‘Every day for the last six weeks I’ve felt my baby move, but I’ve felt nothing since last night,’ she anxiously told me.
‘I’m sure he’s fine in there, he’s probably just having a lie-in,’ I chirped optimistically. ‘We’ll have a little listen.’
I was fairly convinced Karen was just having first-time pregnancy jitters and I was looking forward to reassuring her with that lovely sound of a baby’s heartbeat. With Karen up on the couch, I squeezed some gel onto her tummy and moved my Doppler probe around listening for the baby’s heartbeat.
We both remained silent as we listened for the trace of life. Every so often, between the white noise of interference I could make out a pulse, but it was the slow whooshing sound of Karen’s own arteries pulsating rather than the much faster clicking sound of a baby’s heartbeat. We endured an awful 10 minutes of searching, but however much I tweaked and moved the probe, I couldn’t hear the reassuring beat that would let us know her baby was alive. I finally gave up and Karen got off the couch.
‘Look, Karen, it might just be my Doppler machine or perhaps your baby’s lying at a funny angle or something. I’m going to call the obstetric doctor at the hospital and ask them to see you this afternoon. They’ll do a proper scan and find out what’s going on.’
Just as I picked up my phone to call the hospital, I heard a wail from Karen.
‘Oh my god, Doctor, I think I’m going into labour!’
Karen started screaming in pain and I dialled 999.
The paramedics were with us within minutes.
As she panted and groaned, I helped Karen into the ambulance, tears of fear and pain running down her face. As soon as she was safely on her way to hospital, I called the obstetric registrar to warn him of Karen’s imminent arrival.
I carried on with my surgery that afternoon, but all the while I was thinking about Karen and wondering what was happening to her. Going into labour at 25 weeks is much too early and although I’ve heard of the odd baby surviving when born that premature, the odds really aren’t great. The fact that I couldn’t hear the baby’s heartbeat on my probe made me feel even more despairing of the poor little mite’s chances. Miscarriages before 12 weeks are common and heartbreaking, but losing a pregnancy after 25 long weeks must be absolutely horrendous.
As I was sorting out the last of my paperwork at the end of surgery, I decided to call the obstetric registrar at the hospital to find out what was happening.
‘Are you the GP that sent that woman in with the premature labour?’
‘Yes, that was me. How is she?’
‘Well, you didn’t quite get the diagnosis right.’
‘What do you mean?’
‘She had pseudocyesis.’
‘Oh … could you just remind me what that is?’
The obstetric registrar paused for effect and then gave a sigh. ‘It was a pretend pregnancy. As her GP we thought you might have managed to at least do a pregnancy test before getting all excited and sending the nee-naws screaming round with the flashing blue lights.’ With that the obstetric doctor put the phone down, no doubt greatly amused by his successful belittling of me.
Normally I would be irritated at such an unpleasant dressing down by some smug little upstart, but I was absolutely dumbstruck that Karen hadn’t been pregnant. Why had she lied to me? Why had she put herself through such a bizarre and ultimately humiliating experience? My patients fib to me all the time. Mostly they lie about how much they drink or try to con me into believing that their valium prescription had been stolen and they needed some more. It’s been a long time since I routinely took all my patients’ declarations to be wholly truthful, but when Karen told me she was 25 weeks pregnant, I took it completely at face value.
Shocked and upset, I turned to the internet for support and was amazed by how common and powerful false pregnancies can be. For some women the overwhelming desire to believe they are pregnant can even cause their brain to produce the release of hormones that can lead to real pregnancy symptoms such as nausea and bloating. The hormones can stop periods like a real pregnancy would, often fooling everyone around them. Admittedly, the obstetric registrar was right, a pregnancy test would have given the game away, but I have a sneaky suspicion that they only realised that Karen wasn’t really pregnant once they got out the ultrasound scanner.
