Farewell, Dennis.

Thursday 6th January 1994 Portmere surgery 12:30

Today really was my last day at the surgery. We had a little party at lunchtime. Dr Lewis had made sausage rolls, Valerie Vaughan brought a Victoria sponge cake and Dad supplied a bottle of Champagne. Everybody said that they would miss me. Even Dad seemed upset.
“Have you enjoyed working in the surgery, Dennis?” Dr Lewis took a sip of her champagne.
“I suppose so. I am sad to be leaving.”
“What do you think has been the best thing about working here?”
 “I don’t know.” I looked wistfully at Dr Lewis. “I suppose it must be the patients: getting to know them, seeing them in times of difficulty. I did not expect so many of them to be so brave.”
“Yes, it always surprises me,” Dr Lewis said. “When it comes to serious illness, most of our patients just grit their teeth and get on with it.”
“Are you including me?” said Valerie Vaughan as she came across.
“Come on, Valerie,” Dr Lewis continued, “you are as tough as an old boot. I can’t see you making a fuss about being ill.”
“I hope not, Lois, but you never really know how you will be when the time comes. Anyway, I came to tell you, Dennis, that I’m quite disappointed. I had set my heart on you taking over from your Dad when he retires. I was counting on you becoming my doctor.”
I blushed.
Mrs Vaughan took a deep breath. “I was wondering,” she continued, “what’s Dylan planning to do after he qualifies.”
“He is not interested in General Practice,” I said, “he hopes to become a cardiothoracic surgeon.”
“Oh!” said Mrs Vaughan.
Dr Lewis laughed. “It looks like you will be stuck with me Valerie.”
“I suppose it could be worse . . . for both of us! Well, let’s have a toast. To Dennis and an exciting new career in Journalism. Here’s looking forward to you coming back and writing for the Portmere Post.” Valerie Vaughan raised her glass.
“Yes, good luck Dennis,” said Dr Lewis. “I can’t wait to read your first article.”

Huw Rhys Harris

Thursday 30th December 1993 Maternity ward visit 15:10

Dylan and I went to see Dr Lewis’ new baby, today. He was born 10 days late and had to endure a long labour. Despite this, he was as bright as a button and we could already tell that he was going to be quite a character.
Dr Lewis looked washed out but she was pleased to see us.
We were introduced to little Huw’s father. He adopted a enthusiastic, amicable approach despite our rivalries. Dylan and I were somewhat more subdued in our friendliness.

You have outstayed your welcome.

Sunday 12th December 1993 After breakfast 10:10

I had decided that I had to tell Dad that I was leaving the practice. I could not put it off any longer. I had managed to get a place in Liverpool next October to study Journalism. Endaf, my closest friend, and I planned to go travelling in the meantime.

“To be completely honest, Dennis, you have outstayed your welcome,” Dad said after I nervously explained the situation. “When I agreed to let you do work experience in the practice, I envisaged you staying for several weeks, perhaps a couple of months. I certainly didn’t expect you to be with us for six years. Originally, I wondered if you would want to go on and study Medicine. Perhaps, you would eventually take over from me in the practice. However, it soon became clear to me that you didn’t have the qualities required for a career in Medicine. I think Journalism is a reasonable option. I can certainly see you as a tabloid reporter. What do you think, Daphne?”
Mum didn’t answer.

Mum’s roast potatoes.

Sunday 5th December 1993 Sunday lunch 13:10

“I’ll have that roast potato if you are not going to eat it, Daphne.” Before Mum had a chance to answer, Gran reached over and pierced the last potato with her fork. It was large, golden, crispy specimen that both Dad and I already had designs on.
Gran smiled at us and took a crunchy bite.
Dad made no attempt to hide his annoyance. “You seem to be making splendid progress with that stomach of yours, Doreen. I am sure you’ve eaten more than me, today.”
“Well, as you know Desmond, my gastroscopy was almost entirely normal. There was only the tiniest hint of gastritis.”
“You didn’t need any treatment then?”
“No.”
“And, all the symptoms have gone?”
“Yes.” Gran looked pleased.
“Even that gnawing emptiness?”
“Everything cleared up the day after.”
“Really?”
“You sound surprised, Desmond.”
“I just find it quite remarkable, Doreen, that’s all. You’d had those symptoms for at least three months and they disappeared straight after the gastroscopy.”
“Well, once I knew that there was nothing much causing them, they all went. I don’t think I would expect anything else.” Gran gave Dad a condescending look and took another bite of the potato.

Bed blocking.

Friday 26th November 1993 After dinner 19:30

“It’s Valerie.”
My Dad was absolutely horrified. He stared angrily at the telephone handset. “Mrs Vaughan! Why are you ringing me at home on a Friday evening?”
“I have just heard that they are planning to close Whitby Park Hospital.”
“Not exactly, Mrs Vaughan. They are converting it into a community resource centre. That way, local residents will still benefit from it. There will be a dietician, physiotherapists, occupational therapists, community nurses and volunteer counsellors. They intend to recruit an art therapist and a walks coordinator.”
“A walks coordinator!”
“Yes, Mrs Vaughan. Gentle exercise like walking has both physical and psychological benefits.”
“I am well aware of that, Desmond. I go for a walk every morning: perfectly coordinated by myself!”
“Not everyone is as lucky as you, Mrs Vaughan.” My Dad looked up at the ceiling and shook his head.
“Hmmm . . .” Mrs Vaughan grunted unhappily. “So you are suggesting that opening a community resource centre makes up for the closure of 25 community hospital beds?
“Not exactly, but . . .”
“It is a Health Authority ploy, Desmond. You know that as well as I do. They want to save money by shutting the community hospital and they hope to soften the blow by opening a resource centre. A resource centre will not help the bed situation in Portmere Hospital. At the moment, there are 5 elderly patients blocking beds because they cannot manage at home and there is nowhere else for them to go. There will be even more bed blocking if we lose 25 community hospital beds.”
“Don’t forget the care homes, Mrs Vaughan.”
“All the local care homes are full. Percy Potter has just been sent to a care home in Shropshire. It was the only one available. It’s a two hour drive from here.”
My Dad paused: “I think that the main issue, Mrs Vaughan,” he was using his most considered and diplomatic tone, “is that community hospitals are no longer thought a safe option . . . in a modern health service that is . . .”
“Not like hospital corridors, then?”
“Valerie, we . . .”
“We? We? What do you mean, Desmond?”
“Nothing.”
“What do you mean, Desmond?”
“Nothing.”
“Yes, you do, Desmond.”
“Well, I am actually on the Whitby Park Hospital Closure Committee. I was persuaded to join to represent local GPs. We’ve been looking at the best options for . . .”
We all heard Valerie Vaughan slam her phone down. My Dad looked sheepishly at us and picked up the local paper.

Do head lice really prefer clean hair?

Friday 19th November 1993 Morning coffee break 12:00

“Do head lice really prefer clean hair?”
“Of course not, Dilys. We only say that so we don’t upset the dirty children and their parents.”
“Oh!” Dilys looked disappointed.
“Don’t listen to him, Dilys.” Dr Lewis said. “Desmond is trying to be controversial. I don’t think head lice mind if hair is clean or dirty.”
My Dad was not deterred. “If you think about it, every time you wash your hair you get rid of a few head lice. If you only wash it every three weeks, they will obviously build up. They do lay eggs every day.”
“Normal washing is not really going to be enough.” Dr Lewis said.
“I disagree, Lois,” my Dad continued, “in my opinion, it is almost impossible for head lice to cling on to sleek, glossy hair that has been thoroughly washed at least three times a week and lovingly brushed several times a day.” Dad patted his own hair as he said this. “They will just slide off. Head lice like sticky tangled hair with lots of knots.”
Dr Lewis frowned. “They won’t slide anywhere. They have all got six tiny claws so they can grip tightly onto the hair shafts and the eggs are glued on.”
Dilys wrinkled her nose up when she heard this. “How do you get rid of them, then?”
“You can use insecticide lotions,” Dr Lewis said, “but I think that the best way is to wash your hair, add plenty of conditioner and then use a fine-tooth comb to dislodge them. You need to comb the hair for a good ten minutes to do this. You should repeat the process every few days.”
My Dad chuckled and shook his head. He went back to signing the repeat prescriptions.

Ten minute appointments!

Thursday 11th November 1993 Morning coffee break 12:15

Dr Lewis came into the staff room, looked at her watch, sighed loudly and sat down heavily.
“Well,” she said, I have reached that uncomfortable, final stage of my pregnancy when almost everything is beginning to annoy me?”
“I know exactly what you mean,” said Andrea Jones as she got up to make some coffee.
My Dad nodded sympathetically. He could still vividly remember those last weeks of Mum’s pregnancies.
“It’s ten minute appointments, today!” exclaimed Dr Lewis. “ I really despair of them, Desmond,” she said.
“We only had 6 minutes when I qualified, Lois.”
Dr Lewis ignored this. “A ten minute appointment is fine if you’ve got a cold or a sore throat or a touch of cystitis but it’s no good for a proper medical problem. My first patient this morning had some very odd neurological symptoms. It took me ages! Then I saw Hugh Parry who sounds like has almost certainly got lung cancer. Jack Davies is still complaining bitterly of feeling tired but now admits that he is depressed. Mary Jones has had another relapse of her severe anxiety. After that, I did three quick pill checks and a medication review. Carys Lloyd was next. She came about her back but burst into tears. She and her husband have separated. He has been having an affair. Dafydd Grey was feeling fine but his blood pressure was very high. I saw two children with temperatures and Alice Hogan whose asthma has been playing up. Cheryl Lane has started drinking heavily again. My last patient was poor Richard Owen. He is deteriorating. It took him 3 or 4 minutes just to get into the consulting room and a similar time to get dressed after I had finished examining him.”
“No wonder you finished so late,” said Andrea Jones.
“I feel we are doing these patients a disservice,” Dr Lewis continued. “If you go to see your solicitor or your accountant, you get at least half an hour. If you are seeing your doctor about a potentially life threatening problem, you get ten minutes. It’s ridiculous.”

Stuck in his chair.

Thursday 5th November 1993 Morning surgery 11:10

Bill Parry was already very overweight when his cherished, first wife died. For years, she had provided an abundance of delicious treats. Bethan, his second wife, knew she had a lot to live up to and did not want to disappoint. She worked her socks off in the kitchen. She was secretly pleased when Bill began to gradually gain weight but, in public, she admonished him. “If you are not careful, you’ll have a heart attack, Bill.”

“Goodness me,” my Dad said, when they arrived this morning. “This is the biggest that I have ever seen you, Mr Parry. You will have to do something.”

Bill nodded, turned to his wife and smiled sheepishly. She promised that he would start a strict diet straight away but, she warned my Dad, they did have afternoon tea booked for Sunday to celebrate their anniversary.

At the end of the consultation, Bill was stuck in his chair. His huge hips were firmly wedged between it’s wooden arms and he couldn’t move. Eventually, Dylan and I had to haul him up while Dad leant on the back of the chair to stop it lifting.

Bill smiled at Bethan again. He did not seem a bit worried.

Sitting on a time bomb.

Thursday 28th October 1993 Morning surgery 10:30

“How are you Mr Rowlands?”
“He’s not bad, doctor. His breathing is better.” Mrs Rowlands sat attentively beside her husband.
“Yes, they increased my water tablets while I was in hospital. That seems to have helped.”
Dr Lewis looked directly at Mr Rowlands with a very concerned expression. “I see you’ve got an aortic aneurysm.”
“Yes, they did a scan to look at my liver and they spotted it. I’ve not been having any symptoms.”
“The aorta is our main blood vessel,” Dr Lewis explained to us. “It runs from the heart through the chest and abdomen and then divides up into the iliac arteries which supply our legs with blood. As you get older, the walls of the aorta can become weak and it can swell or bulge.”
“My aneurysm is 7 cm in diameter,” said Mr Rowlands. “The aorta should be less than 3 cm. They wanted to operate but, because of my heart condition, they thought there was a good chance that I wouldn’t survive. I don’t want major surgery at my age, anyway.”
“He is 87 after all!” Mrs Rowlands said.
“I am afraid that this aneurysm is likely to keep getting bigger,” said Dr Lewis. “At some stage, it will almost certainly burst.”
“It will be curtains for me, then”, said Mr Rowlands. “I’ll be gone in a flash.”
“Don’t say that, Dai.”
“It’s true, Liz. At least, it will be quick. That’s what Mr Thomas said. He was the vascular surgeon that came to see me. He was quite direct.”
“He said you were sitting on a time bomb,” Elizabeth Rowlands looked anxiously at us.
“I am. I’m sitting on a time bomb.”
“You are being very brave,” said Dr Lewis.
“I am doing my best,” said Dai Rowlands. “I am frightened but I am trying not to think too much about what’s likely to happen.”

Heartsinks.

Friday 21st October 1993 Morning surgery 10:00

My Dad looked over at us, a resigned expression on his face. “After you’ve qualified,” he said, “you will have to deal with quite a few patients like Mrs Rosser. Heartsinks we call them in the trade.”
“She seemed to be in terrible pain,” Dilys said.
My Dad nodded. “There are three important points to remember about heartsink patients. First of all, whatever their symptoms are, they are always far worse than anybody else’s and, as you have heard, are likely to be described dramatically and sometimes catastrophically. Secondly, all investigations will be surprisingly normal. This will sometimes make the patient even more worried. Lastly, any treatment you give them will either not work or cause dreadful side effects.”
“How on earth do you deal with these patients, Dr Dennis?” Dylan asked.
My Dad chuckled. “Put on a brave face, reassure them as much as you can, don’t do any tests and don’t prescribe anything. Easier said than done I am afraid.”

Diabetic retinopathy.

Thursday 14th October 1993 Morning coffee break 11:35

“What do you think, Dilys?”
“I don’t know, Dr Lewis. I have been over this so many times. I never remember it for long.”
“Perhaps you need to think about it slightly differently,” said Dr Lewis. “I will tell you how I look at it. We know that most of the long term complications of diabetes are due to bad circulation. The circulatory changes that we see in people with diabetes are different to the normal circulatory changes that occur as we get older. Can you remember what those differences are?”
“Yes,” said Dilys. “The changes occur more quickly in diabetes and, as well as affecting the large blood vessels, they also effect the small vessels like the blood vessels in the eyes and the kidneys.”
“Good,” said Dr Lewis. “Now the retina at the back of the eye is usually a nice pink colour because it has a very rich blood supply. The rods and cones use up a lot of energy. They need plenty of oxygen and nutrients.”
Dilys knew the retina was pink but had not really thought about why.
Dr Lewis continued: “The first important changes we see in patients with diabetic retinopathy are ischaemic areas.”
“Are they cotton wool spots?
“Yes, they are . They’re pale patches called cotton wool spots which is exactly what they look like. Another name for them is soft exudates.”
Dilys smiled.
“The retina compensates for these tiny, blocked blood vessels by producing new blood vessels. These new vessels are not as good as the originals so what do you think happens?”
“They can leak or burst. You can get haemorrhages,” said Dilys.
“Excellent! Now the retina is very sensitive. The leaks and haemorrhages are irritant. The affected areas of retina become inflamed.”
“Do you get scarring or fibrosis?” Dilys asked.
“You do. The inflammation leads to fibrosis. The fibrosis causes traction and distorts the back of the retina. It can pull on a blood vessel and cause a large haemorrhage or even cause a retinal detachment. This would have a severe effect on the patient’s vision. Do you know how diabetic retinopathy is treated?”
“They burn the new blood vessels with a laser.”
“Good. This blocks the vessels but it stops the leaking and haemorrhage. It means there will be less inflammation or fibrosis.” Dr Lewis paused and took a breath. “To sum up, then: circulatory damage affecting the small retinal vessels causes pale areas of ischaemia, new blood vessels are formed to help mitigate this, the new vessels leak or burst and this causes inflammation and fibrosis. The ischaemic areas, the haemorrhages and the scar formation all damage the patient’s vision.”
Dilys smiled. “Thanks, Dr Lewis. It seems to make sense but I am not sure I will remember it.”

I would prefer to have a colonoscopy.

Sunday 10th October 1993 Afternoon tea 16:15

“I would prefer to have a colonoscopy,” Gran said as she took another slice of cake.
“You can’t just have whatever investigations you fancy, Mum. They are doing a gastroscopy because they think there is something wrong with your stomach.”
“I know but I can’t bear the thought of them pushing that tube down my throat. I choked last time.”
“I am sure you didn’t choke. Everyone gags when they have a gastroscopy. You’ll be fine.”
“Well, it’s not my cup of tea, Daphne. I would much rather a colonoscopy. I don’t mind the indignity or the wind.”
Dad took a sausage roll. “If I remember, Doreen, your last gastroscopy was perfectly normal.”
“It certainly won’t be normal this time, Desmond.”
“Your symptoms seem very similar.”
“The gnawing emptiness is much worse.”
My Dad sighed. “I’m not sure what gnawing emptiness means from a medical point of view.”
“I imagine it is very similar to hunger pains,” Mum suggested and frowned at Dad.
“I should think so,” Gran agreed. She tutted.
“I don’t know.” Dad shook his head. “You’ve certainly not lost your appetite.” He was looking at the empty sandwich and sausage roll plates.
“I’m eating to keep my strength up. Even you must realise the importance of that.”
Dad chuckled. “Well, Doreen, my money is on a perfectly normal stomach again.
“And I’m expecting a large gastric ulcer at the very least, Desmond.”
“Well, we’ll find out on Tuesday,” Mum said. “I’ll make another pot of tea.”

A missed appointment.

Thursday 7th October 1993 Morning surgery 09:55

“Hi, Dr Dennis, it’s Penny in reception. Richard Rees has just come in. He insists he has got an appointment with you at 10 o’clock this morning.”
My Dad frowned at the ‘phone. “He is not on my list, Penny.”
“I know.”
“Actually, come to think of it, I think he was supposed to see me at 10 o’clock last Thursday. He didn’t turn up. He must have got his dates muddled.”
“I will check in the appointment book. Will you see him today?”
“I can’t really, Penny. Things are a bit hectic. Can you ask him to make another appointment?”

5 jelly babies.

Friday 24th September 1993 Morning surgery 10:15

My Dad had an altercation with a patient this morning.
“She is obviously drunk,” he muttered when she arrived at his consulting room door. Miss Nerys Hughes was unsteady, her speech was slurred and she had threatened Penny Parry in reception.
My Dad tried to explain our ‘Acceptable Behaviour Policy’ but Miss Hughes was too agitated to take any notice and started shouting. My Dad got up quickly and stated, in an equally loud voice, that he was going to immediately escort the patient from the building. He stepped forward to grab her arm.
Dr Lewis heard the commotion, came rushing out of her own room and spotted that Miss Hughes was hypoglycaemic. To be honest, even I thought she looked very pale and sweaty.

Miss Hughes recovered quickly after 5 jelly babies. She apologised. Dr Lewis made her and my Dad shake hands before she left.

One of those people who sorted things out.

Friday 17th September 1993 Morning coffee break 11:50

“I had my appendix out when I was 14,” said Dr Lewis. “The diagnosis was delayed. They said it was tucked behind the bowel. I had peritonitis by the time they operated. I didn’t pick up after the surgery. The infection had spread into the wound. It was an abscess, really.  I was on antibiotics but they weren’t as strong in those days. Everyone was very worried. They thought they might need to operate again but, because I was so unwell, they weren’t sure I would survive another anaesthetic. The ward sister decided that something needed to be done. She was one of those people who sorted things out. I remember being taken into the treatment room. She probed the wound. She said it would be painful. Once she had made a big enough opening she pressed and squeezed. Eventually, all this thick, yellow pus came out. It was mixed with blood. It stank. I was in tears by the time she finished but I got better very quickly after that. I will always remember her. I think that was why I decided to go into Medicine.”

When did your father die?

Thursday 9th September 1993 Morning surgery 10:40

“When did your father die, Carys?”
“It was on the 16th September 1991, Dr Lewis. Next Wednesday, it will be two years exactly.”
“He died of lung cancer, didn’t he?”
“Yes, he did.”
“Was he in a lot of pain?”
“He was in terrible pain.” Cerys looked worried. “Do you think this pain could be due to lung cancer?” She rubbed the right side of her chest.
“Not at all. What I am trying to say is that, if you have lost someone very close to you, it is not unusual to feel unwell when the anniversary of their death approaches. We see it quite a lot.”
“With the same symptoms?” Carys looked puzzled.
“It can be the same symptoms but not always.”
“I don’t think I’m getting this pain because my father died.”
Dr Lewis looked down at Carys’ notes. “You came to see me in September last year. You had pain in the right side of your chest then.”
“I don’t remember that.”
“It’s in your records. I presume that that pain soon got better.”
“It must have.”
“It sounds like you are getting a similar pain now.”
“It’s not imaginary. It’s too severe.”
“Well, I don’t think it is anything serious. Your heart sounds fine and your chest is clear. It could be muscular. I think it will settle down in the next week or two.”

Haven’t they got targets for that sort of thing?

Sunday 5th September 1993 Sunday Morning 09:05

Mum came in and put the Sunday papers down and a carton of milk.
“I have just seen Caradog outside the chapel, Desmond. He is devastated.”
“It’s a terrible tragedy,” my Dad said. “Moira died last week: the day after her aortic valve replacement.”
“He was very angry. Apparently, the consultant said that the surgery was urgent. Moira still ended up waiting just over 12 months.”
“I know, Daphne. I chased them up several times.”
“It’s ridiculous to have to wait 12 months for urgent heart surgery!” Mum looked annoyed.
“Haven’t they got targets for that sort of thing?” said Declan.
“Targets are part of the problem,” my Dad said. “When I spoke to the consultant, he explained that their number one target was that no one should wait more that 12 months for cardiac surgery.”
“That seems reasonable for routine operations,” said Declan.
“The problem is,” my Dad continued, “that there are no targets for urgent cases. They have got so many patients to deal with that everyone ends up waiting 12 months. If they squeezed in the urgent cases, it would delay all the others. If the hospital breaches their targets, they get fined. With a problem like aortic stenosis, a few extra months can tip the balance. Once the heart muscles are compromised, your chances of surviving major surgery are significantly reduced.”
“Poor Moira,” said Mum as she filled the cafetière.

The Bristol 4.

Thursday 26th August 1993 Morning surgery 11:20

“How long have you been constipated, Mrs Evans?”
“Ever since I was a child, Dr Lewis. I was a holder then. I never had time to go to the toilet. I think I was about 11 years old when I realised that, if I took a book, I could sit there for a bit longer. It has gradually got worse as I have got older. I have to take laxatives now.”
“When do you take them, exactly?”
“If I haven’t been for a few days, I will take some lactulose. I’ll take four teaspoons every night until I am opening my bowels properly.”
“I see,” Dr Lewis nodded.
“Of course, it’s a cycle that keeps repeating itself.”
“Well, that’s the problem, Mrs Evans. Most laxatives take a day or two to work so you have got to plan ahead. I think you would be better off taking a small dose every day. You can fine tune the exact amount depending on how things are going. Two teaspoons in the morning might be a good staring point.”
Mr Evans nodded. “I could try that.”
“What are you aiming for?”
“As you’ve always said, Dr Lewis, a Bristol 4: the perfect stool.”

Myelodysplasia.

Sunday 22nd August 1993 Morning walk 10:00

It was a particularly cold morning for August and Elfed Edwards was paler than usual. His face was ghostlike: his skin looked almost translucent.
Elfed had been striding along Stanney Lane at a brisk pace and had stopped to say ‘hallo’. He smiled cheerfully and shook my hand. He turned to Declan who couldn’t help staring.
“I am very anaemic,” he explained, “but I am well adjusted to it.”

There are no ambulances in Wales.

Thursday 12th August 1993 Morning coffee break 11:45

My Dad groaned and put his coffee down. Andrea handed him the phone.
“I am in the middle of my coffee, Mrs Vaughan. I have just finished a very tricky surgery.”
“There are no ambulances in the whole of Wales, Desmond.”
“There are no ambulances in Wales! Don’t be ridiculous!”
“Harry Charlton woke with severe chest pain yesterday morning. Mildred Charlton phoned 999 immediately. The paramedic turned up at 8 o’clock today.”
“You must be mistaken, Mrs Vaughan.”
“Harry’s electrocardiogram confirmed a heart attack. Of course, he had missed his chance of thrombolysis by then. A 60 year old man in Newport who was vomiting blood had to drive himself to The Royal Gwent Hospital.”
“Mrs Vaughan . . .”
“In Haverford West, one of the GPs took an unconscious child to the Emergency Department in his own car.”
“I am sorry, Mrs Vaughan, but you’ve gone too far this time. In fact, to be completely honest, I think that you have lost the plot. I’ll tell you what I am going to do. When I have finished my coffee, I am going to phone Mair Parry, the psychiatrist. I will ask her to see you this afternoon. In the meantime, I would strongly advise you not to leave the house. Pack an overnight bag. I will let you know when I have spoken to Dr Parry.” My Dad put the phone down firmly and sighed.
“It’s true, Desmond,” Andrea Jones said as she brought some chocolate digestives over.
“I know, Andrea. I should have realised this was going to happen. She has been teetering on a knife edge for several months, ever since poor Mrs Bingham died.”
“I mean that it’s true about the ambulances. We had a memo from the Welsh Ambulance Service this morning. There are no ambulances in Wales. Apparently, it is classified as a business continuity incident.”
“That can’t be right, Andrea. It would have been all over the News.”
“Yes, you would have thought so.” Andrea said. She and my Dad both took a biscuit.

Belle Bailey

Friday 6th August 1993 Morning coffee break 11:40

“Well, Belle Bailey is going into Ashbury Lodge, at last.” My Dad sighed.
“I didn’t think Mr Bailey would ever let her go. He has been so determined to look after her. He was telling me that they had been together for 74 years.” Dr Lewis smiled.
“He couldn’t cope any longer. It’s broken him, really. He was such a fit man for his age. Now, he’s pale and drawn. He’s lost weight. He’s nervous. It’s pitiful to see him.”
Dr Lewis turned to us. “Dementia can be such a terrible illness. For the last two years, Belle Bailey has not recognised her husband. Then, if that wasn’t bad enough, she has started accusing him of being an imposter. It usually happens at night when they are getting ready for bed. She will become restless and pace around the room. She’ll ask him to leave, insisting that her husband is due home. Sometimes, she swears. She scratches and bites him.”
“She won’t settle if he stays there,” my Dad added. “He often has to sleep in the car.”

It must be acute glaucoma!

Thursday 29th July 1993 Morning surgery 10:10

Dilys came rushing excitedly in as soon as Mr Gaunt left the room.
“Mrs Cunningham’s got acute glaucoma, Dr Dennis.”
“Try not to be so dramatic, Dilys. Always remember that common things are common. I’ve only ever seen two cases of acute glaucoma and I have been in the practice for thirty years. We’ll prescribe some chloramphenicol drops.”
“Her eye is red but it’s not conjunctivitis, Dr Dennis. Last night, she had an awful headache and felt sick. This morning she woke up with a terrible pain behind her right eye. Her vision was very blurred. She vomited twice. I have checked her visual acuity. She cannot even see my fingers properly.”
“She has probably forgotten her glasses.” My Dad took his spectacles off. “Here, she can borrow these. Check her eyesight again.”
Dilys looked exasperated. “She did bring her glasses and I did check her vision with her glasses and without them just like Dr Lewis showed us.”
My Dad sighed and got up. “I suppose I will have to have a look but I don’t think it is likely to be glaucoma.”
“She’s been seeing halos. Her pupil is dilated and doesn’t react. Her cornea looks cloudy. She’s got all the symptoms and signs. It must be acute glaucoma.”

Another satisfied customer.

Thursday 22nd July 1993 Morning surgery 11:00

“Let me know if you are not improving, Mrs Mills.”
“I am sure I’ll be fine, Dr Lewis. It’s always the same. I get some new symptoms. At first, I will try to ignore them but they get worse. I start to worry. It’s a vicious circle. The more worried I am, the more severe the symptoms become. Eventually, I decide to make an appointment to see you. Of course, having to come for a check-up makes everything seem more real. By this morning, I was very anxious.”
“I am sure you were.” Dr Lewis smiled reassuringly.
“But, now you’ve seen me and examined me, I feel fine. I can almost guarantee that I won’t get that pain or the nausea again.”
“Well, as I say, I don’t think it’s anything too serious but it is always best to make sure.”
“Thanks, Dr Lewis.”

Empathy.

Thursday 15th July 1993 Morning surgery 09:10

My Dad has never been empathic. His matter-of-fact approach is nothing like Dr Lewis’. It annoys Mum when she is ill but most of his patients don’t seem to mind. I have come to the conclusion that I am of a similar character to Dad whilst Dylan is usually too engrossed in the medical details of the patient’s illness to think about anything else.

This morning, Dilys and Dr Lewis were doing a women’s health clinic whilst the three of us did a normal surgery.
Our second patient had severe epididymo-orchitis. His right testicle was the size of a small football. It was hot, red and looked extremely painful. In fact, we didn’t dare examine him.
My Dad shook his head grimly when he saw it. He even squeezed Malcolm Bryant’s upper arm in a sympathetic but manly way. Dylan looked visibly shaken. He did not ask a single question. I had that horrible sickly feeling in the pit of my stomach.
After Mr Bryant left, we all instinctively checked our own testicles.

Cases like this restore one’s faith in human nature.

Ideas, concerns and expectations.

Thursday 8th July 1993 Morning surgery 10:10

Valerie Vaughan started to get up then stopped, sat down again and frowned at my Dad.
“Desmond, I have no doubt that the majority of our consultations would have a far more satisfactory outcome for both of us if you took the time to explore my ideas, concerns and expectations.”
“I have never been an ideas, concerns and expectations man, Mrs Vaughan.”
Valerie Vaughan nodded knowingly. “I don’t suppose it was included in your training all those years ago.”
“Actually, it was. But, I think it is an approach that suits a particular type of doctor. It doesn’t come naturally to me.”
“That hardly surprises me,” Valerie Vaughan stated. “My worry is that this slight deficiency on your part may mean that my health care is not as well tailored to my needs as it should be.”
“I always do my best, Mrs Vaughan. You know that.”
“You never summarise, either.”
“I am not a summariser.  You could see Dr Lewis. She is a great advocate of patient centred practice and a skilful summariser.”
“I don’t think dumping me on Dr Lewis is the answer.” Valerie Vaughan frowned again.
“What were you expecting, Mrs Vaughan?”
“I want you to up your game, Desmond. That’s all.”

Daphne’s savoury soufflés.

Thursday 1st July 1993 Evening surgery 18:25

“Hi, Dr Dennis! It is Penny from reception.”
“Yes.” My Dad frowned at the telephone handset.
“Mr Martin has just rung in. He is not feeling 100%. He wondered if you could pop in and see him on your way home.”
“I am sorry, Penny. Daphne has started making savoury soufflés on a Thursday night. They come out of the oven and 19.05 and they have to be eaten straight away. You can’t mess about with soufflés.”

Complete heart block.

Thursday 24th June 1993 After dinner 19:30

Dr Lewis is always pleased if one of her patients tells her what they think is wrong with them. “I like to know what my patients are thinking and, if they are correct, it makes things much easier for me.”

My Dad takes exactly the opposite view. He will become visibly irritated and usually come up with something as far removed from their speculations as possible. This can work out quite well if the patient is a poor diagnostician.
Mr Parker had come in this morning insisting that he had experienced three simple faints over the last few days. Fainting was a family trait that had affected his father, his paternal aunt and his sister.
Despite his protestations, my Dad packed Mr Parker off to hospital and by 2 o’clock he had had a pacemaker fitted.

I dread to think what would have happened if he had told my Dad that he thought he was in complete heart block!

Valerie Vaughan’s beds.

