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Wednesday, October 26, 2016

Making of a Child Psychiatrist: (54) Moving towards General Practice (3)

We moved into an upstairs Kingsmead flat, and Jonathan enjoyed having access to his grandparents and a house to roam when his little brother was taking his mother’s attention. He had always been rather an independent little explorer, and on one occasion had gone AWOL from our hospital flat, walking to the local shops on the path next to a main road. Luckily someone recognised him, and he was returned safely. The Kingsmead rear garden was walled and had an expanse of grass, so it was safe to let him run without fear of major injury. We were happy with our extended family, and felt settled and supported.
I began my steep learning curve in general practice, trying to get to know the geography of Birchington and the most economical way to find a particular house, meeting new patients and their families and trying to get a handle on who was related to whom. This was before computers, so we had cryptic little notes in Alan Bowie’s elegant longhand on slim ruled buff cards in packets all sorted in alphabetical order in a wall of little boxes. The clinic staff were welcoming, provided rapid access to notes, and seemed to know which forms needed to be completed for blood specimens. I did not yet have my own prescription pad, but was able to use temporary pads after I had introduced myself to the two pharmacists and their staff in the village. In particular I got to know our three midwives, two district nurses, and a health visitor – everyone keen to tell me about what they did each day, which patients were struggling, and who might need home visits.
Home visits occurred after a morning surgery, and there was always a short list. With luck I could get them completed before heading home for lunch. I found it a strange process knocking on front doors explaining who I was, and then intruding into people’s privacy, sitting in lounge rooms absorbing the atmosphere, meeting other family members keen to meet this young man trying to hide his baby face with an emerging beard. Trying to gain a sense of the history of the current problem and what might be necessary was sometimes easy, but often complex. Patients seemed to be on a plethora of medication, but I decided not to change things too quickly given I was the ‘new boy’, and did not want to be dismissed as a meddler until I felt I was on secure ground. Sometimes I would meet up with one of the nurses in the home, and they were able to both inform my practice and translate so that everyone could understand. Eventually it dawned on me that a home visit was a rich insight into people’s family relationships and manner of living, whether they were wealthy professional people using their holiday or weekend home or those on welfare living on the local caravan site.
Two afternoons a week, I had small antenatal clinics where I had a shared arrangement with the midwives, and was happy to be guided by them until I knew better (which did not happen often). The strange situation was that almost all the babies in the practice were born at home and, while I knew them all through the antenatal clinic, I was only called in if there were signs of impending problems, or if I needed to do some suturing (and even that was surprisingly rare). We did have the possibility of using what was called a ‘Domino Scheme’ arrangement with the hospitals such that if a birth began to look complicated an ambulance was called, the birth occurring in hospital but involving our practice midwife. There was then a rapid 24-48 hour return home as soon as everything had been sorted. Efficient, great for continuity of care, and good for family and community cohesion. I only remember this program being used for two of my patients during all my time in the practice. Of importance, I don’t remember any losses of either maternal or infant lives.
Once a week I was expected to drive to St. Nicholas, a tiny farming village with two main pubs for a population of only about two hundred people drawn from two main family groups – the ‘Beans’ and the ‘Loves’. It took me ages to begin to understand the generations, and a curious part of me was always on the rather fruitless lookout for possible genetic inbreeding.
The ‘clinic’ was a large room at the back of the local church, with wooden chairs and an oversized oak table. The waiting room was the front end of the church replete with pews and, of course, everyone knew everyone and everyone’s business. There was no equipment and no drug cupboard, so I learned after week one to ensure I took everything with me. I think for many weeks I was an object of curiosity, and it seemed to me that many symptoms were trumped up just to get a look at this new doctor person. Farming people are incredibly resourceful, and have their own ways of managing illnesses. I had to be very gentle, very patient, and very respectful. Word travels very fast in the local pub.
One of those cases you never forget was man in his 50s complaining of epigastric pain. When I explored the history he had had it for at least two months, gradually getting worse. It did not seem to be related to food or alcohol, though a sense of fullness seemed to make it worse. He had had no vomiting, but when I questioned him, from time to time there had been some rather tarry black stools over the previous few weeks. I examined him in the chair, but really needed to examine his belly with him flat on his back. I don’t know what the vicar would have thought, and I don’t know whether he or the church council ever found out, but with my patient stretched out on the ancient table with his head on a jumper, I examined his ‘soreness’. He had a solid mass about the size of an orange where his stomach was, and it was tender to touch. He was not jaundiced. I got his wife in, and explained to the two of them how concerned I was. I wrote a brief letter in long hand explaining my findings, and phoned for an ambulance to Margate Hospital. I am not sure he was happy with ‘this new bloke’, even if his wife popped in the next week to tell me what had happened. When the opportunity occurred, I did a home visit, only to find out he was on the back of a tractor somewhere out towards Reculver. He was to survive fairly well and active for almost two years.
