Thank goodness for the humble chest X-ray. X-rays show the air in the lungs as black and the bones as white. Fat, even a thick layer of it, can be seen through if the clever radiographer cranks up the exposure of the film. I was depending on the chest X-ray to show me a reasonable picture of her lungs to help work out what might be going on. The portable chest X-ray was done and the picture soon showed up on the computer monitor. To my relief, the image was reasonably clear and I could see the white fuzzing of infection in the lower part of her right lung that was probably causing her problems. Oddly though, the infection wasn’t the only thing that I could see. There was some sort of electrical device implanted on the left side of her chest wall. I was used to seeing pacemakers on a chest X-ray film. These are implanted under the skin on the chest; the wires from them travel to the heart and give off electrical pulses to help prevent it beating too slowly. This didn’t look like a pacemaker though, because I couldn’t see any wires travelling from the machine to the heart.
I called over one of the other doctors to have a look and soon there was a small collection of us crowding round the monitor trying to work out what the device was. I thought it might be an implantable defibrillator but one of the other doctors pointed out that these have visible wires too. The cardiology registrar, who was also staring in confusion, had heard about a wireless pacemaker being developed in America and wondered if this was a version. As the number of doctors surrounding the monitor grew, the debate on the identity of the mystery device intensified. During a rare moment of quiet, a voice from the back of the crowd piped up, ‘It looks like a Nokia 1101.’
Everyone turned round to look at the baby-faced medical student at the back.
‘Nokia don’t make pacemakers,’ the cardiologist snapped impatiently before returning to his debate with the emergency medicine consultant.
‘No, the Nokia 1101 is a mobile phone. I used to have one and it looks identical.’
There was a moment of silence before the cardiologist continued to shout down the student for even considering that a mobile phone could be implanted inside her chest. I went back to see the patient. With a bit of help from one of the nurses I leaned her forward and pulled apart a large roll of fat on the left side of her back. I pushed my hand in and felt what I was searching for. The Nokia 1101 needed a bit of a tug, but it soon came free and I returned to the collection of doctors around the monitor to show them my catch. The medical student quite rightly enjoyed his moment of triumph while the cardiologist left quietly, shoulders slumped.
The coroner
It was 8:15 on a Wednesday morning and I had just arrived at work. I had barely taken off my coat when the receptionist put a call through to me.
‘Morning, Dr Daniels, it’s the coroner’s office here.’
A wave of anxiety washed over me. The coroner only calls when someone has died and usually when that death is unexpected.
‘Barry Dawkins. Know him? Date of birth 22 April 1963. He was found dead at home last night by his wife.’
The name rang a bell but I really couldn’t picture him. Having been born in the year 1963 made him only just 50. Why had he died? That’s much too young.
My slow NHS computer was taking a lifetime to boot up. I was repeating the name Barry Dawkins over and over in my mind. Why couldn’t I picture him? Who was he? Had I missed something? Of course, with more than 6,000 patients registered at our surgery, one or two tend to fall off their perch every month or so, but normally these are patients who are expected to die and the coroner doesn’t get involved.
The coroner’s office deals with deaths that are violent or unexplained. They often call for a post-mortem and sometimes order an inquest to clarify the details surrounding the death. A coroner’s inquest can be a scary place for doctors. They are not a criminal court and so can’t attribute criminal negligence, but they often still involve a doctor standing up under oath and trying to justify why they did or did not do something with regard to a patient’s care.
When I finally got Barry Dawkins’ notes up, I scrolled through in a slight panic wondering if I might have missed something. He’d been in a few times recently for a review of his blood pressure and diabetes, but that was about it. My biggest fear was that he had presented with symptoms that I had dismissed, which he had then gone on to die from. Could he have had a burst aorta that I’d dismissed as simple back pain, or a bleed on the brain that I’d thought was a migraine? I was mightily relieved to see that no such mistake had been made, but a pang of guilt washed over me as I realised that selfish self-preservation was all I’d been able to think about upon hearing of this man’s untimely death.