Sunday 20th June 1993 Sunday morning 09:15

“I have been thinking about Mrs Vaughan’s beds, Desmond. You should help her.” Mum had made bacon and eggs for a change. She was watching Dad like a hawk, hoping she might be able to stop a splodge of egg yolk ending up on his best pyjamas.
“Hospital beds are nothing to do with me, Daphne.”
“The way I see it, Desmond, is that everyone working in the NHS has a degree of responsibility. We all know what’s going on, but no one is saying very much or doing anything.”
“What can we do?”
“Maybe you could rally some of your colleagues. There are over 30,000 general practitioners in the country. If every GP took action, I am sure the government would listen.”
“I doubt it!” Dad chuckled. He pierced a large tomato with his fork and a jet of hot juice shot out. Before Mum had a chance to intervene, he mopped it off the tablecloth with the corner of his toast.
“I am going to talk to my nursing friends this week. Maybe we’ll start a petition. I feel I’ve got to do something.”
“We are meeting the Secretary of State for Health on the 27th of August.” Declan had finished his breakfast and picked up the paper.
“Don’t be ridiculous, Declan!”
“We are, Dad. Mrs Vaughan and I arranged it.”
“Hmm! Whose going to be there, then?” My Dad asked sceptically.
“Valerie, Mr Thompson from the hospital, Virginia Bottomley, me and you.”
“Me?”
“Yes, you’re representing GPs in the area.”
“I won’t be there, Declan. I can assure you of that.”
“I think you will, Dad. Mrs Vaughan says you will probably get struck off if you don’t turn up. Mrs Bottomley is looking forward to meeting you.”

An occupational hazard.

Thursday 10th June 1993 Morning surgery 11:17

I had never really thought about why the lady who worked in the chip shop always had a bandaged leg. Harriet called my Dad and I in to see her today. She had a huge varicose ulcer. It was horrible: enough to put us off fish suppers for the next few Fridays.

Mrs Blackwell was a stout woman who insisted that she couldn’t lose weight. She had not been able to tolerate the thick, elastic bandages that Harriet had persuaded her to try. They made her leg drip with sweat. Sitting down and putting her feet up for a couple of hours every afternoon was out of the question.
“It’s never going to heal then,” my Dad said.
Harriet sighed.
“These varicose ulcers are an occupational hazard for me, Dr Dennis.” Mrs Blackwell said matter-of-factly.

A hidden agenda?

Thursday 27th May 1993 Morning surgery 09:00

Valerie Vaughan turned the handle and started to open the consulting room door. She paused and looked round at my Dad. She waited.

“Aren’t you going to check whether I’ve got a hidden agenda, Dr Dennis?”
“You have already mentioned 23 symptoms this morning, Mrs Vaughan. I am quite sure you’ve put all your cards on the table.”

You should have come earlier.

Thursday 20th May 1993 Morning surgery 10:10

“The pain has gone?” My Dad asked worriedly.
“Yes, doctor. It started yesterday morning. I woke up with it. It was quite severe. It was easing off by the evening. I thought that that was because I had taken a paracetamol after lunch. I couldn’t feel it at all this morning. I didn’t take any more paracetamol in case it came back before I saw you.”
My Dad sighed. “What a shame you couldn’t get an appointment yesterday!”
“I did try. You were chock-a-block. The receptionist was very helpful. She did her best.”

Chained to the hospital railings.

Friday 14th May 1993 After work 18:45

“Hi, Desmond! How was work?”
“It wasn’t too bad, Daphne. Have you seen the news?”
“No, I haven’t. To be honest, I haven’t stopped all day.” Mum was tidying the kitchen after preparing dinner.
“Valerie Vaughan and Carole Crosby chained themselves to the hospital railings, this morning. I think they are still there.”
“You’re joking! What on earth for?”
“They are protesting about the lack of beds and the waiting lists.” My Dad sighed cynically.
“Good for them! Someone needs to do something.”
“It won’t make any difference.”
“Valerie is a determined woman. I expect she has got something else up her sleeve.”
“Probably something equally stupid.”
“God! I hope she’s not thinking of throwing herself under an ambulance, Desmond.”
“Well, Daphne, I have always said that if you believe in something very strongly, you have to be prepared to make sacrifices.”

Another patient has woken up in the hospital mortuary.

Sunday 9th May 1993 Sunday Morning 10:00

“Another patient has woken up in the hospital mortuary, Desmond.” Mum was reading Friday’s Portmere Post. “Apparently, he had been there for two days.”
“I have always dreaded that,” said my Dad. “Imagine pronouncing someone dead and then finding out that they have come round in the undertaker’s or, even worse, at the funeral. It would be so embarrassing. What would the mourners say?”
“If that happened to you, Desmond, I am sure Harri Owen would make it seem like a miraculous resurrection rather than another medical error.”
“Yes,  a good minister is worth his weight in gold, Daphne. Mind you, I think that these incidents are much more common than we realise. I will never forget John Briggs, the builder?”
“I don’t think you told me about John.”
“Yes, I did. Trefor Own was the undertaker. On the day of the funeral, he checked Mr Briggs for one final time before nailing the coffin shut. He wanted to make sure everything was exactly as it should be. He found John’s arms up, over his chest, as if he had been reaching for his neck. The top button of his shirt was undone!”
“Trefor had probably forgotten that he had left him like that, Desmond.”
“Trefor would never do that, Daphne. He was always meticulous and John hated a tight collar. He never wore a formal shirt. Well, Trefor went to get his wife’s compact mirror. Even though he couldn’t see Mr Briggs’ chest moving, there was a hint of condensation on the glass. He called an ambulance at once. Mr Briggs was taken up to the hospital. It was another three weeks before he died properly. He was already riddled with cancer so there wasn’t much they could do.”
“Who was the doctor?”
“It was old Iorwerth ap Ieuan who had confirmed death the first time. He was in his eighties, then. He was as deaf as a post and never changed the batteries in his hearing aids. I would be surprised if he could hear anyone’s heart beating. Both the lenses in his spectacles were cracked so he couldn’t see much either. By the time he had climbed the stairs to see those poor, terminally ill patients of his, he would be gasping for breath and struggling to talk. He was in almost as precarious a position as they were.”
“Was he struck off, Desmond?”
“No, everyone felt sorry for him. He had only continued working because they couldn’t find a replacement.”
My Dad looked thoughtfully at the remainder of Mum’s toast and honey. He had already finished his own breakfast.

“I was talking to Morris Price the other day.”
“Morris Price?” Mum asked.
“Yes, Morris Price. He works in the crematorium.”
“I don’t think I know him.”
“Yes, you do. He is Lynne Mathias’ brother. Anyway, he was telling me that it is not unusual for them to hear terrible screams as the oven doors are closing.”
“Desmond!” Mum gasped, “I don’t believe you!”
“That’s what he told me, Daphne. It is not something either of us would joke about.” My Dad reached over and picked up Mum’s last bit of toast.

Mrs Bradley and Mr Wilson.

Thursday 29th April 1993 Morning coffee break 11:35

“I’ve just seen Mrs Bradley, Lois. She is doing remarkably well.”
“I really didn’t think she would cope after her husband died, Desmond. He’s done everything for her for years. He was completely devoted to her.”
“She said she was determined to look after herself and she has. She has got rid of her home helps. She is cooking and cleaning. She goes for a walk every day. She does her own shopping. She has started gardening. Yesterday, she even cut the grass.”
“It is surprising how much people can do when they have to.” Andrea said as she brought in some letters.

“Do you remember Wyn Wilson, Desmond?”
“Of course I do, Lois. I used to feel so sorry for him. His wife was such an insufferable talker. She drove me mad.”
“She even tested my patience.”
“That’s saying something!” My Dad smiled grimly. “Mrs Wilson would always come in with Wyn if he was unwell. I would ask him how he was and she would immediately take over. She would describe his symptoms in lurid detail and add a few more that he invariably denied. He sat there as quietly as a mouse as she quickly answered every question on his behalf.”
“She was the same everywhere, not just in the surgery.” Lois added. “I remember being behind them in the bakery when she chose his lunch.”
“It was no wonder that he was chronically depressed.” My Dad sighed empathically.
“Didn’t Mrs Wilson have a stroke?” Andrea asked.
“She did. She had a stroke that affected her speech and nothing else. She could understand everything but she couldn’t say a single word. Following this, Mr Wilson had to speak for his wife. He did not seem to mind and, gradually, a transformation came over him. He became a happier more light-hearted man.”
“She seemed happier too, Desmond.” Lois said.
“Yes, I think she was. It must have been a relief for her to get a rest from that continuous talking she was doing. I wonder how they are getting on.”

Sylvia Elias.

Thursday 22nd April 1993 Morning surgery 11:30

“How are you, Mr Elias?”
“To be honest, doctor, I have not been feeling too well. I have been sleeping badly. I have been tired. I’ve felt a bit depressed, really.”
“I am sorry to hear that.”
“It’s my wife, I think. I hardly ever see her. She is out all day. She comes home late at night. I am usually in bed by then. She is sleeping in the spare bedroom now.”
“Look, Mr Elias,” my Dad said, leaning forwards, “Sylvia’s dead. She died almost a year ago.  You know that. You looked after her yourself, at home.”
Mr Elias nodded. His eyes filled with tears. “I miss her. I thought I would get used to it. I thought I would get used to not seeing her as much. Things don’t seem to be getting any easier. I don’t know why she never comes home early. I hear her at night. She keeps me awake. She will be talking for hours. It is usually a man that she talks to. It shouldn’t make me annoyed but it does. I do try to trust her.”
Mr Elias sighed and continued.
“She’s not eating much. She gets up late so I put her breakfast out every morning. She never touches it. I think she drinks her tea. She washes and dries the cup after. She has always liked Earl Grey. They are out all day, then. I suppose they have lunch out. Maybe they have a big meal. She never takes our car. I imagine he drives. There must be something going on. I don’t see how this man can just be a friend. She had a very serious boyfriend before we met. They were engaged. She has often wondered about him, over the years. Sixty years we were married, Dr Desmond.”
“Yes, there aren’t many of us who can say that, these days.” My Dad said.
“The time drags when you are on your own. I never go out in case she comes back. She doesn’t like coming home to an empty house. I make dinner for us both. I put hers out on the table and cover it; ready to pop into the oven. She never touches it. I don’t make food for him. Their voices are loud. I don’t like hearing them talk. Even her voice grates. It gets on my nerves.”
“Listen, Harry! Sylvia’s gone. She’s died. You have to accept it. Sometimes, people imagine these things. It is not surprising when you think of how long you were together.”
“How would I imagine all this, doctor? She wears a new set of clothes every day. I wash and iron them for her. She always takes the bit of pocket money I leave out. Of course, she has stopped doing the shopping now and she doesn’t like cooking. She hasn’t baked a cake for a long time : not since she was ill. I was wondering, Dr Dennis, if you could come to talk to her. You could explain how I feel. She has always had a lot of faith in you.”

It looks like anaphylaxis, Harriet.

Thursday 15th April 1993 After lunch 13:18

When Harriet pressed the alarm, Dr Lewis was the first to arrive in the treatment room. We crowded in behind her.
Mr Thomas was lying on the couch looking pale and frightened.
“His eyes are puffy,” said Dr Lewis. “His lips are swollen. Look at his neck!” There was a flush of red that seemed to be spreading up from under his shirt. Dr Lewis quickly checked the patient’s pulse. A red rash started to appear on his hands.
“It looks like anaphylaxis, Harriet.”
“He’s on amoxicillin, Dr Lewis.”
“I took one just before I left the house,” said Mr Thomas. His swollen lips made his speech slightly slurred. Dr Lewis asked him to stick out his tongue. It was beginning to swell. Mr Thomas coughed.
“Can I have some adrenaline, Harriet?”
Harriet nodded. While she got the adrenaline ready, Dr Lewis checked Mr Thomas’ blood pressure.
“That’s quite low, she said. Dennis, can you get a drip ready. Dilys, can you set up the oxygen. Will you phone an ambulance for me, Dylan? 999, please.”
Dylan rushed out towards reception.
“Thanks, Harriet. Alright, I am giving 0.5 ml of 1 in 1000 adrenaline intramuscularly into his right upper arm. It’s 13:20.”
“Do you want to get me another dose ready?”
“Yes please, Harriet.”
Dilys put the oxygen mask on and asked Mr Thomas to breathe slowly but steadily in and out.
“How’s that drip, Dennis?”
“It’s ready, Dr Lewis. Do you want me to put the cannula in? Mr Thomas’ veins look quite good.”
“Please, Dennis. I’ll check his blood pressure again.”
“Do you want hydrocortisone, Dr Lewis?”
“Not yet, Dilys. It’s 13.25 and his blood pressure is still low. I will need to give him another dose of adrenaline first.”
“His lips are starting to improve and his eyes are less puffy, Dr Lewis.”
“Excellent. Thanks, Harriet. Right, that’s another 0.5 ml of adrenaline given at 13:27. It’s a bit later than I wanted but he is improving.”
“How are you, Mr Thomas?” Dilys shouted.
I feel better. Mr Thomas’s speech was already clearer.
“The drip’s in, Dr Lewis.”
“Well done, Dennis! Do you want to run 500ml of normal saline through? Once Dennis has done that, Dilys, you can give 200mg hydrocortisone intravenously. I will give him some piriton.”
“The ambulance will be here in 6 minutes, Dr Lewis.” Dylan announced excitedly as he arrived back.
“I’m feeling much better,” said Mr Thomas. “Do you really think I should go in?”
“You will still need to be admitted for observation,” Dilys explained. “Sometimes, these severe reactions can flare up again after a few hours.”

Dr Lewis is pregnant.

Thursday 8th April 1993 Morning coffee break 11:30

Dr Lewis is pregnant. She told us this morning after coffee. Dylan and I did not even realise she was married. In fact, we found out later that she’s not which is even more shocking but, at least, it gives us both a glimmer of hope.
Dad muttered something about maternity leave and locums. He was in a bad mood for the rest of the day and refused to give antibiotics to any of his evening surgery patients.

The dirty jumper gene.

Thursday 1st April 1993 Dinner at home 19:10

“Look at you, Dennis! You are such a mess!”
I glanced down. There was a splodge of brown gravy on the front of my jumper. I tried to wipe it off but only smeared it over a bigger area.”
“Do you think that they will ever find a cure for the dirty jumper gene, Desmond?”
Declan laughed but Mum was right. Grandad had been plagued by it. It had driven my grandmother mad. Dad obviously had it and his brother, Uncle Dermot. The twins were terrible. It looked like I was developing the same problem pretty quickly. Only Declan had been spared the family curse. He could come straight home from school, shovel down a bowlful of spaghetti bolognaise and still end up with a spotless white shirt.
“Before they treat any gene, they’ve got to find out which one it is, Daphne.” Dad’s sprout wobbled precariously on his fork as he spoke. Mum frowned.
“I think they have got plenty of more important genes to sort out before they go looking for the dirty jumper gene,” said Declan.
“It means that people like Dennis and I will have to continue to suffer quietly,” said Dad glumly, “because dirty jumpers aren’t given the high public profile they deserve.”

“I was reading an article on genetic engineering the other day,” said Declan. “It said that any single gene might be responsible for more than one bodily function.”
“That’s very interesting,” said Dad.
“I was wondering if the dirty jumper gene was the same one that makes you pee on the bathroom floor.”
“I wouldn’t have thought so, Declan. I never pee on the bathroom floor.”
“Yes, you do, Desmond!” We all exclaimed in unison.
Dad went bright red.

A major incident.

Thursday 25th March 1993 Lunchtime 13:00

“I hope this is an emergency, Mrs Crosby!” My Dad looked angrily at the telephone handset and took another bite of his sandwich.
“It’s more than an emergency, Dr Dennis. I consider it a major incident.”
“You will need to speak to the major incident team, then. Would you like the telephone number?”
“No thank you, Dr Dennis. I am up at the hospital with Mrs Vaughan.”
“Goodness me! I hope she’s alright!”
“Mrs Vaughan is not ill or injured, Dr Dennis. We’ve been called up here. Mr Davies should be arriving at any minute.”
“What’s going on?”
“There are 7 ambulances stuck outside the Emergency Department. They have all got seriously ill patients in who are waiting to be seen. One has been here since 2 o’clock this morning. The Emergency department is jam-packed. There are no medical beds available in the hospital. It’s chaos!”
“I don’t think that . . .”
“A farmer with two broken ankles is being brought in by the fire service. The police have gone to pick up a sick child. The only free ambulance is dealing with a suspected heart attack in Bramwell’s Department Store. Mrs Vaughan wants you to come straight here.”
“I am in the middle of a busy surgery, Mrs Crosby.”
“It is 1 o’clock, Dr Dennis. You invariable stop for lunch at 1 o’clock. I can actually hear you chewing your ham and pickle sandwich.”
“It’s a working lunch.” My Dad sighed. “I’m signing the repeat prescriptions. I have probably got several visits to do when I’ve finished.”
“Dr Lewis has already done the visits. I’ve checked with reception.”
“I am sorry, Mrs Crosby, I really cannot . . .”
“Dr Dennis, I suggest that you come up to the hospital as soon as you have eaten your lunch. I don’t think Mrs Vaughan will tolerate a lack of cooperation on a matter of such importance. She is already in a fiery frame of mind.”

Two more ethical dilemmas.

Wednesday 17th March 1993 In bed 07:55

I have fallen in love with Dr Lewis.
I know that a student should never fall in love with his teacher and a patient should never fall in love with his doctor but I couldn’t help it and, to be frank, I don’t care. I’m prepared to suffer the consequences.

This morning I woke up with a terrible pain in my leg. It was the worst pain that I have ever had in my life and I was glad. Well, I was glad until I phoned the surgery. Dr Lewis couldn’t see me: all her appointments were already full. I had to explain to the new receptionist that it wasn’t really appropriate for me to see my own father and, then, I had a heated discussion with the senior receptionist about whether I should be expected to see the locum. I think we both put the ‘phone down firmly at the same time.
My leg wasn’t swollen but it was pale. It felt cold. I went to the toilet. I could hardly put any weight on it. It was beginning to look like a home visit would be needed. I struggled back to bed.

I was scared, now. My leg was numb. It felt like a slab of ice. My toes were purple. Few patients survive vascular surgery in Portmere Hospital. I did not want to ring for an ambulance but I knew I had to. I wouldn’t make it downstairs to the ‘phone again with this leg. I shouted for Mum.
Surprisingly, for a nurse, Mum was unsympathetic. She did not even look at my ischaemic leg. She glowered at me until I got up. I was sent downstairs with a slap to the back of my head.

That’s how I found myself in the kitchen, trying to eat my breakfast and put my school uniform on at the same time.

How do vaccines work?

Thursday 11th March 1993 Morning surgery 09:50

“How do vaccines work, Dr Dennis?”
It took me a few seconds to realise that Jack was talking to me.
“Jack wants to be a doctor like you, Dennis.” Mrs Butterworth said by way of explanation.
I smiled awkwardly and wondered whether I should tell them that I wasn’t a doctor or even a medical student.
Dr Lewis looked up from the clinic letter she was reading about Mrs Butterworth.  “Come on, Dennis,” she said mischievously, “how do vaccines work?”
I took a deep breath. “When a harmful virus gets into the system,” I said, “our white blood cells have to try to get rid of it. To do this, they make antibodies. However, they have to produce exactly the right antibody for that particular virus. If a new virus attacks us, it takes our white blood cells between one and two weeks to make enough of the correct antibodies.”
“Is that why your Dad always says I will be better in a week or two when I’ve got a virus, Dennis?”
“I suppose it is,” I said. “If the same virus attacks us again, our white blood cells remember which antibody we need. They can produce them straight away, before we become ill.”
“Is that why you only ever get chicken pox once?”
“Yes, the majority of people get it once but you can lose your immunity as you get older. Most vaccines are made from viruses that have been inactivated or killed. That way, when they are injected, they trigger our immune system but do not make us ill. When the real virus comes along, our white blood cells are ready with the antibodies.”
“Thanks, Dr Dennis.”
Dr Lewis smiled. “Do you want to explain to Jack how antibodies work?”
“I know that, Dr Lewis. They punch holes in the viruses. Our teacher told us.”

“What’s the best thing about vaccines, Jack?” Mrs Butterworth asked proudly.
“I don’t know.”
“Yes, you do. You told me last week.”
“No, I didn’t!” Jack went bright red.
“You said that, when you have a vaccine, you are not just protecting yourself. You are helping to protect your family and friends as well.”
“That was what Mr Harrison told us. I don’t care if Katie gets a virus off me.”

Kayleigh Curtis

Thursday 4th March 1993 Afternoon surgery 16:10

My Dad picked up the telephone. “Good afternoon, Mrs Curtis. You’re ringing about Kayleigh?”
“Yes, I am. She’s been asleep since she came back from school, doctor.”
My Dad looked at his watch. It was ten minutes past four.
“Has she been unwell in the last couple of days?”
“No, not really, doctor.”
“Has she had a cold or a cough?”
“No, doctor.”
“Do you think she has had a temperature?”
“She doesn’t seem hot but I haven’t got a thermometer.”
“Right . . . is she eating and drinking?”
“She hasn’t had anything to eat since lunchtime. She had a drink before she went to sleep.”
“Has she been sick?”
“No, doctor.”
“Has she had any diarrhoea?”
“No, doctor.”
“Right . . . mmm . . . “
“It’s not like her at all, doctor. I am quite worried, you know. I wondered if you could come up and check her over.”
“I don’t think we need to do that, Mrs Curtis. She is just a bit sleepy. She is only four years old and she has probably had a busy day. These little ones do get tired in school. I don’t think that she is seriously ill.”
“Well, how can you say that if you haven’t seen her, doctor?”
“I just don’t think she is.”
“This is flipping ridiculous!”

My Dad frowned and looked at the phone. “I am sorry, Mrs Curtis. Did I say that or did you?”

We need beds . . .

Thursday 25th February 1993 Morning surgery 10:10

“I hope this is urgent, Mrs Vaughan.” My Dad looked angrily at the telephone handset. “I am in the middle of a busy surgery.”
“I consider it extremely urgent, Dr Dennis.”
“Well . . . what’s happened?”
“I have been called to Miss Lilian Lightman’s. She fell this morning and was unable to get up for two hours. As you know, she has an arthritic knee. She didn’t injure herself but her knee is dreadful. She hasn’t been able to go out of the house for 6 months. It is quite a struggle for her to walk across the room, even with her Zimmer frame. She can’t get in and out of the bath. The pain is affecting her sleep. She can’t go on like it.”
“She is going to have a new knee, Mrs Vaughan.”
“Yes, she has been on the waiting list for nearly 3 years. Her operation was cancelled twice at short notice because there were no beds.”
“That will be due to winter pressures.” My Dad explained.
“The last time it was cancelled was in September. Before that, it was in May. You can hardly blame winter pressures.”
“As far as surgery is concerned, Mrs Vaughan, winter pressures have a knock on effect throughout the year.”
“I am not happy about the situation, Dr Dennis. Miss Lightman is getting quite depressed. Can you do anything?”
“I am afraid I can’t, Mrs Vaughan. Basically, we need beds . . .” My Dad caught himself just in time. “Listen, I’ve got to go, Mrs Vaughan. I have a patient waiting. He looks quite poorly.”

Daydreaming.

Sunday 14th February 1993 After lunch 13:30

I knew that if I collapsed, Dr Lewis would save my life. I trusted her completely.

What could make me feel better than regaining consciousness and seeing her kind face gradually come into focus, hearing her call my name and watching her expression change from fear to relief. Perhaps that sense of relief would be so strong that she would inadvertently lean forward, kiss my forehead and rub my shoulder as tears poured down her face.

I can imagine her sitting beside me while I convalesce in a comfortable hospital bed and sunlight streams through the windows. She will listen attentively as I reflect on my short and uneventful life and we will discuss a future where, for medical reasons, she can never leave my side.

Dr Lewis’ cardiopulmonary resuscitation training.

Thursday 11th February 1993 Lunchtime 12:30

1 and 2 and 3 and 4 . . 1 and 2 and 3 and 4 . . 1 and 2 and 3 and 4 . . 1 and 2 and 3 and 4 . . 1 and . .
Breathe . . . . Breathe . . . .
1 and 2 and 3 and 4 . . 1 and 2 and 3 and 4 . . 1 and 2 and 3 and 4 . . 1 and 2 and 3 and 4 . . 1 and . .
Breathe . . Breathe . . . .
1 and 2 and 3 and 4 . . 1 and 2 and 3 and 4 . . 1 and 2 and 3 and 4 . . 1 and 2 and 3 and 4 . . 1 and . .
Breathe . . . . Breathe . . . .
1 and 2 and 3 and 4 . . 1 and 2 and 3 and 4 . . 1 and 2 and 3 and 4 . . 1 and 2 and 3 and 4 . . 1 and . .
Breathe . . . . Breathe . . . .
Come on, Desmond! Keep up!
My Dad already looked exhausted.
1 and 2 and 3 and 4 . . 1 and 2 and 3 and 4 . . 1 and 2 and 3 and 4 . . 1 and 2 and 3 and 4 . . 1 and . .
Breathe . . . . Breathe . . . .

Dr Lewis always insists on using a metronome for our practice CPR training.

My Dad has no sense of rhythm which may explain his success rate.

Note: This post has been updated in accordance with the current UK Resuscitation Council guidance. In fact, Dr Lewis was actually part of the original 30:2 campaign.

Does anyone know why we get atrial fibrillation?

Thursday 4th February 1993 Morning surgery 10:00

“Does anyone know why we get atrial fibrillation?”
Dilys shook her head. Even Dylan looked puzzled. “Is it due to a re-entry circuit or an automatic focus?” he asked.
“No one really knows,” said Dr Lewis, “there are lots of theories. It is the commonest cardiac arrhythmia and it has been suggested that it might be due chronic damage to the heart and the left atrium, in particular. Can you think of any conditions that lead to atrial fibrillation?”
“High blood pressure,” said Dilys.
“Good,” said Dr Lewis. “If you look through the records of our patients with atrial fibrillation, you will find that many of them also have hypertension. High blood pressure puts a constant strain on the heart. It damages the atrial muscle cells leading to inflammation and scarring. The electrical activity of these damaged cells is affected and they generate impulses chaotically. We think this can lead to atrial fibrillation.”
“Mitral stenosis causes increased left atrial pressure,” said Dylan. “Is that why patients with mitral stenosis are susceptible to atrial fibrillation?”
“Excellent, Dylan, that’s right,” said Dr Lewis. Even Dilys looked impressed. “It also means,” Dr Lewis continued, “that if we convert a patient with atrial fibrillation due to chronic heart damage back into a normal heart rhythm they are very likely to slip back into atrial fibrillation again. That’s why we often try to control the atrial fibrillation rather than get rid of it completely.”
“Don’t you get atrial fibrillation in young, healthy patients?” asked Dilys.
“Yes, you do,” said Dr Lewis. “I imagine it is a different mechanism in young patients without any obvious underlying heart disease. Now, let’s assume that we’ve got an elderly man who has chronic heart damage due to a 10 year history of hypertension and angina. He is probably susceptible to atrial fibrillation. Can you think of anything that might set it off?”
“Mmm . . . I know . . . an overactive thyroid, Dr Lewis.” Dilys smiled.
“Good . . . anything else, Dylan?”
“Pneumonia and I think it can be set off by a clot on the lung, a pulmonary embolism.”
“I am sure you can get it after cardiac surgery,” added Dilys.
“Very good, both of you,” said Dr Lewis. “In patients that are susceptible to atrial fibrillation there are lots of things that can set it off. You can look the rest of those up this evening.”

We want beds . . . beds for every patient!

Thursday 28th January 1993 Morning surgery 09:00

My Dad looked put out when Phil Davies and Carol Crosby came in with Mrs Vaughan. Carol Crosby had brought in an extra chair from the waiting room. My Dad glanced at his appointment list. Mrs Vaughan had just booked a single slot at 9 o’clock. He frowned and cleared his throat.
“We’ve come about Mrs Bingham,” said Mrs Crosby.
“Oh, Mrs Bingham!” My Dad sounded relieved. “Listen! I am really sorry to have to tell you this but poor Mrs Bingham passed away in the early hours of this morning.”
“We know that. That’s why we’ve come.” said Mrs Vaughan. “Do you know where she died, Dr Dennis?”
“In the hospital?”
“Well, of course. Do you know where she died in the hospital?”
“I presume it was Ward 7.”
“No.”
“Ward 5?”
“No. Mrs Bingham died on a trolley in the link corridor. She had been on the trolley since Dr Lewis sent her in on Monday afternoon.”
“It was an old trolley,” said Phil. “The cushions were really worn and hard. There was no pillow.”
“She couldn’t get comfortable.” Mrs Crosby added. “She kept shifting around.”
“There were 8 patients in the link corridor,” said Mrs Vaughan, “including Mrs Bingham. There was another elderly lady, Mrs Ripley, who was vomiting all night. There was a confused man who kept shouting. Another man was very breathless: he was sat up on his trolley, on oxygen.”
“It’s a disgrace!” said Mrs Crosby.
“It’s criminal negligence!” said Phil Davies. “You know, as much I hated my mother, Dr Dennis, I would never have wanted to see her die like Mrs Bingham, to see her go through that.”
“It is clearly inhumane,” said Mrs Vaughan.

“Mrs Bingham was in a lot of pain. When the doctor came to see her, he thought she had an inflamed pancreas: pancreatitis. He took bloods. He said he was coming back but he never did. I don’t imagine he had time. There were patients stacked up everywhere. The nurse came and gave Mrs Bingham a painkilling injection at midnight.”
“It was only because I told her what I thought,” said Phil. “No one would have come otherwise. The nurses were rushing around all over the place.”
“Yes, Mr Davies insisted,” said Mrs Crosby.
“We realised that she was going to die by then,” said Mrs Vaughan. “Her breathing was very shallow and irregular. She was trembling. Her hands were blue and cold. She was hardly responsive.”
“She seemed more comfortable after the injection,” continued Mrs Crosby. “She drifted off to sleep.”
“She stopped breathing at 6 o’clock this morning,” said Phil. “That was it, then. They did not try to resuscitate her.”
“They didn’t know she’d died until you went to tell them, Phil.”
“Another lady on the corridor died at 7 o’clock. She had had a very big stroke. I don’t think they could have done anything for her.”
“Listen,” my Dad said. “I am sorry. These things do happen. At certain times, the hospital can get extremely busy.”
“At certain times! What are you talking about, Dr Dennis?” Phil Davies glared. “There are never any beds. We’ve had enough of it. We want beds.”
“You don’t look ill,” said my Dad.
“Not, now! But, if we need to go to hospital, we all want beds.”
“I can hardly ask them to reserve 3 beds in case you are ill.”
“We are not just talking about us, Dr Dennis. We want beds for every patient.”
“I would really like to help but it is nothing to do with me. You will need to contact the Secretary of State for Health.”
“The Secretary of State for Health!” Phil looked astounded. “Don’t be ridiculous! He won’t take any notice.”
“Well, I can’t help.”
“We are your patients, Dr Dennis. You have a moral responsibility to make sure that there are proper facilities for us when we are ill.”
My Dad took a big breath.
“How often has Mrs Bingham come to see you over the years?”
“I can’t remember.”
“How often?”
“Hardly ever. Maybe, 4 or 5 times apart from when she had the children.”
“Had she ever been to hospital?”
“No.”
“Never? Are you sure?”
“I am sure. She had never been to hospital.”
“She had worked all her life hadn’t she?”
My Dad nodded.
“So, she’d made her contribution to the National Health Service?”
“Yes.”
“Then, the first and only time she need the hospital, they couldn’t look after her. They didn’t have a bed. She died on an old trolley in a dark corridor. Is that acceptable?”
My Dad did not know what to say.

“We want beds . . . beds for every patient!”
“We want beds . . . beds for every patient!”
“We want beds . . . beds for every patient!”