As a doctor it is never nice to know that you’ve got something completely wrong, but there is an odd reassurance in knowing you are not the only one to have made that mistake. Apparently an obstetrician in the US had been fooled into taking things one step further when a woman with a false pregnancy came in to see her claiming to be nine months pregnant. When the doctor couldn’t find the baby’s heartbeat, the woman was rushed straight to surgery and given an emergency caesarean section in a desperate attempt to save the imaginary baby. It was only when they cut her open and dug around in her abdomen for a bit that they discovered there was in fact no baby to save. Makes my mistake seem relatively trivial in comparison.
I would love to have spoken to Karen again. I wasn’t angry, just confused. Did she really think that she was pregnant? Was it part of some sort of odd delusional belief that was part of a wider mental health problem? Was it just some peculiar form of attention-seeking behaviour? Sadly, I’ve never found out, because Karen never came back to see me.
Playing God
I’d been called out for a home visit to see Miss Blumenthal, a 94-year-old lady who was living in one of our local nursing homes. I had never met her before, but I had visited other patients at this home and it didn’t have the best of reputations. The nurses who worked there were nice enough, but the organisation was poor and the big company who owned the home seemed to run it purely to make the maximum profit. It was always understaffed and the nurses and carers were paid a pittance. Any competent members of staff moved on quickly to better employers, leaving a few stragglers who would perhaps struggle to find any work elsewhere.
I stood ringing the doorbell for several minutes before Carmela, the nurse in charge, finally opened the front door for me. She looked very flustered.
‘Sorry, Doctor, lunchtime always very busy, busy.’
Carmela was Filipino and her English really wasn’t great.
‘So, what’s been going on then, with Miss Blumenthal?’
‘Miss Blumenthal not been eating or drinking for last few days,’ she told me, reading from a scrap of paper she’d pulled out of the pocket of her tunic.
‘Anything else you can tell me?’
Carmela studied her scrap of paper for any further information but there was clearly none. ‘I’ve been off the last few days,’ she shrugged.
‘Best go and see her then, shall we?’
Carmela led me through a network of corridors and fire doors before we reached Miss Blumenthal’s room.
‘Hello Miss Blumenthal, I’m the doctor.’
Miss Blumenthal opened her eyes briefly and mumbled something in a foreign language.
‘She used to sometimes speak to us in English, but she doesn’t any more. She only speaks to us in Polish now.’
This wasn’t unusual in people with Alzheimer’s. Even if they are completely fluent in a second language, as they slip further into dementia, they almost always lapse into speaking only their mother tongue. Carmela was wrong about the language she was mumbling in, though.
‘She’s not speaking Polish, that’s Yiddish.’
Carmela looked at me oddly: ‘But is say on her record that she is Polish.’
‘She may well have been born in Poland, but she’s Jewish and the language she is speaking is Yiddish. It’s actually closer to German than Polish.’
Carmela nodded, but looked at me suspiciously, as if I was trying to play some sort of odd trick on her. I sat on Miss Blumenthal’s bed and held her hand. She opened her eyes and I smiled at her but her look remained completely vacant. She mumbled something, again in Yiddish. Yiddish was the first language of my great-grandparents. It was once the co
mmon language of Jews all over Eastern Europe, but has now pretty much completely died out. The only words of Yiddish I know are ‘shmuck’ and ‘chutzpah’, neither of which were likely to have any great value in the current situation.
I turned my attention back to Carmela. ‘So, Miss Blumenthal doesn’t communicate much these days, but what can she do when she is well?’
Carmela again looked at me as if I was asking some sort of trick question.
‘I’ve never met Miss Blumenthal before, so I need to know how she is normally,’ I explained patiently. ‘For example, a couple of weeks ago what could she do?’
I was met with further awkward silence, so I tried to clarify things further.
‘Could she walk and eat and go to the toilet by herself?’
‘Oh no, Doctor,’ Carmela replied, relieved that she had finally got to grips with my line of questioning. ‘She used to sit in lounge, but not any more.’
