Practitioner I

“Name?” she enquired, her spectacles tilting downward to a diary on her desk, a pen in her hand poised to tick off my name.

“No, um, that is, I’m not here to see the Doctor”, I said.

She gazed up at me over the top of her specs, her brow wrinkling with enquiry.

“Actually, I’m a medical student. Um, I’ve come to, ah, work, with the Doctor…for a bit.”

“Oh, yes, of course you have,” she replied, smiling faintly while taking in my white shirt and badge, along with the awkward self-consciousness radiating from my blushing face. She gestured with her pen towards a door near her desk.

“Just knock and go in, Doctor,” she said. “Doctor is expecting you.”

Somewhere in the midst the freneticism of Final Year, comes the Community Health Block, offering a few week’s respite from the pressure-cooker routines within the confines of the Grot. Community health is a brief exposure to life outside the Hospital, in Primary Care: General Practice, Day Clinics, and small Rural Hospitals. As final-year medical students, we had, at last, been deemed sufficiently proficient not to completely embarrass our Alma Mater, safe enough for us to stretch the umbilical cord which had tethered us for so long to the IMS and which tied us still, to the Grot.

For the first fortnight of this period, I had been allocated to Dr Harry Zimmerman, a General Practitioner who carried out his trade from an apartment in one of the city’s genteel tree-lined suburbs. A brass plaque on the door of his second-floor flat was the only indication that this location housed a medical facility. Doctor Zimmerman’s practice clearly did not rely on passing trade.

Feeling apprehensive on my first day, I had arrived in good time, my white tunic cleaned and pressed, my IMS ID card flapping proudly from its pocket. I had trawled self-consciously through a congested waiting room, my steps terminating before an oddly out of proportion mighty mahogany reception desk. Here sat the bespectacled Receptionist, clad in a flowery dress and cardigan, her desktop territory replete with the accoutrements of her trade: patient folders, scribbled notes, invoices, a well-inscribed diary, a cylindrical container of pens and pencils, and a small telephone switchboard.

The thrill of having been addressed as Doctor for the very first time helped to dilute somewhat my general apprehension. Pulling my shoulders back a little, I made my way in the direction indicated.

The wood-panelled door was emblazoned with a second brass plate which proclaimed Dr Harold Zimmerman M.B.Ch.B. (Illustrious Medical School).

An alumnus, I was pleased to see.

I knocked cautiously, and then, when no reply was forthcoming, more firmly.

“Come in, come in,” a breezy-sounding voice wafted through the panels.

I came in, and saw a short, dark-haired man seated in an upholstered office chair at a small wooden desk on the far side of the room. As I entered, a broad smile lit up his face.

“Well, hello, hello,” he said, shooting across the room on his chair, its wheels spinning smoothly on the polished parquet floor.

“Come in, come in,” he added with evident enthusiasm, getting up briefly and cranking my hand firmly up and down as though he were pumping water at the Broad Street pump.

“Uh, hi,” I said, a bit taken aback.

“How are you?” he enquired warmly, still smiling at me.

I felt my feelings of awkwardness dissolving a little in the glow of unexpected camaraderie radiating from this short friendly man.

“Uh, fine thank you,” I replied. “Um, how are you?”

“Perfect,” he replied, “just perfect, thank you.”

“Uh, I’m supposed to observe you, um, for two weeks.”

“Yes, indeed, you are,” he said, a twinkle in his eye. “I need observing.”

“Oh, um, I wouldn’t have thought so,” I said stupidly, my slowness of wit and general nervousness leaving me struggling, despite this short bobbing Doctor clearly doing his best to put me at ease. “Um, it’s very nice here,” I added lamely.

“Do you think so?” he asked, sounding surprised but looking pleased as he glanced briefly around his domain. “Well, come in, come in, make yourself at home.”

Still grinning, he flopped into his chair and rolled back across the floor, the fingers of one raised hand beckoning me to follow. He parked at his desk and jabbed at an intercom button with a stubby middle finger.

“My backup has arrived,” the Doctor intoned to the air above the intercom.

“Yes Doctor,” came the reply.

“We have met, we have exchanged greetings, our numbers have been fortified with the addition of a young sage. You may send in the next victim.”