Impulse control disorders.

Thursday 21st January 1993 Morning surgery 11:00

“I think I may have a smidgin of Parkinson’s.”
“Parkinson’s?”
“Yes. I know that I haven’t slowed down in general but my walking’s not as good. I’m certainly not striding out like I used to. Now and again, something comes over me and I shuffle along very quickly. I don’t seem to have any control over that. I’ve got a mild tremor. It has only affected my right hand. You’ve probably noticed that I am quite adept at supressing it.” Mrs Vaughan looked down at her hands. They were clasped together in her lap. She leaned forward, towards my Dad and whispered. “Between you and me, I have been suffering with constipation for the last few months. Before that, I was as regular as clockwork.”
“Mrs Vaughan . . .”
“My writing has become very small and untidy. It is now worse than my doctor’s.”
“I don’t think . . .”
“My sense of smell is not quite right. Looking back, that started before everything else, 4 or 5 years ago.”
“You have always suffered from sinus . . .”
Mrs Vaughan ignored my Dad again. “I have been reading about impulse control disorders.” She turned to us. “They can be caused by the treatment for Parkinson’s disease. As I’ve got older, I’ve started to gain more and more pleasure from shopping expeditions. Vera, my sister, and I love to go on a spending spree in Manchester. Of course, Vernon doesn’t approve. He has always kept a tight rein on the purse strings. We are lucky if we get away twice a year. It would be nice to have an excuse, a medical reason verified by my doctor. I am sure that I would only need the tiniest dose of dopamine.”
“Mrs Vaughan, if you did develop an impulse control disorder, it wouldn’t necessarily be a shopping addiction. You might become a compulsive gambler.”
“That would be impossible, Desmond. I hate gambling. I have never even been into a bookmakers.” Valerie Vaughan looked distastefully at my Dad, then turned to me and continued. “Before you say anything, Dennis, I don’t think I could become a sex maniac either. If I was still in my 20s, I might give Dilys a run for her money but I couldn’t do anything like that at my age. No, it would be shopping for me and maybe an extra glass of sherry on a Friday evening.”

Motor neurone disease.

Thursday 14th January 1993 Dinner 19:00

“How was Dr Lewis?” my Dad asked.
“She was alright.”
“Did she have a good Christmas?”
“She said it was very quiet.”
“Really!”
“Yes, and New Year. She didn’t go to a party or anything.” For some reason, I had felt relieved when Dr Lewis told me this.”
“Did you see any interesting patients, today?” Mum asked.
“We did, actually. Dr Lewis thinks that Norman White has got Motor neurone disease.”
“Motor neurone disease?” Dad looked surprised.
“He has been feeling tired and weak for a while. Then, over the last couple of months, he has started to have problems swallowing. When Dr Lewis examined Mr White’s mouth, she could see fasciculation of his tongue. The muscles in his arms were doing the same thing.”
“Trust Dr Lewis to pick up a rare condition like that,” Mum said. She always looked very impressed when she spoke about Dr Lewis. I smiled to myself.
“I think we’ve only had 3 or 4 cases since I’ve been in the practice,” said Dad. He looked thoughtfully at his shepherd’s pie. “I hope Dr Lewis is wrong.”
I scowled. “Why?”
“Motor neurone disease is terrible, Dennis,” said Mum. “I couldn’t bear it. I think it is one of the worst illnesses you can have. Do you remember Jim Padgett, Desmond?”
“Of course, Daphne. I won’t ever forget Jim. He used to have awful choking episodes. The slightest thing could set them off: a lump of phlegm, a tiny bit of food and even drinks. Beryl used to get so frightened. Jim tried to be as brave as he could. We would go rushing up to the house but there wasn’t much we could do. Either they would settle or they wouldn’t.” Dad sighed.
“How did he die in the end?” Mum asked.
“He got pneumonia, aspiration pneumonia.” Dad looked at me. “We think some food went down into his lungs and set off an infection. It was a blessing really.”
Mum nodded emphatically in agreement. “Do you know it’s been 10 years since he died, Desmond?”
“It doesn’t seem as long ago as that. I suppose we are due another case, then.”

For Simon, it was a bad time to become ill.

Thursday 7th January 1993 Morning coffee break 11:50

“There are two gentlemen to see you, Dr Lewis.” Andrea ushered them into the staff room. “Gary Grant from the Child and Adolescent Metal Health Service and Paul Knowles from the Community Mental Health Team.”
“Good morning, Dr Lewis. We’ve come to discuss one of your referrals.”
Dr Lewis looked puzzled. “One of my referrals! I’m surprised you’ve got time.”
“Well, we haven’t,” said Gary, “but it’s a tricky one. We thought it would be better to talk to you in person.”
“It’s that patient you referred to us 3 weeks ago, Simon Rowley,” Paul explained. “He sounds like a troubled young man.”
“Yes, he is. I’ve been very concerned about him.” Dr Lewis said.
“It seems as if he is in a deep depression.” Paul continued. “Of course, it is to be commended that you have been seeing him every two weeks, Dr Lewis. Thankfully, you have been able to do so.”
“Like I said, I have been very concerned about him.”
“Well, those frequent thoughts of self-harm he’s been having are quite alarming. It is a relief that he has only cut himself twice and superficially, at that.” Paul took a deep breath as he said this. “We hope that the burns on his arms may have been accidental.”
“I don’t . . . “
“You have also pointed that he does not really have any established support network,” Gary interrupted quickly. “His social circumstances are chaotic to say the least. We haven’t even got the reassurance of a cohesive family unit. Like you, we are both extremely worried about him.”
“Although we are extremely worried,” Paul stated matter-of-factly, “he does not quite meet our urgent assessment criteria.”
“Nor ours,” said Gary.
“I thought he might not,” said Dr Lewis. She shook her head.
“It means that we would have to see him routinely,” said Paul. “Neither of us can offer anything in between routine and urgent. We cannot see him ‘fairly soon’ as you requested. Those sort of appointments don’t exist.”
“Now, this throws up a conundrum.” Gary said. “We suspect that you are already aware of it which is why you referred him to both of us. Simon had his 17th birthday at the end of last month. At the moment, in the Child and Adolescent Mental Health Service, our routine waiting list is 12 months. By the time we are able see him, he will have just turned 18. Unfortunately, we cannot assess or treat patients who are over 18 years old. The regulations are very strict. As an adult, he would need to be seen by the Community Mental Health Service.”
“That’s where I come in,” said Paul. “The good news is that our waiting list is not as long. At the moment, it is only 9 months. In fact, I could offer Simon an appointment on 9th September next year but he will still only be 17. In the adult mental health service, we cannot assess or treat patients who are under 18 years old. These are irritating regulations but they are important.”
“You can see our predicament, Dr Lewis?”
Dr Lewis frowned.
“For Simon,” Gary continued, “it was a bad time to become ill.”
“I have got a bit more good news regarding our adult service,” Paul continued. “We have managed to recruit two new community psychiatric nurses. They are joining us in 3 months, on the 5th of April. We estimate that, once they start, our routine waiting list will be reduced to 6 months.” Paul looked at Dr Lewis and smiled.
“Sadly, that won’t help Simon,” Gary said.
“Of course not,” Paul nodded. “But it is good news. I am also going to have to ask you to re-refer him to us in June, Dr Lewis. It is against our policies to ‘hold’ referrals in case anything happens, if you know what I mean.” He winked and took the referral letter out of his briefcase and handed it to Dr Lewis.
“We did hope there would be some sort of compromise,” said Gary. “That’s one reason why we thought it would be helpful for both of us to come today. Whilst we were waiting for you to finish surgery, we went over the whole situation in detail. I think we have explored every avenue but I’m afraid there isn’t anything we can do. There does not seem to be a solution.”
“I am sorry to say that there is no flexibility in the system,” said Paul.

Love Story.

Wednesday 30th December 1992 Before bed 23:15

It had been a very quiet Christmas. Dad was on call on Christmas Day and Boxing Day: he’d been busy and we’d hardly seen him. Gran was at Deidre’s. Declan had spent most of his time at his girlfriend’s house.

Everyone was back home this evening and Gran had come for turkey soup and dumplings. There was nothing worth watching on the television so Mum suggested a video and we eventually agreed to Love Story. She had never been able to persuade us to watch it before. It wasn’t as bad as I expected.

The Portmere Surgery Christmas Bran Tub.

Thursday 24th December 1992 Lunchtime 13:15

I knew that the probability of Dr Lewis picking the present that I had bought for the Portmere Surgery Christmas Bran Tub was low. In fact, if everyone took part as expected, there was only a 1 in 27 chance that she would choose it. Despite this and the fact that it cost quite a lot more than the suggested budget, I decided to buy the perfume. I had had several discussions with the girl in Debenhams who seemed to know everything there was to know about perfumes. She assured me that this particular scent would be perfect for the slightly older more sophisticated lady whilst still having the subtle hints of youthful romance that I wanted.

In the end, Dylan’s earrings were selected. Dilys was horrified when Dr Lewis opened them. They were the exact pair that she had set her heart on. She had even dragged Dylan into the jewellers to see if he thought they suited her. Only he could miss that sort of Christmas hint.

It looked as if it would be a poignant Christmas for me but a nightmare for Dylan.

Informed consent.

Thursday 17th December 1992   Whitby Rd, Portmere 12:57

It was an unfortunate set of circumstances. It was raining heavily; visibility was poor. My Dad had just been on a course on informed consent. He had been having a collaborative discussion about the risks and benefits of treatment with almost every patient this morning so he was running really late. Mr Parry wanted to get his treatment before the chemist shut for lunch. He dashed across the road without looking properly. The lorry driver braked but the lorry skidded on the wet tarmac. There was a terrible bang. Mr Parry was pronounced dead at the scene by the ambulance men.

Mr Watts?

Thursday 10th December 1992   Morning surgery 09:200

“How did Mr Watts describe his dizziness, Dennis?”
“Mr Watts?”
“Yes, he’s the patient that we’ve just seen. He only left the room a minute ago.”
“Oh! I thought he had headaches.”
“He did have headaches, Dennis, but dizziness was his main symptom.”

“What about you, Dylan?”
“I’m not sure, Dr Lewis.”

It wasn’t unusual for me to be distracted but, usually, Dylan never missed a thing.

All these symptoms.

Thursday 3rd December 1992   Morning surgery 10:50

Maldwyn Morgan finished talking and took a deep breath. He looked worriedly at us. My Dad drummed his fingers on the arm of his desk as he thought.
“Listen, Maldwyn, the only way that I can explain all these symptoms is to suggest that you have developed three completely different illnesses at exactly the same time. Even then, I cannot account for your throbbing arm or the line of itchy spots on your left leg.”

An irresponsible diagnosis of asthma.

Friday 27th November 1992   Respiratory Disease Performance Panel 08:15

“Good morning Dr Dennis. Welcome to the panel. I would like to start by introducing everyone. I am Professor Melanie Mortimer, Specialist Consultant in Adult Respiratory Medicine at The Royal Brompton Hospital. I am pleased to be able to welcome two esteemed respiratory colleagues. Next to me, on my right, is Dr Matt Montague. Matt is one of the Consultants in Alder Hey Hospital. He has a particular interest in asthma in children. On my left is Dr Malcolm Morrison. I am sure you know Malcolm. He is a Consultant Respiratory Physician in Portmere Hospital.”
My Dad smiled at the three consultants.
Professor Mortimer continued: “As you know, you have been charged with making an irresponsible diagnosis of asthma on at least five separate occasions. It is Dr Malcolm Morrison who initially reported these, shall we call them, shortcomings.  We have had a good look each patient’s medical record. Four of the patients are adults and one is a child. As far as the adults are concerned, we feel that the circumstances are all very similar. We would, therefore, like to go through one case in detail with you.”
My Dad nodded.
“The patient we have chosen is a Mr Peter Purvis. He is 27 years old and he has been registered with you ever since his birth. Apart from the usual childhood illnesses, he has rarely needed to come to see the doctor. Now . . . on the 23rd November last year, Mr Purvis came to see you with what you have documented as an acute bronchitis. You noted that he had had a cold and a cough for a week. He had been coughing up some green sputum. He was slightly breathless. He thought he’d had a temperature and he had been feeling mildly shivery at times. Mr Purvis has never smoked and he has had no previous chest problems. Do you remember the case, Dr Dennis?”
“I do.”
“You examined his chest. There was a little wheeziness. You also measured his peak expiratory flow rate which was 500.”
My Dad nodded.
“Excuse me, Professor Mortimer. Can I ask Dr Dennis a question?”
“Of course, Malcolm.”
“OK, Dr Dennis, what sort of peak flow rate would you expect in a patient like Mr Purvis?”
“I would imagine it would be about 600.”
Dr Morrison frowned gravely. “I am afraid things really aren’t as simple as that Dr Dennis. It depends on . . .”
“That does seem a reasonable ball park figure, Dr Morrison.” Professor Mortimer said as she glanced down at the Mr Purvis’ records. “Right, you prescribed an antibiotic, Dr Dennis, and asked Mr Purvis to come back and see you if things didn’t settle down. I think we can assume that he did improve because you did not see him again until the 2nd May when he consulted with further chest problems. On this occasion, he had not had much of a cold. He had had a dry cough. He was fairly wheezy and finding it difficult to sleep at night. You examined him and found a lot of wheeze, expiratory wheeze in both lungs. You have described the wheeze as . . . I can’t read this . . . ah, yes . . . as polyphonic wheeze.”
Both Dr Morrison and Dr Montague chuckled and raised their eyebrows.
“Let me carry on please, gentlemen. This time, Mr Peter Purvis’s peak expiratory flow rate was 400, considerably lower than in November.”
“Yes, it was,” my Dad said.
“You did not specifically mention that you suspected asthma but you did note that there was no family history of asthma. You also stated that the patient was suffering from hay fever.”
“Excuse me, Professor Mortimer. Can I ask Dr Dennis another question?”
“Of course, Malcolm.”
“OK, Dr Dennis, can you tell me what diagnostic criteria you use to make a diagnosis of hay fever or allergic rhinitis?”
“Mmm,” My Dad said. “Do you know, I have never really thought about it. To be honest, I think most of our patients make the diagnosis themselves. If I remember correctly, Peter told me he had hay fever.”
“Your patients make the diagnosis of hay fever themselves!” Dr Malcolm Morrison looked extremely worried. “How irregular!” He shook his head.
“Even though you did not make a diagnosis of asthma,” continued Professor Mortimer, “you prescribed treatment usually used for asthma: a ventolin inhaler and a course of steroid tablets.”
“That’s correct,” said my Dad. “He was quite wheezy as I have noted.”
“You also asked the patient to come back in two weeks to make sure that his symptoms had settled down.”
“I did.”
“You saw Mr Purvis again on the 15th May. By this time, he was feeling much better His chest was completely clear and his peak expiratory flow rate was 620.”
“His peak flow had come up quite nicely with the treatment,” my Dad said.
“On the 28th of July, Mr Purvis was back. This time, he had not had a cold. After cutting his lawn at the weekend, he had started to feel wheezy. This got gradually worse over the next few days resulting in him coming to see you on the Tuesday. His chest was really very wheezy and his peak expiratory flow rate was down to 350. You recommended that he restarted his ventolin inhaler and you gave him a further course of steroid tablets. Two weeks later, he had again improved. His chest was completely clear and his peak expiratory flow rate was back up to 610. It was at this stage you made a diagnosis of asthma and suggested that Mr Purvis started taking a preventative inhaler; incidentally, a rather expensive treatment. Anyway, this seems to have done the trick because, at the end of October when Mr Purvis came to see the asthma nurse, he was feeling his normal self, he had not had to use his blue inhaler at all and he had not had any further wheezy episodes.”

Professor Mortimer looked up from the notes. “We are not quite sure, Dr Dennis, how you came to the conclusion that Mr Purvis had asthma.”
“You don’t seem to have considered arranging spirometry,” said Dr Montague. “Isn’t it likely that Mr Purvis simply had a chest infection that had not completely cleared up or was it possible that he had had three chest infections, one after another?
“I don’t think so,” my Dad said.
“Could this just have been three temporary episodes of wheeziness?” Dr Montague continued.
“Isn’t that what asthma is?” my Dad asked.
“Did you think about requesting an opinion from Dr Morrison?” Professor Mortimer wondered.
“Well, I didn’t think it was really necessary,” my Dad said. “Dr Morrison has got a very long waiting list. It is about 12 months for a non-urgent referral.”

“Well, let’s get on to the next case,” Professor Mortimer spoke impatiently. “This is the child who supposedly has asthma. Would you like to lead on this, Matt?”
“Of course, Melanie. This case is also causing us all a great deal of anxiety, Dr Dennis. Now, young Philip Padgett was just 3 years old. You saw him with six separate episodes of wheeziness. After the sixth episode, you made a diagnosis of asthma and started him on a preventative inhaler. Interestingly, this was the same expensive treatment that you started Mr Purvis on although, obviously, you used a lower dose. To be fair, you also prescribed a spacer.”
“You seem to have made a diagnosis of asthma here with absolutely no objective measurements,” Dr Morrison interjected.
“It is very difficult to make objective measurements in a 3 year old, Dr Morrison.” My Dad said.
“I am afraid I do have to agree with Dr Dennis there,” Dr Montague said. “You did note that Philip’s older brother is asthmatic. However, I am not sure that we can say that the younger brother of every asthmatic patient is also likely to be asthmatic.”
“No, but it is something I always take into account, Dr Montague.”
“Mmm . . . I think you have done more than taken it into account. As a general rule, Dr Dennis, in the field of paediatric respiratory medicine, I can say with some authority that one never makes a diagnosis of asthma in a child under 4 years old. I find it most disconcerting that you have diagnosed asthma so readily in this young child. I presume that you have a paediatric department in your local hospital? If that’s the case, I can’t see why you haven’t used it.”
“Hear! Hear!” Dr Morrison exclaimed. “I agree completely. Anyway, Matt, wouldn’t it have been more appropriate to call this child a happy wheezer rather than an asthmatic?”
“Actually,” my Dad said, “he wasn’t really a happy wheezer. He seemed to get very frightened when his breathing was bad.”
“I don’t think the term ‘happy wheezer’ means a wheezy child of a happy demeanour.” Dr Montague explained. “I think the term ‘happy wheezer’ means the child is wheezy but the wheeze is not causing any respiratory embarrassment.”
“I wish the same could be said of you, Dr Dennis. I feel you are causing the profession a great deal of respiratory embarrassment.” Dr Morrison looked very pleased with himself when he said this and his two colleagues couldn’t supress large smiles.
“He was a perfectly happy child when he wasn’t wheezy, Dr Morrison,” my Dad rejoined. “I am afraid, if I cannot call him asthmatic, I am going to have to call him an unhappy wheezer.”
“These so called asthmatic or wheezy children are invariably well with completely clear chests when we do see them in the clinic,” said Dr Montague. “I sometimes think that our colleagues in general practice have rather vivid imaginations.”
“The trouble with asthma,” my Dad said, “is that the symptoms and signs come and go. If one of my patients is wheezy, they can pop down and see me on the very same day or, if I am unexpectedly busy, on the next day. They may wait 6 to 12 months for an appointment in the paediatric clinic. Who knows if a patient is going to be wheezy in September, next year. If I remember, little Phillip was a lot better with his brown inhaler. He became a happy little boy who did not wheeze.”

“I think we have heard enough, Dr Dennis.” Professor Mortimer spoke impatiently. “It troubles me that, in addition to the fact that you have made at least five diagnoses of asthma on rather flimsy grounds, you don’t seem willing to learn from our experts.”
“I really don’t . . .”
“I am afraid that we need to draw the proceedings to a close, Dr Dennis”, Professor Mortimer interrupted. “We have all got more important matters to deal with. Our unanimous recommendation is that you should be banned from making a diagnosis of asthma in either adults or children for the next 3 years. You should, on no account, initiate a prescription for an expensive, preventative inhaler without the patient being assessed by an appropriate specialist. We also recommend that you should undergo intensive training on the use and interpretation of spirometry. Any breach of our recommendations could lead to a hefty fine and a temporary period of suspension from your practice.

An ugly duckling.

Thursday 19th November 1992   Morning surgery 10:20

“How are you, Catherine?”
“I’m alright Dr Lewis. I’m just worried about another mole.”
Dr Lewis turned to us. “Catherine is one of those patients who has numerous moles: she’s got more than 50. It is thought to be an inherited tendency.”
“Dad’s got loads. I’ve got 137 at the moment, I think. It is hard to count them exactly. My Mum checks my back for me. She gets very flustered because there are so many.”
“It means that Catherine is at a slightly higher risk of skin cancer.”
“I don’t sunbathe and I always wear factor 50 even in Winter.” Catherine looked over at us. “Anyway, I’ve got this mole on my back. I think it’s a new one. It’s bigger and darker than the others.”
“Has it been sore or itchy?” Dr Lewis asked.
“No.
“Has it been bleeding?”
“No, I don’t think so.”
“We better have a look then.”
Catherine took off her shirt and turned round. There were moles all over her back. Most were small, light brown bumps. Some were flatter but similar in colour. A few had an orange tinge. The mole that Catherine was worried about was immediately obvious. It was much darker than the others and had a smooth, shiny surface.
Dilys got up to have for a closer inspection.
“What do you think, Dilys?”
“It’s quite flat.” She felt the mole with the tip of her finger as she spoke. “It feels smooth.”
“What about the colour?”
“Most of it looks black but this area is brown and, at the bottom, there is a reddish pink patch.”
“Good, so there are 3 colours?”
“Yes and it’s an unusual shape. It’s a bit lopsided.”
“Asymmetric, Dilys.”
“Yes, asymmetric and there is a dent or a notch on the side.”
“A notch is an important feature to look out for. Can you measure the mole?” Dr Lewis handed Dilys a tape measure.
“It’s 8 mm in length and 7 mm across.”
“So, we’ve got a new mole that looks quite different from Catherine’s other moles, what we sometimes call an ugly duckling. It is flat, 7 x 8 mm in size, asymmetric in shape with a notch and it contains 3 colours. Are you worried about it?”
“Yes, I am.” Dilys answered straight away.

Dr Lewis waited for Catherine to put her shirt back on and sit down.
“I am afraid this is quite a worrying mole, Catherine. It could be a skin cancer, a melanoma. It will need to be removed and tested.”
I thought it might be, Dr Lewis.”
“You should hear from the dermatologist very quickly.”
Catherine nodded and smiled. She wiped a tear from the corner of her eye and got up quickly to leave.

There’s something different about Dr Lewis.

Thursday 12th November 1992   Morning surgery 11:00

There is something different about Dr Lewis. Obviously, she has had her hair cut but it’s not that. There’s something else. I keep watching her but I can’t work it out. Could it be her now visible, slender neck and shoulders? Her skin looks so soft. Maybe it’s the way she tilts her head slightly when she turns it. I don’t think the way her mouth relaxes into a warm, easy smile has changed. I hadn’t realised how kind her eyes were.

Dylan seems to be paying her a lot of attention, too. He has been asking his most intelligent questions and wants her opinion on everything. ‘Thank you very much, Dr Lewis,’ he says every time she answers. Dilys has sensed his interest and is getting annoyed with him.

I don’t know why I’m here.

Thursday 5th November 1992   Morning surgery 11:20

“I don’t know why I’m here, Dr Dennis.”
“It was to review your medication.”
“Oh! I’m still taking the tablets. I don’t need them but I’m still taking them.”
“I think you do need them, Ray. You were really ill.”
“Anyone would be ill if they had been through what I’ve been through.”
“Are you keeping yourself busy?”
“Not, really.”
“Are you looking for work?”
“No, I’ll never work again. Once you’ve been in the Met, done the initial training and worked for 3 or 4 years, you’re ruined. The job’s too stressful. There are hundreds like me out there. Every single one of them is wrecked. You see them waiting at bus stops but never catching buses, standing aimlessly on street corners or sitting in cafes for hours.”
“Could you do something else? Something less stressful?”
“I can’t even think about work. I told you, they’ve ruined me.” Ray shook his head.
“It’s a shame after all your training.”
“You never forget those skills, though. I could still go under cover. Put me in any room full of people and I’ll blend in. I’ll disappear.”
My Dad nodded. “I suppose it’s second nature to you.”
“I was number one for surveillance in my unit. Even now, I never miss a thing. I was outside the Vauxhall Factory in Rossmore road last weekend. There was a gang of men there, planning a hit on Bramwell’s. I automatically went into surveillance mode. I watched everything. I made a mental note of every potential witness. I could describe them all to you now. I was going to intervene as the men approached the shop but one of them recognised me. I’d prosecuted him several years ago for an armed robbery. I saw him whispering to his cronies. He must have called the job off because I was there. They sauntered past the shop then, joking and laughing as if they were out for a Saturday afternoon stroll.”
“Do you do any exercise?”
“I don’t need to. Haven’t you heard about Hendon? The physical training is unbelievable. Once you’ve been through there, you never lose that fitness. Every day after our theoretical classes, we’d go straight to the exercise yard. The instructors were psychopaths. They worked us like dogs. They tried to break us down. All around me, other trainee coppers would be dropping like flies: cramp, dehydration, heat stroke. I was one of the few that could withstand the regime. Physical extremes have always made me stronger and sharper.” Ray gave my Dad a knowing look.
“How long were you in the police for?”
“Not long. I got out as soon as I could. There’s a few that stay in the force. They’re the ones with something wrong with them, something up here.” Ray pointed to his head. “To put it bluntly, they’re mad. The sane ones like me get out while they can.”

Could it be shingles, doctor?

Thursday 29th October 1992   Morning coffee break 11:40

My Dad sighed and sat down.
“Do you know,” he said, “I’ve seen four patients this week who were all adamant that they’d got shingles and yet not one of them had a rash.”
“Don’t you enjoy the diagnostic challenge, Desmond?”
“No, I don’t, Lois. What’s more, it means that if any of them does end up with shingles, we will have to see them again as soon as the first spots appear.”

“The only symptom that Charlie Ryan had was a peculiar feeling down the outer aspect of his right thigh.  Apparently, his wife had exactly the same sensation in the same leg before her shingles in 1986. He was very put out when I explained that his symptoms did not meet my diagnostic criteria and that I would not be able to prescribe aciclovir.”

I don’t want to die of dehydration.

Thursday 22nd October 1992   Morning surgery 09:20

“I don’t want to die of dehydration, doctor.”
My Dad did not say anything.
“I have read in the paper that they are letting cancer patients die of dehydration up at the hospice. They say that it is a terrible way to die. It sounds so inhumane.”
“You are not a cancer patient, Mrs Vaughan.”
“I may be one day, doctor. If it happens, I want you to be there with a drip.”
“To be completely honest, Mrs Vaughan, I am not sure I agree with you. Dehydration can be part of the natural process that takes place when we die of conditions like cancer. As we get weaker, we stop eating and then we stop drinking. I think it is Nature’s way of protecting us.”

We’ve both brought lists.

Thursday 15th October 1992   Evening surgery 18:10

“Good evening, Dr Dennis. Catrin has come with me. I hope you don’t mind seeing her as well. She has been trying to get an appointment for two weeks.”
“I have spent ages on the ‘phone. I’ve rung every day.” Catrin Davies did not try to hide her irritation. “It’s impossible to get through.”
“We thought you wouldn’t mind,” Mrs Davies continued, “as it is your last appointment of the day and we won’t be holding any other patients up. We have both brought lists. We thought it would be quicker. Do you want to get them out, Catrin?”
Catrin rummaged in her handbag and found the two pieces of paper. “Our problems are quite similar so that should be easier too.” She smiled.
My Dad visibly relaxed. They probably both had a virus.
“My headaches are right over my eyes,” Catrin continued. “They feel like a heavy weight pressing down.”
“She’s sleepy with them,” Mrs Davies added.
“Very sleepy. Sometimes, Mum can’t wake me up.” Catrin looked worriedly at her mum.
“My headaches are at the back.” Mrs Davies smiled. “They seem to start in my neck which is very stiff. I can feel it creaking. It’s horrible! It goes right through me.”
“Sometimes, I can hear it!” Catrin said. “We are both off our food but I feel sick and Mum’s got awful heartburn. Our bowels are playing up, too. I’m constipated.”
“I’ve got diarrhoea.”
“It is difficult to know who is the most tired. We are both very weak. Mum is exhausted. Tom is having to do everything.”
“He’s very good. He doesn’t mind.”
“I have been breathless at times,” Catrin added.
“My breathing is quite good. In fact it has felt better than usual, which is a relief.” Mrs Davies looked pleased to be able to report this.
“We have both got pins and needles in our feet. They are really uncomfortable. We can’t bear them being touched. Mum won’t get into a hot bath. Hot water doesn’t seem to affect me.”
My Dad sighed.  “Listen ladies, this isn’t working for me. If you had something straightforward like sore throats, I could have managed to deal with both of you in one appointment.”
“We have got sore throats, Dr Dennis. I told you, Mum! We should have started with our sore throats.” Catrin Davies glared angrily at us. “Now, we are going to have make two more appointments.”

My migraine.

Thursday 8th October 1992   Lunchtime 13:10

“I am afraid Dr Lewis is away today so I’ll have to do the tutorial for you.” My Dad had come into the staff room. We looked apprehensively at each other.
“What were you going to discuss?” he asked.
“Dr Lewis was going to go over psychosomatic illness.”
“Mmm . . .” my Dad said. He rubbed his chin thoughtfully. “Psychosomatic illness is a very interesting topic. It needs some preparation though. I am not sure that I can do it now. I know what I’ll do, I’ll tell you about my migraine.”
We looked at each other again. Dylan sighed.
My Dad sat down and loosened his tie. “We’ll start from the beginning: when I was in junior school. I am a bit embarrassed to say so now but I was one of the cleverest children in the school. I was very competitive and took great pride is being at the top of the class.” He smiled knowingly at Dylan.
“My parents were very glad to see me doing well and they encouraged me. I passed the 11 plus without too much difficulty. I ended up going to a very good grammar school with an excellent reputation for getting students into university. That’s all I wanted then, to go to university.”
“Why was that, Dr Dennis?” Dilys asked.
“I am not sure, really. It might have been because my uncle went to Cambridge. He had a big influence on me.”
“Did you always want to study Medicine?”
“No, not then. I hadn’t thought about what I wanted to do. I just wanted to go to University.”
My Dad paused and took a sip of his coffee.
“Things were very different in the grammar school. In the first year, I was really struggling. My homework was always carelessly done. I never seemed to have time to check anything over before handing it in. I was soon near the bottom of the class. I started to get fed up and lose confidence. My work got even worse. I felt quite despondent.”
Dylan shifted impatiently in his chair.
“I remember my form teacher talking to me just before Easter. He knew that I was finding things difficult. He said that the school based almost everything on examination results. If I worked hard for my exams, I could get into a good stream. I realised that this was my opportunity and I studied every night for 2 months. I got my Mum to test me regularly until I knew my work inside out.”
Dylan yawned loudly. Dilys looked at her feet. I blushed. I always found Dad’s tutorials embarrassing.
“I ended up doing very well in the exams and I managed to get into the B stream. No one wanted to be in the A stream because it was full of odd characters.”
“Dylan was in the A stream.” Dilys laughed. Dylan glared at her.
“For the next two years,” my Dad continued, “I did exactly the same. My course work was terrible but I was near the top of the class for all tests and exams. I felt pretty pleased with myself and my old confidence returned.”
“I thought you were going to tell us about your migraine.” Dylan asked. He was getting annoyed.
“I am just coming to that. It was towards the end of the fourth year when I had my first migraine. I didn’t know it was a migraine at the time. In fact, I didn’t diagnose it until I was in the second year of medical school. It happened in the middle of a maths test. It started almost imperceptibly, a slight distortion of my vision that I couldn’t quite put my finger on. This gradually became worse with jagged, coloured lines, shimmering and blank areas where I couldn’t see anything. It was a bit like the pattern you see when you look directly at a bright light bulb. As this ‘visual aura’ progressed, it became harder to see the test paper. I had to move my eyes around to utilise the clearer areas of vision. Even then, some of the fractions and equations were distorted and difficult to see. It was tricky to do the work but not impossible and took longer than usual. I was pleased that I still managed to complete all the questions. The symptoms lasted for about 30 minutes. I was left with a dull headache. I have never had severe headaches with my migraines.”
“I thought everyone got really bad headaches with migraine.”
“Not really, Dilys. Some patients don’t get a headache at all. What other symptoms can you get with migraine?”
“Nausea and vomiting . . .”
“Yes, I do occasionally feel sick but I’ve never vomited.”
“Anything else?”
“Dizziness . . . photophobia . . .”
“Very good.”
“Can’t you get tingling and numbness or even paralysis?”
“Excellent, Dylan. Tingling often starts in the hand and spreads up to the face. You usually get weakness rather than complete paralysis, though. Only a small proportion of patients get numbness or weakness.”
“Isn’t migraine more common in women?”
“Yes it is, Dilys. Anyway, we’ll carry on with the story. At the time, I was quite worried about the symptoms but felt reassured when they disappeared completely. I guessed that the episode might have been a consequence of all those weeks spent staring at books. But, I was worried. What would happen if I had these episodes during examinations in future? It would have been impossible to complete a difficult paper. I was relying on my exams results. I knew that my course work would never be good enough. I thought about doing less revision but it would be too risky. I was in a quandary and anxious for weeks. Some mornings, I woke up with a horrible feeling of dread. I couldn’t bear the thought of not doing well at school.”
My Dad looked at us and took another sip of his coffee.
“Of course, as it turned out, I ended up doing progressively more revision over subsequent years. I did my O-levels, A-levels and, then, spent 5 years at medical school in Cardiff. That was when I had to work the hardest. During this time, I continued to have regular migraines. Sometimes they were caused by tiredness or bright lights. Sunshine or car headlights could set them off, particularly if it was wet. However, the majority were related to studying.”
“How did you manage to pass everything?” Dilys asked anxiously.
“Well,” my Dad said, “In all that time, I have never had another migraine during an examination. They have always occurred, very conveniently, a day or two after one exam or a similar time before the next. They never even disturbed my revision. I have always thought that that was a remarkable coincidence.”
“It was a coincidence, wasn’t it?” Dilys said. “You were very lucky, really.”
“Yes, I was. Gradually, as I have got older, my migraines have occurred less and less. I only get one or two a year now.”

