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Wednesday, March 8, 2017

Making of a Child Psychiatrist: (61) The General Practitioner (6)

There were two other times of excitement when John was away on holiday. He was a part time police surgeon for the Isle of Thanet, and needed a person to be named as taking his place. He said it was never onerous, sometimes really interesting, and always good to be on the side of the police, and you got paid. I accepted the job of a stand-in, probably mostly on the grounds of being paid a little extra. A young family always costs more than you ever think it will.
We got through the first week well, with no calls or problems. Then there was a call from the Margate lockup. They had a young man in custody behaving strangely. They thought he was mad; please would I give my opinion and advice.
When I arrived at the police station, I was escorted down to the cells. The young man, tall and lean, well bronzed and with the long hair and beard of the era, was totally starkers – that is he had no clothes on. He had discarded them, and police had gradually collected them into a rather dirty pile. He appeared to have soiled himself rather badly, and was using his faeces to write dirty words on the walls and draw odd diagrams. “I am sorry, doc, he is really crazy and filthy. There was nothing we could do to stop him”, said the young policeman holding his nose, and leaving the area “to allow you to do what you needed to do”. I sat down on a chair outside the cells and several feet away from our smelly young man (ie out of range). He smiled at me. “Look”, he whispered, “I’m not mad, Doc. But I thought if I put on a bit of a show, they might want to get rid me.” “So what did you do?” “Well I was at a party, and we had all had a few. I guess I was a bit noisy, and a neighbor came across the road and told us all to ‘quieten down’.” “You know how it is. I was a bit pissed, and thought I would have a go at him, so I abused him a bit, and then he called the police saying I had threatened him. I didn’t really; I was just having a bit of fun.”
I checked out some basic facts about his background and family, and whether he had done anything like this before. He denied it. Had he ever had any psychiatric treatment? “No.” Rather miserably (appropriately so), he said he just wanted to go home. He gave me his long-term girlfriend’s home phone number, and I asked her a series of questions. Nothing suggested any sort of genuine mental health problem. I asked the police what they might charge him with? Probably ‘Being a public nuisance’. I decided it was probably all a storm in a teacup, and the police were free to charge him and let him go home; maybe after he had had a shower in their bathroom. I left, shaking my head, but also slightly amused. The things you can et asked to do as a doctor!
The other piece of excitement that fortnight was at Haine Hospital; half way to Ramsgate. It was an old Sanatorium, now in part turned into a convalescent home and in part a geriatric hospital. Again, this was one of John’s extra jobs - being a part time assistant geriatrician. The phone call suggested they had a man in his 40s who was convalescing from an operation on his leg. He had begun to feel breathless for no apparent reason, needed oxygen but was still beginning to turn blue. Staff members were anxious and did not know what to do. “Yes, he has a drip up. Can you please come quickly?”

I would guess the journey took me about 20 minutes taking the back roads, and I wondered why I had not suggested they call an ambulance to take him to Margate Casualty. I arrived, and was raced to one of the wards. Our patient was indeed very unwell, breathing hard, and with a slight purplish tinge around the neck and throat. He could not talk much, but complained of a sudden onset of pain in the left side of his chest. He had not had an injury to his chest, but was post-operative, but I could detect no evidence of pain in his legs to suggest a deep vein thrombosis as the cause. They had done an ECG, and that appeared normal to my eye. So I began to listen to his chest, which from the outside looked very normal. The right side was normal, but on the left side I could not hear any breath sounds listening at the front, side or back. When I percussed the side of his chest it sounded much louder than the right side. There was no available Xray facility at Haine. Somewhere deep in my brain it clicked that this man might have a pneumothorax? I have no idea from whence that idea emerged. It was just there as the most likely diagnosis. I took an enormous risk, asking for a large bore needle – the widest they had – some local analgesia, and a scalpel. As soon as I could, I pushed the wide bore needle in between two ribs, and was gratified to hear an expulsion of air with the next struggling intake of breath, and the next and the next. When I turned around I had three open mouthed nurses looking at me. I suggested they call an ambulance. It was only then that I realised how much I had perspired inside my three piece suit; I had not even taken off my jacket and put on a gown. Perhaps I had heard stories back when I worked at King’s Casualty; perhaps I had read about pneumothorax at some time. But I had known it was an emergency and, from somewhere deep inside, dredged up what to do. I had been right (but suppose I had been wrong)! 

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