A Seaside Practise

by Tom Smith

  As I was still on call I couldn’t join them, so I resigned myself to the role of wallflower, watching the inevitable descent into chaos unfold. Mairi and I teamed up with the minister and his wife, sadly not the most riveting of conversationalists, to make an awkward foursome in an unobtrusive corner, sipping orange juice and ginger ale.

  It wasn’t long before I had to put my medical knowledge into action. High heels, a threadbare stair carpet and a stomach full of pink gin combined to cause a lady guest to trip and twist an ankle. She lay on the bottom stair, moaning gently and holding her foot. Various semi-drunken and some frankly fully-drunken gentlemen and ladies offered their services, until our hostess interrupted them with ‘There is a doctor here, would someone fetch him?’

  My quiet evening ended. One of the waitresses hired for the evening was a patient of mine, so she came over to us and grinned at me.

  ‘Milady would like you to come into the hall, please, doctor. One of the ladies needs your attention,’ she said. Then, whispering, ‘I don’t think it’ll be the last time tonight.’

  The crowd parted like the Red Sea as I approached the casualty. A quick feel of the swollen ankle confirmed that it was simply a sprain. I asked ‘milady’ for some ice and a bandage. There was plenty of ice – it was in buckets placed in every room, cradling bottles of wine. Bandages took a little longer. Milady needed to ask the butler where they might be. Milord, naturally, had no idea and was already, only an hour or so into the evening, in no fit state to find them.

  As I set to work organising a cold compress and a firm bandage, I could hear the conversation around me. Kensington mixed with Morningside as their subject switched from gossip to the competence of the man bending over their friend. My mixture of Birmingham and Glasgow – not an accent they would have heard much - obviously unsettled them.

  ‘Can we trust him?’ said a female voice with clipped BBC tones. ‘After all, what would a decent doctor be doing in a backwater like this?’

  ‘Of course you can trust him,’ came another female voice, this time a soft Highland one. I grinned to myself. ‘He is a brilliant doctor. You couldn’t have a better one,’ the voice carried on. It was Mairi’s.

  Milady was nothing if not direct.

  ‘How do you know it’s just a sprain?’ she asked me. ‘Shouldn’t it be X-rayed, just in case it’s broken?’

  I counted to ten under my breath, then showed her – and the gaggle of interested bystanders around us – how I diagnosed the sprain.

  ‘If it were broken,’ I answered, ‘it would hurt when I squeeze here or if I thump the sole of her foot.’

  I squeezed her anklebones together and thumped the sole of her foot. My patient did not yelp.

  ‘If it is sprained, it will hurt if I twist the outside of the foot downward, like this.’

  I twisted it downward. She yelped, quite loudly. My point was made quite well, I thought, but not entirely to the patient’s satisfaction.

  ‘So how do you treat a sprain?’ Milady was persistent.

  I continued my bandaging.

  ‘Just remember RICE,’ I said. ‘Rest, Ice, Compression, and Elevation. You bind the joint in ice, quite tightly, raise the foot to above body level, and leave it there for twenty-four hours. The patient can start to walk the day after that.’

  When I finished the bandaging, two large men lifted her to a nearby sofa, where she spent the rest of the party ordering more drinks. She seemed to take very well to lying on her back with her legs on the armrest, so I assumed she was used to the position.

  I took a sip of my dry ginger ale, and watched as an older man weaved his way towards me. I groaned inwardly. He was a typical ‘spot diagnosis’. At medical school we would have ‘spot’ sessions, in which the students sat in a row, and patients were asked to walk in front of us, entering the room by one door and leaving by another without uttering a sound. Our task was to note any abnormalities in their looks or their gait that would betray their underlying disease, and write down the most likely answer on a note pad. It was a popular class: we saw twenty patients in about ten minutes, and after a dozen sessions or more we became expert at ‘spotting’.

  This man was flushed, shaking, bleary-eyed, unsteady, and carried a large glass the same colour as mine in his left hand. It wasn’t ginger ale. He used a stick to lean on with his right.

  ‘I hear you’re a quack,’ he said. It was a bad start. Doctors don’t like being called quacks, even in fun, at a party. ‘Tell me,’ he said, ‘what’s macrocytosis? My doctor says I have it, and it means I have to go off the booze. Do I really have to?’

  This one is trouble, I thought.

  ‘Well’, I said, ‘it means your red cells are a lot bigger than they should be.’

  ‘What’s that got to do with the booze?’ he asked.

  ‘It’s a sign that your liver is giving up. It’s not able to provide the right proteins to make normal cells. You are probably anaemic, too. Only giving up alcohol altogether will make it right.’

  Then I took the plunge – probably unwisely.

  ‘For a start, you shouldn’t be drinking that,’ I said, glancing at his glass. ‘You are in deep trouble if you drink at all. You need to give your liver a total rest.’

  ‘Pah,’ he said.

  I’d never heard someone say ‘pah’ before, but it was clear enough.

  ‘You quacks are all the same,’ he said. He waved his glass at me. As it passed a few inches under my nose I caught the sweet smell of neat malt whisky. He swallowed a large mouthful.

  ‘You always want to spoil a man’s fun.’

