13 page)

In an ideal world I would set up a syringe driver, which is a pump that slowly injects morphine automatically into the patient until the pain is controlled. But it was 3 a.m. and Mrs Briggs needed pain relief now. There was no way that I was going to be able to organise a syringe driver tonight. I took the family aside and explained that I wanted to give her an injection of morphine. I explained that it might decrease her level of consciousness but would ease the pain and agitation. The family was well aware that she only had a few hours left and they wanted them to be peaceful and pain free. They were happy for me to give the injection. I drew up the morphine into my syringe and slowly injected the clear fluid under her skin. In front of my eyes, her tense agitated body relaxed. I only gave her a few mils, but she had so little flesh on her that she didn’t need much for it to take effect. As Mrs Briggs writhing body calmed, so did the torment on the faces of her family. Her breathing became shallow and she slipped into a deep coma and died a few hours later.

Her family was immensely grateful. It wasn’t euthanasia, but perhaps my injection of morphine sped up her death by a few hours. Many of my day-to-day actions as a GP lead me to question the ethics of the choices I make. However, I never doubted that my decision to give Mrs Briggs morphine that night was the right thing to do. My fears about giving morphine are more about the family and how they might react. If I had thought that the family wasn’t on my side, I wouldn’t have given the morphine. Not because the wishes of the family are more important than the wellbeing of the patient, but because I wouldn’t want to have to defend my actions in court. Mrs Briggs would have suffered but I’m not prepared to be labelled as the ‘next Shipman’. People accuse doctors of playing God by choosing when patients live or die and sometimes we do, but as long as our decisions are made with compassion and not arrogance, I’ll make no apologies.

Betty Bale’s cat

Betty Bale is the only patient that I can remember from my first six-month stint as a doctor. She was admitted to my ward on my first day and was still in that same bed when I finished six months later. She was only in her late sixties but had suffered a severe stroke, which meant that she was pretty much completely paralysed. She could speak but it was slurred and she dribbled. It was always an effort to make out her words and even more of an effort for her to say them. She couldn’t swallow so had to be fed through a tube running straight into her stomach. All in all, it was a fairly miserable existence.

Strokes are unpredictable and some people recover all of their function, others none and most something in between. For the first few weeks, Betty had intensive specialist physio and speech therapist input, but it soon became clear that she wasn’t going to recover much of her movement. Previously independent, this was very difficult for Betty to accept. It was sensitively suggested by the consultant that she would need to go to a nursing home to be looked after. Betty’s speech was poor but she made it crystal clear where he could stick his nursing home idea. ‘I’m going home!’ she would shout as best she could. ‘I want to see my cat.’ Betty’s mind was as sharp as ever. She wasn’t confused about her diagnosis, she just hadn’t accepted it. If her disabilities had been more manageable, she could have gone home with carers visiting regularly. Unfortunately, Betty needed 24-hour nursing care because of her swallowing problems and severe paralysis.

Betty was taking up a hospital bed on an acute medical ward. It was a complete waste of resources as we were doing nothing for her, but she refused point blank to go to a nursing home and so what could we do? With intact marbles, we couldn’t ship her out against her will so we were stuck. Each morning we would do our ward round leaving Betty to last. Doctors hate feeling helpless so none of us really wanted to go in to see her. As the most junior member of the team, I was usually thrown in to say hello. My attempt at a friendly ‘good morning’ was always greeted with a stoical ‘I want to go home’ and invariably an ‘I want to see my cat.’ Betty had never married and had no children. She had painfully few visitors and we often heard her crying to herself as we hurried past her room. It was a miserable situation but one that seemed impossible to solve.

It was decided between the junior doctors and nurses that we were going to bring in her cat for a visit. We knew that if the consultant or, worse still, the infection control nurse found out, we would all be for the high jump, but after so many months of feeling so incapable of helping Betty, we decided we were finally going to do something for her. It was agreed we would sneak the cat in on her birthday. Like a military operation, the cat was picked up from Betty’s neighbour and smuggled on to the ward. The cat was a miserable old moggy with clumps of missing fur and she hissed at anyone who came close. We couldn’t believe that this was the precious creature that had been so desperately missed. Betty was, however, over the moon. ‘My cat, my cat!’ she cried. The cat herself seemed less than overwhelmed by the reunion but did at least allow Betty to hold her for a few minutes and even seemed to let out the odd token purr.