The coroner disrupted my thoughts.
‘So, Dr Daniels, what medication had you been prescribing him? Did you start him on any new medication just before he died?’
Bloody hell, I hadn’t even thought about that. Could some wayward prescribing on my part have contributed to his death? Suddenly, I sharply switched back into self-preservation mode. The medications I had prescribed to Mr Dawkins were all fairly common, but as the coroner was hinting, they could have all potentially killed him: the aspirin could have caused a bleed from his stomach; the diabetes medication could have dropped his blood sugar causing him to die of hypoglycaemia; the blood pressure tablets might have caused him to faint and bash his head; and the combination of his cholesterol tablets and excessive drinking might have given him liver failure.
I carefully explained all the medications to the coroner, and as I put the phone down I sat quietly stewing in a light sweat, again wondering about my potential influence over another man’s life. I took another good look through Mr Dawkins’ notes. Much as I was annoyed by the computer record’s constant flashing up of targets, one number did jump out at me from Mr Dawkins’ records. His risk score of dying in the next 10 years was 47 per cent. Clearly a stupid statistic to remain on the records of a man already dead, but basically the computer was working out the risk of him having a heart attack or stroke based on his weight, blood pressure, smoking history, diabetes, cholesterol and age. The statistic was basically stating that despite being young, his other risk factors made dying not that unlikely. I was still a bit worried that the medications I had prescribed might have killed him, but I was now also considering that perhaps his death had resulted in me not having treated his risk factors aggressively enough.
I took a good look through his notes and was reassured by the amount of time the doctors and nurses at this surgery had spent advising him to stop smoking and lose weight and take better control of his diabetes. We were constantly trying to get his blood pressure under control and, to be honest, I’m not really sure what more we could have done for him.
I still had a nervous wait for the result of the post-mortem. When it came, it was no surprise to learn that he had died from a massive heart attack, but I can’t pretend that my initial reaction wasn’t relief that I had played no untoward part in his demise. In some ways we should consider it a success that we now see the death of a man in his 50s as such a shocking event. It didn’t used to be, and it is because doctors and patients have got better at reducing the risk factors. I phoned up his poor widow to offer my condolences and support and she asked me if she could book into our stop-smoking clinic.
Mr Goodson
‘HELLO MR GOODSON. CAN YOU HEAR ME? IT’S THE DOCTOR.’
I was kneeling on a doorstep in the pouring rain shouting through a letter box.
I had received a phone call that morning from Mr Goodson’s worried niece. She had been receiving increasingly odd letters from him over the past few months and wanted me to go and make sure he was okay. At this point, I wondered whether as his closest relative she might want to demonstrate her concern by visiting herself, but she gently pointed out that she was phoning me from her home in New Zealand, so as his GP responsibility for his wellbeing fell to me.
Mr Goodson doesn’t have a phone and he had previously always communicated by writing kindly letters to h
is niece in New Zealand. Recently the letters had been becoming increasingly paranoid in nature, warning her of a conspiracy regarding a dangerous network of computers controlled by the British royal family and the Kennedy family in America. According to him they were plotting to control the world by placing a grid of electromag-netic energy around it that would have power over our minds. In the most recent letter she had received, Mr Goodson had accused her of being part of the conspiracy too, and it was at this point that she decided to give me a ring.
I hadn’t met Mr Goodson before. He had been registered at our surgery for years but, despite being 73 years old, his computer records suggested that he didn’t have any health complaints. He didn’t answer our letters advising him to come in for flu jabs and health checks and so up until now we had always respected his choice to keep away and left him in peace. The phone call this morning changed all that and I couldn’t ignore his niece’s concerns. It would appear that his paranoid thoughts were likely to have been ongoing for some months now, so there wasn’t any real reason to rush round that same day, but just last month I’d discovered that one of my patients had lain dead on his sofa for four months without anyone realising. I didn’t want another of my patients to suffer the same fate, hence the situation I now found myself in, shouting through a letter box in the pouring rain.