A few seconds later, there came a knock at the door, which opened to admit a pretty young lady, dressed in a smart black mini-skirt, a revealingly-tailored black blouse, black stockings, shiny high-heeled shoes, elegantly styled hair, and skilfully applied make-up.

“Yes, hello,” said the Doctor, blinking up at the woman through his spectacles. “Come in, come in,” he added, gesturing to a chair next to his desk. “What’s seems to be the problem, Madam?”

The young lady flashed a winning smile at the Doctor, held out her hand and said: “Penelope, Doctor, Eli Lilly, so pleased to see you again. I won’t take a lot of your time – I can see that you’re very busy, as always. I’ve just come to update you with the latest information on some of our products.”

“Oh,” said the Doctor looking suddenly dejected, his smile evaporating and his shoulders sagging a little. “Well, what do you have for me today?”

Undaunted, Penelope hefted a large blue leather hold-all onto the desk. The word ‘LILLY’ was embossed prominently on the side of the bag, which she now upended and shook gently, causing it to disgorge its contents onto the Doctor’s desk. Out clattered an eclectic collection of items: coffee mugs, towels, whisky tumblers, golf balls, caps, corkscrews, pens, leather folders, and a couple of pairs of cufflinks. Each was similarly embossed with the name ‘LILLY’, along with the trade name of a proprietary drug.

“Thank you very much,” said the Doctor as, with a comprehensive sweep of his arm, he shunted the entire haul, including the blue bag, into a large cardboard carton on the far side of his desk, this receptacle being already half-full of similar oddments.

“Where do I sign?” asked the Doctor, again blinking up at the young lady through his specs.

“I’d love to tell you about our anti-depressant, Doctor. Prozac has become an essential tool…”

“Sorry, no time, no time” said the Doctor, as he squiggled his initials on a clipboard presented by Penelope.

He jabbed the intercom button.

“Next please,” he instructed quickly.

“Thank you for coming Petunia,” he said absently, waving goodbye from his wheeled chair.

‘Petunia’, no longer smiling, was led out by the receptionist, who had led in an elderly shuffling man. The frail-looking man collapsed slowly into the chair at the side of the desk.

“Morning, Harry, lovely to see you” said the Doctor, gripping Harry’s with resurgent enthusiasm.

“Hello Doctor,” wheezed the patient, sliding a little lower in his seat.

“So, Harry, what brings you in today?” asked the Doctor.

“It’s this pain I have – like last time, in my solar plexus, and that burning behind my breast-bone has come back, especially after eating, or when I bend over.”

“Ah,” said the Doctor knowingly, as with three fingers, he prodded the disconsolate-looking man in the epigastrium, just below the sternum, causing him to wince.

“Ah,” said the Doctor again, kneading Harry’s upper abdomen.

“Ahh,” groaned Harold, grimacing. “Don’t do that Doctor – it hurts.”

The Doctor sat back in his chair and then made a grab at his prescription pad on which he scribbled ‘Ulsanic 1 bd’, ‘Gelusil 1 prn’.

“Harold, Harold,” said the Doctor, aiming a stern look at the patient. “You’ve been cheating again, haven’t you Harold? That’s why it’s playing up again. Now, remember what you promised?”

“All right, Doc,” groaned Harold, as the Doctor handed him the prescription.

“Harold, my dear Harold,” said the Doctor with a small shake of his head. “You keep your side of the bargain, and you won’t have to spend so much on antacids.”

“OK, Doc, OK,” Harold muttered, as he departed, shuffling, out of the office.

With the door closed, the Doctor rolled his chair back a bit and swivelled around to face me, demanding suddenly, “What’s the diagnosis?”

This unexpected interrogation reduced me to stammering.

“Uh, peptic ulcer disease, no, um, or at least, gastritis, or maybe, both, and, uh, gastric reflux, possibly a hiatus hernia,” I offered, feeling my face growing hot. Having suffered some of Harold’s symptoms myself, this was a subject with which I was a little familiar.

“Why do you say that?”

