Q J Med 2004; 97: 183-184
QJM vol. 97 no. 3 (c) Association of Physicians 2004; all rights reserved.
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Dr Scrooge's casebook
‘Dear Doctor,’ I wrote to the medical registrar, ‘This woman appears to have surgical emphysema extending from her chest into her neck and face ... ’I saw the patient three days before Christmas. I had just completed my last surgery before going off for two weeks’ break with my family. There was one home visit to do, then Christmas lunch with the team, and my work would be finished for the year.
I set off in the car to do the visit, but the Christmas traffic was backed up for nearly a mile, and I decided to turn round so as not to miss the lunch. No matter, I thought, I could do the visit on the way home when the traffic might be lighter. It sounded as though the patient only needed a quick eyeballing anyway.
I had already talked on the phone that morning to the domiciliary care manager who had asked for the visit. The patient was a woman in her sixties, a known alcoholic who lives alone and frequently has falls. The manager was concerned about an escalation in the drinking and the falls, with the woman apparently looking even more battered and bruised than normal as a result. However, the manager's main concern was that the patient's accommodation was clearly unsuitable. The neighbours were protesting about the loud drinking bouts, and they were afraid that she would injure herself. In the new year, the manager said, we would have to get the social workers in and get her moved to somewhere safer and more suitable. I noted the phrase ‘in the new year’ with relief. The patient was not one of mine anyway, so the long-term arrangements would be someone else's problem. I could nip in and out of the house, check that the woman was mobile and no more incoherent than usual, and still get home by mid-afternoon.
The traffic was no better at the second attempt. I cut up a couple of cars in order to change lanes and gain a few seconds’ advantage. When I rang the bell at the flat, the woman pulled aside the curtain in her bedroom, and signalled to me that she would come to the door and I should wait. She then managed to totter round to let me in, although she asked for my arm to lean on as we walked back to the bedroom. The place was bleak and disgusting, and I had to fight a feeling of being repelled by the woman herself. To save time, I asked her a few curt questions and checked her over while I did so. She had a swollen face that I assumed was the consequence of having two massive black eyes, but she managed to open both eyes when I asked her to. Her limbs were covered in bruises, and the skin had been sheared off her knees, with old slough in places. However, she told me she had made a cup of tea earlier and had drunk it. She also kept saying something about chicken and bacon, but I could not follow it. Her speech was honking and slurred, seemingly not just from the alcohol but perhaps from some other, lifelong impairment.
By now I was feeling impatient. I was angry about the traffic, angry about my vanishing afternoon, and angry with the colleague I was covering for (even though he had swapped the session at my request so I could get away). I had my own priorities, and making sense of the chicken and the bacon was not one of them—I wanted my holiday to start. Her condition was shocking, but no doubt chronically so. She was sufficiently mobile to survive, and to get to her phone or her front door. The care manager would visit again tomorrow in any case. I was reaching the point where I had decided to quit the flat and resume my life unimpeded by the needs of others, including people like this woman who live at the margins.
As an afterthought, I decided to check her chest. In the midst of the stuff about chicken and bacon she had mumbled something about being short of breath, but I had paid no attention, because I was only really concerned about her mobility. Now it occurred to me that she might have broken some ribs in a fall as well, so I reluctantly asked her to take off her blouse. As I pressed on her sides, I felt something I have only ever felt once before: a sensation similar to treading freshly fallen snow underfoot. Then I realised why her face was so swollen.
At first she refused to go into hospital. The chicken and bacon, it turned out, were going to be part of a lunch that she was looking forward to, and was still due to arrive from ‘Meals on Wheels’. For various reasons, it took another hour to set up all the arrangements to get her admitted, including half a dozen phone calls and involving a further journey to the surgery and back to meet up with the care manager. The Christmas traffic was no better this time either.
As I finally composed the letter for the ambulance crew to take up to hospital with the patient, I reflected on how GPs manage to reduce turbulent experiences like this into the clipped, logical and efficient narrative of clinical medicine. How many hospital doctors, I wondered, would be interested in the larger narrative: the squalor in which we see so many of our patients live, the pressures that lead us to cut corners, and the guardian angel who looks us after when alienation and meanness of spirit threaten to take us over.
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