A swollen, red, beefy tongue.

Thursday 1st October 1992   Morning coffee break 11:53

My Dad dropped heavily into his chair. “I’ve just had an earful from Mrs Bailey, Lois. She says that I missed her B12 deficiency for 6 months.”
“I’m sorry, Desmond. I did explain that the result was borderline. I only checked her blood because she brought a magazine article in and said she had all the symptoms.”
“When I originally saw her, she was feeling a bit under the weather. After reading the article, she realised that she was more seriously ill than she thought. She was exhausted. She had been running an intermittent, low grade temperature: she reported figures between 37.6 and 37.8°c. There were pins and needles in her hands and feet. She had noticed that her complexion was a waxy, yellow colour. Her usual foundation didn’t suit her any more. She was off her food and her mouth was sore. I half expected her to stick a swollen, red, beefy tongue out at me.”
“Oh, Desmond, you are awful!”
“Of course, she didn’t because it was probably perfectly normal. Then, everything got dramatically worse after you told her the blood result. She insisted that she was now a neurohaematological emergency. She said that her spinal cord could collapse at any moment or her bone marrow could go into shock. She wouldn’t leave the room until I had given her the first injection. She threatened to make a formal complaint or sue me.”
“Oh, I am sorry, Desmond.”
“She’s a pernicious woman, Lois.”

A continuous cough?

Thursday 24th September 1992   Evening surgery 17:00

“A continuous cough? I am not sure what you mean, Mr Russell.”
“It’s just a continuous cough. I don’t know what else I can say.”
“Do you know,” my Dad turned to us, “in all my time in the practice, I don’t think I have ever seen a patient with what I would regard as a continuous cough.”
“What about babies with whooping cough, Dr Dennis?”
“That’s very true, Dilys. I hadn’t thought about babies with whooping cough. They can’t stop coughing. Are you worried that Natalie has whooping cough, Mr Russell?”
“No, I hadn’t thought of whooping cough either.”
“To be honest, we hardly see any whooping cough these days. I suppose some patients with chronic, severe chest conditions like pulmonary fibrosis cough all the time. Do you remember Mr Perkins’ cough?”
We all nodded. Mr Perkins had had an awful cough. He and his wife found it very distressing.
Nathan Russell cleared his throat. “Actually, I’m following the criteria for our departmental definition of a continuous cough, Dr Dennis. I think the definition has been nationally accepted so you must be aware of it.”
“I see.” My Dad raised his eyebrows.
“Yesterday morning, Natalie coughed for 48 minutes.”
“You timed it?”
“Not really. She started coughing just after my alarm went off at 06:45 and she did not stop until she came down for breakfast at 07:33. If she comes down then, it gives her exactly enough time to eat her cereal, get dressed and catch the bus.”
“I was fine for the rest of the day.” Natalie smiled.”
“Would that be considered a continuous cough, Mr Russell?”
“Not quite. You need to be coughing a lot for one hour for it to be counted as continuous.” Nathan Russell paused. “This morning, she had two further bouts of coughing.
“Did either of those last for an hour?”
“No . . . no . . . it’s not just that . . . our criteria for a continuous cough is that the patient either coughs a lot for an hour or they have 3 episodes of coughing within 24 hours.”
“I see,” my Dad nodded.
“Natalie started coughing at 09:25 this morning so, unfortunately, we couldn’t include yesterday’s episode within the 24 hours.”
My Dad seemed confused.
“Even though it wasn’t a continuous cough at that stage, Natasha, my wife, was worried and decided to book an appointment with you. Then, on the way here in the car, just before we arrived, Natalie started coughing again. That was the third episode today so we can now regard her cough as continuous.”
“Mmm . . .” My Dad looked at Natalie and Mr Russell as he considered the situation. “Dennis, have you got your dictionary?”
“Yes, Dad.” I got my Concise Cambridge Dictionary out of my pocket.
“Before he decided to go into Medicine, Dennis had considered becoming a journalist.”
“A sports journalist, Dad.”
“I don’t think Mr Russell needs to know all the details, Dennis. Anyway, with wanting to be a . . . journalist, he got into the habit of using the dictionary every day. Can you look up continuous, Dennis?”
“Yes, Dad.” I opened the dictionary to find the correct page. “According to this, it means without pause or interruption.”
“Does it mention occurring a lot for an hour?”
“No, Dad.”
“What about occurring 3 times in 24 hours?”
“No, I think that would be regarded as intermittent as far as a cough is concerned.”
“I agree with that, Dennis. Mr Russell, have you got a dictionary in Public Health?”
“We haven’t, doctor.”
“I think it would be very useful to have one. If you and your team made a point of referring to it regularly, I am sure that all of us and, when I say that, I mean the public in general and not just the medical profession, would find it easier to understand what you were trying to say.”
“It is a good point, Dr Dennis.”
“Have you got a spare dictionary, Dennis?”
“Yes . . . but, it’s just a learner’s dictionary.”
“That’s perfect.” My Dad looked pleased.
“Mr Russell can have it. I don’t use it any more.”
“I will bring it in in the morning, Mr Russell. You can pick it up from reception.”
“Thank you. I won’t keep it, Dennis, but, if you don’t mind, I would like to lend it until we can get one of our own.”

Have you been kissing anyone?

Thursday 17th September 1992   Morning surgery 11:00

“Have you been kissing anyone?”
15 year old Alice Braithwaite blushed. I could have died of embarrassment.

Last night, I had arrived home to find Declan in bed. He had a terrible sore throat and the glands in his neck were the size of golf balls. He had been exhausted all day and reported a temperature. Every one of his muscles was aching.
Dad promised to check him over in the morning if he wasn’t better but Mum had diagnosed glandular fever.

Had she been kissing anyone? Every night for several weeks, Alice and Declan had been snogging like mad in the park. Half the kids in Portmere had seen them.

Alice bit her lip. Dad had been quite composed until then, when he caught on. His cheeks turned crimson. He coughed but did not ask any more questions.
“You’d better book in for a blood test,” he said grimly.

A stye?

Thursday 10th September 1992   Morning surgery 09:40

“A stye?” My Dad looked angrily at the telephone handset.
“Yes, I’ve got a stye, Dr Dennis.”
“As a busy family doctor, I don’t concern myself with the comings and goings of styes, Miss Beedon.”
“It’s huge!”
“Styes are all much of a muchness. There may, admittedly, be some minor variation in size but they are never huge.”
“This feels enormous.”
“They often feel bigger than they actually are.”
“It looks enormous in the mirror.”
“You didn’t need to phone on the emergency line about a stye.”
“I couldn’t get through on your appointments number. I thought it was it was going to burst.”
“It would be a good thing if it did burst. It would let all the badness out. Styes usually disappear quickly after they have burst.”
“What time would you like me to come down?”
“I don’t want you to come down, Miss Beedon. As I have already explained, we do not deal with styes in Portmere surgery.”

A painful arm.

Thursday 27th August 1992   Morning surgery 10:50

“Are you suggesting that this pain is due to stress, Dr Lewis?”
“I think it is, Mrs Owen. Stress related symptoms are very common.”
“It can’t be! It’s so severe. I can hardly move my shoulder. My arm is aching all the time. It feels like a dead weight.”
“Psychological symptoms are often worse than those caused by real illness.”
“That doesn’t make sense to me. How can they be worse?”
“I think it does make sense but it is difficult to understand. Apart from your shoulder, what is your biggest worry at the moment, Mrs Owen?”
“Well, it’s Dewi’s job, of course.”
“Has he heard anything?”
“Nothing definite but it does look as if he is going to almost certainly be made redundant. There are about 30 of them losing their jobs.”
“What will you do?”
“I don’t know. He doesn’t think he will be able to get another job. He is 58 years old. There’s nothing here in Portmere.”
“Will he get any redundancy pay?”
“Not really. He’s not worked there for long. I think we’ll have to sell the house.”
“I’m sorry. You have put so much time and effort into it.”
“It’s all we’ve done for the last 5 years, Dr Lewis. It has been our pride and joy. It was going to be our pension. Listen, do you mind if we don’t discuss this. To be truthful, I can’t even bear to think about it.”
“Have you been worrying about it a lot.”
“I haven’t, really. I have managed to put it out of my mind completely. I am hoping something will happen but it seems unlikely.”
“You are in a very difficult position, Barbara.”
“Yes, I am.”
“Do you think it is possible that you could have turned this situation into a painful arm?”
“Why would I do that, Dr Lewis?”
“Well, in some ways, it’s easier. You can take painkillers. You can even get someone else to deal with it: your doctor or the physiotherapist.”
“No, this shoulder is something separate,”
“Have you talked to Dewi about the house?”
“No, he is worse than me. He doesn’t say much at the best of times.”
“Well, I think you both need to sit down and discuss it. Perhaps there are alternatives. Maybe selling the house doesn’t need to be as bad as you think.”

You tick every box.

Thursday 20th August 1992   Morning surgery 10:00

“You tick every box, Mr Williams.”
“What do you mean, doctor?”
“Well, you are 93 years old for a start.”
“I didn’t think it was considered appropriate to assess someone on the basis of their chronological age, these days.”
“I agree with you completely up until the age of 89 years but, after that, we have to think very carefully. You have had high blood pressure for 50 years and diabetes for 23 years so we know that your circulation must be in an awful state. That has been confirmed by 3 heart attacks and a touch of cardiac failure. You’ve also got chronic renal impairment.”
“I’ve got no symptoms from that.”
“Most people don’t until they reach the final stages. You are beginning to get a bit forgetful.”
“Only names!”
“Yes, just names, at the moment.”
“Most people of my age forget a lot more than names.”
“I must say I think you’ve got a touch of Parkinson’s.”
“Parkinson’s? In October, you told me that you were quite sure that I had benign essential tremor and not Parkinson’s.”
“Well, I think I got that wrong. You’ve definitely slowed down. You’re stooping, you’re not swinging your arms much or smiling.”
“Thanks!”
“Anyway, the point is, with all this going on, you are not really a suitable patient for resuscitation. Your body is coming to the end of it’s working life.”
“I don’t know, Dr Dennis. I feel quite well. I would still like to give it a try.”

Thank God he’s a doctor!

Friday 14th August 1992   At home 21:20

My Dad thinks he’s funny. His dream job would be writing the jokes for Christmas crackers. Thank God he’s a doctor!

For 5 years, he’s been haranguing me to include a couple of his ‘medical jokes’ in my case book. Well, he’s eventually worn me down and I’ve given in. I am hoping that you won’t notice them but, if you do, I’d like to apologise in advance.

 

Do you think he needs a hip replacement?

Thursday 13th August 1992   Morning surgery 09:20

“We’ve just seen Robert Parry for you, Dr Lewis.” Dilys started her presentation with her customary enthusiasm. “He is a 72 year old man with a 2 year history of left sided hip pain. It has been getting gradually worse, especially in the last few months.”
“He is limping badly and using a stick,” Dylan said. “He says he can walk about 200 metres, now. He used to be able take his dog for miles.”
“He feels the pain here.” Dilys put her hand on her hip. “It radiates into his groin, like you said Dr Lewis, and down the front of his leg. He’s got a bad back but he says that’s a different pain. His hip is very stiff when he gets up in the morning or after he has been sitting down. It can take about 15 minutes to loosen up.”
“What were your examination findings?”
“I think he has got a Trendelenberg gait.” Dylan look pleased with himself.
“No, he’s not Dylan. He’s just got a bad limp.” Dilys frowned at Dylan. “He has got wasting of his thigh muscles, all his hip movements were very restricted especially internal rotation . . .”
“He’s got a fixed flexion deformity.”
“I was going to tell Dr Lewis that, Dylan. We did Thomas’ test.”
“I suggested doing it, Dilys. You . . . “
“Very good,” Dr Lewis interrupted. “Do you think he needs a hip replacement?”
“Well,” Dilys explained, “he can’t cut his toenails. He’s having trouble getting out of the bath. He even says he has to pull his leg up to get into the car.”
“He can’t do much gardening now. He’s got quite a big garden,” Dylan added.
“His biggest worry is his wife. She’s got dementia and he’s the carer. He’s really worried he won’t be able to look after her for much longer.”
“It does sound like he needs a new hip,” said Dr Lewis.
“He’s worried about going into hospital. Who would look after Mrs Parry whilst he’s there?” Dilys looked as worried as Mr Parry must have been.
“We could probably arrange for her to go into a residential home whilst he is in hospital and when he is recovering from the surgery,” Dr Lewis said reassuringly. “We can ask social services to look into that.”
Dilys looked relieved.
“Does he need painkillers?”
“He says he prefers not to have any. He does take paracetamol now and again.”
“Would you like me to come and explain things to him?”
“No, we can do that, Dr Lewis,” Dilys said. “Do you want Dylan to write the referral letter and I’ll phone social services.”
“That sounds perfect,” said Dr Lewis, “after all, Dylan is very good with all the technical terms. I am sure he will impress the orthopaedic surgeons.”

I think I’ve got polycythaemia.

Thursday 6th August 1992   Morning surgery 11:40

“I think I’ve got polycythaemia, Dr Dennis.” Mrs Vaughan turned to us. “That means that my blood is too thick, students. I’ve got all the symptoms. I’ve got headaches and night sweats. I’m itchy. The itching is terrible after my bath. Vernon has to give me a cold shower immediately. My hands and feet are burning and they’re quite red. I’ve got awful tinnitus and I keep having nosebleeds.”
“Last week, you were convinced that you were anaemic, Mrs Vaughan.” My Dad drummed his fingers on the desk.
“Yes, I was tired, dizzy and slightly breathless. I wondered if the anaemia was related to my indigestion which has been much worse than usual.”
“If I’m not mistaken, Mrs Vaughan, polycythaemia is the exact opposite of anaemia.”
“Mmm . . . I am quite aware of that, doctor. Anyway, do you want me to book in for a blood test?”
“No, I don’t. You had a blood test 6 weeks ago and it was perfectly normal.”

Mrs Vaughan sighed. She got up and went to leave the room. She stopped as she reached for the door handle.
“Dr Dennis.  . . I would be extremely concerned if an elderly patient of mine was anaemic one week and polycythaemic the next . . .”
“Well, I wouldn’t, Mrs Vaughan and, to be honest, I don’t think I am ever likely to see such a case.”
Mrs Vaughan glanced appealingly at us. We all shook our heads.

A quadruple appointment.

Thursday 30th July 1992   Morning surgery 10:00

Mrs Ellis came in followed by four children. She glanced at my Dad.
“Don’t worry, doctor. I’ve got a quadruple appointment.”
My Dad nodded but looked worried.
“I wondered if you could see one extra patient, though,” Mrs Ellis continued. “It won’t take more than a minute. It is something very simple.”
“I’ve actually got two things wrong with me, Mum.” 5 year old Samantha spoke very clearly. “I’ve got a terrible headache and I’ve stubbed my toe.”
“I didn’t know you had a headache, Samantha. I just wanted Dr Dennis to look at your toe.”
“I’ve had a terrible headache all morning.” She turned to my Dad. “My toes is only stubbed, Dr Dennis. I did it on Monday. I kicked the door. You can look if you want.” Samantha started taking her shoe off.
“Cameron has still got his cough, doctor.” Mrs Ellis sighed. “He has had it for 7 weeks, now. He gets quite wheezy.”
“I don’t get wheezy, Mum.”
“Yes, you do, Cameron. You get quite out of breath when you run.”
“That’s because he is too fat, doctor,” Samantha said cheerfully.
“Yes, he’s much too fat,” added Sadie. “We’ve told him to lose weight.”
“I don’t think it is just his weight, girls. I am worried about asthma, doctor.”
“I’m not asthmatic, Mum.”
“You had eczema as a baby, Cameron. Eczema and asthma go together.”
“It was me that had eczema, Mum, not Cameron.” Carwyn scratched his arm to prove his point.
“Well, eczema and asthma run in families, Carwyn.” Mrs Ellis looked inquiringly at my Dad.
He nodded obediently.
“Carwyn is still constipated,” Mrs Ellis added. “He won’t take his laxatives which doesn’t help.”
“He gets awful wind,” said Samantha. “It stinks.”
“Sometimes he makes a mess in his pants.” Sadie and Samantha grinned and wrinkled their noses up.
“No, I don’t!”
“Yes you do, Carwyn.”
“I’m afraid he does, doctor, occasionally.”
“You see! We told you, Dr Dennis.”
“Maybe Cameron has hay fever, doctor. He sneezes a lot.”
“That’s just dust, Mum. It’s probably why I’ve got the cough. I’ve never had eczema, I haven’t got hay fever and I don’t want asthma.”
“It’s not about what you want, Cameron. No one wants to be ill. Samantha did not want to hurt her toe.”
“No, I didn’t want to, obviously.” Samantha interrupted. She had finished taking her shoe and sock off. “Here, Dr Dennis. Look, it’s stubbed.”
My Dad nodded in agreement. Samantha’s toe was bruised and swollen.
“Do you want to look at my head? The headache is still there.”
“Dr Dennis hasn’t got time to look at your head today, Samantha.”
“Do you want to look at my tummy, doctor?” Sadie asked. “It hurts and, every time I go for a wee, it stings.”
“She is going an awful lot, doctor.”
“I need to go again now, Mum.”
“No, you don’t, Sadie. You can wait.”
“I can’t wait, Mum. I’ll wet myself.”
“No, you won’t, Sadie. You’ll be fine. I’m getting a lot of backache, doctor,” Mrs Ellis continued. “I get it every night. Maybe, it’s the mattress. We have had it since we were married.”
“My headache’s right here, Mum.” Samantha rubbed her forehead.
“We’ve heard about your headaches, Samantha. Dr Dennis wants to hear about my back, now. I have never really had back problems before. Paracetamol doesn’t help. John thought I should get something stronger. It’s affecting my sleep. The traffic on the main road is very loud as well. The lorries make the house vibrate. Samantha gets up early, usually about 6 o’clock, so I feel quite tired. I sometimes have a nap after lunch while these are all at school. I haven’t told John. He doesn’t notice if I haven’t done all the housework. John’s hearing is awful, doctor.”
“He can hear me, Mum.”
“You’ve got a very loud voice, Samantha. The machinery at work is noisy and I don’t think he wears his ear defenders. I think he needs a hearing test.”
“Dad doesn’t need a hearing test, Mum. Can I put my sock and shoe back on, Dr Dennis?”
My Dad nodded.
“Would stronger laxatives help?” Mrs Ellis turned towards Carwyn.
“I don’t need laxatives, Mum.”
“Yes, you do, Carwyn. You have really smelly poo. That’s because he is constipated, isn’t it, Dr Dennis?”
“He won’t eat any vegetables, doctor, and the only fruit he eats are apples.” Mrs Ellis frowned.
“I eat loads of fruit, doctor,” said Samantha. “Peaches are my favourite but we don’t have those a lot. I eat millions of carrots. That’s why I’m not constipated. I go to the toilet every day.”
“They all eat a lot of fruit, doctor, except Carwyn.”
“I don’t each much fruit, Mum.”
“Yes, you do, Cameron. You’re always eating all the bananas. That’s why there’s never any left for me and Sadie.”
“It’s not fair, Cameron. We really like bananas.”
“We all do, apart from Carwyn. Has Cameron got asthma, Mum?”
“I don’t know, Samantha. I think Dr Dennis will have to listen to his chest. He probably wants to check my back as well.”

Identical twins with hyperthyroidism.

Thursday 23rd July 1992   Morning surgery 11:10

“I know thyroid problems run in families but I’ve never heard of identical twins presenting on exactly the same day with severe hyperthyroidism, students. It must be extremely unusual.” My Dad chuckled. I could tell he didn’t believe us.

He didn’t bother to look at the girls himself but said he didn’t mind us doing blood tests if we felt that it was really necessary.

Quite a nasty knock on his head.

Thursday 23rd July 1992   Morning surgery 09:23

“Good Morning! It’s Declan Dennis here, the assistant bed manager.”
“Good Morning, Declan. How are you?”
“Hallo, Dr Lewis. I’m fine, thanks.”
“Are you busy?”
“It’s not too bad. We’ve got four patients on the way in. There are three being discharged this morning and another three or four this afternoon. Unless anything unexpected crops up, we will have more than enough beds for the rest of the week. I’ve got one of the bays in Ward 10 in reserve, just in case, but I think we will be alright.”
“You sound very well organised. Listen, Bernard Digby has had quite a nasty knock on his head. He fell off his steps in the garden and was briefly knocked out. He seems fine now and I don’t think there’s a fracture but he’s on Warfarin. I think he will need to be assessed.”
“OK . . . why is he on warfarin, Dr Lewis?”
“It was for a mitral valve replacement, Declan. He had rheumatic fever as a child.”
“I’ll just make a note of that. We can see him on Ward 8 . . . hang on a second . . . let me see . . . there we are . . . we’ve got a free scan slot at 11:45 am . . . good. Can he be on Ward 8 by 10:15, Dr Lewis? We’ll get him clerked in and then he can have his brain scan.”
“I am sure that won’t be a problem, Declan. Thanks very much.”
“Thanks, Dr Lewis.”

The palliative care check list.

Thursday 16th July 1992   Morning surgery 10:10

“Right . . .” my Dad hesitated, “how are you, Mrs Shaw?”
“I suppose I am not too bad, considering . . . It was quite a shock, you know. I certainly did not expect them to find a brain tumour.”
“Your symptoms were very suggestive of a straightforward stroke.”
“Yes, Dr Bradley suspected that the tumour had caused a small bleed. He said that that had led to the sudden paralysis. It’s much better, now. I have only got very slight weakness left.”
“They’ve put you on dexamethasone?”
“Dr Bradley said it will reduce the swelling around the tumour. It seems to be working. The headaches have gone.”
“Are they going to give you any other treatment?”
“I wouldn’t have surgery at my age, not brain surgery. They have offered me radiotherapy but I don’t think I will go ahead with it. My cousin, Cicely, was very vague after her radiotherapy. I wouldn’t want to be like that. They have said that they can’t get rid of the tumour completely, anyway. They think it is a recurrence of my bowel cancer. That was 7 years ago! I thought I was clear of it.”
“It is unusual for bowel cancer to come back after that length of time.”

“Well, I thought that I ought to come to see you, Dr Dennis, now that I have been discharged. I wanted to put you in the picture. I am feeling quite well at the moment. The girls are very upset of course. Nancy is coming down next week.”
“As it happens . . .” my Dad cleared his throat. “There was something that I wanted to ask you.”
Mrs Shaw smiled.
“The health authority has given us a new form to complete with all our terminally ill patients. It’s called the ‘palliative care check list’. Would you be happy for me to fill it in?”
“Of course, doctor.”
“The check list is intended to help you to think about the treatment you want as your condition deteriorates and whether there are any treatments that you don’t want.” My Dad paused as he read the form. He looked up at Mrs Shaw.
“It sounds like a good idea.” She smiled again.
“Right, we’ll start. Mmm . . . where would your preferred place of death be?”
“At home, doctor.”
“Yes, I think most patients would prefer to be at home.” My Dad ticked the form. “If we cannot manage to look after you at home, would you be prepared to go to a nursing home or the hospice?”
“The hospice, I think. They are very good. Cicely was happy there.”
“I presume that you would agree to have any treatment to make you more comfortable: painkillers, anti-sickness medication, oxygen . . .”
“Yes, I think so.”
“What about a drip? If you were unable to drink, would you want to go on a drip? We could even do that at home.”
“Not really. Wouldn’t that just prolong matters?”
“I suppose it would. I’ll put no for that, then.” My Dad cleared his throat.
“Do you want antibiotics if you get a chest infection or a water infection?”
“Yes, I don’t mind having antibiotics.”
“Alright . . . if you couldn’t eat, would you want to be fed artificially? That’s usually through a tube that goes into the stomach.”
“No thank you, doctor.”
“What about a ventilator, a breathing machine. Would you want to be put on a ventilator?”
“No thank you, doctor. I am quite sure about that.”
“Lastly,” Mrs Shaw, “what if your heart stopped beating or you stopped breathing? Would you want to be resuscitated?”
“Mmm . . . I suppose it depends . . . what do you think, Dr Dennis?”
“I can’t decide. It’s up to you.”
“Well, if you thought I would be alright and live for a few weeks, I would like to be resuscitated but if you thought that I would end up as a vegetable I wouldn’t.”
“I am sorry, Mrs Shaw, there’s no room for comments on the form. It has to be yes or no.”
“I’m not sure, doctor.”
“You’ll have to decide.”
“Can I think about it? Could I discuss it with Nancy?”
“Not really! I was hoping to send the form in tomorrow. They want them back as soon as possible.”
“I don’t know.”
“To be honest, I don’t think that there is a lot of point in resuscitation at this stage, taking everything into account.”
“Alright, doctor.”
“I’ll say no, then.”
My Dad signed the bottom of the form and put it into the wire tray on his desk. He got up to help Mrs Shaw out of the chair.

Waiting.

Thursday 9th July 1992   Home visit 14:20

“He is deeply unconscious, Mrs Hughes. I don’t think it will take very long.”
“It has all happened quickly. It will be a relief for him, doctor.”
“He seems comfortable. I don’t think he’s suffering.” My Dad sat down on the sofa.

“Do you want sugar in your tea, Dr Dennis?”
“No thank you, Mrs Hughes.”

“Of course, you never knew our son.”
“I didn’t realise that you had children.”
“Just Edward. He died before you started in the practice.” Mrs Hughes brought a leather wallet in from the kitchen. She took out an old black and white photograph and handed it to my Dad.
“Edward developed leukaemia when he was ten years old. There was no treatment in those days. He passed away two weeks after it was diagnosed.”
My Dad looked at the picture. He glanced up at Mrs Hughes.
“Jim was very close to him,” she continued. “He has been up to the cemetery every week. He hasn’t missed a single Sunday in 52 years. I suppose he’s been waiting, really.”

Downright cheerful.

Thursday 2nd July 1992   Morning coffee break 11:48

My Dad sat down and sipped his coffee.
“Some patients are downright cheerful, whatever life throws at them,” he said. “I have just seen Mrs Green. She’s got advanced breast cancer. It has spread into her lymph glands. She is not eating properly. She has lost weight. She’s tired and breathless. She knows that the cancer’s going to catch up with her before long. Dr Muller told her that she won’t live for more than three months.”
“We don’t see her very often,” said Dr Lewis.
“No, she just gets on with things. She is always smiling. She never complains. She said she was fine today. She looks quite well but the glands in her neck are very big and hard.”
“Are they painful?”
“Apparently not!”

My whole body feels as if it has been trampled on.

Thursday 2nd July 1992   Morning surgery 10:00

“How are you, Martin?”
“I feel awful, Dr Lewis. The pain is dreadful. My whole body feels as if it has been trampled on.”
“I thought it was your lower back?”
“Yes, that’s the worst but everything hurts.”
“So, the increased dose of morphine hasn’t helped.”
“If anything, the pain is more severe. I can hardly move. You will have to give me something stronger.”

It sounds like renal colic.

Thursday 25th June 1992   Morning surgery 09:19

“We’ve seen Griff Evan’s for you, Dr Lewis. He is in terrible pain. It sounds like renal colic.”
“It’s awful,” added Dilys. “The worst ever! It starts here,” she continued and grasped her right loin just below the ribs, her fingers reaching towards her spine. “It comes around the front and goes down towards the groin.” Dilys glanced at Dr Lewis and whispered. “Sometimes it shoots right to the tip of his penis.”
Dylan winced.
“He can’t keep still. He’s been pacing around the room.  He tried sitting down and then lying flat but he had to get up again. He said that he was rolling around on the floor at home. He’s even made me feel agitated.” Dilys shuddered.
“They do say that renal colic is one of the most severe pains there is.” Dr Lewis looked very concerned.
“He doesn’t drink enough water, Dr Lewis, even in this hot weather. That’s probably why it’s happened.”
“Proper hydration is extremely important, Dilys.”
“He has felt nauseous with the pain,” said Dylan. “He’s not been sick, so far.”
“How long does the pain last?” Dr Lewis asked.
“Griff says that it builds up over about 2 hours and is really bad for 3 or 4 hours. When it subsides, there’s a slight ache that doesn’t go away completely.”
“Has he been hot or shivery?”
“No and it’s not been stinging when he passes water either and he hasn’t been going all that frequently.”
“Has he passed blood?”
“No but there were a few specks of blood when Harriet checked his urine: microscopically, I mean. He was really worried about that.”
“It is quite common to have traces of blood in the urine with kidney stones, Dilys. I think they say it occurs in about 80% of patients.”
“Yes, I told him it often happens but he was still worried.”
“Do you think we need to organise any tests?”
“I would send off a mid-stream urine test for infection and get some bloods.” “ We should do an x-ray. Is an intravenous pyelogram the best?”
“We normally get a plain x-ray of the tummy and then an intravenous pyelogram.” Dr Lewis said encouragingly. “Right, Dylan, are we going to give him some painkillers?”
“Don’t you normally use a pethidine injection, Dr Lewis? It’s very strong.”
“Good. He is going to need something very strong for this pain. What is the most important side effect of pethidine?”
“It might make him sick?”
“Yes . . . anything else? Can he drive home?”
“No, it will make him sleepy.”
“That’s correct. Is there someone with him?”
“Yes, his Dad brought him.”
“We will give him an injection then his Dad can take him home to bed. It takes about half an hour for the pethidine to work. He needs to drink as much water as he can for the next few days. Hopefully, he will pass a tiny kidney stone. They are often the size of a grain of sand. I often suggest patients pass their urine through a sieve.”
Dilys wrinkled her nose up. She had been planning to make some fairy cakes at the weekend.
“Kidney stones can be quite large though, can’t they, Dylan asked.
“Yes, they can. The biggest type of stone is called a staghorn calculus. These adopt the appearance of a staghorn because of the shape of the collecting ducts inside the kidney. However, most stones are round and can be up to half an inch or an inch in diameter. Bigger stones might need to be removed surgically.”
“Does he need to go into hospital?” Dilys asked.
“We’ll wait and see. If the pain is not improving in the next 12 hours,” Dr Lewis said, “or it’s getting worse, he might need to.”