It would be nice to finish the story with Betty making a miracle recovery because of the amazing healing power of feline friendship, but that didn’t happen. Betty was still paralysed and eventually, after many reluctant months, did have to go to a nursing home. Betty’s case sticks in my mind because it shows how despite all the wonderful facilities that modern hospitals contain, it was a mangy cat that made one woman’s suffering lessen for a short period at least.

Vaccines

Sebastian was three years old and looking fairly miserable. He was very sweet and, despite being a bit unhappy and feverish, he was keen to tell me that he had a stethoscope like mine at home. His mum had brought him in as she was worried about his rash. He was covered in spots. ‘Has he had all his jabs?’ I asked casually as I took a closer look. ‘No, we don’t believe in vaccines,’ Mum replied matter-of-factly. I was shocked. I had mostly worked as a GP in working-class areas and never come across anyone who didn’t vaccinate their children. This day I was working in a leafy north London suburb and discovered it was almost the norm here. A lot of what we do as doctors is patch people up and keep them going for a few extra years. There is a lot of listening to people’s general health grumbles, giving a bit of reassurance and sending them out of the door with a pretty ineffectual tablet. Medicine is better than it was a hundred years ago but the main reason people live longer and only very rarely die in childhood is due to improved sanitation and nutrition. Clean running water and an abundance of food have saved far more lives than doctors and our medicines. Having said that, I believe the one great achievement of modern medicine is the widespread vaccination of children. Vaccines are cheap, safe and have saved millions of lives both here and all over the world. Measles used to be a major killer in the UK and it has now become a disease that I had only ever read about in textbooks. Despite working as a paediatric doctor both in England and Africa, I had never seen a real life case of measles.

Until this day, that is. Here it was in front of me, the widespread rash all over the body and the classic lesions in the mouth. I ‘Googled’ measles and, sure enough, Sebastian’s rash looked the same as the one on my computer screen. My final test was to grab Sue, our oldest receptionist, and bring her into the room. ‘Is this measles?’ I asked her. Taken aback but flattered to be asked her medical opinion, Sue took a quick glance and said, ‘That’s it. All four of my kids have had it.’ There it was: measles, a disease that killed millions of children before widespread vaccinations almost eradicated it completely. As a doctor who had only practised medicine in the twenty-first century, I should never have seen this disease. Measles was back and had become a disease of the middle classes. A disease of Hampstead, Wimbledon and Harrogate – so frustratingly unnecessary.

I was actually quite angry. Sebastian’s mum was unrepentant. ‘I think it is important for my child to build up his own natural immune system. He is on a special whole-food diet that boosts it naturally.’ I was fuming now. ‘The immune system is very specific,’ I tried to explain calmly. ‘The only way that Sebastian can become immune to measles is to either have the vaccine or to have the disease itself, assuming he survives it. He can eat all the organic dates and wholemeal rice in the world, it won’t give him immunity to measles, mumps, rubella, diphtheria, tetanus, meningitis C, whooping cough, haemophilus influenza and tuberculosis. These really aren’t nice illnesses, you know!’ It was not the time to be angry as Sebastian was quite unwell. There is no cure for measles but having no experience of the disease, I wanted the paediatricians to check him over. I sent them up to the hospital with strict instructions for Mum to keep Sebastian isolated from the other children in the waiting room.

Not all children can have vaccines. They can be harmful to children who have diseases of their immune system such as HIV or those having chemotherapy for cancer. Previously, these children were protected because healthy children were all vaccinated and so a disease outbreak was prevented. Now that healthy children such as Sebastian are no longer being vaccinated, these vulnerable children are at risk. The last thing a child on chemotherapy needs is a bout of measles. Vaccinating isn’t just about protecting your own child.

