Thursday, January 28, 2010

The mark of Kane

In hobbles Adam, a man plainly in distress. So much so that he's had to bring Eve along, just so he can lean on her. He's bent double, and obviously struggling with severe back pain. Eve crosses the room and sits, but Adam elects to remain, standing hunched at the end of the desk, grimacing in a pantomime of pain that mimics a Greek mask of tragedy.

Through anguished gasps he manages to tell his tale, with Eve contributing when it all gets too much. He was lying on the floor, prone rather than supine, watching the TV and minding his own business, when he was thunderstruck by a searing pain in his back. Eve takes up the narrative and points out that this pain was occasioned by Kane, their eldest boy, blundering into the room, tripping over dad's trailing legs and landing full force with the point of his elbow right in the middle of Adam's back-- somewhere around L4-S1 for those in the know about such matters.

Four days on and Adam is still in anguish. So I offer to examine him, and stand to walk behind him for a delicate prod. Sure enough he's exhibiting quite a lot of tenderness to touch, but mainly out wide, away from the crucial bones of the spine. These exams are usually easy enough to do through a t-shirt or similar, but since this month Amdridge has been temporarily twinned with Arctic Greenland, everbody's arriving swathed in layers, so to get my anatomical bearings I've had to ask Adam's permission to lift them to have a proper look. As I do I can't help but notice the fetching tattoo he's sporting, right at the pint of impact. In a calligraphic Gothic hand the artist has spelled out his son's name. Verily the mark of Kane.

Friday, January 15, 2010

"Badges, badges?.... "

Yes it's complete the quote time on the old caseblog again. The above comes from one of my favourite movies, see if you can come up with the line that follows, whilst I tell you a tale of woe.

Mac' was in his seventies, and was a true Celtic patriarch. He had a large family and they in turn have gone off to have large families of their own, but most have not gone that far away, so their tight knit "clan" is always on hand to gather round in times of adversity. A few years ago Mac' developed a malignant disease, and it was treated, but by the time it had been staged it was on the cards that it had spread and would be reappearing sometime, somewhere.

(Cleverer docs than your humble interlocutor have ways of telling this, by looking at the histology of the "primary" tumour, the degree to which it has invaded the surrounding tissue and the extent of involvement of lymph nodes nearby for example.)

Late last year Mac' developed some tummy trouble and a little pain. Shortly after this he developed jaundice, and it was pretty clear that the disease had come back. He had a couple of speedy consultations with the oncologists, and started treatment which he and we all knew to be palliative. The clan duly gathered, and it was plain that he was going to be well supported and cared for, and we slipped into an easy routine of checking in now and again to see all was well, and letting him steer his course through what we all knew, but never said, was to be his final illness. This was his choice, and we worked hard to respect it.

There are times when you really don't need to ask a question to know the answer. Mac's whole demeanour and approach to his symptoms let us know he knew he was running out of time and really wouldn't appreciate us jabbering on about it. He wanted to get on with living his final days, not confront what came after. In his last week he finally had to admit that there was a little more pain that he was willing to put up with and accepted the offer of a morphine syringe driver to give him small regular trickle doses of opiate, rather than having to rely on intermittent administration of oral medication.

At the time of his recurrence he was introduced to the "Badge Nurse" who looks after terminal illness. From then on he had little to do with them, really neither needing nor wanting their input. Still we are supposed to offer "Gold Standard" care these days and so the badge nurse took it upon themself to visit from time to time. Returning for the first time in a month just after New Year, said nurse, noting the deterioration, pointed out rather too bluntly to Mac' that he was not long for this world. The "clan" politely thanked them and showed them the door.

Twenty four hours later Mac' had died.

He was ready and had no need of the information. What should have been an elegant decline into the everafter has been marred for his remaining family and they are profoundly unhappy. Still at least our "Badge Nurse" can tick a box on their "Gold Standard" protocol :-(

Friday, January 08, 2010

So where did everybody go?

Even readers far from these shores might have noticed that Dear Old Blighty in general, and Ambridge in particular, have been experiencing a little local difficulty with the weather. Here it hit on Tuesday, and shows little sign of clearing up until well in to next week. The result has been chaos on the roads, dire prognostications over our ever more fragile supply chain for simple necessities like fresh veg and gas as well as grit for the roads. Oh, and a sudden fall in demand for our services.

On any given day our surgery will offer fifty plus "emergency" appointments for use that day only and for urgernt need. And on any given day most of these will be filled. Not so this week. Indeed fewer than half that number have been required. So either everybody has suddenly got better, has gone elsewhere or has revised their opinion of what "emergency" means. I'm guessing it's the latter. No, I'm sure it's the latter-- after all we're all guilty of doing the same when it suits us.

Working in hospitals in the 80s it was apparent when there was a major sporting event everybody stopped wanting urgent attention. I worked over the Live-Aid weekend, and at least one Royal Wedding, and for the hours those events were on screen life in hospital became very quiet. The same used to happen when blockbuster movies were first broadcast on TV, but in these days of mutliple channels and instant DVD release that seems no longer to happen.

It's not particularly surprising that events, be they popular or merely inclement, affect our behaviour, but I am fascinated at the extent to which they can alter our perception of "urgency".