No, it was not the sunset that brought tears:
From Avatar Land© 2015 Am Ang Zhang
This is extracted from another post that is about not just the strange medical condition that I have to wait 30 plus years for an answer but to the Junior Doctor that I fondly remembered. This brought tears to my eyes as it was NHS at its best.
Now are we seeing the end game. Well only 54,000 pawns left on the Chess Board.
.........Perhaps we should catheterise her. She had not been seen to use the toilet for hours although she was not drinking much. She was still going round in her room – we gave her the side room and a nurse – and we put on an input output chart so we knew. The new junior doctor’s car broke down so she was late in examining her.
Bother, I forgot it was changeover time, when new doctors came in for their new six-month rotation. This is one of the days of the year not to be ill.
“Good work Sister. What do we do without you?”
Sister did the catheterisation but only got about 150ml. The mass was still there.
I phoned Ob-Gyn. The consultant had left for home, but I got her Senior Registrar.
He came over. Yes, it was possible that she was pregnant but unlikely as there were no breast changes. He would hate to do an X-ray but that seemed justified in the case of an undiagnosed abdominal mass.
My mind was racing now. Sometimes you do have to believe what you see. Sometimes you have to believe the parents. She was not one of those girls. She could not be pregnant. So now we had to go through the differential diagnosis for abdominal mass in a young girl of thirteen.
Ovarian cyst was the obvious one.
This big?
Possible.
No. It cannot be.
The x-ray came back. The tell tale tooth was there and yes – a Teratoma, the distinctive type of tumour that can include teeth, hair, sometimes, even a jaw and tongue. I guessed just a split second before the results came back. How annoying.
Working diagnosis: Teratoma with possible toxic psychosis.
Emergency operation was arranged. Yes, she would be fine a little while after the operation, I reassured the parents.
Junior Doctor arrived:
Junior Doctor arrived:
The junior arrived and took some history and did a quick physical before she was prepared for the theatre. This petite doctor with a very babyish face told me that on her first day in her last job she had to do an emergency tracheotomy. This time she had been on call for the last three nights and the battery in her old Mini could not cope with the heavy frost so she had to wait for AA before coming. She was most apologetic for not having got in earlier.
She asked if I had seen many toxic psychosis cases and I asked if she had come across any in her psychiatric placement. As with all good psychiatrists answering a question with another is in our blood and here it worked well.
Neither of us knew what was to hit us next.
At 2 A.M. I had a call from her.
“Your patient – I mean our patient could not be aroused after the operation. Yes they removed the teratoma, complete and intact. It is bigger than any specimen I have seen but she could not be aroused. Any ideas?”
“Call the paediatrician on call in the regional paediatric unit and I will be in.”
What happened? I asked myself as I drove to the hospital.
What had we done? This was fast becoming a nightmare situation.
What was I going to say to the parents?
Something else was going on here, and I was not happy because I did not know what it was. I was supposed to know and I generally did. After all I was the consultant now.
Thank goodness she could breathe without assistance. That was the first thing I noticed. I saw mother in the corner obviously in tears. She asked if her daughter would be all right. I cannot remember what I said but knowing myself I could not have said anything too discouraging. But then I knew I was in tricky territory and it was unlikely to be the territory of a child psychiatrist.
A good doctor is one who is not afraid to ask for help but he must also know where to ask.
“Get me Great Ormond Street
“I already did.”
She is going to be a good doctor.
“Well, the Regional unit said that they had no beds so I thought I should ring up my classmate at GOS and she talked to her SR who said “send her in”.”
Who needs consultants when juniors have that kind of network? This girl will do well.
“Everything has been set up. The ambulance will be here in about half an hour and if it is all right I would like to go with her.”
“Yes, you do and thanks a lot.”
I told mother that we were transferring her daughter to the best children’s hospital in England
Faith & Prayer
When I got into work later that day, my secretary asked how my patient was as she heard from her friend that the church was going to hold a 24-hour vigil for her.
Trust my secretary. She knew someone from the same church and she always had the knack of extracting information first hand.
“They say this may be the work of the devil as the doctors and surgeons all did the right things and removed this big tumour but the devil must have got to her.”
I did have a vague fear that there might have been some anaesthetic accident but quickly told myself off for thinking along that line. I knew all the anaesthetists and such a thing could never have happened.
I was back at the hospital to deal with an overdose case. The junior was there and we had a chat in Sister’s office.
They had to ventilate her. That was the first thing she told me. I thanked her for going up there and she said it was scary but she felt important and the mother who was in the ambulance could not thank her enough.