Griff looked apprehensively at us as we explained the situation. He obviously didn’t like the idea of a large kidney stone. We did our best to give him reassuring smiles.

I think he is having a heart attack.

Thursday 11th June 1992 Morning surgery 08:40

“Good Morning, Declan!”
“Good morning, Dr Roberts!”
“Declan, I’ve got a 60 year old man who has had severe, central chest pain for the last hour. It is radiating up into his throat. He is slightly breathless and sweaty. He’s . . . to be honest, Declan, I think he is having a heart attack.”
“It sounds very much like it, Dr Roberts.”
“Do you want to know his clinical observations?”
“I don’t think that’s necessary. We need to get him into hospital as soon as possible. Have you called an ambulance?”
“It is on the way. They estimate an arrival time of 6 minutes.”
“Is he on oxygen?”
“Yes, I’ve set it at 4 litres/minute.”
“I think you can increase that to 8 or 10 litres/minute if he doesn’t suffer from chronic obstructive airways disease, Dr Roberts.”
“I am always very cautious about oxygen.”
“Have you tried an angina spray?”
“He’s had two puffs, Declan. It has given him a bad headache but it’s starting to help the chest pain.”
“What about aspirin?”
“Aspirin? No . . . mmm . . . I thought I would phone you first. I will give as aspirin as soon as we’ve finished and I will increase the oxygen.”
“Excellent,” Declan said, “right . . . it will be 6 minutes before the ambulance arrives, 5 minutes for them to scoop and stabilise and another 8 minutes before he is here. He should be in the Emergency Department by 11.37?”
“I would think so, Declan.”
“OK . . . I will have the thrombolysis team waiting for him in ‘resus’. I think I will mobilise the Air Ambulance. I would like them on standby in case we need to transfer to Liverpool. Anything else, Dr Roberts?”
“No, Declan, I think that’s everything.”
“Thanks then, Dr Roberts.”
“Thanks, Declan.”

We’ll just change the guidance.

Friday 5th June 1992 Morning coffee break 10:39

“Good morning, gentlemen.”
“Good morning, Nathan. How was the holiday?”
“It was fantastic! You really should try Trinidad, Nick.”
“Nesta and I prefer to stick to what we know, Nathan. We both love Mauritius. I don’t think we’ll ever tire of going there.”
“Nerys and I were thinking of going to the Carribean, next year,” said Neil. “It will be our first exotic holiday.”
“I would highly recommend it,” said Nathan.

“Look . . . Nigel has arrived. We can start.”
“Good morning, Nigel.”
“Good morning, gentlemen.”
Nathan Russell shuffled impatiently through his papers while he waited for Nigel to sit down.
“We’ve got a lot to get through this morning and I’ve arranged to meet Natasha for lunch. I had hoped we could start on time today.”
“Listen, I am sorry that I’m late and I apologise for bringing this up again,” Nigel cleared his throat as he spoke, “but, while we are all together . . . I would like to discuss Ebola.”
“Ebola?” Nathan frowned.
“Ebola’s not going to come here, Nigel.” Nick spoke tersely.
“You can’t be sure of that, Nick. Are you aware of how dangerous it is?”
“Of course I am, Nigel! It has a very high mortality.”
“The mortality is at least 50%, Nick and it may be as high as 90%. Depending on the strain. It is highly infectious.”
“It is not contagious in the sense that influenza is.”
“No, it is not, Nick. It is transmitted by contact with body fluids. However, a patient with vomiting and diarrhoea is very infectious and healthcare workers are at particular risk. My concern is that we have not got enough personal protective equipment.”
“That old chestnut! You are always worrying about personal protective equipment, Nigel.”
“If doctors and nurses are dying because they don’t have the proper protection, there will be a public outcry.”
“We discussed this in March, Nigel. We bought a large supply of personal protective equipment last year. It’s in storage in Surrey, not far from where you live!”
“We bought 1000 sets, Nathan. If there is a significant Ebola outbreak, they won’t last longer than a few weeks.”
“The whole kit and caboodle for Ebola is very expensive, Nigel. We can’t afford to waste money on equipment that we’re never going to use.”
“I know it is expensive, Nathan but, we’ve got to have it. We owe it to our staff.”
“We have two warehouses full of personal protective equipment that you insisted on acquiring for the supposed 1989 influenza pandemic. It has been there for 5 years. If we have to, we can use that.”
“You know that personal protective equipment for influenza is not adequate for Ebola, Nathan. It doesn’t satisfy the World Health Organisation recommendations.”
“They tend to be a bit over the top with their recommendations. We’ve got our own Ebola guidance. It’s not quite as stringent.”
“The equipment doesn’t even comply with our own guidance, Nathan.”
“If there is an Ebola outbreak, we’ll just change the guidance.”
“We will completely lose credibility if we do that, Nathan.”
“I don’t think so, Nigel. I will get Peter in the College to endorse the new guidance.”
“Phil Green, in the Institute, will give it his stamp of approval,” Nick added. “and I am sure Arthur in Health and Safety will be happy to oblige. I will speak to him personally.”
“Most other developed countries seem to be following World Health Organisation advice.” Nigel insisted.
Aren’t we now classed as a third World country with regard to health care?” Neil chuckled.
“I am sorry, Neil.” Nigel retorted quickly. “I’m not in the mood for facetious remarks. An Ebola outbreak would be a catastrophe. We . . .”
“Look, Nigel,” Nathan interrupted. “Personally, I am happy to use the equipment that we’ve got for influenza. It will be fine. That, as far as I am concerned, is the end of the matter.”

“Right, let’s get on with this morning’s business.” Nathan looked at his watch. “We haven’t got all day. The first item on the agenda is Dr Desmond Dennis.”
“I thought we had sorted Dr Dennis out in our March meeting.”
“We did fine him quite heavily, Nick, but he is still using the same flimsy aprons for minor surgery.”
“Shouldn’t this be a health authority problem?” Neil sighed impatiently.
“They have asked us to intervene, Neil. They see it as a potential public health problem. If you remember, gentleman, we had a look at one of Dr Dennis’ aprons last time. The plastic is extremely thin. I don’t think they are any more substantial than cling film. Dr Dennis bought a large consignment of these from China. He insists that they are suitable.”
“He did point out that, in over 30 years of minor surgery, he has just had two wound infections,” said Nigel.
“We have only got his word for that.”
“He submitted some convincing figures last time we met.”
“They were his own figures though, Nigel.”
“Look,” Nathan stepped in again. “I have tried as hard as I can to be sympathetic towards Dr Dennis but I have to admit I agree with the Health Authority. I do think we need to intervene. If this is left, it could become a serious public health issue.  Dr Dennis has clearly ignored our previous concerns. My recommendation is that the next step should be suspension from the medical register. I suggest that we refer him to the General Medical Council for consideration of this.”
“I am not sure we need to go as far as that. It seems quite extreme.”
“I am sorry, Nigel. I am going to have to overrule you there as the Chairman of the Committee. Is everybody else in agreement?”
Nick and Neil nodded.
“Right . . . do you want to bring Dr Dennis in, Nick. We can explain our decision to him.”

Have you got another patient for us today?

Wednesday 20th May 1992 At home 11.00

“Good morning! It’s Declan Dennis, the Assistant Bed Manager.”
“Good morning, Declan. How are you today?”
“I am fine thanks, Dr Roberts. How are you?”
“I’m not bad, Declan. Another busy day! How is Bronwen Foulkes?”
“She is picking up nicely. She was very anaemic as you suspected. We think she has got a peptic ulcer. She is having a blood transfusion today and I have booked her gastroscopy for Thursday.  She can come home on Friday if everything’s stable. We have done a provisional discharge letter but, obviously, it will need updating on Friday. We will give her a copy and pop it in the post.”
“You are very efficient, Declan.”
“I am doing my best. Have you got another patient for us, today?”
“Yes, I have, Declan. It is a Mr Jordan Brown.

Carbon monoxide poisoning.

Thursday 14th May 1992 Morning surgery 11.37

“Carbon monoxide poisoning? I think you may be right, Mrs Vaughan.”
“You think that I might be right?” Mrs Vaughan look surprised.
“Yes, you have got a lot of the symptoms. Throbbing headaches, nausea, loss of appetite, drowsiness . . .”
“I have, haven’t I?”
“Yes, my only concern is that your husband has not been affected. That is the only fly in the ointment.”
“Vernon is a very resilient man, doctor.”
My Dad looked Mrs Vaughan up and down thoughtfully. “I am well aware of that, Mrs Vaughan.”
“If it is carbon monoxide poisoning, do I need to go into hospital? Are you going to call an ambulance?”
“I don’t think there’s any need for that.”
“Are you sure, doctor? Carbon monoxide poisoning can be very dangerous.”
“You need to get that old boiler of yours checked, Mrs Vaughan. I have told you about it before. I want you to go home and open all the windows and doors. After you have done that, phone Mr Thomas, the heating engineer. He needs to come this morning. While you are waiting for Mr Thomas, I suggest that you and Vernon to go to Mrs Williams’ for a cup of tea. Once the boiler is fixed, you can go home. The symptoms should settle very quickly.”

The assistant bed manager.

Thursday 7th May 1992 Morning surgery 10.30

“Good morning! It’s Dr Declan Dennis in admissions.”
“Declan? Have I got the wrong number?”
“No, Dad. I told you! I’ve got a job. I’m on work experience. I’m the Assistant Bed Manager.”
“Don’t be ridiculous, Declan!”
“I am, Dad . . . have you got a patient for us?”
“Mmm . . . well, yes . . . I wanted to send in John Whitworth.”
“What is his date of birth and his address?”
My Dad read these out to Declan
“And what is wrong with Mr Whitworth, Dad?”
“He’s got a flare up of his chronic bronchitis and emphysema, Declan. That means he has usually got a very bad chest and . . .”
“I know that, Dad and I think they call it chronic obstructive airways disease now. I have had training. Are you sending Mr Williams in by ambulance?”
“I think I am going to have to, Declan. He does not look very well at all.”
“Can you ask them to bring him straight up to Ward 7?”
“You don’t want him to go through the Emergency Department?”
“No. We’ve got a bed here for him. If he goes to the Emergency Department, he will be hanging around for ages.”
“Are you sure, Declan?”
“Yes, Dad. I’m sure.”
“Thank you very much, Declan.”

“By the way, Dad, we are sending Bob Tanner home today.”
“Very good.”
“Yes, in the end he did not have pneumonia or septicaemia. In fact, we couldn’t really find anything wrong with him.”
“I am sorry about that, Declan. Perhaps I shouldn’t have sent him in.”
“Don’t worry about that, Dad. He is a very nice man. He helps serve the tea and biscuits every afternoon. We all thought he looked ill when we first saw him, anyway. He should be back first thing in the morning. Listen, Dad, I’ve got to go. I’ve got to ring Dr Roberts back.”

I think he’s died.

Friday 1st May 1992 At home 01.30

“Is that, Dr Dennis?”
“Yes, it is.” The phone had woken my Dad. He yawned then cleared his throat. He blinked.
“It’s Marjorie Bowen, Jack’s wife. I think he’s died, Dr Dennis. I think he has but I’m not sure.” Mrs Bowen sobbed. “I don’t know what to do. Are you able to come out?”
“I don’t think we need to come in the middle of the night, Mrs Bowen. Do you want to tell me exactly what has happened?”
“You said, when you came on Tuesday, that you didn’t think it would be more than two or three days. He has not really been conscious since then. He has not had anything to drink. Today, his breathing has been irregular. It has been quite quick at times and noisy. I haven’t left him all day. Catherine has been here.”
“What was he like this evening?”
“Just the same, really. There were a couple of times when I thought he was going to stop breathing. You could tell that he was getting weaker. He has been very peaceful. Even when we moved him, there was no reaction.”
“What’s happened now?.”
“It was just after midnight. He twitched, groaned then went completely still. I waited for him to take another breath for ages but he didn’t. I shook him gently but nothing happened.”
“Are you still with him, Mrs Bowen?”
“Yes, I’m right next to him. I have been here watching him for an hour.”
“Can you look at his hand for me? What’s it like?”
“It’s purple, doctor.”
“Can you feel it?”
“It’s cold, very cold.”
“Put your hand on his forehead for me.”
“That’s cold too, doctor.”
“If you put your face close to his, can you hear him breathing?”
“No, I can’t hear anything.”
“Have you got a small mirror, Mrs Bowen?”
“There’s one in the bathroom. Catherine, can you get me the mirror?” Mrs Bowen called to her daughter.
“Right, I’ve got it.” She spoke quietly.
“I want you to put it in front of his mouth: to see if there is any condensation.”
There was a pause. “No, there’s nothing, doctor.”
“Can you shake him again? Just gently, like you did before.”
“He’s not responding.”
“Alright, Mrs Bowen, he has passed away. I don’t think there is any doubt about that. Is he in a comfortable position?”
“His head is twisted lightly. I’ll just straighten it.” There was a clunk as Mrs Bowen put the phone down.

“There we are, doctor. I have pulled the sheet and the blanket up over him.”
“Good. You can phone, the undertaker in the morning. Are you going to use Brian Griffiths?”
“Yes, I think so. He buried Jack’s parents and his brother.”
I will pop in to see how you are, after surgery tomorrow evening. Why don’t you have a drink of warm milk now and try to get some sleep.”

There were no gloves available.

Wednesday 29th April 1992 At home 20.07

“Is that Dr Desmond Dennis?”
“Yes, it is.”
“Hallo! It’s Arthur Milne here from the Health and Safety Executive. I am sorry to ring you in the evening but we have been very busy this week.”
“That’s alright, Mr Milne. I have just finished my supper. What can I do for you?”
“Your cleaner, Ms Mandy Shaw, has submitted an incident report to us. She alleges that she burned her left little finger with bleach on Monday whilst working in the surgery. There were no gloves available.”
“They have been difficult to get hold of.”
“So you accept the allegation, Dr Dennis?”
“Yes, I cleaned and dressed the injury myself.”
“As far as the Health and Safety Executive is concerned, Dr Dennis, it makes no difference to us if you were trying to get hold of suitable gloves or not. An injury at work is an injury at work.”
“I see.”
“Besides, I don’t think there is a shortage of gloves at the moment. In fact, now that I think about it, my wife bought a pack of gloves from our local supermarket this weekend.”
“I prefer to buy cost-effectively in bulk, Mr Milne.”
“I am sure you do. Anyway, we are going to impose an on the spot fine of £300. You will receive notification of this in the post within 72 hours. I have also recommended that Mrs Shaw seeks a modest compensation payment. I trust you will not dispute this.”
“Mmm . . .” My Dad paused. “No, Mr Milne. No, of course not.”
“Excellent. That’s all I need to say, then. Thank you, Dr Dennis. Good evening!”

The proper equipment.

Wednesday 22nd April At home 21.36

“Good Evening,  Dr Dennis. It’s Paul Mathias here from the General Medical Council.”
“Good Evening, Mr Mathias. I’m surprised that you’re ringing at this time. “
“Well, we’ve had a complaint about you, Dr Dennis. Mr Lionel Bennett rang us this morning.”
“Oh, yes, Mr Bennett, I visited him last week.”
“Yes.  There were three distinct strands to his complaint but a common theme, I think. To start with, he alleges that you examined his throat with a teaspoon. Is that correct?”
“I did. We had run out of tongue depressors. Andrea had forgotten to order any this month. Mind you, it was one of his own teaspoons, not one that I found in my pocket.”
“He also claims that you guessed his pulse rate.”
“That is not true. I felt his pulse.  It was going at approximately 100 beats per minute. I couldn’t give a more precise figure: my watch has gone in for repairs.”
“Thirdly and finally, he says that you diagnosed a chest infection without listening to his chest.”
“That’s correct, I had left my stethoscope at home. However, he clearly had a chest infection. He had had a cough with thick, green sputum for a week. He had been feverish and shivering. Over the last few days he had started to feel out of breath. He had a fast pulse and a raised respiratory rate. I could hear him wheezing as soon as I went into his bedroom. I don’t think I needed a stethoscope.”
” Listen,  Dr Dennis, I am sure that your diagnosis of left basal bronchopneumonia was correct. However, you must agree that not having the proper equipment is extremely damaging to the reputation of the profession. What are your patients going to think if you turn up with half a medical kit or a broken spyghnomanometer? We had a surgeon referred to us last week who had made his own face mask from a paper doily. Can you believe it? He was struck off immediately.”
My dad did not say anything.
“Of course, we will be referring one of our performance panels, Dr Dennis. That is routine in a situation like this. I would also like to add, from a personal point of view, that I think you are a disgrace.”

Four broken ribs.

Thursday 16th April 1992   Practice complaints meeting 13:30

Dr Lewis has had what my Dad calls a vexatious complaint. John Jones had collapsed in the waiting room. Harriet and Dr Lewis had successfully resuscitated him. Because of their enthusiasm, he had suffered four broken ribs. Mr Jones claims that he had only fainted and not had a cardiac arrest. He insists that he did not need to be resuscitated and certainly did not need four broken ribs. He says that Dr Lewis did not check his pulse.

Dr Lewis admitted that she had not checked the patient’s pulse. However, she had no doubt that he had had a cardiac arrest. Harriet, the practice nurse, concurred with Dr Lewis.  She was first to arrive on the scene and was also adamant that the patient had arrested.
“He stopped breathing and his head flopped to one side,” Harriet said. “He quickly began to turn blue and cold. His eyes were staring blankly up at the ceiling. I could see his pupils dilating in front of me.”

“Now, look ladies,” said my Dad, “let’s think about it from the patient’s point of view.” He always likes to smooth these situations over. “I am not saying that it happened on this particular occasion but it is possible that a health professional might try to resuscitate a patient who had not had a cardiac arrest. It could happen in the heat of the moment.”
Dr Lewis looked at the floor. Harriet went bright red.
“I always consider it useful in dilemmas like this to consider the worst case scenario,” he continued. “Harriet, what is the worst thing that could have happened here?”
“Well . . . I suppose he could’ve had six broken ribs.”
“No . . . I didn’t mean that.”
“Are you thinking of a punctured lung, then?” Harriet looked annoyed.
“No, as far as I can see, the worst case scenario would be if the patient had had a cardiac arrest but you and Dr Lewis thought he had fainted and, as a consequence, you did not attempt to resuscitate him and he died.”
“Don’t be stupid, Desmond!” Harriet and Dr Lewis both exclaimed in angry unison. “We would never do that and it’s far worse.”

Mrs Andrea Jones brought our coffees over. “At least he wouldn’t have complained, then,” she said and sat down.

Extremely thorough.

Thursday 9th April 1992   Morning surgery 10:20

“I saw Dr Lewis last week, Dr Dennis. I couldn’t get an appointment with you.”
“Dr Lewis is very good.”
“Yes, I must say, she was extremely thorough and, when I say extremely thorough, I mean extremely thorough.” Mrs Vaughan stared at my Dad.
“Have you not seen Dr Lewis before, Mrs Vaughan?”
“No, I haven’t, Dr Dennis. I have always come to see you.”
My Dad raised his eyebrows. “Do you remember when I first started in the practice, Mrs Vaughan?”
“Of course. I remember my first appointment with you. It was that awful tinnitus.”
“Yes, that was the start of a long series of appointments: weekly appointments for the most part. I will admit that, occasionally, we have managed to stretch your attendances out to fortnightly.”
“I have only ever come when I’ve needed to, Dr Dennis.”
“If you cast your mind back to that first year, Mrs Vaughan, I think you will remember that I was extremely thorough.”
“You often insisted I stripped right down to my underwear.”
“Exactly! I was, after all, fresh out of training. Since then, we’ve got to know each other. I think that my experience has helped me understand how the stresses and strains of life upset you: how they exert physical effects on you. Intuitively, I know when I need to be thorough and I know when I can afford to take short cuts. I hope you are not mistaking this expertise for negligence.”
Mrs Vaughan frowned.

“What I really came to tell you, Dr Dennis, is that I have decided to consult Dr Lewis for the foreseeable future. I hope that you won’t take that personally.”
“Of course not, Mrs Vaughan, and if there is anything you want further advice on or if you want a second opinion, don’t hesitate to come back to see me.”

Dentistry for doctors.

Friday 3rd April 1992   Morning coffee break 12:17

My Dad was in the process of making himself a coffee. Mrs Andrea Jones, our practice manager, came in clutching a large, glossy brochure.

“Look at this, Desmond! It arrived this morning and I have just finished reading it. It’s another, new government scheme: ‘Dentistry for Doctors’.”
“DENTISTRY FOR DOCTORS! DENTISTRY FOR DOCTORS!” My Dad picked up his mug and threw it against the wall as hard as he could. It shattered. Small bits of china and instant coffee granules flew everywhere. He stormed out of the staff room, slamming the door behind him.

Hidden sensitivities.

Thursday 26th March 1992   Portmere Hospital 16:57

“Good afternoon, Dr Delany.”
“Good afternoon, Dr Dennis. It’s nice to see you. Why are you wearing your school uniform? It’s far too small!”
“It’s not mine. It’s Dennis’. I got up late this morning and I was trying to get dressed in a hurry in the dark. I think Daphne must have laid our clothes out on the wrong chairs last night.”
“Have you been in work like that all day?”
“Yes . . . by the time I realised, morning surgery had already started. I have had no time to go home and get changed.”
“Has Dennis been to school in your clothes?”
“No, he refused to go.”

“Anyway, I’ve come about these results.”
“You’ve come in about the results?” Dr Delaney looked surprised. “Couldn’t you have ‘phoned?”
“I did ring. I rang at half past eight but you hadn’t arrived at work. At ten o’clock, you were busy in the lab. I just missed you at quarter to twelve and then, at one o’clock, you were on your lunch break. At half past two you were in the weekly pathology meeting. At twenty to four, you had popped out to get some paracetamol. I thought the easiest thing would be to come up and try to catch you.”

“So, this is Mrs Dorothy Baxter,” my Dad continued holding up the laboratory report. “Her date of birth is 14th June 1936. I saw her on Monday. She had been unwell for 3 or 4 days with pyelonephritis.”
“Pyelonephritis, Dr Dennis? Don’t you mean cystitis?”
“No, pyelonephritis.”
“Perhaps you mean cystitis with a bit of muscular back pain?”
“No. Mrs Baxter had been quite poorly. She had a high temperature and shivering. She had been feeling sick and vomited twice. She had a severe pain coming from the right kidney and radiating into the right groin. She was having to go to the toilet very frequently and, when she did so, there was a severe, burning sensation. I must say, she looked quite unwell when I saw her.”
“Mmmm . . .” Dr Delaney still did not sound convinced.
“I prescribed Ciprofloxacin. It is one of the antibiotics you recommend for pyelonephritis.”
“Yes, we do, if it is pyelonephritis.”
“I wrote PYELONEPHRITIS on the form in capital letters.”
“Right.”
“The laboratory tests confirm that she does have a urinary tract infection. You have tested 3 antibiotics against the infection. The first antibiotic was trimethoprim. Unfortunately, Mrs Baxter is allergic to trimethoprim.”
“Allergic? Are you talking about a proper allergy or do you mean that she has had side effects when she has taken trimethoprim in the past?”
“No, she is allergic. I prescribed it last year and she came out with a severe, itchy rash. She also had swollen eyes and swollen lips.”
“That’s unusual with trimethoprim.”
“Yes, it’s unusual. It is the first case I have seen for about 10 years. The next antibiotic was nitrofurantoin.”
“A good, old fashioned choice.”
“Mrs Baxter has renal impairment so we can’t use it for her.”
“Renal impairment. . . that’s unfortunate.”
“The third antibiotic is amoxicillin. According to your sensitivity tests, amoxicillin will not work for this particular infection.”
“It’s resistant.”
“I am not sure why you have included it in the results though.”
“It is one of our three standard antibiotics. We always do,” Dr Delaney explained.
“Yes . . . but you haven’t put ciprofloxacin on the list. That’s the one I prescribed. I don’t know whether it will work or not.” My Dad looked slightly flustered.
“Is she feeling better?”
“She is a bit better but she is not fully recovered.”
“Has she improved as much as you would expect with an antibiotic that is working effectively?”
“Not quite.”
“As you know, Dr Dennis, ciprofloxacin is one of those antibiotics that we prefer you not to prescribe. Although it is extremely effective, it’s expensive and has got some rather unpleasant side effects. It also appears to be particularly good at encouraging bacteria to develop resistance.”
“It doesn’t look as if we’ve got much choice in this situation,” my Dad said.

“A group of us,” Dr Delaney explained, “all the consultant microbiologists in Wales in fact, got together and agreed that we would keep the sensitivities of some antibiotics hidden. Ciprofloxacin is one of those. We felt that these would help us discourage family doctors from prescribing these particular antibiotics.”
“In some ways,” my Dad said, “I agree with your sentiments but it can be a bit of a nuisance when you are treating a patient with pyelonephritis.”
“You only need to make a quick ‘phone call to the lab.”
“Listen,” my Dad said, looking at his watch, “I suppose that the thing I need to know is whether Ciprofloxacin is the correct antibiotic for Mrs Baxter.”

“Let me have a look, Dr Dennis.” Dr Delaney took the microbiology form from my Dad. He held it up to the light. “It is actually written on the form. It’s just that we use invisible ink for those special antibiotics.” Dr Delaney took a JIF lemon out of his pockets and squirted a fine spray of lemon juice onto the form. “Look . . . there we are . . . this particular infection is sensitive to ciprofloxacin. It should work a treat.”
“Thank you, Dr Delaney.” My Dad took the form back and off he went.

We think she’s dead.

Thursday 19th March 1992   Morning surgery 09:50

Mrs Charles’ daughter and son-in-law wheeled her into the consulting room. My dad looked surprised. She was almost completely covered by a white, cotton sheet. All we could see were two purple feet.
“Why is she covered up?” My Dad asked.
“We think she’s dead,” Marian Moffat whispered. “We didn’t want to upset anyone in the waiting room.”
“Dead?”
“Yes, we think so.”
“What’s happened?”
“She has not been so well since her birthday in January. She is 93 now! She’s been tired and sleeping a lot. She’s been off her food.”
“Mmm . . .” my Dad rubbed his chin.
“This weekend, she was very poorly. She stayed in bed. She didn’t eat a thing for 2 days: she said she felt sick. She . . .”
“She’s been drinking enough, though.” Maldwyn Moffat interrupted. “She still loves her cup of tea.”
“Yes,” Marion Moffat continued. “Maldwyn makes the tea exactly how she likes it. Then, yesterday, she seemed better. She got up. She wanted to come to the supermarket with me but I didn’t think it was a good idea.”
“She seemed fine again this morning.”
“She woke up early, came down and ate her breakfast. She had a look through the local paper. She dozed off.”
“She was sleeping peacefully,” said Maldwyn Moffat. “I made myself another cup of coffee and was going to read the paper when she stopped breathing. She groaned and then just stopped breathing. I called Marion immediately.”
“We were going to ring for an ambulance but I knew she didn’t want to go to hospital. I didn’t know what to do.” Marian Moffat’s was breathing quickly as she spoke. “Maldwyn just picked her up and we brought her straight here.”
“There’s nothing of her. She’s as light as a feather.”
“Well, we better have a look at her.” Dad carefully lifted the sheet. Mrs Charles’ head was slumped down onto her chest. Her face was blue. A trickle of saliva dribbled from the corner of her mouth.
“Mrs Charles!” My Dad called her name. There was no response. He shook her shoulder; nothing. He asked me to check her pulse. I couldn’t feel it. Her hands were stone cold.
“She is dead, I’m afraid.”
Marian Moffat sobbed. Maldwyn put his arm around her shoulders.
“Do you think I should have tried to resuscitate her?” asked Marian, wiping her eyes. “I’ve been on a course.”
“Would she have wanted that?”
“I don’t think so. She didn’t like anything technical. She wouldn’t even watch Casualty.”
“She died comfortably at home,” my Dad said. “I am sure that’s what she would have chosen.”
Marian and Maldwyn Moffat nodded in agreement. “What should we do, now?”
“I think that the best thing to do is take her back home and pop her into bed. I’ll ring the undertaker and explain everything. They can pick her up when you’re ready.”

Pins and needles and numbness.

Thursday 12th March 1992   Morning surgery 11:20

“I’ve got pins and needles and numbness, doctor.  They are affecting my thumb, my index finger, my middle finger and, funnily enough, just this side of my ring finger. I don’t understand why just half of my ring finger would be affected.”
“That does seem strange, Mrs Vaughan.” My Dad raised his eyebrows and looked at us.

“The symptoms seem much worse at night. I’d say it was painful then. In fact, my wrist really aches.”
“Have you noticed any weakness of your thumb?”
“I have.  If you look at the palm of my hand you can see that the muscles on this side, by my thumb, are a little bit wasted.”
“They’re called the thenar muscles.”
“Yes. My grip has definitely been affected. I can’t give Vernon a good pinch anymore.” Mrs Vaughan paused. “I have also noticed that, if I tap firmly here on my wrist, I get a horrible, prickly, shooting sensation affecting those same fingers. I don’t like it at all.”
“Are you trying to tell me that you’ve got carpal tunnel syndrome, Mrs Vaughan?”
“Of course, I’ve got carpal tunnel syndrome, Dr Dennis. I know that. But I have also been feeling tired and I’ve put on some weight. What I want to know is, is my carpal tunnel syndrome due to hypothyroidism?”

Declan comes of age.

Saturday 7th March 1992   After breakfast 10:45

Something horrible has happened to Declan. All of a sudden, he has grown taller and filled out in a manly way that doesn’t suit him. His voice is deeper. He has adopted an authoritative tone which none of us like. He has been called up to Portmere first team but I am quite sure he’ll only be sitting on the subs’ bench. Worst of all, he has taken an interest in girls and, surprisingly, one or two of them seem to like him.

Off you go, then.

Thursday 5th March 1992   Morning surgery 11:10

Roger Brightman had not stopped talking for 20 minutes. He had rushed from one symptom to another, was worried about two rare conditions that he could not possibly have had, wanted to know the treatment options for both and had several questions about the side effects.
By then, my Dad had heard enough. He got up and held the consulting room door open for him.
“Off you go then.”
Mr Brightman was still talking away as he went down the corridor.

A medical coincidence.

Thursday 27th February 1992   Morning surgery 10:20

“Why is everyone’s blood pressure 132/74 this morning, Dr Dennis?”
“Mmm . . .” my Dad said thoughtfully, his face turning red. He coughed and cleared his throat.
“I suppose that’s just the way it is, Dilys. It’s what we call a medical coincidence.”

I’m sorry to bother you.

Thursday 20th February 1992   Morning surgery 10:20

“I’m sorry to bother you, doctor.”
“That’s alright, Mr Jackson.”
“I know that you are a busy man.”
“Yes, I am.”
“Well, as I said to you on the ‘phone, I’ve got this rash under my arm. I will take my shirt off and you can have a look.”
My Dad stood to get a closer look. He peered into Mr Jackson’s armpit. “There’s not much to see.”
“It’s quite itchy.”
“It can’t be all that itchy.”
“It is, honestly.”
“Have you tried anything for it, any cream?”
“No, I haven’t, Dr Desmond. I wanted to see what you thought, first.”