After five minutes of yelling and banging on the door, I was on the verge of giving up and hoping he was simply out rather than lying dead somewhere inside. I knocked on his next-door neighbour’s door, who helpfully told me that she was fairly sure he hadn’t been out in days, so I returned for a few last desperate shouts through the letter box.
‘IF YOU DON’T LET ME IN I’M GOING TO HAVE TO BREAK THE DOOR DOWN.’
This last-ditch attempt to persuade Mr Goodson to open the door was an empty threat. I really didn’t have the strength or inclination to break down a front door, but just as I was ready to give up and go back to the surgery, I thought I heard some stirring from within the house. I kneeled down again on the doorstep to peer through the letter box and to my surprise this time I saw a pair of eyes staring straight back at me.
‘You can’t come in,’ he told me calmly. ‘You’re contaminated.’
‘Er, I don’t think I am,’ I answered feebly, suddenly a bit thrown that I was having this bizarre conversation through a letter box.
‘Yes you are,’ Mr Goodson responded confidently. ‘What do you want anyway?’
‘I’m Dr Daniels, your GP. Your niece called me. She’s worried about you.’
‘She’s contaminated too. I tried to warn her but she wouldn’t listen.’
‘Can I just come in for a chat?’
‘You’ll need to decontaminate first. Hold on.’
With that, Mr Goodson stood up and shuffled away from the door. Some moments later a nearly empty and very old bottle of Johnson’s baby oil was pushed out through the letter box and landed at my feet.
‘The electromagnetic rays can’t get through this. It repels them,’ he explained.
Looking at the grubby bottle, I wondered how far I should go along with Mr Goodson’s delusions. I tried rationally suggesting that I had already washed my hands carefully before leaving the surgery, but Mr Goodson made it very clear that this wouldn’t be sufficient. There was a limit to the amount of time that I was prepared to spend shouting through a door while getting drenched by a November downpour, so I gave in and picked up the bottle of baby oil. I made a show of rubbing some of the lotion over my hands while Mr Goodson watched me suspiciously through the letter box.
‘Right, I’m all, erm … decontaminated now.’
‘Your face isn’t. That needs doing too.’
I looked down at the grubby-looking bottle and wondered at its age. Did I really want to rub this stuff on to my face? Johnson’s baby oil is harmless enough, but I couldn’t be entirely sure that, in his paranoia, Mr Goodson hadn’t added less savoury ingredients to the bottle. I stood for a few moments, trying to come up with a better method of gaining entry than smearing this stuff on my face, but when nothing came to mind I reluctantly rubbed the cream over my face, and to my relief I heard the clunk of his front door unlocking.
Once inside I was amazed that Mr Goodson really thought that some sort of contamination was going to arise from the outside world rather than from the filthy state of the interior. It took a while for my eyes to adjust to the darkness, but once they had I was greeted by a stark and miserable sight. Mr Goodson himself was in a terrible state. He had clearly once been a tall man but now he was hunched over and his ragged looking shirt and trousers were baggy on his bony frame. The floor was a bare lino, sticky with grime, and the walls were brown from the tar staining of decades of cigarette smoke. Plates of half-eaten meals and empty food packaging were piled high in one corner of the living room and an awful stench of what smelled like sour milk seeped into the pit of my stomach making me want to gag. All his windows were blocked out by rows of tin foil and empty egg boxes, which were crudely Sellotaped to the glass in what I could only imagine was another attempt by Mr Goodson to deflect the electromagnetic forces he so feared.
‘Do you have a computer, Doctor?’
‘Well, yes.’
‘You need to get rid of it right away. They’re sending messages through it.’
‘What, like emails?’