“Well,” I said, having had a moment for my thoughts to catch up, and feeling a little more on solid ground, “he complained of epigastric pain. He appeared tender on palpation of the epigastrium, and you prescribed Ulsanic and Gelusil, so he probably at least has gastritis, or maybe a peptic ulcer. Also, he complained of postprandial and positional retrosternal pain, so he likely has gastro-oesophageal reflux, probably caused by an hiatus hernia. You said he had been ‘cheating’, so he must be eating or drinking something which you advised him not to; something that would worsen his condition – maybe alcohol?”

I added a little non-committal shrug, confirming my usual feeling of uncertainty.

“Well done my boy, spot on” the Doctor exclaimed with a widening grin. “Yes, Harry does love his cheap wines, especially the sweet ones.”

He scooted back to his desk on his wheelie chair and prodded the intercom again.

“Next please,” he called.

The Doctor’s enthusiasm was infectious. I looked on, intrigued to see what sort of patient would be next.

Clumping footsteps could be heard from the corridor, after which the door was opened to reveal a large woman, clad in a medium-blue crimplene dress, a matching pillbox hat, black stockings, and sensible navy-blue leather shoes. She bore a severe expression on her face. She was dragging behind her a slightly smaller girl of indeterminate age – late teens by her size, about thirteen by her chubby face. The girl stared at us through wide blue eyes, partly obscured under a generous mop of blonde hair. She was dressed in the same pale blue crimplene attire as the older woman, who glowering at us, plonked herself ponderously in the chair at the side of the Doctor’s desk.

“Dok-terr,” the woman announced in a guttural accent. “This is my niece and very adopted daughter. She is the child of my sister. I am much hoping to have her married off in the near future.”

At this, the Doctor’s face developed a sternly furrowed brow, as he raised his eyebrows to glance at the woman over the rims of his spectacles.

There followed a moment of expectant silence

“So, you must be checking her,” Aunty-Mother concluded.

“Ah, yes,” said the Doctor, apparently suddenly understanding. “A check-up, of course… yes, yes… um, Mrs…?”

Aunty-Mother failed to respond. She merely continued to stare woodenly at the Doctor, who giving up, turned to her terrified looking young charge.

“Do you have any particular problems or complaints, my dear?” he asked, his tone gentle.

“No, of course not,” interrupted Aunty-Mother. “She is perfectly healthy, healthy as a horse. She even eats like a horse.”

“Yes, yes, quite,” said the Doctor, gazing at the mother once more. “So you would like her to have a check-up, but she appears perfectly healthy, and has no complaints?”

All he received in return was a continuous glare from the large face seated opposite.

The Doctor tried again.

“How is your appetite?” the Doctor enquired of the younger woman.

“Farr too good,” came the guttural reply from the large woman.

Do you sleep well?” the Doctor asked, turning to the young lady, who had taken up a defensive position, trying to hide herself away beside her guardian Aunt.

“Yes she does that,” interrupted Aunty-Mother. “She sleeps better than a piece of wood. Sleeping is the one thing she does very well, apart from eating.”

“What is your name my dear?” asked the Doctor, a detectable desperation creeping into his usually suave tone.

He seemed to want to hear the young girl speak at least once. Maybe he thought she couldn’t. Perhaps she was mute?

“Her name is Charmaine, but that is not important,” interrupted Aunty-Mother

“Well,” said the Doctor softly. “It’s always nice to know the name of one’s patient.”

“She is not one’s patient. She has come to be checked,” explained Aunty-Mother firmly.

“Ah, yes, of course she has” said the Doctor, seemingly now realising that he was out of options, but still not understanding what was required of him.

The Doctor sat silent for a moment, as though collecting his thoughts. Then, pulling back his shoulders, he continued.

“Right,” he ventured, in as professional a tone as he could muster, “exactly what is it that you would like me to check?”

“To see if she is all in one piece.”

A tinge of redness had suffused Aunty-Mother’s stony face.

The Doctor’s perplexed expression displayed deepening desperation now, as he stared back at the woman.

“To see if she is still a virgin,” stated Aunty-Mother, exasperation colouring her tone and her face further. She held up an index finger, “virgo intacta, I believe you medical people call it.”

At this she released a brief, enigmatic smile.

Following Aunty-Mother’s words, a silence pervaded the room, during which the Doctor glanced briefly at me. Then he turned his gaze back, as he focused an enquiring look on Aunty-Mother.