My Dad straightened up. He put his hands on his hips and looked at Mr Jackson. “Four years ago, Mr Jackson, you had bowel cancer.”
“I did, doctor.”
“I’ll admit that we were a little bit late in picking it up in the practice but the treatment seems to have been successful.”
“It does, doctor. I’m very lucky.”
“Ever since then, Mr Jackson, we’ve given you the benefit of the doubt. We have let you pop in at the drop of a hat.”
“You’ve been very good to me, Dr Desmond.”
“We have seen you at a moment’s notice, no questions asked.”
“You have doctor.”
“You had the slightest sore throat back in January. I saw you immediately.”
“You did, doctor.”
“You had a tickly cough in March. Dr Lewis stepped promptly in, then.”
“She did.”
“In May, you felt sick for 2 or 3 days. We saw you twice.”
“I’m very grateful.”
“Today, you have an itchy rash that is barely visible. You haven’t tried anything for it.”
“I know, doctor.” Mr Jackson looked down at his feet.
“I don’t really like saying this, Mr Jackson, but you are pushing your luck. I want you to go to the chemist and by some cream. A combination should do the trick. Ask for an antifungal preparation with hydrocortisone. I think you will find that it will work very well. In fact, if you get any other skin complaint, I want you to try if first first before you think of coming to see me.”

You’ve had another complaint, Desmond.

Thursday 13th February 1992   Morning coffee break 12:10

“You’ve had another complaint, Desmond.”
“What is it this time, Andrea? We seem to be getting more and more complaints.”
“Don’t worry! It’s just a minor complaint. A written apology should do the trick.”
“What’s a minor complaint, Dr Dennis?” Dilys looked very worried.
“I suppose a minor complaint is where the patient is annoyed but the doctor hasn’t really done anything wrong. Can you think of an example Andrea?”
“Dr Dennis was rude.”
“Yes . . . that usually means that I gave a very clear and unambiguous explanation of the facts.”
“Dr Dennis didn’t listen.” Andrea suggested helpfully.
“Here students, the patient is unhappy that I only addressed 3 out of 5 problems in 15 of the allotted 10 minutes.”
Dylan and Dilys looked confused by this.
“Dr Dennis was running 30 minutes late and did not apologise.”
“Fair enough! I was probably drinking tea and catching up with the news between patients. I should have apologised.”
“Dr Dennis wouldn’t give me an antibiotic.”
“That’s a common one.” My Dad said.
“It’s not as if you would try to make the patient worse by not treating them!” Dilys sounded exasperated.
“Not, usually. It depends, to a certain extent, on the particular patient. If you ask me,” my Dad continued, “for most of these minor complaints, it should be the doctor complaining about the patient.”
“Can doctors complain about patients, Dr Dennis?”
“No, I am afraid not, Dilys.” My Dad laughed.

“What about serious complaints, Dr Dennis?” Dylan enquired.
“Serious complaints are another kettle of fish, completely, Dylan.” My Dad looked at Andrea.
She took a deep breath. “A serious complaint usually means that the doctor has made a mistake with the diagnosis. Sometimes, he has got it completely wrong. Obviously, just like anyone else, doctors are always making mistakes. If Dr Dennis makes a mistake, he doesn’t want to think about it. He would prefer to forget it. If someone complains, he has to go over the whole thing again, two or three times. He has to discuss it with his colleagues which is really embarrassing. He has to apologise to the patient if they have survived or the family if not. We all hate serious complaints.

Dylan and Dilys did not come back after lunch.

Vernon’s changed his mind.

Thursday 6th February 1992   Morning surgery 11:00

“Vernon has changed his mind, doctor. I have had another chat with him and he has decided that he does want to be resuscitated.”
“I think that that is very sensible, Mrs Vaughan. After all, he is fairly fit for his age.”
“There is one condition, though.”
“Right?”
“Yes, he is happy for you to carry out any cardiac massage but he insists that only Dr Lewis should give him the kiss of life. Vernon is quite particular about anything like that. He’s old fashioned.”
“I will make a note of it, Mrs Vaughan.”
“I have had a rethink too, doctor. Although I have had quite a lot of very serious health scares over the years, I think I am in reasonably good shape. I have decided I would also like to be resuscitated.”
My Dad paused thoughtfully and sighed. “Are you quite sure, Mrs Vaughan?”
Mrs Vaughan frowned. “Yes, I am. Ideally, I would like my own doctor, young Dennis here, to give me the kiss of life. However, if Dennis isn’t available, I would happy for it to be done by either you or Doctor Lewis.”

The top ten infections to catch this Winter.

Sunday 2nd February 1992   After breakfast 10:30

“The Sunday supplement has another of those ten top diseases features, Desmond.”
“What is it this time?”
“It’s the ten top infections to catch this Winter.”
“Sounds interesting!”
“For babies they have picked gastroenteritis.”
“That seems reasonable.”
“For toddlers, the number one choice is conjunctivitis.”
“Of course! You feel fine but you won’t be allowed to go to nursery. You can stay at home with Mum. Perfect!”
“In second place, they’ve got impetigo.”
My Dad wrinkled his nose up and shook his head. “Impetigo isn’t as catching as it used to be, Daphne.”
“For primary school children, they have chosen tonsillitis.”
“What about head lice? We see more head lice than tonsillitis these days.”
“They don’t really say what they mean by the top ten. I don’t think it is necessarily the most common infections. Now, for teenagers, we’ve got verrucas and glandular fever.”
“Verrucae.”
“I think you can use either term, Desmond: verrucas or verrucae.”
“It should be verrucae. It’s Latin. Anyway, I agree with their choices. Verrucae are great because you can’t go swimming.”
“I like swimming. I would hate to have verrucas.”
“This is for normal people, Daphne. Glandular fever will get you off PE for months and may help with your exam results.”
“For 16 to 25 year olds, they suggest chlamydia and gonorrhoea.”
“Chlamydia and gonorrhoea! That is hardly suitable material for a Sunday morning!”
“Don’t be such a prude, Desmond!”
“Thank you but I’ve just had my breakfast, Daphne!”
“For middle aged gentlemen and ladies, they also suggest chlamydia and gonorrhoea.”
“If they’ve caught chlamydia or gonorrhoea, they’re not gentlemen and ladies, Daphne.”
“Apparently, chlamydia and gonorrhoea are becoming more and more popular in that age group, Desmond.”
“Not in Portmere.”
“They have picked something very traditional for the elderly, Desmond.”
“What?”
“Tuberculosis. Maybe that’s because you’ll be sent to a Swiss sanatorium. I would love to go to Switzerland for a few months.”
“They don’t do that, these days, Daphne. They just give you antibiotics.”
“Then they’ve chosen pneumonia. It’s the old man’s friend.”
“Yes, it’s a good one to finish off with, Daphne, a very good one if you’re lucky enough.”

Declan’s got a job!

Thursday 30th January 1992   After dinner 19:10

“I’ve got a job.”
Dad and I raised our eyebrows.
“I didn’t think that Alf was looking for a new paper boy,” Dad said.
“He’s not. It’s in the hospital.”
“In the hospital!” Dad coughed and spluttered as his tea went down the wrong way. I gritted my teeth.
“Yes, I am going to be the assistant bed manager. It is work experience but I’m getting paid.” Declan smiled smugly at me as he said this.
Dad looked horrified. “How can you be the assistant bed manager?”
“My training starts next week.”

Can doctors treat their own sunburn?

Friday 24th January 1992   After dinner 20:15

“So a doctor can’t treat his own sunburn?”
“Come on, Declan. I think you are taking this too far. According to the General Medical Council, doctors are allowed to treat their own minor injuries or minor illnesses. However, they do suggest getting a professional opinion as soon as possible. In the case of sunburn, they advise you to see a qualified nurse within 36 hours.”
“Dad could see Mum, then?”
“No! Neither nurses nor doctors are allowed to treat family members. I have told you that before.”
“So, according to the General Medical Council, if you or me are ill, Dad can’t treat us and Mum can’t even look after us.”
“It is difficult to explain, Declan. Mum and Dad have to draw very clear boundaries between their professional and family lives.”
Declan look puzzled.
“I suppose if you’ve something wrong with you that’s going to get better on it’s own, it’s alright. Dad could look after you then.”
“So, if I don’t need treatment, Dad can treat me but if I do, he can’t?”
“That’s not really what I meant, Declan.”
“I always thought that those doctors who single-handedly removed their own appendixes in dire circumstances were considered heroes.”
“That’s different, Declan. That’s because it’s dire circumstances.”
“It said on the News yesterday that the NHS is in dire straits so could Dad remove his own appendix?”

We looked at each other and shook our heads. We both knew it was a stupid question.

The bread and butter of general practice.

Thursday 16th January 1992   Thursday morning 11:50

Dr Lewis seems fascinated by sore throats. “After all, students,” she will say, “they are the bread and butter of general practice.” She will measure the patient’s pulse rate and temperature. She spends ages looking at the tonsils. Sometimes, she examines them twice. She will always check for enlarged lymph nodes. If there is a cough, she will listen to the patient’s chest.

Once she has finished her clinical assessment, Dr Lewis will carefully weigh up all the information she has gathered. She jots everything down and scratches her head. She uses two different scoring systems to work out whether she should prescribe antibiotics or not.

“I think you will need some antibiotics for these tonsils,” she told Ben Barnes this morning. William James seemed disappointed to hear that his sore throat would almost certainly get better by itself. Dr Lewis wasn’t sure about Lesley Hughes and they agreed that she should come back in two days if her throat wasn’t improving.

As far as my Dad is concerned, almost every sore throat will clear up without antibiotics (he is probably right) and he’ll just have a quick look.

Pandora’s box.

Thursday 9th January 1992   Wart clinic 11:00

“How is that small solar keratosis just above your left eyebrow, Mrs Vaughan?”
“That’s a very specific, opening question, Dr Dennis.”
“Well I asked you to come back specifically to review that particular lesion and see if it needs a further dose of treatment. I don’t want to get involved with all your skin tags and seborrhoeic warts again.”
“Don’t you want to know how I am generally?”
“No, I don’t, Mrs Vaughan. That would be like opening Pandora’s box. I can’t risk it. Our cryotherapy appointments are only 4 minutes. You know that as well as I do.”

George Gwilym’s dead!

Thursday 19th December 1991   Before morning surgery 08:47

“George Gwilym’s dead!” Dilys had tears in her eyes. Dylan looked shocked.
“He died last night,” she continued. “He woke up vomiting blood. It was everywhere by the time we arrived: all over the bed, along the hall and on the bathroom floor. It was awful. He couldn’t stop vomiting. The toilet was full of bright, red blood. It just kept coming. A metoclopramide and a prochlorperazine injection made no difference. Dr Dennis said that there was nothing else that we could do. Eventually, we carried George back to his bedroom. We couldn’t leave him crouched over the toilet. He died very quickly once he was back in bed. Dr Dennis thought he’d lost at least 4 pints of blood.”
“It sounds terrible,” said Dr Lewis. “Poor George! How was Gwen?”
“She was distraught,” said Dilys.”She couldn’t stop shaking. Dr Dennis sent her down to make a cup of tea while we tried our best to clear up. In the end, we waited until the undertaker arrived. She was a bit calmer by then.”

Dr Lewis gave us the rest of the morning off. She had to get on with surgery: she didn’t have much choice.

You are looking quite well.

Thursday 12th December 1991   Morning surgery 10:50

“I’m feeling quite well at the moment, Dr Lewis.” George Gwilym sat down. “I am definitely better than I was. I am eating reasonably. Of course, I have to be careful. I can’t eat whatever I fancy and I have to chew everything very thoroughly.”
Dr Lewis smiled.
“I’m not as tired.” George continued. “I think my blood must back to normal. My breathing seems easier. I can keep up with Gwen unless it’s an emergency and she’s in a rush.”
“You are looking quite well,” said Dr Lewis.
The three of us nodded.
“Your blood is almost back to normal. You are still slightly anaemic.”
“I thought it must be better. I’m looking forward to Christmas. We’ve decided to invite the family round for Boxing Day. We always used to. I am not sure why we stopped, really. Gwen thought it would be good to have a get-together. There might not be many more.”
Dr Lewis leant forward  and squeezed George’s hand awkwardly. ” That sounds like a good idea and  I could see you again in the New Year?”
“Yes, I’ll make an appointment on the way out.”

How to catch threadworms.

Thursday 5th December 1991   Thursday morning 12:10

Thread worms

 

 

 

 

 

 

 

 

 

Threadworms live inside your bottom. At night, when you are nice and warm in bed, they come out and lay their eggs on your skin. The eggs are very itchy. If you scratch, the eggs get stuck underneath your fingernails. When you have breakfast, unless you have washed your hands extremely carefully, you will swallow a few of the eggs. These will hatch into baby threadworms inside your intestines. Threadworms don’t usually cause tummy ache but they can cause a wriggly feeling. Lots of people have threadworms and don’t even know it. They often assume that their bottoms are itchy because they haven’t washed properly. If you want to see if you’ve got threadworms, you need to try to catch some.

Just before you go to bed, get a piece of double-sided sticky tape and stick it as close to your bottom as possible. Get into bed as normal. When you are asleep, the threadworms will crawl out of your bottom and get stuck onto the tape. You will find them there in the morning. Remove the sticky tape and peel the threadworms off. Put them into a jar. Take them straight to your pharmacist.

By half time, we both wished we’d brought our homework.

Saturday 30th November 1991   Portmere vs. Newtown 14:10

In the past, we have always tried to go to the first few Portmere matches of each new season. We would arrive at these games with rekindled optimism and, sometimes, even buy programmes. This year, the team’s form was so bad that we hadn’t been to a single game until today. Dad had been ‘too busy’, Mum had had a series of afternoon teas (previously held on Fridays) and, to be completely honest, Declan and I couldn’t be bothered.

There is no doubt that we hadn’t played as badly for years. Dad said that Drew Milburn, our manager, who had been suffering from anxiety and severe panic attacks for the last 12 months was now clinically depressed. He sounded agitated when he spoke on the radio and, as the heavy defeats built up, there were hints of paranoia in his post-match interviews. Drew had had an awful start to the season. He had not managed to find substantial replacements for our two hefty and ruthless centre backs who had hung up their boots in the Summer. Then, in the middle of pre-season training, our entire midfield engine departed for Bethesda Athletic. They had been promised an extra £2.50 a week plus a £1 goal scoring bonus.

Our loyalty as supporters, which had been shaky for a while, evaporated. We probably wouldn’t have come to a game at all but there had been a relatively good result last week: our first goal in a 4:1 defeat against Caersws who were sixth in the league. There was also a rumour that we had signed an experienced attacking midfielder from Porthmadog but it seems as if this may have been a publicity stunt.
“What’s the point in having an attacking midfielder if you haven’t got a decent striker, anyway?” Declan had asked.

“God . . . it looks as if Reg Rowlands has put on another stone,” muttered Declan as the players came out. Reg was our right winger but looked more like a prop forward.
Newtown won the toss and decided to change ends. Our lads were horrified and, at first, looked as if they were going to refuse to move. By the time they had jogged over to the other side of the field and shuffled into position most of them were gasping for breath. Reg signalled to our manager that he was ready to come off but there were no substitutes so his request was ignored.

Declan and I settled back into our seats to enjoy the game.

By half time, we both wished we’d brought our homework.

Working in harmony.

Thursday 21st November 1991   Morning surgery 11:11

Dylan and Dilys looked sheepishly at each other as they came into the room.
“We’ve just seen Adam Andrews for you, Dr Lewis.” They both accidentally spoke in unison and laughed.
“You start, Dilys,” said Dylan.
“Adam is 12 years old.” Dilys cleared her throat. “He has had lower abdominal pain since Tuesday. It started off in the middle of his tummy and has now moved to the right hand side. It’s there all the time and he says it’s really severe. He has never had this pain before.” Dilys turned towards Dylan.
“He has hardly eaten and is not drinking much,” Dylan continued. “He feels nauseous and was sick twice last night and once this morning. He has had a bit of diarrhoea. His Mum said that she didn’t think he’d had a temperature.”
“He looked pale and his tongue was dry,” said Dilys. His pulse was 104 and his temperature was 37.8°c. He was tender in his right iliac fossa with some guarding. We both though that he had rebound tenderness.”
“Definitely,” said Dylan. “We checked twice.”
“We got Harriet to test his urine. It was clear. Do you want to sum up for Dr Lewis, Dylan?”
Dylan took a breath. “Adam is a 12 year old boy. He has had worsening abdominal pain for two days. On examination he has a raised pulse rate and a low grade temperature. He has signs of appendicitis. We think he needs to go into hospital.”
“Definitely,” said Dilys.
“Very good,” said Dr Lewis. “I am very glad to see you working in harmony at last.”
“Adam’s Mum has brought his pyjamas and his toilet bag. Do you want us to phone the hospital?”
“I think so, Dilys,” said Dr Lewis. “Once you have done that, you can both sit down and write the referral letter.”
Dilys looked pleased but Dylan groaned.

A thin set of notes.

Thursday 14th November 1991   Morning surgery 10:50

Valerie Vaughan stomped into Dad’s room. She sat down and looked angrily at him. She was obviously in a bad mood.

“I would like to see my medical notes, Dr Dennis.”
“Your medical notes?”
“Yes, my medical notes. I think I’ve got every right to see them.”
“Why do you want to see your notes, Mrs Vaughan?”
“I would like to see what’s in them.”
“Yes, but what has made you want to see that after all these years?”
“Well, last week I saw Dr Rothman, the locum.”
“I know.”
“You were away, fortunately. He said to me that he has never seen a woman of my age with such a thin set of notes.”
“I see.”
“He said that he was very surprised that I had never had a single, serious illness. My past medical history was completely empty.”
“I see.”
“He said he was shocked that, apart from a few blood tests in 1979, I had never been referred for investigations or sent to see a specialist. He seemed to think it was unheard of.”
“I see.”
“Over the years, Dr Dennis, I have come to see you fairly frequently with, what I would regard as, a number of serious health complaints. In all that time, you have not made one proper diagnosis! I have never had any treatment. It is a wonder I am still here!”
“Well, you are still here, Mrs Vaughan, and, to me, you are looking as fit as you ever have. As far as I am concerned, a thin set of notes is a credit to both of us.”

Chest pain 3 ways.

Thursday 7th November 1991   Morning coffee break 12:00

Dr Lewis gave each of us our coffee and sat down.
“Right, I would like to discuss 3 different types of chest pain whilst we are having coffee this morning. You can start, Dylan. How would you describe cardiac pain?”
“Well . . . it is usually in the middle of the chest or on the left side. The pain can radiate into the left arm or up into the throat or jaw. Sometimes, it goes through to the back. Most patients describe it as a severe, aching pain. It can feel like pressure or a heavy weight on the chest.”
“Good! Is there anything that brings it on or makes it worse?” Dr Lewis asked.
“Exercise: walking, especially uphill or in a cold wind.”
“Excellent, Dylan. Do you know of any associated features?”
“Breathlessness, sweating . . .”
“Dizziness as well,” said Dilys.
Dylan frowned. “I know that, Dilys. I was just going to tell Dr Lewis before you interrupted.”
Dr Lewis shook her head and looked at them both. “I have had enough of this bickering. I would like you to try to work as a team. Help each other!”

“Dilys, it’s your turn,” Dr Lewis continued. “Pain due to indigestion can be very similar to cardiac pain. I would like you to tell me some of the differences.”
“I suppose that indigestion occurs lower down, in the epigastric area.” Dilys glanced at Dylan and spoke quickly. “It can radiate through to the back as well. Food often affects the pain. It can make it worse or help sometimes . . .  some patients with ulcers get hunger pains . . .  I nearly forgot that.  Indigestion is not normally affected by exercise. It may be associated with nausea or burping.” Dilys paused briefly and took a breath. “If the patient has a hiatus hernia, they may get a lot of heartburn or acid reflux. I don’t think indigestion pain is usually as severe as heart pain.”
“Of course not!” said Dylan.
Dr Lewis raised her eyebrows. “Actually, it can be very difficult to distinguish between the two,” she said. “You have to make sure that patients don’t try to catch you out. I think Mr Jones, our first patient this morning, was playing his symptoms down. His pain sounded very typical of angina to me.”
“I thought that,” said Dilys.
“Jenny Derbyshire, on the other hand, was very dramatic.” Dr Lewis continued. “She insisted that she was having a heart attack even though the pain sounded exactly like her normal oesophageal spasm. She gets it every time her hiatus hernia flares up.”
“She didn’t look too pleased when you suggested Gaviscon,” said Dilys.
“It always seems to help.”

“Right, Dennis, do you want to tell us about pleuritic pain?” Dr Lewis turned towards me.
“Pleuritic pain is sharp. It’s like a knife. It hurts when the patient breathes in.”
“Yes . . . A lot of patients say that the pain catches their breath.”
“Ross Conwy said it was just like his broken rib.” I continued. “We saw him with Dad last week.”
“The pain can be very similar. Pleuritic pain is usually affected more by breathing than moving whereas the pain due to a broken rib can be affected as much by both.”
“It is usually on one side rather than in the front,” I added, “and patients may feel out of breath with it.”
“Good.” Dr Lewis smiled.
“A patient with pleuritic pain might have the symptoms and signs of a chest infection,” Dilys added.
“Yes,” said Dr Lewis. “A chest infection is one of the commonest causes of pleurisy.”
“It could be caused by a clot,” added Dylan.
“Quite right, Dylan. As we all know, it is very important not to miss a clot.”
“What about lung cancer?” asked Dilys.
“Yes, lung cancer can cause pleuritic pain,” said Dr Lewis. “That’s something else we don’t want to miss.”

“There you are. There are 3 common types of chest pain for you to think about; cardiac pain, pain due to indigestion and pleuritic pain. I would like you to look them up tonight to reinforce your knowledge. I may test you tomorrow.”

The same blocked nose.

Wednesday 30th October 1991   Morning surgery 10:40

“You’re back . . . with the same blocked nose?” My Dad looked up as Mr Palmer came in.
“Yes, doctor. I made sure that I booked a routine appointment when you weren’t on call.”
“Well, I’m still very busy. I’m running late.”
“Do you want me to book a different day?”
“No, no. We will have to sort this blocked nose of yours out. You say that you have had it for 10 years?”
“Yes, doctor.”
“And there wasn’t any injury?”
“No, doctor.”
“No one has ever punched you on the nose?”
“No, doctor.”
“Are you certain? Surely, someone must have, at some stage.”
“I don’t think so, doctor.”
My Dad did not look convinced but he carried on.
“Does your nose run a lot?”
“No, not much.”
“Do you get a lot of thick yellow or green catarrh?”
“No, doctor.”
“Do you get nosebleeds?”
“No . . .”Mr Palmer shook his head.
“Do you snore?”
“Yes, that’s the problem, really. I snore loudly.”
“I see.”
“It’s affecting my wife, doctor. My snoring keeps her awake. She is always tired. She is getting irritable. She’s had enough.”
“I see. Does this blocked nose bother you, personally?”
“No, it doesn’t, doctor.”
“So you are here because it is upsetting your wife.”
“Yes. She is at the end of her tether.”
“Well, Mr Palmer, perhaps it’s your wife I should be seeing.”
“I have booked her in with you tomorrow afternoon, doctor.”
“Tomorrow afternoon?”
“Yes.”
“Thursday?”
“Yes.”
“I am on call tomorrow afternoon. It is going to be really busy. I know that we are always busy but tomorrow afternoon will be busier. Dr Lewis is away again. Did the receptionist tell you that tomorrow afternoon was just for emergencies?”
“She did, doctor. I am very worried about my wife. I think that she is depressed.”
“She may be depressed, Mr Palmer, but I don’t think she is going to commit suicide because you’ve got a blocked nose. You could have waited until next week.”

One of the best things about general practice.

Thursday 24th October 1991   Morning coffee break 12:20

Dylan and Dilys have been telling us about their career plans. Dylan wants to be a cardiac surgeon but Dilys is thinking about general practice.

My Dad smiled encouragingly at her. “One of the best things about general practice,” he said, “is the fact that the majority of illnesses that we see improve on their own. It is comforting to know that, whatever we do, there is a good chance our patients will get better.  We can get the diagnosis completely wrong, we can order inappropriate investigations and we can make a real mess of the treatment but most of them still pull through. Only a small proportion of the patients we see really need our help.”

My nose is blocked.

Thursday 17th October 1991   Morning surgery 09:40

“My nose is blocked.”
“Your nose is blocked?” My Dad sounded annoyed.
“Yes, doctor.”
“Dr Lewis is away. I am on call. I’m very busy and you have come because of a blocked nose?”
“I am sorry, doctor. I didn’t know that you were on call and I thought you were always very busy.”
“Yes, we are. Did the receptionist tell you that I was only seeing emergencies this morning?”
“No, doctor.”
“Well, she should have. Right . . . how long have you had a blocked nose?”
“Mmm . . . about 10 years, doctor.”
“You have had a blocked nose for about 10 years and you have come to see me today, of all days?”
“Yes, doctor.” Mr Palmer looked guiltily at his feet.
My Dad took a deep breath and stared angrily at Mr Palmer. It was one of those looks that he gives me if I have done something awful.
“Look, doctor,” Mr Palmer continued, “I said I was sorry. I didn’t realise you were on call today and I had no idea it was emergencies only. I will book another appointment.”
“I think you better. I am in no mood for blocked noses, today.”

 

It’s not bowel spasm.

Thursday 10th October 1991   Morning surgery 11:00

“It’s not bowel spasm, Dr Dennis.”
“It sounds like it.”
“I’ve been having bowels spasm since I was 14 years old. This pain is not the same. It’s in a different place. It doesn’t feel like that pain.”
“Are you constipated?”
“I am and I’m not.”
“What do you mean?”
“I am always constipated but, at the moment, I am less constipated than I have ever been. The pain is not due to constipation.”
“Are you bloated?”
“Yes and I’ve got wind. Burping or passing wind doesn’t make any difference so it’s not that. It’s something new.”
My Dad took a deep breath and sighed.

A blanching rash.

Thursday 26th September 1991   Morning surgery 08:50

“Thanks for fitting us in at the last minute, Dr Dennis.” Mrs Farley looked very flustered. “I am so worried about this rash. It started yesterday but was much worse this morning.”
“That’s alright, Mrs Farley.” My Dad reassured her as she undressed Adam.
“As you can see, he’s fine in himself. He’s not had a temperature or a sore throat. I checked the rash with a glass, of course.”
“What happened? Did it disappear?”
“Yes, it did, doctor.” Mrs Farley took Adam’s vest off.
“Mrs Farley, I thought that if a rash blanched or disappeared with pressure, we could all be reassured.”
“Well . . .  yes, doctor, but as soon as you think about meningitis you’ve got to get them checked out; haven’t you?”

Fragmented care.

Thursday 19th September 1991   Morning surgery 10:10

“Well, at least Mr Lane has taken my joints seriously. He had a good look at my knee. He was extremely thorough. He is arranging a completely new set of x-rays from a variety of perspectives. He is referring me to the spinal specialist for my lower back and also to the shoulder specialist. He was quite surprised that you had not addressed my shoulder problem. He said that, if my thumb does not improve in the next few days you should refer me to the hand specialist. That’s why I have come, Dr Dennis.”

Just a bit of wax.

Thursday 12th September 1991   Morning surgery 09:20

“What’s that?”
“It’s my auriscope.” Mrs Lightfoot. “I am going to look into your ear.”
“No, that yellow thing.”
My Dad tilted the auriscope so he could look at the earpiece. “Oh! It’s just a bit of wax . . . probably from Mr Blackwell.”
I thought my Dad was going to wipe the earpiece on his sleeve but something stopped him at the last minute and he went over to the sink and gave it a thorough wash.
Mrs Lightfoot still flinched when he examined her.

On a knife edge.

Thursday 5th September 1991   Morning surgery 10:50

“We’ve just seen George Gwilym for you, Dr Lewis. He says he’s on a knife edge.” Dylan and Dilys had come to Dr Lewis’ door.
“He was bleeding from the tumour,” Dilys said. “It had eaten into a big blood vessel.”
“They think that because he was on warfarin, he lost about 6 pints of blood. He was lucky to have survived.”
“They stitched the vein and gave him a transfusion.”
“The doctors wanted to stop the warfarin but they were worried about him having more clots. They have given him heparin injections instead. They told him the injections were safer.” Dylan did not sound convinced.
“He wants to know if it is better to die of a haemorrhage or a blood clot.”
“I don’t think there is a lot to choose between the two,” said Dr Lewis. “If I was George, I think I would just keep my fingers crossed.”
“That’s what we thought.” Dylan said. Dilys looked flabbergasted.

How bad is that pain, Mr Riley?

Thursday 29th August 1991   Morning surgery 10:20

“How bad is that pain, Mr Riley?”
“I would give it a score of 2 out of 10.”
“2 out of 10?” My dad looked very surprised. “That’s hardly any pain at all.”
“These pain scores are all relative, Dr Dennis.”
“I know that but a pain with a score of 2 out of 10 cannot be anything more than mildly uncomfortable. As far as I can remember, the lowest pain score we have ever had in the surgery has been 5 out of 10. No one gets a pain less severe than that. Am I right, Dennis?”
“I think so, Dad. Veronica White did say her back pain had come down to 3 out of 10 after you put her on codeine.”
“Yes, but that was after treatment, Dennis.” My Dad sighed impatiently. “She was 6 out of 10, initially. Well, Mr Riley, to be honest, I am not sure why you have come to see us.”
“I thought you might like to check my tummy, doctor.”
“I don’t think we need to do anything like that. We will just keep an eye on things for the moment. However, if your pain goes up to 4 or 5 out of 10, I want you to come straight back to see me.”

Holiday reading.

Thursday 15th August 1991   Lunchtime Agia Galini 12:00

Like clockwork, at midday on the first Thursday of the holiday, Mum, Dad and I all finished our third Summer blockbusters. Declan was still on the second page of his first novel.
Mum frowned. “You’re not doing very well, Declan.”
“He’s spent most of his time looking over the top of his book.”
“No, I haven’t. Dennis. I thought you were supposed to be bringing Kumar and Clark anyway.”
“It was too heavy,” Mum said. “You know your Dad won’t pay for any excess baggage.”

Kostas had saved us our usual sun beds under the fig tree. On the opposite side of the pool were a new family. Mr and Mrs Barton and their three attractive daughters
“I hope you haven’t had your eye on one of those young ladies, Declan?”
“No Dad, it’s just a boring story.”

Kumar and Clark is a famous textbook much loved by medical students.

 

Camping in Scotland.

Friday 9th August 1991   After dinner 20:20

It wasn’t until my Dad found out that the Vaughans were going camping to the Shetlands at the same time as Mum and him, that he decided to go back to Agia Galini. After all, the decision had been a bit impulsive in the first place and who wants to spend two weeks in Unst in the rain. Declan and I had not managed to sort a holiday out with our mates and so Dad booked tickets for us as well.

Dad had to keep the new arrangements very quiet to avoid any repercussions during Mrs Vaughan’s fitness to travel medical. Apparently, her insurance company always insist on a full check up on the day before she travels. Because of this, he didn’t tell Mum we were going to Greece until tonight. She was furious because she had packed all the wrong clothes.

Odds or evens?

Thursday 8th August 1991   Morning surgery 10:00

“I just have one remaining problem, doctor. I thought we could discuss it today.” Mildred Mercer sat down and smiled.
“I thought that there were two left?”
“There were but one is better.”
“That’s good news.”
“I have done a new list doctor.”
“Very good. Now, what did we discuss last Thursday?”
“My itchy rash, doctor and . . . “
“No, I mean odds or evens, Mrs Mercer. Did we discuss odds or evens?”
“Mmm . . . evens, we started with evens.”
“Yes, we did. What about Monday?”
“That was odds, doctor.”
“Yes, that’s right, Mrs Mercer, and today?”
Mrs Mercer looked down at her list. “Well, today should be evens, doctor, but I have only got one problem. That’s awkward.”
“It’s very awkward, Mrs Mercer. Are you sure that there is nothing else wrong?”
“No, doctor, everything else is fine. It’s just this . . .”
My Dad stood up. “I am sorry, Mrs Mercer, I will have to stop you. I am going to have to ask you to make another appointment.”