  Now that it was obvious that I wasn’t a bearer of good news, he turned away and shambled off. I turned to join the three other teetotal partygoers in the corner.

  I didn’t make it across the room. I felt a hand at my elbow. It was the lady of the house.

  ‘Doctor, I’d like to thank you for looking after our guest. You did such a splendid job. I do hope you are enjoying yourself,’ she said.

  It’s about the same as enjoying an average surgery, I thought, but I smiled, and said that I was.

  ‘I wonder, however, if you would do me a great kindness,’ she continued. ‘Could I have a quiet word with you in the library?’

  I looked across at Mairi, deep in conversation with the minister’s wife. We glanced at each other, and a ghost of a smile flitted across her face. She knew what was happening.

  ‘Lead the way,’ I said.

  I’d seen pictures of libraries like this in Agatha Christie films. Hercule Poirot or Miss Marple would sit in them, with all the suspects around nervously awaiting the dénouement. The leather-bound books were floor-to-ceiling, with a wrought iron gallery all round, reached by spiral staircases at two of the corners.

  There was a huge leather-topped partner’s desk in the centre of the room with a massive armchair, covered in the same leather, at one side. Lady Carruthers sat in it, and reached forward to open the main drawer. She drew out a large brown envelope, placed it on the top of the leather and took out its contents.

  There were about a dozen full-size X-rays, mostly of someone’s abdomen. She switched on a powerful table lamp, and invited me across to look at them. I held them so that the light shone through them.

  ‘What do you see here, doctor?’ she asked me.

  I was obviously on trial. She was showing me a full set of barium X-rays – the first few of a ‘swallow’ and the rest of an enema.

  ‘How did you get these?’ I asked her. ‘Shouldn’t they be in a hospital department?’

  ‘They are mine,’ she said. ‘I always have them with me just in case they are needed. What do you think?’

  I thought she was pushing her privileges as a hostess miles too far, but decided not to say so.

  ‘The swallow shows you have a small hia
tus hernia. The enema shows that you have diverticular disease,’ I said. ‘Quite a lot of it. What more do you wish me to say? Do you have many problems with them?’

  ‘Not at the moment, but as you are going to be my doctor, you had better know what you are dealing with – and so had I’.

  ‘Well, if you can make an appointment at the surgery in the next few days, I’d be glad to discuss it with you. But I’m not going to treat an X-ray. I’ll treat you when you have difficulties with them, but maybe half the guests here tonight would probably have X-ray appearances like this. Many people have small hernias, and most of us get diverticuli as we grow older. Most of the time they cause no symptoms. It’s just that you have the X-rays to prove them and most other people don’t.’

  ‘Are you saying that I have COMMON complaints?’ she asked, obviously shocked.

  Oh my God, I thought, I’ve done it again. I had offended so many people tonight, but to offend my hostess was the ultimate. But I stuck to my guns.

  ‘Yes,’ I said. ‘Probably the two commonest complaints in older people’.

  ‘So I’m OLDER, too,’ she barked.

  Maybe I’m not so good at this social mixing, I thought. I’m just getting in deeper.

  ‘Well, over forty,’ I said, lamely.

  ‘So how would you treat them?’ she asked.

  ‘The best way to treat a hiatus hernia is to keep to a normal weight,’ I said.

  ‘So I’m FAT, as well,’ she roared.

  Then she burst out laughing.

  ‘It’s all right, doctor, I’m pulling your leg. It’s been a delight meeting you. I’m sorry that so many people are leaning on you tonight. I’ll behave. I’ll see you next month when I come for my usual prescriptions and we will talk then. Oh, and thank you. You’ve done me a big favour this evening.’

  ‘A favour?’

  ‘Yes. You managed to insult my brother-in-law. He and my sister are going off in a high dudgeon tomorrow morning, and they have cancelled their plans to come and live here. Thank God.’

  ‘What, just because of me?’ I said, astonished.

  ‘Yes. It seems you weren’t too sympathetic to Hector, her husband. He doesn’t take kindly to be told to stop the tipple.’

  Hector, I thought. Good name for him.

  ‘I’m sorry if I offended them’ I said.

  She waved her hand. ‘I’m not. I can’t stand them, and the thought of them living here was horrifying. Let’s go back to the others.’

  We returned to the rest of the company in good spirits, she hanging on to my arm as if we had known each other for years. She rescued Mairi and me from the minister and his wife, then rescued us from further information seekers. How she made it clear to the others that they shouldn’t talk more medicine with me I don’t know, but she did. We have been good friends ever since.

  Chapter Nine

  Battling with the mind

  Our first summer in the practice was idyllic. We finally found a house in Collintrae that suited all our family needs, with a granny annexe that could quickly be converted into a surgery, waiting room and dispensary. The local joiners, electricians, plumbers and builders were keen to help us to stay, and went to work to transform it. It was sad to leave the kindly nuns, who had fought with each other for the privilege of baby-sitting, but their cottage was always going to be a stop-gap until we established a new doctor’s house at the centre of the practice.