“I did told you,” continued the formidable woman, “I want her to be married off as soon as possible, but no respectable young man will accept her if she is no longer a virgin.”

At this point, the young lady burst into tears. Still staring at Aunty-Mother, the Doctor reflexively lifted a box of tissues, holding it to one side in the general direction of the snivelling sounds, as he continued to stare at Aunty-Mother.

“There, there, my dear, take some of these,” he muttered distractedly.

“Um, I think I understand,” the Doctor said, speaking slowly, running the fingers of one hand through the hair on the back of his head.

“It is not too complicated,” came the guttural reply.

The Doctor got up from his chair and for a change, actually walked across the office to the examination couch. He drew the curtain around the examination couch and then directed the tearful lass into the enclosed alcove. As she lay down, the Doctor looked back at me.

“Perhaps it’s better if you stay out for this one,” he said quietly, with an apologetic looking grin, as he disappeared behind the screen.

After a brief interval, a short scream emitted from behind the curtain. Aunty-Mother continued to glare stony-faced as the Doctor, snapping off some latex gloves, reappeared around the edge of the curtain.

“Yes,” he said, his tone serious, but with a glimmer of a smile playing around the corners of his mouth. “She’s a virgin all right.”

Aunty-Mother looked grimly satisfied.

“Good, thank you Dok-terr, that will be all,” she said. With that Aunty-Mother grabbed out of the office, the slightly damp young lady in tow.

“Phew,” sighed the Doctor, slumping back in his wheelie chair. “Thank goodness she’s gone.”

He punched the intercom button, his energetic vigour returning slowly.

“Next please,” he said, “and try to make sure it is a patient.”

The office door opened and the flowery reception lady appeared.

“Your next patient, Doctor,” she said, with a little emphasis on ‘patient’.

In waddled a short, rounded, olive-skinned woman, wrapped in a headscarf and what seemed to be multiple layers of robes and cloaks, which smelled as if she had been wearing them for quite some time.

“Hello, Doctor,” she said, with a somewhat middle-eastern intonation.

“Ah, Mrs Ritipke, and how are you today?”

“Not so good, Doctor. Not so good. In fact, I’ve got a headache; and my eyes, they burn; my stomach, Doctor, it is a total nightmare. And my knees Doctor, they’ve been paining me ever since I saw you last, and also my feet.

“Ah,” the Doctor said, looking serious. “What about your elbows?”

“Terrible, Doctor.”

“And your shoulder?”

“Oh Doctor, bad, very, very bad.”

“Not to mention uh, your ribs?”

“Terrible, Doctor, the most terrible pain, especially at night.”

“Let’s check your blood pressure.”

Mrs Ritipke shuffled over to the examination couch to which the Doctor was pointing. She lay back carefully with her head nestled on the pillow, an angelic expression enveloping her face.

“I think,” mused the Doctor, “that perhaps our medical student should get some practice. Would you care to check the blood pressure, Doctor?”

I approached the expectant patient and unfurled the cuff of the wall-mounted sphygmomanometer.

“Um,” I asked gingerly, “could you hold out your arm, please?”

Mrs Ritipke obediently lifted a podgy limb, covered with many layers of fabric - the concentric sleeves of her many garments. I began the task of uncovering her upper limb, starting at the wrist, rolling and sliding the sleeves up her forearm, but this proved exponentially challenging: the higher up the arm the layers of fabric rose, the more entangled they became, eventually forming an ugly scrunched-up, sausage-like thing below her elbow.

I tried to push the horrible sausage further up her arm, but it wouldn’t budge. I tried to unravel her sleeves back down her forearm, but the layers had become entangled with each other and appeared to have fused, forming a solid mass of circumferential fabric which obstinately refused to move.

I felt my face reddening and my skin beginning to prickle. It seemed the only available course was to wrap the cuff of the sphygmomanometer over the fabric.

This operation terminated in an unsightly fashion. Once the canvas cuff had been wrapped around the patient’s robed arm, it bulged outwards, forming an ugly, lumpy conical shape, with the cuff stretched over the fabric sausage beneath.

I began to compress the rubber bulb to inflate the cuff, while searching for a pulse by palpating the upper forearm below the elbow. This was fruitless: there was no pulse to feel within the adiposity of the podgy forearm. Even in those of slender build, the brachial artery is usually palpable only in the antecubital fossa, in front of the elbow joint, which in this case was currently covered in the tangled sleeves.

