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Friday, March 31, 2017

Making of a Child Psychiatrist: (67) The General Practitioner (12); A bit more Child Psychiatry +

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.

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