Odds or evens?

Monday 5th August 1991   Morning surgery 10:10

“You are back, again, Mrs Mercer. Didn’t Dennis and I see you last Thursday?”
“Yes, I couldn’t remember what you said about problem number 4 and I wanted to discuss the remaining problems, if that’s alright, and I have one new problem.”
“A new problem?” My Dad sounded surprised.
“Yes, it started this morning.”
“So, you’ve got five problems?”
“Yes.”
“Have you written a new list?”
“No, I have brought last week’s list. I have added the new problem.”
“Fine, can you re-number the list for me, from 1 to 5?”
Mrs Mercer looked puzzled but did as she was asked.
“Excellent,” my Dad smiled reassuringly, “we will do odds today and start with problem number 1.”

Odd or evens?

Thursday 1st August 1991   Morning surgery 10:20

Mrs Mercer looked flustered. She sat down and started rummaging through her handbag.
“I am just trying to find my list, Doctor Dennis.”
“Your list?” My Dad raised his eyebrows.
“My list of problems, doctor. I don’t want to forget any.” She held up a scrap of paper. “There we are.”
“Most of my patients just have one problem at a time, Mrs Mercer, that’s much easier to remember.”
“It is not my fault that I’ve got so many problems, doctor.”
“No, I suppose not.” My Dad sighed. “What would you prefer, odds or evens?”
“Odds or evens?”
“Yes, Mrs Mercer, odds or evens?”
Mildred Mercer looked perturbed. “Well, I’ve got seven problems on my list.”
“Evens, then. That will be easier for me.  We will start with problem number 2?”

Athlete’s foot.

Thursday 25th July 1991   Morning surgery 11:30

Athletes foot new

 

 

 

 

 

 

 

 

 

 

 

“Come on, Phil. When did you last do any exercise?”

Phil’s feet were dripping. The skin was macerated and peeling off. His soles were a mouldy green colour with crimson and white splodges. His trainers, I suppose they were his only pair, were damp and squidgy. I know it’s harsh to say it but Phil stank.

“That looks more like Trench foot than Athlete’s foot, Mr Davies. It would have been amputated in 1915.”

We think he is bleeding from the tumour.

Thursday 18th July 1991   Morning surgery 08:53

“We’ve just seen George Gwilym for you Dr Lewis. He’s not well at all. He’s much weaker.” Dylan and Dilys had come to Dr Lewis’ door. They looked very concerned.
“He is really pale: he’s as white as a sheet.” Dilys said.
“He’s dizzy. He feels faint when he stands up. He was quite wobbly coming in from the waiting room.”
“He’s having awful pain. It’s there all the time, in the top of his tummy and going through to his back.” Dilys rubbed her own tummy and winced.
“He’s got black stools!”
“We think he’s bleeding from the tumour.”
“Obviously!” Dylan frowned reproachfully at Dilys. “He looks very anaemic and he’s got meleana. His pulse is racing and his blood pressure is low. He must be bleeding from somewhere. The tumour is the most likely cause.”
“He’s a warfarin patient which means he’s at high risk of a gastrointestinal bleed.” Dilys added helpfully.
“Dr Lewis knows that! Would you like us to call an ambulance, Dr Lewis? We could put a drip up.”
“Yes, you put the drip up, Dylan, and I’ll ring for the ambulance.”

Pain scales.

Thursday 11th July 1991   Morning surgery 10:20

“Dr Desmond, I’m in agony. I know you don’t like pain scales but the pain in my left ankle is just the same: it’s 6/10 still. The pain in my left buttock is worse: it’s now 9/10. The pain in my tummy is 12/10.”
“Hang on, Mrs Vaughan, I thought that a score of 0/10 meant that you had no pain at all and a score of 10/10 was the worst pain you could ever imagine.”
“Yes, that’s right, doctor.”
“Well, how can have you scored 12/10? It doesn’t make sense to me.” My Dad looked genuinely puzzled.
“The worst pain that I have ever had was that headache. I don’t know if you remember it. You thought that I had had a brain haemorrhage.” Mrs Vaughan paused.
“No, I don’t remember that. I don’t think I ever thought you had a brain haemorrhage.”
“Yes, you did. It was a few years ago. I had a terrible headache and you definitely thought that I had had a brain haemorrhage.”
“Are you sure? I don’t think I sent you into hospital.”
“No, you didn’t, doctor. Actually, I was very surprised that you didn’t. Vernon wanted to report you. Anyway, let’s not discuss that. It was the most severe pain I had ever had and, in fact, the most severe pain I could ever imagine having. I scored it 10/10.”
“That seems reasonable.” My Dad nodded.
Well, the pain that I’ve got now, in my tummy, is more severe than that headache. That’s why I have scored it 12/10. It makes perfect sense to me.”

Cath and Len.

Thursday 27th June 1991   Morning surgery 09:40

Len Logan came in and sat down. His wife, Cath, followed him, clutching a scrunched up hanky over her mouth. Her face was bright red.
“We have come about our coughs, doctor.” Len smiled. “I think we’ve probably both got the same virus.”
“Virus! My cough can’t be a virus. It is unbearable, doctor. It goes on and on and on. I can’t stop coughing. I’m really worried about it.”
“Don’t get carried away, Cath. You know, as well as I do, that those coughs that come in never ending spasms, that make your throat hurt and seem to leave you struggling to take a breath, are usually in your throat and not on your chest. They feel much worse than they really are. They almost invariably get better on their own. Dr Dennis has always said that.”
My Dad nodded.
Cath glared at Len.“My cough is much worse than yours.”
“Exactly. That’s what I am saying. These quiet, unobtrusive coughs like mine are the ones you need to worry about. A cough like mine could be the first sign of pneumonia or even lung cancer. Having said that, I have only had my cough for a week and I feel fine otherwise, so I don’t think I’ve got either. Putting two and two together, it seems likely we’ve both got different versions of the same thing. What do you think, doctor?”
“I think you are probably right, Len.”
“I wouldn’t have come. Cath wanted to see you about her cough and she made my appointment without telling me. I am afraid we have wasted your time.”

Intensive care.

Thursday 20th June 1991   Morning surgery 11:30

“I am sorry, Mrs Baxter. They haven’t even got room along one of the corridors for you.”
“I don’t mind, doctor.”
“Things seem to be getting worse in that hospital. Sister Salter has looked everywhere. All the wards are full and the emergency department is overflowing. They’ve even got patients in the stair wells. She has just found a lady down in the laundry that everyone had forgotten about.”
“I’ll be alright at home.”
My Dad knew from the grim expression on her face that Mrs Baxter was still in a lot of pain.
“You can’t go home . . . Hang on! There’s no reason why you can’t use one of our corridors. They’re just as good as those in the hospital, really. Well, slightly narrower perhaps but otherwise just as good. The one between Doctor Lewis’ room and reception is quite private. There’s enough room for the staff to squeeze past you, the receptionists will easily be able to keep an eye on you and, if you deteriorate, Dr Lewis is just around the corner. It will be ideal!”
“Are you sure it’s alright, doctor?”
“It’s perfect, Mrs Baxter, and if there’s no bed for you by 7 pm, I will take you home, myself. Daphne’s a trained nurse, as you know. One way or another, you’ll be getting intensive care tonight!”

Three second opinions.

Thursday 13th June 1991   Morning surgery 10:10

Mrs Vaughan did not look too pleased when she saw that Dylan and Dilys were sitting in with us again.
“Come on, Valerie,” my Dad encouraged her. “At least you will get three second opinions.”
“In theory, Dr Dennis, that sounds very good. However, both you and I know that there is only one opinion that you ever take any notice of. It’s not mine or Dennis’ and it certainly won’t be the opinion of either of your students.”

Delusional infestation.

Thursday 6th June 1991   Morning surgery 09:10

Delusional infestation Inbox x (1)

 

 

 

 

 

 

 

 

 

 

 

 

“Well, that’s another 47 we’ve got rid of today, Caitlin. Do you want to make an appointment to come back tomorrow?”

Delusional infestation is a condition where patients believe that their bodies have been invaded by tiny mites. These hungry parasites burrow in through sweat glands, hair follicles and even the roots of eyebrows and eyelashes. As they crawl under the skin, they cause intense irritation and patients may become inconsolably distressed. Occasionally, the symptoms are so realistic that even the patients’ doctors become convinced of the existence of these imaginary creatures.

Breathing in and breathing out.

Thursday 30th May 1991   Morning surgery 09:30

“I’m not having another spirometry test, Dr Dennis. It’s a waste of time!”
“I don’t know why you are saying that, Mrs Vaughan.”
“It’s breathing in that I’m interested in, Doctor. I’m not getting enough oxygen and you get oxygen by breathing in. That’s my problem. I don’t care about breathing out.”
“I don’t understand you Mrs Vaughan. You had spirometry in 1985. It was normal.”
“Of course it was normal! Harriet, the nurse, checked how well I could I breathe out. I can breathe out perfectly well.”
“I see what you mean. You are right. Spirometry primarily tells us how well you can breathe out but that gives us an overall idea of how your lungs are functioning. After all, you can’t breathe in without breathing out. Spirometry is particularly useful for people with a tendency to wheeziness.”
Mrs Vaughan took a deep breath, sighed, got up and walked towards the door.
“I am sorry, doctor. Spirometry was obviously not the correct test to demonstrate my difficulties in 1985 . I very much doubt if things will be any different now.”

The auscultatory gap.

Thursday 23rd May 1991   Morning surgery 11:20

“I am very worried about this gentleman’s blood pressure, Dr Dennis. It’s 160/100.”
“No, it’s not, Dylan. It’s 140/80.”
“I checked it in his right arm, Dilys and you checked it in the left arm. The British Hypertension Society recommend checking the blood pressure in both arms then taking the highest reading.”
“But you checked it as soon as Mr Pemberton came into the room, Dylan. You hardly gave him time to sit down. I had a little chat with him before I checked his blood pressure. He was quite relaxed by then.”
“Dr Dennis doesn’t have time to hang around having a little chat every time he checks someone’s blood pressure, Dilys.”
“And you pumped the cuff up really tightly. I could see it hurt him.”
“You have to do that because of the auscultatory gap.”
“No, you don’t, Dylan. If you want to check for an auscultatory gap, you are supposed to feel the radial pulse while you pump up the cuff.”
“I am not sure that I believe in the auscultatory gap,” my Dad said. “There are a lot of things about blood pressure that we don’t really understand.”
“Listen, Dr Dennis, can you check Mr Pemberton’s blood pressure so we can see what it really is?”
“There’s no point in me checking it, Dylan. It’s bound to be very high now he has heard both of you bickering.”

“Look, Mr Pemberton,” my Dad said, “I think it is reasonable to assume that your blood pressure is somewhere between the 2 figures; let’s say 150/90. In my book, that’s not too bad. I suggest we continue the same medication and check it again in 2 months.”

 

Cerys Bevan’s notes.

Thursday 16th May 1991   Morning surgery 09:39

“Good Morning, Dr Dennis. Thanks for fitting me in at short notice. It’s Malcolm Travis here.”
“Yes, of course, Mr Travis.”
“I’ve brought you these. They’re Cerys Bevan’s notes. You left them in our front room when you came to visit Mary yesterday.”
“Did I?”
“Yes, you were in a rush. Quite a lot of visits, you said. Mary is feeling much better by the way.”
“I’m glad to hear that.”
“Anyway, I thought I had better bring the records straight back to you. You wouldn’t want them falling into the wrong hands.”
“Of course not! Thank you very much Mr Travis. Thanks for bringing them in.” My Dad took the notes and looked up at Mr Travis, waiting for him to leave.

Mr Travis sat down. He cleared his throat.
“Mary and I had no idea that Cerys was so depressed. It’s hard to believe she lived just a few doors down the road from us. We must see her 3 or 4 times a week. Neither of us had an inkling of what was going on. We feel like bad neighbours. Mary said it wasn’t surprising that she suffered from severe depression after everything she had been through: 3 miscarriages and 2 abortions within a few years. I can tell you that was a shock, Dr Dennis. She had a violent husband. I think I would have started drinking too much as well. Reading all that, Mary said, made her realise how lucky she was. She admitted to taking me for granted. I don’t think I would have put it quite as strongly myself.”
Malcom Travis paused.
“Anyway, it looked as if Cerys was improving, as if she was getting herself back together. But, then she tried to commit suicide, just 4 weeks ago. I can tell you that floored us both. If it had not been for that inquisitive postman, she would be dead!”
Malcolm Travis took a deep breath before continuing.
“We have done some thinking, Mary and I. We feel we have been self-absorbed as a couple. There is no doubt that Cerys is lonely. Mary is going to visit twice a week. She is good at talking to people. I will go there on a Sunday. I can help out in the garden. Now we know why it’s been neglected. At least something good has come out of this.”
“Out of what?” My Dad asked. I don’t think he was concentrating properly.
“Out of you leaving the records on the sofa.”
My Dad didn’t say anything.
“By the way, Dr Dennis. It goes without saying that neither Mary nor I will mention this to Cerys. We both understand the importance of confidentiality. We know how serious something like this could be. Mum’s the word.”
Malcolm Travis got up, leaned forward and shook my Dad’s hand before leaving the room.

I’ll just get my list, doctor.

Thursday 9th May 1991   Morning surgery 10:00

“I’ll just get my list, doctor.”
“List?”
“Yes, as you know, I usually see Dr Lewis. She likes me to bring a list of my problems.”
“I am afraid that lists don’t work for me, Mrs Harris.”
“If I don’t bring a list, doctor, I won’t remember all my problems.”
“As far as I ‘m concerned, Mrs Harris, if a problem is serious enough to be discussed with your doctor, you will remember it.”
“That’s not what Dr Lewis thinks and I’m not entirely happy with your attitude, Dr Dennis.”
“I’m very sorry Mrs Harris. I am afraid that there are certain matters on which Dr Lewis and I completely disagree.”
“Perhaps I should make an appointment to see Dr Lewis then. She wasn’t available today.”
“I think that that would be the best option, Mrs Harris.”

Bell’s Palsy.

Thursday 2nd May 1991   Morning surgery 10:40

“This gentleman seems to have had a stroke, Dr Dennis.”
“I don’t think so, young man.” Valerie Vaughan ushered Vernon into Dad’s consulting room. “Hmm . . . is this another medical student?” she said looking at Dilys who was sitting next to me.
“Yes, this is Dilys. She’s in the fifth year with Dylan.” My Dad smiled at Mrs Vaughan.
Dylan opened his notebook: “Vernon Vaughan is a 78 year old . . .”
“Excuse me!” Mrs Vaughan interrupted. “It’s always a good idea to start by allowing the patient to speak for himself. In fact, I would regard that as my number one learning point for today and I am sure Dr Dennis would agree.” Mrs Vaughan continued without giving my Dad a chance to respond. “Vernon, can you explain how your symptoms started? I think you developed some discomfort in your right ear?”
“Yes, that was on Monday. It was just behind my ear.”
“Then, last night, you noticed weakness of the right side of your face. Your mouth started to sag and you were dribbling. Cleaning your teeth was difficult.”
“Yes, that’s right.” We could see that Vernon’s face was lopsided when he spoke
“This morning, breakfast did not taste quite right?”
“It didn’t have much taste at all, Valerie.”
Mrs Vaughan looked at us. I could sense this was another important learning point.
“Vernon, have you noticed any weakness of either arm or leg?”
“No, they seem fine.”
“Are you sure, Vernon?”
“Yes, Valerie.” Vernon winced.
“Are you in pain, Vernon?”
“No, it’s your voice, Valerie. It’s really grating today; more than normal.”
Mrs Vaughan shook her head dismissively. “It would be very unusual, Dylan,” Mrs Vaughan continued, “for a stroke to cause weakness of the facial muscles but not affect the arm or leg. Normally, if the right side of the face was affected, we would expect paralysis of the right arm and leg.”
Dylan nodded sheepishly.
“You will notice that Vernon cannot raise his right eyebrow.” Vernon tried. He managed to lift his left eyebrow but there was no movement of the right side.
“Close your eyes, Vernon.”
Vernon could not close his right eye properly.
“Can you see the way Vernon’s right eye rolls upwards when he tries to shut it?”
We all nodded.
“That’s called Bell’s Phenomenon,” Mrs Vaughan said. “They used to say that it confirmed the diagnosis but, more recently, it has been discredited, I think.” Mrs Vaughan looked at my Dad for confirmation. “We need to look at the whole picture; don’t we Desmond?”
My Dad nodded.
“So, it looks like the diagnosis is Bell’s palsy.” Mrs Vaughan continued. “The symptoms are due to swelling and inflammation of the facial nerve and not a stroke.” She turned to my Dad. “I don’t know if you still recommend steroids, Dr Dennis.”
“I will need to have a look at him first, Mrs Vaughan.”

My Dad confirmed the diagnosis, wrote out a prescription and arranged to see Vernon again in two weeks.
Mrs Vaughan took the prescription and turned towards Dylan. “I can’t see this young man getting through finals, Dr Dennis. It is such a waste of tax payers’ money.”
My Dad chuckled. “I am sure he’ll be fine, Valerie. He is brighter than he seems.”

Titch, Terry and Rod.

Thursday 25th April 1991   Morning surgery 10:50

Titch and Terry

 

 

 

 

 

 

 

 

 

 

Titch Mitchelson, Terry Talbot and Rodney Masters had all started smoking together in the second year in Grammar School. At lunchtime, they would nip into the park behind the school and share a fag. They would have a couple more on the way home.
They quickly realised that smoking made them feel calmer. It helped with exams, other stressful school events and, later, with job interviews or driving lessons. It was a godsend for romantic difficulties and family crises. It did not have to be entirely personal. When 19 year old Rod was dumped by Jane Finch, all three of them spent a whole morning smoking; one cigarette immediately followed by the next.
Why not have a cigarette to celebrate? There weren’t many better rewards for a Portmere victory, a good night out or a new car.

Titch and Terry gave up smoking after Rodney died of a heart attack at the age of 65. Unfortunately, it was a bit too late by then and they had both developed chronic bronchitis and emphysema.

Terry was overweight and slow. Lazy, Titch called him. If Terry got a chest infection, his lips and his fingers would go blue through lack of oxygen. He would become sleepy and difficult to wake up.
“You haven’t got much respiratory drive, Terry.” Titch would say when he visited him in hospital.
They both knew that, during one of these episodes, Terry would drift off into unconsciousness and never wake up.
“It’s not a bad way to go,” Terry did his best to reassure himself.
Titch, on the other hand, was a wiry, determined character. He would keep puffing away whatever happened. Even when he was sitting on the couch, he was breathing quickly. That’s how he managed to keep his oxygen levels up. He was always a nice pink colour.
“I feel like I am constantly running,” he said.
Titch knew that he could not carry on like this forever but he was determined to keep going for as long as he could.

Cross purposes.

Thursday 18th April 1991   Morning surgery 09:10

“I’ve got this awful pain in my tummy, doctor. It’s right up here.” Mrs Carter pressed her clenched fist up against the bottom of her breastbone.
“When did it start?”
“I can’t eat a thing. I can’t face any food.” She looked grimly at my Dad.
“Are you being sick?”
“I’m getting hunger pains.”
“Does it hurt to swallow?”
“You wouldn’t believe the wind I’ve got. The burps are terrible.”
“Have you felt bloated?”
“I am bringing up all this acid. It tastes so bitter.” Mrs Carter coughed.
“Have you lost weight?”
“The pain is going right through into my back. I can’t move with it.”

“Do you think this could be an ulcer, Mrs Carter?”
“My vertigo is back, doctor. It’s awful.”

Lots of small clots.

Friday 12th April 1991   Home visit 10:00

“Good morning, Dr Lewis.”
“Good morning, George. When did you come home?”
“On Tuesday . . . you were right, I was having clots.”
“It’s Dilys and Dylan you need to thank, George. They made the diagnosis.”
George Gwilym smiled at the students. He held out his hand. They both shook it. Dilys seemed embarrassed but Dylan looked pleased with himself. “Dr Harper said I was having lots of small clots,” George continued. “He said that small clots are quite difficult to diagnose. Apparently, a big clot is easier to pick up.”
“I thought you were anaemic to start with, didn’t I?” Dr Lewis was blushing now.
“Mmm . . . “ said George. “Don’t worry about that. Anyway, I am feeling a bit better already. Dr Harper thought it would take a few months before my breathing got back to normal.”
“It might not ever be as good as it was,” Dr Lewis said.
“Well, there’s a lot going on,” said George.

Not quite ready for oxygen.

Thursday 11th April 1991   Morning surgery 11:20

“Despite being younger and giving up smoking a few years ago, Emrys Evans is quite a lot further along the road than his brother, Eifion.” My Dad had just finished examining Emrys.
“I don’t think being asthmatic has helped.” Emrys said. He was slightly breathless just talking.
“No,” Dad turned to us, “Emrys has been quite a bad asthmatic since he was a child. Asthma and smoking don’t mix. Emrys is really struggling with his breathing, now. He cannot manage anything more than the slightest slope and, even on the flat, he is much slower than his wife and grandchildren.”
“My grandchildren get very annoyed. They don’t want to go shopping with me any more.”
“He is already on 3 inhalers and we have been thinking about adding a tablet,” my Dad continued.
“I don’t know if I fancy the tablets, Dr Dennis. Don’t they cause a lot of side effects?”
“Some patients get side effects but the majority don’t. I think it is worth a try if it helps your breathing. What are the common side effects of aminophylline, Dylan?”
“Nausea, diarrhoea, headache, irritability, sleep problems, palpitations, low potassium, convulsions . . . . . .”
“Very good, Dylan, but I just wanted the more important ones not the whole list. You are going to put him off the idea of taking them completely.”
“I’m sorry, Dr Dennis.” Dylan looked at the floor. Dilys raised her eyebrows.
“Don’t worry, Dylan. Now, Mr Evans has had to go into hospital twice in the last 12 months because of his chest. He is coming to see me every couple of months. I think it is fair to say that we are getting to know each other quite well. You could almost consider us friends.”
“I don’t like wasting your time, doctor.”
“You’re not wasting my time, Emrys. Your chest is pretty bad these days. We expect to see a lot of our chronic bronchitics as they deteriorate.”
Emrys frowned.
“I suppose that our next big conversation will be oxygen,” my Dad continued. That’s always an important step. Do you think Emrys is ready for oxygen yet, Dilys?”
“No, Dr Dennis. His colour is still quite good and he seems to be managing. You would want to get his oxygen levels checked in the hospital, first.”
“Excellent! We tend to give oxygen if patients have persistently low blood oxygen levels. Do you know how many hours a day the patient needs to use the oxygen for?”
“16?” Dilys wasn’t sure.
“It’s 15 hours, Dr Dennis.” Dylan corrected Dilys a bit too enthusiastically.
“Shut up, Dylan! I don’t think one hour is going to make much difference.”
“You are probably right, Dilys, but if we follow the official line, oxygen needs to be used for 15 hours every day. They say, if you do that, it makes you live longer. However, it’s quite a commitment. Most patients see it as a last resort. As you say, I don’t think Mr Evans has quite reached that stage.”

“Let’s try the aminophylline tablets. If they don’t help or you get side effects, you can stop them.”

Chronic bronchitis.

Thursday 4th April 1991   Morning surgery 09:00

“Well, this is how it usually starts, Mr Evans. A smoker’s cough. Bronchitis once or twice a year. You have probably noticed that you are slightly out of breath walking to the Newsagent’s in the morning. Of course, as you point out, your difficulty breathing could be due to your age or a general lack of fitness. Perhaps it’s because you are a little overweight. Those chest infections are nothing that a quick course of antibiotics won’t sort out and who doesn’t, at some stage, get a cough that goes on for months and months . . . and months?”
Eifion Evans raised his eyebrows. He didn’t say anything.
“I am aware that you would rather not have a breathing test,” My Dad continued. “What’s the point? What’s it going to tell us that we don’t already know? You certainly wouldn’t want an inhaler. We all know where that could lead! You agree that it would be better to stop smoking but, funnily enough, a cigarette seems to help that cough.”
“Alright, Dr Dennis,” Eifion Evans looked at Dilys, Dylan and myself with an expression of resignation. “I will have a breathing test if you really think it will help. I just didn’t want to end up like my brother, that’s all.”

Mrs Eleri Goldman.

Thursday 28th March 1991   Lunchtime 13:07

My Dad must have ducked into the newsagent’s at exactly the same second that Mrs Eleri Goldman collapsed. He had picked up The Times and was so intent on the front page that he heard nothing of the commotion outside; cars skidding, passers-by crying for help and Sally Goldman crying uncontrollably. It was only when Alun Warne came running in, shouted his name and grabbed him by the arm that he became aware that there was a serious emergency taking place behind him.

My Dad has never liked performing in public and I don’t think he could have imagined anything worse than having to run out to attend an unconscious patient lying in the middle of the high street. The traffic in both directions had been stopped and a large audience of people including a coach load of American tourists, who were visiting Portmere for the day, had already gathered.

He seemed to stand there for ages as if he wasn’t sure what to do. Then he quickly knelt down and checked the pulse in Mrs Goldman’s neck, took off her glasses and removed her false teeth. He made a fist and thumped her firmly in the centre of the chest. The crowd gasped. He checked her carotid pulse again, shook his head and started surprisingly professional looking cardiac massage.

We’re worried he’s having clots, Dr Lewis.

Thursday 21st March 1991   Morning surgery 10:05

“We’ve just seen George Gwilym for you Dr Lewis. He’s not well at all. He’s much more breathless than last time.” Dylan had come to Dr Lewis’ door. He looked very concerned.
“His lips are going blue.” Dilys said.
“He’s having a pain in his chest. It’s really sharp and catches when he takes a breath.”
“It’s pleuritic.”
“Obviously!” Dylan frowned reproachfully at Dilys. “He’s got quite a fast pulse, too. It doesn’t sound like a chest infection and I don’t think it’s the anaemia. He’s much too breathless for that, now. We’re worried he’s having clots, Dr Lewis. We think he needs to go into hospital straight away.”
“He’s a cancer patient which means he’s at high risk of clots.” Dilys added helpfully.
“Dr Lewis knows that! Would you like us to call an ambulance? I’ll ask Harriet to get the oxygen.”
“Yes, you ring for the ambulance, Dylan. I’ll go and have a look at George.”

A little bit breathless.

Thursday 14th March 1991   Morning surgery 09:30

“How are you, Mr Gwilym?”
“Well, I’ve been quite good really, Dr Lewis. The stent seems to be working. I am still eating quite well. The only thing is, I’ve been feeling a little bit breathless, just over the last week or so.”
Dr Lewis looked concerned. “Have you had a cold?”
“I haven’t.”
“Are you coughing?”
“No.”
“Have you had any pain in the chest?”
“No, none at all.” George Gwilym reassured Dr Lewis.
“What’s your breathing like at night?”
“It seems fine, then.”
“Can you lie down flat in bed?”
“Yes, that’s no problem.”
“You don’t wake up out of breath?”
“No.”
“Are your legs swelling?”
“No.”
“Have you had any trouble with your breathing before?”
“No. I haven’t.”

Dr Lewis examined George Gwilym’s chest. In fact, we all had a listen. She checked his pulse and blood pressure.
She sat down. “Your chest sounds fine to me.” The three of us nodded in agreement. “Your blood pressure is on the low side and you do look pale. I am wondering if you are slightly anaemic. That can make you breathless.”
“I do feel dizzy at times.”
“Yes, anaemia could make you feel dizzy as well. We will book you in for a blood test tomorrow morning. We’ll see you again next Thursday for the result.”

Dylan and Dilys.

Thursday 7th March 1991   Morning surgery 11:59

Cardiff uni emergency illustration

 

 

 

 

 

 

 

 

 

By the end of their first surgery, it was obvious to Dr Lewis and I that Dylan and Dilys, our new medical students, were in love.

They had spent the whole morning glancing furtively at each other. They sat very close together so that their elbows or knees, at least, were always in contact. Their hands would accidentally collide, Dilys would grab Dylan’s arm and during longer consultations, he would find himself leaning against her.

The worst thing was when Tiffany Jones brought her new baby in. He was only 3 weeks old and, to be fair, he was cute. Dilys could not contain her excitement. She was all over Tommy. Dylan controlled his emotions more stoically but you could see that, even from a distance, he took an almost fatherly interest in the child. I got the impression that, as soon as we had finished surgery, they were going to rush off and start a family of their own.

Testicular torsion.

Thursday 28th February 1991   Morning surgery 11:40

After Dr Lewis had finished examining Arthur Rowe’s tummy, she took a peek down his trousers. I thought his mum might call the police.
“There we are, Dennis,” she said, “a very painful, swollen, purple testicle.”
Even though she knew I did not want to become a doctor, she made me look. “Don’t touch it,” she warned.
Dr Lewis really didn’t need to tell me that. No one wants their testicles touched at the best of times. In this situation, it would be unbearable.

“In testicular torsion, Dennis. The testicle is twisted. The twist cuts off the blood supply. In effect, Arthur’s testicle is strangling itself. If we want to save his testicle, it has to be untwisted quickly. They suggest it should be operated on within 6 hours.”

“You will need to take him straight to hospital, Mrs Rowe.”

Her heart is going like the clappers!

Thursday 21st February 1991   Morning surgery 10:05

My Dad scowled and picked up the phone. He hates being interrupted in the middle of a consultation.
“It’s Penny from reception, Dr Dennis. I am sorry to disturb you. I have just had a phone call from Mrs Gwenllian Graham. It sounds like she’s in atrial fibrillation.”
“I wouldn’t have thought so, Penny.”
“I am quite sure she is. She says her heart is going like the clappers. It’s all over the place. She feels breathless and dizzy too. She is coming out in cold sweats.”
“Mmmm . . .”
“I have arranged for Harriet to do an ECG and I’ve squeezed her in with you, after.”
“Squeezed her in with me?”
“Yes, I have squeezed her in between Mavis Marsh and Alan Adams.”
“Mavis Marsh! She always takes ages. She’ll probably have a long list of problems.”
“Yes, when I spoke to her yesterday, she said she had seven problems she wanted to discuss with you.”
“You will have to ring her and cancel, Penny. Tell her I’ve had a serious emergency. You can book her in for next week.”
“She won’t agree to that, Dr Dennis. She said that three of her problems are very urgent.”
My dad groaned. “You will have to try, Penny.”
“Don’t worry! Everything is sorted out. Mrs Graham has agreed to see Dennis first. All you will need to do, is decide whether she should go into hospital. That won’t take more than a couple of minutes. I can even ask Dr Lewis to look at the ECG if you want.”
“I am perfectly capable of diagnosing atrial fibrillation, Penny.”
“I am sorry, doctor. It was just a suggestion.”

Safety netting.