I applied the stethoscope in a hopeful manner to the general area below the cuff. As it inflated further, the layers of canvas of the cuff slid slowly apart over each other, in a circumferential fashion around the arm, as the cuff loosened progressively. The machine’s rising mercury column slowed before it reached an adequate height within its glass tube, and then, even before I could open the valve, the mercury started to fall, as the cuff fell apart completely. Nowhere was the pulse either audible or palpable. The serenely reclining patient’s blood-pressure was clearly not going to be measured.

“Well,” interrupted the Doctor, from his chair, “what’s the blood pressure then, Doctor?”

“It’s, um, unrecordable, uh, that is, I can’t…” I croaked, stammering with self-conscious embarrassment, my face growing hot.

“What?” the Doctor replied, sliding alongside on his chair, and looking on with intrigue at the floppy posture of the cuff, with its pressure balloon still prominently inflated.

“No, no, Son,” he said kindly, standing up out of his chair and examining the loosened cuff and tangled sleeve. “You can’t work in this mess.”

He removed the cuff from under the patient’s arm and returned it to its little wire mesh resting cage on the wall. Then the Doctor, with growing intrigue, spent a few moments inspecting the sleeve-sausage, jiggling it between his forefingers and thumbs, as he too tried to dislodge the thing. Then, with a resigned-looking shake of his head and shrug of his shoulders, he seemed to abandon this course of action, reaching instead for an enormous pair of scissors.

“This won’t hurt a bit, Mrs Ritipke,” he advised as he cut firmly through the fabric sausage and then, continuing upwards, cut through all the layers of fabric covering the arm. He severed the cloth near the top of her arm and we watched it slide silently onto the floor.

“Mrs Ritipke,” said the Doctor, seeming to gain momentum, “we just need to perform the same procedure on the other side.”

So doing, he amputated the untouched sleeves of the garments encasing her other arm. All the while, Mrs Ritipke smiled sweetly at the Doctor, either not minding or unaware of this mutilation of her clothing.

“There we are,” said the Doctor triumphantly once we had seen the second set of sleeved fall to the floor. He nodded his head with a satisfied glance at Mrs Ritipke’s bare arms.

The Doctor then grabbed the cuff, wrapping it rapidly and expertly around Mrs Ritipke’s now entirely naked right arm.

“The cuff must always be applied neatly,” the Doctor said to me, in an explanatory tone. They’ll fail you in the finals if you apply a blood pressure cuff untidily.”

The Doctor stood back then, and allowed me to take the blood pressure reading.

“The other one now,” instructed the Doctor. “Do the other arm.”

I was able make a neat job of applying the cuff to the other arm, and the pulse was clearly audible. I relayed my findings with confidence.

“Your blood pressure is very good today, Mrs Ritipke,” said the Doctor, wheeling himself back to his desk.

He wrote out a prescription as Mrs Ritipke arose from the examining couch and examined, with a little curiosity, her newly-tailored garments, with their much reduced sleeves.

“Mrs Ritipke,” added the Doctor, looking earnest, “those sleeves of yours were far too tight again. They were impeding your circulation. You’re much better off now, with your arms free. This will aid your circulation immensely. Many of your symptoms were the result of poor circulation. Thanks to this clever young Doctor, the problem has been solved, and you will now feel a lot better.”

“Thank you, Doctor. Thank you so much. You are both too kind,” said Mrs Ritipke as she departed.

The Doctor looked on at the closed door for a moment, gently shaking his head.

“Always like that,” he said. “She locks herself up in those tight-fitting, smelly old garments. I’ve had to snip off her sleeves on several occasions in the past. I doubt that she could wriggle out of those garments without assistance. She never seems to mind the sleeves being snipped off.

He seemed to be lost in a reverie for moment, before continuing.

“Anyway, bear in mind that it is best to position the cuff on bare skin, and make sure you apply it firmly, and always neatly.”

To this day, I make sure that the cuff is neatly and firmly applied whenever I take a blood pressure reading. I’ve never, however, been brave enough to surgically excise the sleeves from a conscious patient, before applying the cuff.