Darryl

‘What can I do for you today, Darryl?’

‘’Allo Dr Daniels. How are you?’

‘Fine, thank you, Darryl.’

‘I ’ope you’re ’aving a good day and that.’

Darryl was a local thug who had somehow avoided ever having been locked up despite years of fights, assaults and petty crime. He tended to be rude and demanding so his less than impressive attempt at being charming meant that he must have wanted something.

‘I need a letter to say I couldn’t go to my community service last Thursday.’

‘Why was that?’

‘I had bad flu.’

It annoys me when people say they have flu when actually they have a bit of a cold. However, it wasn’t the time to correct Darryl. He was significantly bigger than me and I have naturally cowardly tendencies.

‘Are you still unwell?’

‘No, I’m better now.’

‘Well, why didn’t you come in at the time you were unwell?’

‘I phoned up the receptionist and she told me that there were no appointments available except for emergencies. She also told me that my symptoms were probably viral and I should take some paracetamol and go to bed.’

We had clearly trained our receptionists too well and now Darryl had worked out how to get out of his community service without getting in the shit.

‘I didn’t want to waste an emergency appointment and that.’

How noble of you, Darryl. Such a shame that your high sense of altruistic morals couldn’t have been better demonstrated when you were kicking the shit out of some poor lad who’d accidentally spilt your pint. (I thought this rather than said it, for obvious reasons.)

I really didn’t want to write a letter for Darryl. I also had had a bit of man flu that Thursday. I had ventured in and spent the day feeling miserable. I didn’t see why Darryl couldn’t have done the same. I imagine he had a few beers the night before and decided to give the leaf sweeping a miss for the day, knowing he could hoodwink some foolish GP into writing a letter to get him off the hook.

‘My probation officer says I need a letter and that. I’m on my last warning for missing community service days. They’re threatening to take me back to court and put me away.’

So there I was, writing a letter as if to excuse my child from doing PE at school:

Dear Probation Officer,

We both know Darryl is an unpleasant little scrot who will do anything to slime his way out of trouble and get out of doing any work. He tells me he had a bit of a snuffly nose last week (boo hoo) and now wants me to write a letter so he doesn’t have to go back to court to face a breach of his community service order.

Please send him straight to jail and lock him up for ever as I am in a particularly unsympathetic mood due to the fact that I’m running late because of time-wasting twats like Darryl.

Yours sincerely,

Dr Benjamin Daniels

This was the letter I would love to have written. One day I will write it and bask in momentary satisfaction before they suspend me for unprofessional conduct and Darryl comes to my house and beats seven lumps of shit out of me. I hoped the probation officer would read between the lines of the more mundane letter that I actually wrote:

Dear Probation Officer,

Darryl tells me that he couldn’t go to his community service last Thursday as he had symptoms of a viral infection. He was not examined at the time and his symptoms have since resolved.

Yours sincerely,

Dr Benjamin Daniels

Nothing in this letter required any small degree of medical knowledge or skill, but the very fact that it was written by a doctor rather than his aunt Doris meant that Darryl would probably get off the hook with the court and avoid going to jail.

The pat dog

My last hospital job before I became a GP was in psychiatry. I already knew that I wanted to be a GP by this stage and, given the large amount of psychiatry in general practice, I thought that it wouldn’t be a bad idea to spend six months learning a bit more about mental health. The job I had was actually in forensic psychiatry. I was on a locked ward with patients who were supposedly ‘criminally insane’. I loved going to parties and telling people I was a forensic psychiatrist. It sounds good, doesn’t it? It gave people the impression that I was akin to the Robbie Coltrane figure in
Cracker
, solving crimes and bringing insane criminals to their knees with my brilliant questioning and diagnoses. The reality, of course, was very different. I wasn’t really a forensic psychiatrist, I was the junior doctor attached to the forensic psychiatry team. I wandered around the ward doing the odd blood test and checking blood pressures. Occasionally, I would write a letter to the Home Office asking whether a patient would be allowed to go to his sister’s wedding as long as he promised not to drink too much or murder anyone.