She was impressed with mother’s faith and trust in God.
She said mother was near to tears. It was bad enough to have such a large Teratoma and then to have the patient unconscious with no one knowing what was going on was very frightening.
“I have seen some deaths as a medical student but never since I was registered. I do not want this to be my first.”
I knew the feeling well but what could I say? A doctor has to face it some time.
“Do you believe there is God?” She asked
“Do you really think I can answer that one?”
“Well, you have more experience.”
“To me it is like reading a good book. You would not know until the end.”
“So you mean I am not going to know until then.”
“Interpret whichever way you like. I remember Jung in his Memoir gave quite an account on the Holy Trinity. There were seventeen bishops in Jung’s family including his own father. Jung had always been puzzled by deity and the bible and most of all by the concept of the Holy Trinity. I know many religious philosophers struggle with that too. By some accident he had access to his father’s inner library. He saw this folder clearly marked Holy Trinity. The relief was phenomenal. He could now have the answer. He hesitated before opening the folder.”
“What did the folder contain?”
“See, you want the last chapter. I wanted to know as well. The folder contained pieces of blank paper.”
“That was it?”
“That was it.”'
“Well. My view is this. We are here. We live. We help others to live and maybe we do not ask too many questions and we might or might not in the end know the answer.”
Back to the patient:
“But do you think this girl is going to live though? I do not want this girl to be my first death. It would be so awful.”
“Neither do I. I keep saying to myself that it is now over seventy two hours and she is still alive and I do know that some cases of viral encephalitis can be very dramatic in presentation and recovery.”
“But which virus?”
“The nearest I have is Herpes.”
“Mother’s cold sore.”
“You have noticed that too.”
“I was with her for a long time.”
We had our own prayer for her too. Let it be Herpes encephalitis and all would be well.
I left the hospital feeling slightly strange. I just had a philosophical encounter with a young doctor. How strange it is that threats of death always get one thinking about these things.
The girl remained unconscious although the word was that the EEG was more hopeful than was first thought. GOS decided to transfer her next door to Queen Square National Hospital Queen Square
There was now a candlelight vigil at the church and it was hoped that there would always be a lit candle until she came home. The story was in the local paper and radio. Faith was now on field test if not on trial. The doctors were not. They had done their best.
On the 10th day the ventilator came off, and she was able to breathe without support.
They then started a vigil in the girl’s home.
By the 23rd day, as my optimism was about to give in, word came from the hospital that she became conscious. It became big news in the papers.
When mother came home from London
No virus was ever isolated and her diagnosis on discharge was that she had a variant of Encephalitis Lethargica[7].
“Did you agree with the diagnosis?” The junior asked me when I saw her next.
“Why should I be arguing with the best neurological centre in the world? It is harder to argue with a variant of Lethargica. However the next few months or years will be important. If she is well then Herpes fits in better and often it is an allergic type of reaction on first exposure. But if she is like those in Awakenings[8], then Encephalitis Lethargica.”
I saw her at the local hospital rehab a couple of times. Initially there were a good deal of residual symptoms including awkward gait and dis-inhibition. She became better and was moved to a specialised centre and that was the last I heard of her.
Post Script:
“Ten years later mother came to see my secretary and left a photo. It was a photo of her daughter and her new baby. She had been working at the local bank since she left school, met a very nice man and now she had a baby. Mother thought I might remember them and perhaps I would be pleased with the outcome.
I was very pleased for them too but I would hate for anyone to put faith or god to such a test too often.”
We provided World Class Medicine without trying. A quote from a fellow blogger, Dr. No.
Dr No said...
Excellent post - and yes, that is exactly how it used to be. World class medicine without even trying - we just did it, because that is what we did, just as the dolphin swims, and the eagle soars. A key, even vital feature was that the doctors looking after their patients did not need to worry about money or managers. They just got on with it. There was no market to get in the way of truly integrated care. Some may point out that 13 year olds with teratomas are rare, and that is true, but what this case shows us, precisely because of its complexity, is just how capable the system was. And most of the time (of course not always), it dealt just as capably with more routine cases. "How is (sic) the new Consortia going to work out the funding and how are the three Foundation Trust Hospitals going to work out the costs." Exactly. And then: who is going to pay for the staff and their time to work out out all those costs and conduct the transactions?
Can it be that it was all so simple then
Or has time rewritten every line
If we had the chance to do it all again
Tell me - Would we? Could we?
The Way We Were
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