‘So she’s bed bound.’
‘Yes, Doctor.’
‘And she’s incontinent of urine and faeces.’
‘Yes, Doctor.’
‘And occasionally she mumbles away in her language but doesn’t seem to understand you?’
‘Yes, Doctor.’
‘And you have to spoon-feed her puréed meals?’
‘Yes, Doctor, but last few days she is refusing to eat or drink.’
Carmela was smiling now, relieved that we seemed to have at least partly bridged what had once appeared to be an impassable chasm in our ability to communicate.
‘Does she have any family?’
‘Nobody. There is a nephew in Canada but we haven’t heard from him in years.’
Miss Blumenthal closed her eyes again and lay passively as I examined her.
As I rolled up her sleeve to check her blood pressure, I saw a series of green numbers tattooed on the inside of her left forearm. I stopped cold. It was a concentration camp tattoo. I had only seen one once before, but it was unmistakable. She opened her eyes and caught me staring dumbstruck at her forearm, but there was still not the slightest glimmer of expression in her face. In the relative peace of her nursing home, I couldn’t possibly imagine what horrors she must have witnessed 70 or so years ago in a Nazi concentration camp.
I remember as a medical student speaking to another patient who survived a concentration camp. He described a Nazi doctor separating the new arrivals into those who looked well enough to work and those who looked too weak. He was only 15 years old at the time, but the doctor chose him to live and placed his parents and little sister in the line that went straight to the gas chambers. I spent many hours after that conversation wondering how any doctor goes from learning about saving lives to choosing which people live and which die in a death camp. Looking at Miss Blumenthal’s tattoo, I wondered if she had faced some such doctor all those years ago. Had that doctor looked her up and down and chosen her to live?
It was now my turn to make a decision about Miss Blumenthal’s future. It was a different time and place, but in some ways there were stark similarities in the decision-making process. I was a doctor deciding whether I believed Miss Blumenthal might be able to survive the next few months. I was having to try to place some sort of value on her life and then make a decision based on my conclusion. Unlike the Nazi doctor, I’d like to think that my decision was going to be based on compassion and kindness, but it was still a massive decision to make, the significance of which wasn’t lost on me.
‘Does she need to go to hospital, Doctor?’ Carmela asked me.
‘Well, yes and no. She has stopped taking anything orally, so unless she goes to hospital for intravenous fluids, she’ll get dehydrated and die.’
‘I’ll call an ambulance, Doctor.’
‘Hold on. She’s 94 years old with advanced dementia and very little of what could be considered quality of life. She can’t walk or communicate or toilet herself. She may also die in hospital regardless of the fluids. It might be kindest to keep her here rather than have her end up on a trolley in a busy emergency department.’
‘What do you want to do, Doctor?’
‘Well, really we should make a team decision. You and the staff here have been looking after Miss Blumenthal for some years now and knew her when she was less unwell and less demented. Have you any thoughts about what she might have wanted in this sort of situation? Did she make any sort of living will?’
Carmela continued to look at me with an expression of confusion. The idea that she could and should be part of this important decision-making process had clearly never occurred to her. As far as she was concerned, I was the doctor and this was my judgment to call and mine alone.
I had been working in A&E only the day before and it was absolute mayhem. There were trolleys of patients stacked up in the corridor and security guards wrestling with burly drunks in the waiting room. If one of my patients really needs hospital treatment, then the busyness of the hospital wouldn’t be a deciding factor, but I really wasn’t convinced that hospital was the best place for Miss Blumenthal – she faced what was undoubtedly the final phase of her life. Whatever my misgivings about the nursing home, her room was calm and peaceful, the surroundings were familiar and the staff were caring.
‘Okay, I’m not going to send her to hospital. I’m going to sign a “not for resuscitation” form and the plan is to keep her comfortable here.’
‘What if she gets worse, Doctor?’
