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Friday, March 10, 2017

Making of a Child Psychiatrist: (63) The General Practitioner (8)

There is a great joke about being on night call as a doctor. Late one night he was called, and listened respectfully to the story of a school aged child with a high temperature. There were no symptoms or signs serious enough to suggest a pneumonia, or even a bronchitis; more likely the child had a tonsillitis. The doctor recommended two aspirin and said he would call round in the morning. Later that night he was called again by the very anxious father saying the temperature was not settling down, the child was in great distress, and he wondered if the doctor would go round to the house. The doctor again listened carefully, but was unperturbed and suggested perhaps bathing him down with cool water and providing more aspirin. He would call round in the morning.
Some months later, the doctor had a serious breakdown in the house plumbing with a toilet that would no longer flush properly and was becoming offensive. Somewhat late in the evening he phoned a local plumber and explained the story. The plumber listened respectfully, and then said: “I suggest you give the toilet two aspirin, and I will call round in the morning!”
As a doctor, I can say it is rare to not respond even if you are certain the problem is minor in medical terms. It is a fact that the worst loud noise you can hear as a doctor is the phone ringing in the middle of the night. You have to wake from an often very deep sleep, and are expected to have engaged your thoughtful brain prior to making any comment on the story. More often than not you simply get up, put clothes on and go round to the house because you KNOW that the most important part of the consultation will be putting your patient’s mind at rest whatever the problem, and however serious it really is. Jan describes one occasion where I had had a bit of a rough night with three or four calls. Eventually I got back to bed, but then the alarm went off on the clock. The story goes that I rather sleepily picked up the phone and said “Doctor Martin. How can I help you?” before Jan told me it was just the alarm to get ready for the day.
I frequently went out to see children in acute pain with an ear ache, or ‘not able to breathe’ because of enlarged and infected tonsils. What was clear is that an antibiotic given at night along with appropriate analgesia, begins to do the trick fairly soon, and allows people to get some sleep because the doctor has seen the child and confidently provided a diagnosis and a clear management strategy.
And then there are babies that seem to be very happy to be born early in the morning, and leave some physical damage along the way that demands attention as soon as possible. And of course coronary thrombosis often chooses the wee small hours to strike.
And there are many medical problems that can catch you out. A colleague of ours had been round to see an elderly man several times after evening surgeries with recurrent attacks of ‘dizziness’. Eventually he was called again and refused to go out on the grounds he had been out several times and found nothing. The next night when it was my turn to be on call I was asked to go to the house. When I got there several minutes later, the man had an acute left hemiplegia, losing all of his power down his dominant side, with some mixed sensory loss, as well as some slurring of speech. Unfortunately, the story was classic of a build up of Transient Ischaemic Attacks (TIAs) most likely due to a partial blockage in a carotid artery. If he had been sent to hospital somewhat earlier, he would have had a medication to thin his blood, or even an operation on the offending artery, and not have been so damaged and not required such heroic rehabilitation efforts to regain his former self. It is always irritating to be called out frequently and find nothing, but as a doctor you have to avoid the trap of anger and disdain blocking your ability to ask the right questions and reach the correct solution. And, sadly, none of us is immune to frustration and irritation.
Several cases have caused me frustration. One was a friendly grandmotherly lady who came to see me on several occasions complaining of chronic constipation, describing in graphic detail what she could feel through her abdominal wall in what must have been the descending colon. She asked my opinion. She refused examination, as she had several times before, but did deny blood in her stool (”Oh no, nothing as horrible as that, doctor”). I had tried to give her advice several times, with no success, but tried again. I suggested that perhaps she needed more roughage or fruit in her diet (refuted), or perhaps she was not drinking enough fluid each day (refuted), or perhaps she needed to do a bit more exercise (refuted with examples of what she did each day - which admittedly should have been enough). Perhaps she would like to try an aperient (tried those) or perhaps a small enema from the district nurse (refuted with horror). She had organised a peculiar theory of strings attached to her skin at one point and attached under the skin, inside to her bowel. “Normally” she said, “all I have to do is to pull or massage one about here, followed by another along here, and then this one.” She pulled up her blouse a few inches to show me the upper left part of her tummy, pointing to a slightly pink area that had obviously been rubbed recently. I could think of no anatomical explanation that made any sense. I had previously discussed her with John, and he had smiled and said: “She’s a nutcase!” (whatever that meant). I could think of nothing useful to say, but suggested (slightly tongue in cheek, and hoping it did not show) “Have you thought of reversing the order of pulling the strings?” She looked at me blankly for a moment and then said: “Do you know, I never thought of that. Thank you doctor. I will go home and give it a go.”
I did not see her for several weeks, but nearly bumped into her in the local supermarket one Saturday, when out shopping with Jan. “Doctor,” she said conspiratorially, “you know that suggestion you made?” I nodded. “It worked… and I’ve been meaning to come and see you to thank you. Nice to see you with the your wife. Enjoy your afternoon.” And off she toddled. I guess you have to celebrate your successes, even if you have not the slightest idea of what was going on.
The other lady who caused me immense frustration was a lady I her early 60s, tall, elegant and with a slightly imperious and direct manner, and a loud voice. Without fail, rain or shine she wore an elegant wide brimmed summer hat. She had an erratic wide based gait when walking down the corridor, and I had always wondered about its origin. But somehow, I could not bring myself to ask the question; it seemed intrusive, and there was never any obvious connection to the small problems she presented in the consulting room. (Privately, I called her my ‘Ship at Sea’, meaning a galleon in full flight before a gale force wind). I did once ask her if she had problems with her balance, but she denied it vehemently: “No, no, nothing at all like that.”
She lived alone, had never married, and again I always had that sense that it would be rude to enquire; she gave the impression of being such a private person. Again I checked in with Dr. Hayden, who had seen her a couple of time in the absence of Dr. Bowie. “Lovely lady, never any trouble, and I have no idea what her problems are”. Mmm, very helpful, John. She denied any sort of symptoms, was quite angry when I demanded to take her blood pressure and feel her pulse, and as I gradually (over several sessions and many months) asked about various system problems, she would deny them loudly. Her request was always for a mild sedative to be taken at night, and I kept a check of the numbers prescribed but she did not appear to be abusing them. I would prescribe, give her the prescription, and she would say loudly (and I am sure the staff in the office could have heard): “Thankyou, doctor. I do so much enjoy our conversations. You are such a nice young man.”

Even with all my current experience, I cannot find a reasonable psychiatric diagnosis that might fit. I have mused that her wide gait may have been due to an old cerebrovascular accident, or perhaps Multiple Sclerosis, but I have no evidence. As I noted above, sometimes you have to just celebrate your successes, even if you have not the slightest idea of what was going on.

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