I would never say that general practice was onerous.
Most of the time it was delightful to have responsibility for the care of my
own ‘flock’. Much of it was very ordinary to my growing experience, even if
frightening to some patients. It was a privilege to be able to relieve the
anxieties with confidence.
Of course, Birchington was the kind of place where
people had lived all their lives, or where they had retired from a lifetime of
work in London 25 years ago and were now prone to the ravages of time and age.
So, people had terminal cancers, or serious cerebrovascular accidents, or heart
attacks, or their bodies just succumbed to old age. Part of the job was to be
realistic, to work closely with our district nurses to ensure that our patients
were as comfortable as possible in their last weeks and days. There was no
place for hiding the truth, and often my patients were relieved to have the
story explained to them in terms they could understand where they had been
confused by others not so comfortable to discuss the issues. I guess I had
learned powerful lessons from my Sri Lankan doctor friend’s dying during my
second job at King’s, but also from being with my mother during her last weeks
and days.
So much of what I did was to sit and ‘be with’ someone
during the last stages, particularly when they had few relatives and supports
but refused to be sent to a hospital or home. One of these was Elizabeth who
came from a small family scattered across Southern England, had lost her
parents during the blitz in London, but had been part of that generation of
stoics who ‘soldiered on’. Elizabeth had secondaries from an ovarian cancer
treated years before, and our local oncologist felt their service had reached
the end of the line. Despite her chronic pain and discomfort, she did her
weekly shopping, cooked for herself, and looked after herself as best she could,
adamant she would not accept care. She had worked at the War Office and had a
fund of stories about intrigues that had likely never been told and likely
never would be. Given my own forces’ connections, I found it easy to listen,
and she had the knack of making us both laugh long and loud.
In those days, diamorphine (heroin) was simply part of
the doctor’s bag, and I had carried the same five ampoules around in the back
of my car for at least two years. From time to time, Elizabeth would be in such
pain that the nurses would resort to asking me to help; which I did on a couple
of occasions. Such a useful analgesic with few side effects from a standard
dose; you could see the relaxation of facial muscles as the pain disappeared
and euphoria set in. And the stories got funnier. One of us stayed with
Elizabeth for the hour or so after each injection. Nothing adverse ever
happened, but the injection seemed to allow her to cope for the next couple of
weeks on her oral medications. Elizabeth eventually died in her sleep one night
some weeks later, as she had wanted.
I never felt the need to pop into the chemist and
replenish my small supply, and was only ever to use one more ampoule of my five
- with a patient in her mid eighties, dying from cardiac failure in her own
home shared with a younger sister, also just in her eighties. It was in
response to a heart-wrenching request from the sister, deeply saddened by
watching her sister’s struggle: “Is there nothing you can do to ease her
distress, doctor?” My patient died at home 48 hours later, and the sister came
to the surgery a couple of days later to express her gratitude for ‘being so
kind’.
I guess relieving pain is a major role in a doctor’s life. And
relieving pain from psychological and interpersonal causes rather than physical
was ultimately to become a major part of my life’s direction. And it began in a
seemingly innocuous way.
Ken Fraser had overseen my work with a small number of children
and families for about six months at the Canterbury clinic, when he did me the
honour of asking if it would be possible for me to do another half-day session.
The proposal was that I would visit Lanthorne House once a week, and provide
some medical backup by phone if necessary when Ken was not available. Having
again discussed it with Jan, and then with John, I agreed. I was excited and
daunted, not sure what I would find or how I would manage.
With some trepidation I found my way to Broadstairs, and wandered
into the ground floor of a three-storey building, asking for directions to the
unit. “Upstairs”, they said, “Lift at the end of the corridor”. No enquiries or
checking of identity. So I walked the length of the corridor sensing the
atmosphere (echoing, dingy and empty with cries and whimpering off, and the
smell of ancient dust and old faeces, barely concealed by disinfectant), and
caught the lift to the top floor. Why would you organise an inpatient unit for young
people with psychiatric problems on the top floor? Pragmatic reasons, I guess.
I asked for the charge nurse, and was shown into a cramped office
where there was one of many case conferences going on between the many nurses,
two psychologists, and an activity therapist. I was briefly introduced to the
group, and invited to find a seat on the outer circle, where I listened for the
next hour or so to the challenges of managing 25 inpatients of varying ages and
with a myriad of problems. Fascinating. The charge nurse was clearly in charge,
and stood no nonsense. At the end of the meeting, she asked me what I thought I
might be able to contribute? Not aggressively, you understand, but clearly
marking out her territory and ‘ownership’ of the ward, the staff and the
patients. I stuttered a bit, and then took a one down position saying that I
had had some minimal training in adult psychiatry and some therapies but had only
recently started at the Canterbury clinic working with children and families. I
was happy to do whatever I could to assist her in managing what were quite
obviously a diverse and tough group of clinical problems; albeit I was only
going to be available face to face one half day a week. I must have hit the
right note, because she visibly relaxed and asked me to write up some
medications for two of the youngsters who were being discharged and needed a
supply before they were able to see their own doctor. Writing up medication was
the classic role of the doctor, and safe ground, so I was happy to do that! Would
I like to see round the unit? More safe ground, and I was happy to do that! She
asked one of her junior nurses to escort me round and explain the daily
routine. So, for the rest of the day I was introduced to a range of young
people, two sets of visiting parents and several therapists who were not at
that point deep in therapy. I asked about what types of therapy were available,
whether groups were being run, whether excursions were possible within the
budget, how many people were on night duty, and how emergencies were dealt
with? By this I meant how an individual medical emergency might be handled at
night, and was told that on occasion staff from the two lower floors could be
called in to assist. After afternoon tea, I was trundled back to the charge
nurse who asked if I had any questions? Skating on rather thin ice I asked how
she might like to use me? Clearly all the cases were in the overall charge of
Dr. Fraser, and she would have to discuss with him what I may be capable of
doing. I said that would be fine, and that I looked forward to attending next
week, and hoped I might be of use. My first three hour ‘session’ had been
completed.