Mr Goodson looked at me blankly and I could see that the concept of an email was completely alien to him; we stood in silence for a few moments, with Mr Goodson shuffling around me, his suspicious gaze fixed on my face. Having made such an effort to gain entry to his house, now that I was in, I felt at a bit of a loss as to what to do next. I had successfully confirmed that Mr Goodson was alive and also that he was floridly paranoid and delusional. He was clearly very suspicious of me, so my next step was going to be tricky. I decided I needed to try to gain his trust, but cordial small talk has never really been something I’m any good at.
‘So, how have you been?’ I asked with false brightness.
‘I’m just trying to stay alive, Doctor.’
‘Yes, erm, aren’t we all …? Pretty bloody awful weather, isn’t it?’
‘Water helps conduct the radiation. It can spread in rain water.’
The small talk wasn’t really getting me very far, so I decided to try to address the elephant in the room.
‘So, why do you think everyone is contaminated?’
Mr Goodson went on to describe in some detail his fears about global plots and bizarre conspiracies. Such was the intensity of his paranoia that I knew that there would be no benefit in trying to challenge his beliefs. Mr Goodson needed to have antipsychotic medication and ideally be admitted to a psychiatric unit where he could be safe and looked after until his delusional paranoia settled. I gently introduced the subject of him taking some medication to help make the unpleasant thoughts go away, but he wasn’t having any of it. As far as he was concerned, he was the only one who accurately understood the truth and it was the rest of us who were unwell.
Sectioning is not a decision that anyone takes lightly and it really is used as a last resort, when there are no other feasible options available. Some people manage to stay living independently at home with quite marked chronic delusional symptoms, but Mr Goodson’s symptoms were such that it was preventing him from being able to look after himself. Once someone’s illness leads to the potential to harm themselves or others, the person can be judged as unwell enough to be admitted to a psychiatric unit against their will. Sensibly, such a grave decision isn’t one that I’m allowed to make alone. It requires the joint decision of a GP, a psychiatrist and a specialist social worker, and so when I returned to the surgery I made some arrangements to return the next day with the cavalry.
The following day I met the psychiatrist and social worker outside Mr Goodson’s house. They looked a little surprised when I took from my bag a bottle of Johnson’s baby oil that I had taken from my own bathroom cabinet that morning. When we knocked on Mr Goods
on’s door, he made me push my bottle of baby lotion through the letter box. After it passed his careful inspection, it was posted back out and he intently watched all three of us smear ourselves with the stuff before letting us in.
My biggest fear at that point was that Mr Goodson would point-blank refuse to be admitted to hospital, leaving us no choice but to get the police involved to forcibly detain him. In his paranoid state, this would be terrifying for him, and he was in such a physically frail state that if he put up a fight I was scared he might get badly injured.
Fortunately, the social worker was brilliant. She had a very calming way about her, and without either colluding with his delusions or openly refuting them, she managed to persuade Mr Goodson that he would be safer and better off under the care of the mental health team. It took some time to reassure him about levels of contamination in her car, but eventually off they went and he was able to get the care and treatment that he needed.
Psychosis is a terrifying condition for the sufferer. The strange thoughts and paranoid ideas that can seem ridiculous to us feel absolutely real to the poor person with the condition. The antipsychotic medications available aren’t perfect, but they do help clear away the delusions and return people to reality. Since starting these drugs, Mr Goodson is much better. He is still undeniably eccentric, but the tin foil has been taken down from the windows and I no longer have to smother myself in baby oil in order to gain entrance to his house. Most importantly, he feels safe again and is able to live something resembling a normal life.
Mr Raymond
As a patient Mr Raymond asked little of me. He rarely came into the surgery and when he did he was courteous and undemanding. He had spent some time in prison for child sex offences and each time I met him, I had to try to force myself to be professional and not let the fact that he was a paedophile cloud the way I treated him. My job as his doctor was to treat him with impartiality and compassion as my patient, rather than judge him as a person. This sounds straightforward enough, but I will admit that I found it difficult. He had recently been diagnosed with diabetes and was a model patient, attending all his appointments and sticking to his new diet and medication regime.
Further Confessions of a GP (The Confessions Series) Page 11