I was six weeks into this new life learning how to be a father to my two little boys, attempting to help Jan whenever I could, and the complex steep learning curve of being a local doctor, when I phoned my parents in Bristol to begin to discuss arrangements and a date for Rod’s christening. My father answered the phone and seemed unsure about what he and my mother might be doing. Eventually he came clean and admitted he had been worried about my Mum, who had had a recurrent cough, and had been to her local GP but was not really getting better. He was a little thin on detail, and so I asked if I could speak her. He shouted up the stairs, and there was some discussion, but eventually Mum came down, coughed to clear her throat, and rather quietly answered the phone. I could hear that she was breathless, and that made me curious and anxious. It is unusual for people to get breathless coming downstairs. Bit by bit I dragged the story out. She had had a cough for several months. Yes, there had been phlegm that varied in colour from cream to green. No, it had not changed much despite two courses of antibiotics. I asked if there had been blood in her phlegm. There was a long pause, but when I pressed her she admitted to small amounts over the previous two weeks when she had had a coughing fit. Did she have chest pain? Yes, a nagging dull pain down the left side. Had she had a temperature? No, not really. How long had she been breathless? Possibly over the last couple of months, and it seemed to be slowly getting worse. Had the GP listened to her chest? Yes, the first time, but not since. Had the GP organised an X-ray? No. Did she have another appointment? No. What I knew about my mother was that she had been a smoker of 20 cigarettes a day since forever. I was not just curious now; I was scared.
I asked her to put Dad on the phone. I went over the story, and he added a couple of bits of information. Mum had actually been smoking a bit less recently. She had never been a very physically active person, but really did not want to go anywhere, even in the car. We discussed the local GP, and Dad was obviously furious that so little had been done. I suggested the situation was serious, and demanded he pack up the car and drive to Westgate so that we could get some expert attention for Mum. In the meantime I would phone a consultant physician I knew from student days – Dr. David Lillicrap who had provided the most amazing clinical experience and supervision for me at Ramsgate Hospital in the run up to my finals.
The nearly 4-hour car journey from Long Ashton to Westgate must have been awful for the two of them. My sister Andrea was told they had to stop the car several times for my mother to vomit. She was certainly exhausted when she arrived, and not keen to eat dinner. In contrast she was very keen to hold Jonathan and then her new grandson, which brought smiles and tears. She looked drained, dispirited, and I am sure she knew she was seriously ill. I listened to her chest, and apart from all the crackles I could hear when she breathed, there was an obvious change in tone to percussion about two thirds down her left lung suggesting a pleural effusion. She knew that I knew she was seriously ill, but at that point I simply muttered about some consolidation suggesting a pneumonia. We settled her into bed, and time seemed distorted between then and the urgent appointment David had very kindly arranged for the next day.
David’s news was bad. The Xray had shown a large primary cancer in the left lung with a pleural effusion. In addition there were spots across both lungs suggesting what he called miliary spread (spots everywhere) of metastases (secondaries). He had discussions with a colleague and his team, and they were prepared to try aggressive high dose chemotherapy, but he did not hold much in the way of hope. I explained it all to Dad, and he wanted whatever could be done to be done. David spent a lot of time with Mum explaining the treatment, noting she would have to stay in hospital, and would not be feeling well as a result of the chemicals.
We all lived a nightmare for the next few weeks. Dad spent hours with Mum at the hospital, and was like a shadow for the rest of the time. And, of course, he had the duty to tell Andrea, who needed to take leave from her Teachers Training Course in Totley, Yorkshire, to come down to be with Mum as much as possible. Jan was quietly withdrawn and had to focus on the two boys, but did get to see Mum in hospital. I went to Ramsgate Hospital to sit with Mum as often as possible after evening surgery. She was very unwell from chemotherapy, and distressed that her rich curly brown hair was falling out so quickly. She was amused to have been measured for a wig, and was enjoying wearing different headscarves, but distressed she was stuck in a bed and not getting out into the Spring sunshine. She reported the staff as having been very attentive and kind, although the hospital was old, the paintwork drab, and there was an absence of anything like a view.
I had a time with David Lillicrap about three weeks into treatment, after a set of follow-up Xrays. These were showing very little change in the cancers, though the pleural effusion had receded a bit. He told me that they could not give Mum more treatment than they had given her. They had been as aggressive as they dared, and her body had coped, but there were no other alternatives. He had conferenced her case with several colleagues, but could not hold out any hope.

Mum knew. One evening she said to me: “I’m going to die, aren’t I?” Sitting on the bed, I had to tell her what David had told me, and finished up with having to tell her that she was going to die. She smiled, telling me it was alright, and we wept and held each other. She asked if I had told Dad what I had been told, and then asked me to tell him so that they could discuss it together. I did so; but he had known. He almost lived at the hospital for the next few weeks. Andrea had to return to Totley to start a four-week teaching practice. The day she went, Dad stayed with Mum all day, coming home late in the evening; he looked grey and spent. The following morning we had a phone call to say she had gone. So then Dad had to phone the College Bursar who had to inform Andrea of mum's death, and organise for her to travel back to Westgate. Louie Evelyn Martin died on the 1st June 1970. She was 50.

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