Wednesday 13th February 1991   After dinner 19:45

“What’s safety netting, Dennis?”
“It’s a fancy, medical term that doctors use when they explain how they ask patients to come back to see them if they are not getting better.”
“Isn’t that just common sense?” Declan raised his eyebrows.
“You would think so. But Dad says that none of his patients have got any common sense.”
“Aren’t we his patients, Dennis?”
“No, Declan. I’m with Dr Lewis and you’re with Dr Rothman, the locum.”
“But Dr Rothman is never in the surgery.”
“If you’re ill, Declan, and Dr Rothman isn’t there, you can see Dr Lewis. That’s the way we organise things.”
“Why can’t Dr Lewis be my doctor all the time?”
“She can’t, Declan. She’s too busy. Anyway, the interesting thing about safety netting is that all doctors do it differently.”
“What do you mean, Dennis?” Declan looked puzzled.
“Let’s take Dr Lewis. She likes a tailored approach to safety netting. It depends on the individual patient, their particular disease, their social circumstances and, sometimes, even the day of the week or the weather.”
“The weather? Come off it, Dennis!” Declan obviously thought this was ridiculous.
“Declan, many illnesses are affected by the weather.”
“Hay fever is a good example,” said Mum as she cleared the dishes.
“Exactly! Now, Dad is much more simplistic.”
“You must remember that he has been a GP for many years, boys.” Mum smiled.
“When he safety nets, he say one of three things: don’t come back and see me for at least a week, don’t come back and see me for at least a month or don’t come back at all. I think he goes more by whether he likes the patient than by how seriously ill they are.”

Cardiac arrest!

Thursday 7th February 1991   Morning coffee break 12:40

“Cardiac arrest! Cardiac arrest!”
Dr Lewis and Harriet went flying out of the staff room and down the stairs. I jumped up to follow them but Dad stopped me.
“Hang on, Dennis, Isobel Shaw was having a blood test today. She’s probably fainted again. Let’s wait for the third call.”

Dad offered to make Dr Lewis and Harriet a cup of tea when they came back. You could see from the expressions on their faces that they had mixed emotions. On the one hand, they were pleased that Isobel Shaw had only fainted but, on the other, they had missed an opportunity to save someone’s life.

Fish hook removal.

Thursday 31st January 1991   Morning surgery 11:20

Fish hook NEW

 

 

 

 

 

 

 

The difficult thing about removing a fish hook from a patient’s finger is the barb. You can’t just pull the hook out. The barb is there to make sure that the fish doesn’t get away and, most of the time, it works pretty well.

Once you have anaesthetised the finger you have to push the hook right through. Then, with a sharp pair of pliers, you can snip off the tip of the hook including the barb. After that, the rest of the hook can easily be pulled back out.

My Dad couldn’t understand why anyone would go fishing in the middle of Winter but I knew it was a good time for cod.

Three funerals.

Thursday 24th January 1991   Morning surgery 09:40

“Good morning, Mrs Vaughan.”
“Good morning, Dr Dennis. I’m just here for my review.”
“How are you, then?”
“I’m fine. However, I’ve been to three funerals in the last few weeks. I was at Mrs Austin’s two weeks ago. I was very fond of her.”
“She was a very nice lady. The perfect patient, in fact. She was one of those people who always accepted and was grateful for any medical advice.” My Dad gave Mrs Vaughan a telling look.
“I was surprised that you didn’t go to the funeral,” Mrs Vaughan retorted disapprovingly. “How long have you been looking after her?”
“I’ve told you before, Mrs Vaughan, I don’t have time to go to patients’ funerals. No family doctors do, these days. Of course, I may make an exception for you as you are such an old friend.”
“I haven’t decided who’ll be invited to mine. Anyway, I went to Mrs Grey’s funeral on the Tuesday before. We were in school together. It was such a shame she would never have the flu jab. She might still be here. I’ve been trying to persuade her every year.”
“She was very frail.”
“Then, there was Mrs Chapman. Her funeral was last Friday. That brain tumour was quite a surprise. Sudden onset of weakness in the right arm and not one single headache. Even I thought she’d had a stroke! It was only when the symptoms progressed that the cause became obvious. I don’t think it would have made any difference if you had made the diagnosis straight away, Dr Dennis. Mrs Chapman didn’t think so. She said that they couldn’t have removed the tumour. It was in a very delicate part of the brain. Of course, she would never say a word against you.”
My Dad sighed. “Anyway, how are you getting on with the medication?”
“I’m fine, doctor. No problems at all. It’s only the eye drops. Can I do Vernon’s review while I’m here?”

 

Two tricky telephone calls.

Thursday 17th January 1991   Morning surgery 09:20

Ryan Ellis had celebrated his 18th birthday on New Year’s Eve. Now he had severe pain every time he went for a wee and ‘two swollen balls that hurt like hell’. After a bit of discrete prying by Dr Lewis, he admitted to a new girlfriend.
“I am afraid it’s chlamydia, Ryan.” Dr Lewis patted his knee sympathetically. “I can’t think of any other explanation.”

Ryan’s situation was complicated by the fact that he still had his old girlfriend.
“You’ve got two tricky telephone calls to make, Ryan.”

A mince pie with custard and clotted cream.

Thursday 10th January 1991   Morning surgery 10:40

“How are you, Mr Gwilym?”
“I’ve been good, Dr Lewis. The stent seems to be working. I’m eating quite well, mostly soft foods. I’ve had lots of soups. We had turkey soup every day for a week. I’ve tried mashed sprouts. They’re awful!” George Gwilym laughed. “Gwen has been making some lovely, creamy mashed potato with lashings of butter. It’s very rich. I have a pudding every day. A mince pie crushed up with custard and clotted cream is my favourite at the moment. I’ve managed to put some weight back on.”
“That’s very good.” Dr Lewis said. “Are you getting much pain?”
“Now and again. I get it in the middle of my chest. I am not sure if it’s the tumour or the stent. The painkillers seem to be working, though.”
“The stents aren’t normally painful. It must be the tumour.”
“I thought so. I guessed it was that.” George Gwilym looked apprehensively at us.
“You are bound to get some pain,” Dr Lewis said reassuringly. “Are you keeping busy?”
“I’m doing a bit. I go for a walk every morning. Gwen and I have a day out three times a week. We’ve made a list of things to do. Last week, we went to Powys Castle on Monday and Llangollen on Wednesday. Then, we visited Norman and Marjorie, my cousins. We are trying to meet up with all our relatives and friends. Norman doesn’t go out of the house. He’s got severe Parkinson’s disease. He won’t go in a wheelchair. He complained because we haven’t been to see him for 20 years but he did say he was pleased to see me.”
“I’m sure he was.”
“He asked us to try to go to again. If not, he said he would catch up with Marjorie at the funeral.” George Gwilym laughed again. “Norman has always been pretty straight talking.”

 

Hypothermia.

Tuesday 1st January 1991   At home 09:07

Fred Christmas Day

 

 

 

 

 

 

 

 

 

 

 

At 9 o’clock on New Year’s Day, Gary and Maisy Wilkins found Fred slumped against their snowman. Maisy lifted his hat. Fred was cold and icily blue. They shook him but he wouldn’t wake up.”
“He’s ruined our snowman!” Gary said angrily. “He’s drunk!” Fred still smelt strongly of whisky. Obviously, he had been too incapacitated to walk all the way home last night.
“I think he’s dead,” Maisy said. They both looked down at him.
“We better get Uncle Desmond.”

Dad was still in bed when they ran into the house. He sent me to investigate. I called an ambulance.

Fred was suffering from severe hypothermia. He was lucky to survive.

Portmere vs. Blaenau Ffestiniog.

Wednesday 26th December 1990   Portmere vs. Blaenau Ffestiniog 14:15

The wind was bitterly cold and the rain stung our faces as we walked towards the stadium. We kept our heads down.

Kevin Kendall was on the turnstile. He had his right arm in a plaster of Paris and a sling.
“Hi boys! Your Dad was right about my wrist. He made the diagnosis on the ‘phone! I have broken one of the little bones. He even said it might not show up on the first x-ray. I’ve got to go back in 2 weeks for another check.”
Kevin took our money awkwardly in his left hand and gave us the tickets.
“Would you like a programme?”
We both looked at him as if he was stupid.

We passed the kitchen. Bethan Rees appeared to have made a good recovery from her recent heart attack. She was cleaning the worktops energetically and chatting chirpily to her sister, Lynne. Big Sam was lurking in the background. He’s in charge of the hamburgers and disposes of any stray chips he can find and a few that are not officially missing. Sam looks as if he could have a heart attack at any moment.

Phil was standing in the queue waiting for a cup of tea. We nodded to each other.

“Is that cancer, Den?” Declan was looking at a large, black mole on Mr Crombie’s forehead.
“Don’t be stupid, Declan. He’s had that for years.”

Laurence Lawson walked quickly past us. He coughed loudly and I could hear him wheezing. Maybe I should have given him some antibiotics.

The Blaenau lads were jogging purposefully up and down the touchline. Half of our team were on the pitch, toe poking the ball about. The rest were in a huddle outside the changing room having a final cigarette before kick-off.

It was a dreadful match. We lost 1:0.

Last weekly practice influenza debriefing.

Monday 24th December 1990   Afternoon coffee and debrief 16:50

“Good afternoon, everybody. I am very pleased to report that this week has not been as busy. It looks as if the 1990 influenza epidemic may be waning.” Mrs Andrea Jones smiled and sat down.
“It’s been rather short,” my Dad said. “Perhaps there will be another wave.”
“Don’t say that, Desmond. I remain optimistic that we are over the worst. We should all be able to enjoy the bank holidays.”
“I don’t know. I’ve got this feeling . . . “
“Dr Rothman has been very helpful.” Andrea interrupted. “He has done double-booked surgeries every day. He has been signing prescriptions left, right and centre.  On Wednesday, he made everyone in reception a cup of tea.” She gave my Dad a pointed look as she said this. He didn’t notice and took another bite of his mince pie.
“Mary Lomax has been as busy as a bee. She has managed to vaccinate 200 patients this week. She is so efficient!”
All the staff except Harriet looked impressed.
“Would you like to give us an update on our admissions, Lois?”
“Miss Sandiford has come home. She’s quite well. Dennis and I went to see her on Wednesday. I am very pleased to see that Adam Watson has also been discharged. He seems much better. You’ve seen him, Harriet?”
“Yes, he came for his review. He has promised to take his asthma more seriously in future. He agreed to have a flu jab.”
“I am not sure how useful it is to give someone the flu jab after they have had the flu, Harriet.” My Dad raised his eyebrows.
“I wanted to start him off on the right foot, Desmond. The flu vaccine covers 3 strains of flu. Because there are similarities between the various strains of influenza, they do say that patients who have the vaccine every year build up their general immunity to the illness.”
“You should know that, Desmond.” Andrea raised her eyebrows.
“I have sent in another 6 patients,” Dr Lewis continued, “of these, 4 had influenza and bronchopneumonia and are doing well. However, 2 patients are extremely ill. Idris Jones has developed acute respiratory distress syndrome. This is a complication of a number of conditions including influenza where the virus causes a severe inflammatory reaction in the lungs. It is difficult to treat. The consultants in the Intensive Care Unit are not sure if Idris will survive. The other patient is poor little Rosie Rampling who I sent in on Tuesday. She did have the flu but I couldn’t work out why she looked so ill. They have discovered that she’s got leukaemia. That’s why the flu affected her so badly. They are planning to transfer her to Liverpool for treatment early next week.”
“That’s awful! The poor little girl,” said Penny Parry. All the staff looked shocked.
“These days, the treatment for leukaemia in children is very effective.” Dr Lewis tried to be as reasurring as she could.
“She’s only 4 years old. Lois. What a Christmas she’s going to have!”
Everyone was so upset that Andrea decided to abandon the rest of the meeting.

Typical flu symptoms.

Thursday 20th December 1990   Morning coffee break  12:17

“Mr Gibson was stroppy this morning.”
“Why was that, Desmond?” Dr Lewis was signing the prescriptions. She looked up.
“I said that we wouldn’t visit his wife. She’s had typical flu symptoms: fever, shivering and aching all over. There’s been no cold but she’s had a headache and some tummy pain. She only started feeling ill last night. I told Mr Gibson that we couldn’t go and see every patient with the flu.”
Dr Lewis went back to her prescriptions. The rest of us drank our coffee quietly.

“Did she enjoy her holiday?” Harriet had just finished her soup.
“Holiday? I really don’t have time to ask all my patients about their holidays, Harriet.”
“It was just that Mrs Gibson and her husband came in for their vaccinations at the beginning of November. It was a bit of a rush because they were leaving on the 8th of December. They must have just got back.”
“Vaccinations?” Dr Lewis pricked her ears up. “Where did they go, Harriet?”
“Mmm . . . I am not sure . . . let me think . . . I know, they went on safari, to Africa.”
“Africa! Oh my God, Desmond! She’s probably got malaria. Come on Dennis. We better go and see her straight away.”

It’s not the flu, Mrs Vaughan.

Thursday 20th December 1990   Morning surgery  10:34

“It’s not the flu, Mrs Vaughan. You’ve got a cold.”
“Aren’t we in the middle of an influenza epidemic?”
“Yes, we are.”
“I was under the impression, Dr Dennis, that, in a flu epidemic, any patient with an infection of the upper respiratory tract such as a cold is likely to have the flu virus.”
“That’s right, Mrs Vaughan.”
“And am I correct in saying that some patients with the flu virus have no symptoms at all?”
“You are.”
“Research has been done that proves that?”
“It has.”
“Well, if we are in the middle of an epidemic and I’ve actually got symptoms, I would have thought that I almost certainly have the flu. It stands to reason.”
“Ah . . . I see what you are getting at, Mrs Vaughan. I can understand the confusion. You mean that you’ve got the flu virus. However, as you have so clearly pointed out, having the flu virus is not the same as having the flu. There’s a subtle difference. That, I think, is where I come in. That’s what I’ve been trained for.”

Mrs Austin died last night.

Wednesday 19th December 1990   Afternoon coffee 17:00

“Mrs Austin died last night.” Dr Lewis looked really upset when she told us.
“Listen, Lois,” my Dad said. “You can’t keep getting attached to these patients. You have to maintain a professional distance. At the end of the day, Mrs Austin was just another old lady with heart failure. She wasn’t your grandmother.”
“Don’t be so horrible, Desmond!” Dr Lewis retorted. “She was lovely. She was determined. Until two weeks ago, she did everything for herself. She managed to do all her cooking and cleaning. The house was spotless. She was brave too: she never complained or made a fuss. She was always cheerful. I liked her, Desmond. I was attached to her.”
My Dad frowned.

Could I have the flu jab?

Tuesday 18th December 1990   After dinner  20:00

“Could I have the flu jab, Dad?”
“Don’t be stupid, Declan.” I scowled.
“You don’t work in the surgery. Dad and I have the flu jab because we work in the surgery?”
“What about Mum?”
“She’s a nurse, Declan. Mum has the flu jab because she works in the hospital.”
“Couldn’t you sneak a flu jab out for Declan, Desmond?”
“I am afraid not, Daphne. The government regulations on influenza vaccination are very strict.”
“So, I’ll be the only one in this family who gets the flu!” Declan was quite indignant. “What if I die? Will you be happy then, Dennis?”
“I don’t think you’ll die, Declan.” Mum smiled reassuringly.
“Mum, people do die of the flu,” I protested. “According to the experts, about 10,000 patients die of the flu every year. Some of those people will be annoying, young teenagers like Declan.”

I think it’s influenza.

Monday 17th December 1990   Dennis’ evening surgery 17:30

“I’m sorry, Mr Brightman. That’s what I think it is. You can see my Dad if you want but you will have to wait a couple of hours. He’ll probably say the same as me.”
“What about Dr Lewis.”
“She’s gone out. She had 5 home visits to do.” I looked at my watch. “She’ll probably go straight home afterwards.”
“Haven’t you got any medical students?”
“No, not at the moment, Mr Brightman.”
“Listen. If it won’t offend you, Dennis, I would prefer to wait and see your Dad.”
“That’s fine, Mr Brightman. No offence taken. I will add you to his list.”

It’s just the flu.

Monday 17th December 1990   Dennis’ evening surgery 17:20

“Don’t be such a wimp, Harry! It’s just the flu.”
“I’m not sure why I’m seeing you anyway, Dennis. I thought doctors weren’t supposed to treat their own mates.”
“You don’t need any treatment. You can buy your own paracetamol.”

First weekly practice influenza debriefing.

Monday 17th December 1990   Afternoon coffee and debrief 16:50

Mrs Andrea Jones came breezily into the staff room.
“Good afternoon, everybody.” She said. “Thank you for coming. I thought it would be useful to have a weekly practice influenza debrief. I would like to start by congratulating Desmond. He notified the first case of flu in Wales this year on Thursday 29th November. I understand that, as usual, his report was treated with some derision by the experts in Public Health. However, they announced the 1990 influenza epidemic on the the very next Monday. Well done, Desmond!” Mrs Jones smiled at my Dad.
“I would like to thank everybody for all their hard work last week especially Dennis who came in every day. I know he’s not here but I would also like to thank Declan who has been doing all of Dennis’ homework. I hope your marks don’t take a dip, Dennis.” Mrs Jones laughed and winked at me.
“They’ll probably do exactly the opposite,” said my Dad.
“So far, Harriet and the doctors have seen 397 patients. 374 patients have had uncomplicated influenza. 21 patients have had influenza with secondary infections, mostly bronchitis. We have seen one lady who thought she had wax in her ears. Julian Marshall tried to catch us all out with a primary pneumococcal pneumonia. Dr Lewis spotted that immediately. Well done, Lois! I don’t know if you want to discuss the admissions?”
“Of course, Andrea.” The compliment about her emergency care made Lois glow with pride. “I admitted 5 patients last week. The first was Julian who we have already mentioned. He only needed to stay in overnight because of the speedy diagnosis and referral. On Tuesday, I sent in Mrs Grey, Miss Sandiford and Mrs Mellor. I think most of you are aware that these are three very frail, elderly ladies. All of them had quite nasty bronchopneumonia. Mrs Grey and Miss Sandiford have always refused the flu vaccine. However, Mrs Mellor has had her vaccine every year.”
Dr Lewis took a deep breath and sighed. “I am afraid to say that Mrs Grey and Mrs Mellor passed away on Friday.”  All the staff looked sombrely at each other.
“Miss Sandiford has also been extremely poorly but appears to be picking up. It looks as if she is going to make a full recovery.” Dr Lewis said. “My fifth admission, on Thursday, was Adam Watson. He is a 23 year old asthmatic. He also started with typical flu but this precipitated a very severe asthma attack. Adam is still extremely unwell. In fact, he had to be put on a breathing machine over the weekend. We are all keeping our fingers crossed for him. Like many of our younger asthmatics, Adam has never had the flu vaccine.”
“They don’t think they need it.” Harriet said. “They have no idea how serious influenza or asthma can be.”
“What about you, Desmond?” Andrea looked at my Dad. “Have you sent anyone in?”
“No, I haven’t actually, Andrea. Lois has done most of the visits and seen the more seriously ill patients. She has really taken the idea of the Community Influenza Rapid Action Team Flying Squad to heart and decided to try to run a pared down version herself.”
“Unfortunately, it is not quite the same when there is only one of you, Desmond.” Dr Lois responded. “I did ring Public Health to see if anyone was interested in joining me. Apparently, they were all too busy in meetings.”
“Hmm . . . “ my Dad laughed. “They are probably trying to decide how we should deal with all the extra patients. No doubt they will send us their recommendations in a few weeks.”
“Right,” Andrea continued. “Let’s get on. You’ve all got more patients to see afterwards. We have already administered 650 flu vaccines which is excellent. Well done, everybody!  Of course, in addition to those young asthmatics, we have plenty of other die-hard patients who won’t consider it. Hopefully, the flu outbreak will convince some of them to change their minds. Don’t forget to keep asking.” Everybody nodded.
“I have made a few changes for the next couple of weeks,” Andrea continued. “I realise that none of you are managing to get a proper lunch break. I have arranged for Branwen from Roberts’ Bakery to bring sandwiches, sausage rolls and mince pies every day this week. We have borrowed the tea urn from Portmere Primary School so we can have a continuous supply of hot tea. Dr Rothman has agreed to come in all day Wednesday and Friday to help out with the patients. I have also arranged for Mary Lomax to run a daily flu vaccine clinic to free Harriet up to see more patients. Enid Marshall has agreed to assist in reception. Everyone is rallying round!”
“That’s fantastic, Andrea.” Dr Lewis looked delighted. I knew that my Dad would be very pleased about the sausage rolls and mince pies.
“I have also cancelled all routine appointments for the next two weeks. I think we’ll only need you on Thursday this week, Dennis.  Has anybody got any other suggestions?”
No one did. We all went back to work.

Another trip to Ashbury Lodge.

Thursday 13th December 1990   Morning coffee break  12:45

“There’s been a late call from Ashbury Lodge, Lois. They’ve got 9 patients for you to see.”
“I went there yesterday, Desmond. I saw 5 patients then.”
“Well, 3 of those have deteriorated and there are another 6 that they’d like you to see.”
“They’ve probably all got the flu.”
“I am sure they have, Lois but, if they’ve got the flu, they’ll have coughs and, according to Mrs Thatcham, if they’ve got coughs they’ll be chesty and, if they’re chesty, they need to see the doctor.”

Man flu.

Thursday 13th December 1990   Home visit  11:45

“You shouldn’t have come to see me Doctor. It’s just a slight touch of flu.”
“Your wife was quite worried about you.”
“Yes, Gladys does tend to overreact. Look, if I had known you were coming I would have got up and got dressed. I haven’t even put my pyjamas on; I’ve been feeling pretty warm.”
Mr Greene did look very red and hot. He was drenched with sweat. In places, it was running down his chest. My Dad shook his thermometer and popped it under Mr Greene’s tongue.
“Mmm . . . 42.3*C . . . that’s as high a temperature as you can get!”
“I’m sure it’s no higher than anyone else’s, doctor.”
“Right, let’s have a look at your throat.”
Mr Greene opened his mouth.
“Mmm . . . .”
“Oh, hang on! Here we go!” Mr Greene’s hands started trembling. As we watched, his arms began to shake and then his legs. Soon his whole body was moving so violently that his bed started clattering noisily on the wooden floor. My Dad leant on the foot of the bed to try to steady it. The attack built up to a crescendo over several minutes and then gradually died down.
“Goodness me!” My Dad exclaimed. “That was a dreadful rigor.”
“A rigor?” Mr Greene said.
“Yes, these attacks of shivering are called rigors,” my Dad continued. “You tend to get them with a high temperature. Have you been aching?”
“He’s been awful, haven’t you Gavin?” Gladys Greene shouted from her bedroom next door. “His arms and legs have been as heavy as lumps of lead. They were so painful he could hardly stand yesterday.”
Gavin Greene nodded reluctantly. “They’re not quite so bad, today, Dr Dennis.”
My Dad looked thoughtfully down at Gavin Greene as he lay on the bed. “Well, Mr Greene, he said. You have definitely got the flu but, I must say, it’s the worst case I have ever seen.” He shook his head as he spoke. “To be completely honest, it’s the worst case we’ve ever had in the practice . . . I don’t know what we can do.”
“I’ll be fine, Doctor Desmond. I am due two more paracetamol now. I’ll get up after you’ve gone and make Gladys some lunch.”
“Make Gladys some lunch!” My Dad looked incredulous. “You are not fit to do anything.”
“I’ll have to, doctor. She’s had another one of her migraines this morning. Her vision’s all lopsided and she’s got a thumping headache. She can’t get out of bed. You know what she’s like if she doesn’t eat a proper lunch. Her indigestion will be awful.”

Tara, Tabitha and Tesni.

Monday 10th December 1990   Morning sugery  09:20

“Good morning! How’s Andrew?”
“He’s been flat out with the flu but he’s a bit better today.” Mrs Tarley sat down. “The receptionist said that, while I was here, I could ask you to have a quick look at the triplets.”
Tara, Tabitha and Tesni were well behaved for 3 year olds. They stood quietly and looked at my Dad from under mops of curly, straw coloured hair. Their cheeks glowed red. They smiled. Each of them had the same front tooth missing. Tesni covered her mouth with the back of her hand and giggled.
Dad did not appear to be moved by their appealing nature. He frowned.
“I am sorry, Mrs Tarley, I haven’t got time today. You’ll have to make another 3 appointments.”

It’s just influenza, Mr Soames.

Monday 10th December 1990   Morning sugery  09:10

“It’s just influenza, Mr Soames.”
“Just influenza! I‘ve got a dreadful headache. It’s right over this eye.”
“You can get a dreadful headache with influenza.”
“I am sure I’ve got sinusitis, doctor.”
“You may be right, Mr Soames. People often get sinusitis with influenza.”
“Don’t I need something for it?”
“Not, really. The influenza will certainly get better on it’s own and sinusitis usually does.”

She’s got the flu, Mrs Price.

Monday 10th December 1990   Morning sugery  09.04 

“She’s got the flu, Mrs Price.”
“But she’s got a really bad sore throat, doctor.”
“Yes, I’ve got an awful sore throat. I can’t eat a thing, doctor. It’s feels like I’m swallowing broken glass.” There were tears in Petra’s eyes.
“You can get an awful sore throat with the flu, Petra. It is one of the normal symptoms.” My Dad tried to be as sympathetic as he could.
“I’m worried she is going in for tonsillitis again. She gets terrible tonsillitis.”
“She won’t get tonsillitis on top of the flu, Mrs Price. I can completely reassure you there. It’s one or the other.”
“I would like her to have some penicillin, Dr Desmond, in case.”
“I am not going to prescribe penicillin for the flu, Mrs Price.”

You’ve got the flu, Mr Wiley.

Monday 10th December 1990   Morning sugery  09:00

“You’ve got the flu, Mr Wiley.” My Dad sighed.
“I am sure I’ve got a chest infection. I am coughing up loads of phlegm.”
“Your chest sounds completely clear. You’ve got typical flu symptoms.”
“I am really sure I’ve got a chest infection, Dr Desmond. If it was just the flu, I wouldn’t have come to see you. It even said on the News last night that we shouldn’t go to see the doctor if we’ve got the flu.”
“Yes it did, Mr Wiley. I am sorry. I assumed that, like the majority of my patients, you hadn’t seen the News.”

Toad in the hole.

Friday 7th December 1990   At home  21.17 

We’re starving!

Mum always insisted that we had to wait for Dad to come home from work before having dinner. Tonight, he hadn’t arrived until 9:15. He looked defeated.
“Oh, Desmond! You must have been so busy.” Mum was very sympathetic whenever he came home late. Declan and I just got annoyed if we were hungry.
“The flu really hit us today, Daphne. To start with, Andrea and Mary were off sick. They were both fine, yesterday, but flat out today. Then, the phones didn’t stop ringing. All our appointments were gone before 9.30 am. I did double-booked surgeries all day. Dr Lewis had 17 requests for home visits. She did 14 of them this morning, an emergency surgery this afternoon and the last 3 visits on her way home. Penny Parry was rushing around trying to calm everyone down but only made things worse. By the time we stopped for a very late coffee, everyone was frazzled. Harriet refused to have a drink. She said it would make her palpitations even worse.”
“No wonder you were so late, Desmond.”
Dad nodded.

“This batter looks remarkably crispy and light, Daphne.” Dad said. He obviously did not want to say anything else about his difficult day. Declan and I had heard enough anyway. We all tucked into our food.

“Listen, Dennis,” Dad had half a sausage poised on his fork. It was dripping with Mum’s unctuous onion gravy. “I am afraid I’m going to have to ask you to come in to help out after school next week. You are just as capable as me of telling our patients that they don’t need antibiotics for the flu.”
“I can’t, Dad. I’ve got loads of homework.”
“Dennis!” Mum exclaimed. “You were just telling me that you’ve got an easy week next week.”
“I didn’t mean it was that easy.”
“Isn’t there teachers’ training on Monday?” She continued.
“Mum!” I groaned.
Dad raised his eyebrows. “I had forgotten about that, Dennis. That’s perfect! You can come in and help. Monday is always very busy. It will be better than moping around at home.”

If you’ve got the flu, dial 222!

Thursday 6th December 1990   Morning coffee break  11.55 

“The government are launching the new Community Influenza Rapid Action Teams tomorrow, Lois.” Mrs Andrea Jones came into the staff room carrying a large glossy brochure.
Dr Lewis looked up. “Really!”
“Yes, it all sounds very impressive. There is going to be a 24 hour help line manned by specialist nurses and doctors from Public Health. They will make a detailed telephone assessment of each patient. Low risk patients with uncomplicated flu will be given the usual advice.”
“Plenty of fluids and paracetamol?”
“Exactly! High risk patients with uncomplicated flu will be offered antiviral antibiotics. They will be able to pick these up from their local pharmacists.”
“It does sound good, Andrea.” Dr Lewis looked visibly excited.
“We will still need to see patients in the practice with suspected chest infections or other complications.”
“I have no objection to that.”
“The most seriously ill patients, those who are too poorly to come to the surgery, will be visited at home by our own Local Community Influenza Rapid Action Team Flying Squad. The flying squad is a hand-picked unit of highly trained intensive care and respiratory consultants with full nursing and ancillary back up. They expect to be able to visit up to 100 patients a day in our area. They are hoping that, with early and comprehensive support, they may be able to prevent the majority of hospital admissions.”
“That’s fantastic, Andrea. It should significantly reduce our workload.” Dr Lewis looked delighted.
“Yes, they estimate that it should cut the additional GP workload during an epidemic by 75%, Lois. We will be able to get on with our normal day-to-day activities.”
“It’s not like the government to think ahead or put extra resources in like this.”
“The chances are, by the time they get all this organised, the flu outbreak will be over.” My Dad said.
“Don’t be so cynical, Desmond! In fact, I phoned the helpline this morning and got straight through to a very nice lady. She told me that they are fully staffed and have actually got reserve teams in place.”
“I can’t believe this, Desmond. It’s too good to be true! We are going to have a very relaxing winter.”
“Yes, it is too good to be true, Lois. Andrea is pulling your leg. It was her idea of a little joke. She knows how worked up you get when the flu starts. It will be backs to the wall, no lunch and late nights as usual, I’m afraid.” My Dad chuckled.
Dr Lewis looked horrified. “That’s really mean, Andrea! If there are no Community Influenza Rapid Action Teams, what’s that brochure?”
“It’s the House of Fraser Christmas Catalogue, Lois. Would you like to borrow it?”

I’m not having the flu jab, Dr Dennis.

Thursday 6th December 1990   Morning surgery  10.50 

“Are you aware that 250,000 people died in the United Kingdom in the 1918 Spanish Flu epidemic, Mrs Highly?”
“I am not having the flu jab, Dr Dennis.”
“They also estimate that influenza causes over 10,000 extra deaths every year.”
“I am not having the flu jab, Dr Dennis.”
“Patients like you with chronic heart disease are over 10 times as likely to die from the flu, Mrs Highly.”
“I am not having the flu jab, Dr Dennis.”
“The vaccine reduces your chance of catching flu by about 70%.”
“I am not having the flu jab, Dr Dennis.”

Nathan Preston and the 1990 flu epidemic.

Thursday 29th November 1990   Morning coffee break  12.22 

“I don’t know why we don’t give school children the flu vaccine,” my Dad said angrily.  “That’s where it starts, in school. I have just seen Nathan Preston and I can guarantee he’s got the flu.”
“He’s our first case, this year then.” Dr Lewis looked up apprehensively.
“Nathan’s going to give it to all his friends,” my Dad continued brusquely, “and, of course, he’ll give it to his parents. His friends will give it to their friends and their parents. Nathan’s Dad will give it to his colleagues in work and his mates in the Pub. Nathan’s Mum will give it to her colleagues in Tesco’s and the members of the ladies’ luncheon club. One way or another, the grandparents will get it. Of course, the teachers will catch it from the children. They will pass it around in the staff room. I suppose Mrs Blunt, the dinner lady, will catch it and Mrs Burns, the lollipop lady. They’ll spread it around at Bingo: everyone wins tonight! Before you know it, we’ll have the 1990 influenza epidemic! It will be on the news and in the papers. If the journalists do their homework properly, little Nathan will be on the front page.”
“Come on, Dennis, you can’t blame Nathan. That’s not fair!”
“Listen, Lois! It’s the same every year. It always starts with a child! If someone had given Nathan Preston the flu jab, it wouldn’t have happened. We could all sit here, enjoy our coffee and not worry about being bombarded with patients next week.”