  The two nurses, Flora in Collintrae and Jane in Braehill, proved to be worth more than their weight in gold as we started to organise ourselves. Together, we settled into a routine. The Collintrae villagers woke up out of their Tuinal-fed daydreams, and the Braehill patients were happy that I used a stethoscope and prescribed the pill.

  However, the change wasn’t always to the good. Stopping the barbiturates may have jolted the patients back into reality, but that wasn’t necessarily for the better. Problems like depression and anxiety started to surface after months and even years of drugged suppression. I began to think that Dr Rose had good reasons to prescribe it after all for some people. Worse still, for a very small number of my Tuinal swallowers, stopping it provoked more severe psychiatric symptoms. Whether the good doctor had prescribed it precisely to deal with those symptoms I couldn’t tell, because I had very few notes on which to base any judgment. There were plenty of times when I wished he had kept better records.

  Dealing with this upsurge of mental illness was a particular problem for me. Throughout my training and in my hospital jobs I had found it more difficult to deal with mental problems (now, it is politically correct to call them psychiatric illnesses) than with any other branch of medicine. Doctors are like this: we can’t help it. There are some medical specialties with which we feel most comfortable, but most of us have an Achilles’ heel – a particular subject that we know we don’t ‘do well’. I have always been very happy with general medicine, with surgical emergencies, with accidents, with children’s illnesses, with pregnancies and with the elderly. I am not over-keen on gynaecology, and I am definitely at my poorest with psychiatry. I know that I have shied away from the subject when I could, passing on the management of mental problems to other doctors as quickly as possible.

  To explain this, I have to go back to my earliest student days. When I left school, I had spent the summer before going to medical school as a nurse in the geriatric ward of what was then called, without embarrassment, a ‘mental hospital’. A collection of large Victorian buildings in the country, so that the patients could be hidden away from public gaze, it housed hundreds of men and women who had been forgotten. There was no pretence at treatment – there was nothing to be done for them. Pills such as barbiturates (like Tuinal, but in much higher doses) were given to keep them quiet and biddable. Most lived in a state halfway between consciousness and sleep. They did not talk to each other, far less the nurses, who were more like warders than health professionals. These sad, forgotten people were considered ‘burnt out’ hopeless cases, who sat and stared, waiting only for their meals and bedtimes, when oblivion could, thankfully, overtake them.

  A few younger in-patients with severe depression (most of them had failed in suicide attempts) were given electroconvulsive therapy (ECT): I had the privilege of watching them convulse on a table, and of caring for them when the inevitable confusion ensued. Worse, a treatment in vogue then was insulin coma therapy, in which injections of insulin were given to deplete the brain of glucose. That made them unconscious, and they were brought round after a determined interval (how it was determined I still don’t know) by an injection of glucose. Witnessing that scared me: some of the patients looked, during their coma period, as if they were dead, and I was always so relieved when they woke up again. They, too, faced the next few hours in a state of confusion. After a few hours they were back in the day ward, and it was difficult to say whether or not the treatment had helped raise their mood. One result was certain: none of the patients who were given the ECT or insulin treatment liked it or gave consent to it with a full understanding of its possible consequences. Any patient I was asked to accompany to the ECT or insulin rooms was always frightened and unhappy beforehand.

  Worst of all was the ‘square’. This was a yard in the centre of the hospital with a bare earth floor surrounded on two sides by the hospital walls, and on the other two by brick walls at least fifteen feet high. From here, the patients could only see a small square of sky and quite a few of them in the yard spent a lot of time looking at it. It was like the exercise yards in poorer American B movies, where the unjustly imprisoned hero is under threat from the psychotic criminals, and often the psychotic warders, too.

  Every day the patients who needed to be kept under lock and key were sent out into this yard for ‘recreation’. Most of them just sat on the benches around the walls, waiting to be called in again for their meals and for bedtime. A few disturbed souls s
tood and shouted at the walls for hours on end. A small group were specially supervised in one corner. They had on thick canvas one-piece ‘suits’, with no pockets and no opening at the front. To get out of them, say to go to the toilet, they had to ask a nurse to untie the cords that ran down the middle of their backs. Occasionally there would be some minor altercation between two patients: they were immediately set upon by the duty nurses and taken into the wards, from where they might well be put into one of the padded cells.

  These were small rooms, just the shape and size of a prison cell, the walls, ceilings and floors of which were lined with a firm rubber. There were no windows and no furniture, so that the occupant could not harm himself. He was placed there naked, so that he could not choke himself on his clothing, and locked in. Outside the door was a dial showing temperature levels. Turn the dial clockwise, and you could turn the cell into a virtual oven. The idea was to make the person inside so hot that they would be bound to calm down. The hospital had a dozen of these cells, most of them in regular use throughout my first summer there.

  The ward I worked in stood by itself, in the grounds. Most mornings, just before seven, I cycled up to the door, past the main buildings, past the market garden and the hospital cricket field. It housed around eighty old men, many of whom had lived in the hospital all their adult lives, and who were now considered to be too old and too institutionalised to be a threat to anyone, including themselves. My first task every morning was to wake them up, take them to the toilets, wash them, dress them, sit them in their favourite seats, then make their beds. It gave me a real respect for the job of nursing, though not perhaps for particular nurses.