‘She probably will get worse. I want you to make sure she’s comfy, encourage her to take fluids and food if she’s not refusing, and if she seems to be getting into any sort of distress or pain, I’ll write up a syringe driver for morphine.’
Doctors are often accused of playing God. My decision not to send Miss Blumenthal to hospital could be perceived as giving her a death sentence, but I don’t see it that way. I was simply accepting that she was coming to the natural end of her life. In an ideal world the patient, family and medical staff are collectively involved in these sorts of tough end-of-life decisions. Unfortunately, sometimes that just isn’t possible and someone like me has to step up and make a judgment.
End-of-life decisions are never easy, but I couldn’t help feeling that my decision was even more emotive given the struggle for survival Miss Blumenthal had faced all those years previously. I knew nothing of her life between then and now but I’d like to think it had been worth the fight. Perhaps reaching 94 years old should even be considered a poignant victory over the evil that had nearly ended her life 70 years earlier.
Simon
‘Yeah, just a quick one for you, Doctor. I need you to refer me to see a psychiatrist.’
‘Right, so why’s that then?’
‘Is that any of your business? I just need to get referred and then you can get on with your day and I can get on with mine.’
‘It doesn’t really work like that. If I’m going to send you to see a psychiatrist I need to be able to explain in the referral letter what specialist help you need. I need to have done an assessment of your mental health and to consider that the severity of your condition is beyond what I as a GP can manage.’
Simon, the young man in front of me, was well dressed and held my gaze with a calm self-assuredness that bordered on cockiness. He didn’t look depressed, anxious or psychotic. He had never been to see me before with any mental health problems and I couldn’t for the life of me fathom his sudden desire to see a psychiatrist.
‘Look, Doctor, I’ll be straight with you. I’ve got myself into a spot of bother and my solicitor says that the judge will look on it favourably if I can show that I’m addressing my anger issues.’
‘What have you been charged with?’
‘Well, they’re trying to pin me with racially aggravated GBH, but it was self-defence and I’m no racist. I mean, I went out with a half-Chinese girl once, so how can I be racist?’
As Simon aggressively declared his innocence, I discreetly tapped his name into Google and read the local newspaper’s record o
f events. According to witnesses, he had had a dispute with a taxi driver, who he had pulled out of the car and punched unconscious. Several witnesses stated that as his victim was lying face down in the road Simon continued to kick him in the head while calling him a fucking dirty Paki. Clearly everyone is innocent until proven guilty, but I was struggling to find empathy with the man sitting in front of me. He was still blaming everyone else rather than showing any remorse and he certainly wasn’t expressing a genuine desire to address any underlying mental health issues he might have.
‘Look, Doctor, I could lose everything here. If I get done for this I’ll lose my job and I’ll have a criminal record for life. I could go down for two to three years.’
I managed to resist the overwhelming desire to tell him that he should have thought of that before he decided to kick a man’s head in. I could feel my blood pressure rising and a little voice at the back of my head told me that I was letting my emotions get in the way of the consultation. I needed to treat this man with impartiality and without judgment. A legal declaration of his guilt or innocence was yet to be made and as his doctor it was my duty to treat his medical needs regardless of anything else. I took a deep breath, and blocking out any personal feelings of dislike I had towards him, I returned to thinking about the primary medical needs of my patient. He wasn’t unwell physically and although it could be argued that anyone with such violent tendencies must have some underlying mental health issues, these clearly weren’t currently something that he had any desire to address. In summary, I could justifiably tell him to bugger off.
‘I’m not going to be able to refer you to see a psychiatrist on the NHS. The psychiatrists have got a really busy caseload as it is with lots of very mentally unwell people in this town. I would only refer you to see a psychiatrist if your mental health merited it, not because it might help you in a court case.’
‘Look, the court case is tomorrow. Once I get off the charge I won’t even go to the appointment. I just need to have a letter from you stating that I’ve been referred.’
Further Confessions of a GP (The Confessions Series) Page 13
