\nNotes

Consultant

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\n Forethought\n
\n Consultant\n
\n Practitioner I\n
\n Rule One\n
\n Haemorrhage\n
\n Emergencies\n
\n Ghostling\n
\n Vanity\n
\n Resuscitation\n
\n Cursed\n
\n Intensive Care\n
\n Bereavement\n
\n Discomfort\n
\n Acknowledgements\n
\n Notes\n

\nForethought

\n\n

Medical internship is an initiation, a ritual endured: in hospital wards, operating rooms, outpatient clinics, and in emergency units, the young inexperienced doctor is cast headlong into a direct confrontation with illness and death.

\n\n

While this would be true for interns working in almost any hospital, interns in South Africa face perhaps a broader spectrum of damaged humanity: from the humblest shack-dweller to the mighty millionaire, the hospital intern is required to bestow on each an identical level of care, while each patient provides the doctor with a unique interaction, every experience a tale of its own.

\n\n

These stories, from my own years as a Student-Intern and then as a newly-qualified doctor, a Medical Intern, in Cape Town in the 1980s, will hopefully pull back the screen a little and allow a peek into the array of conundrums faced by a naive young doctor-to-be as he traverses the interminable corridors, being moulded within the crucible of hospital internship.

\n\n

Grahamstown

\n\n

South Africa

\n\n

November 2019

\n\n\n

Introduction

\n\n

After half a decade of medical school, we encountered the penultimate challenge: Final Year, the clinical year, eleven in-hospital months before facing the fear of Final Exams. We had been wholly ejected now from the campus of the Illustrious Medical School, leaving in our wake the lecture theatres, laboratories, medical library, and cafeteria, which, over the preceding five years, had become our stamping-ground.

\n\n

Since our arrival here as naive Freshers we had played out our teens and early twenties, trudging the uncertain paths of academia, overshadowed continuously by the great old training hospital (The Grot), to which we most of us were headed. The Grot, seemingly, at last, content with our recently acquired, paper-thin academic knowledge, now opened her maw, as she did each year at this time, and consumed us, her latest intake of final year medical students, (aka Student-Interns) entirely. Once entwined within her wards, clinics, and operating theatres, we were supposedly to cement our bookish, newly-minted knowledge by the bestowed privilege of hard work. We would, it was expected, be rendered capable practicing physicians, well, capable of passing our final-year exams anyway.

\n\n

On our first day as Student-Interns, we were berated for an hour or so by several stern looking medical superindents, and then presented, briefly, with several serious looking documents: indemnity forms, confidentiality agreements, applications for parking discs, and such. Having signed our lives away on the various dotted lines, we were assigned in groups to each of the major iatric disciplines, held captive in each for blocks of two months. For the first block - surgery, a handful of us were privileged to be allocated to one of the Grot’s particularly prominent surgical firms, one headed by a prodigioulsy intelligent young English gentleman…

\n\n\n

\nConsultant

\n\n

A precise perfectionist

\n\n

Peter, an intrepid young surgeon, had recently arrived in Africa. His English Gentleman origins could, no doubt, be found in some comparatively genteel hospital in the UK. Peter was the brilliant - the youngest ever Consultant to have been appointed Head of a Firm at the Grot. In keeping with his superior intellect, Peter could appear, at times, a little curt: while in the company of his Junior Doctors and Final-Year Students from the Illustrious Medical School, Peter would endeavour to conceal his friendly nature behind a gruff facade; he was able, with some effort, to sustain this illusion for up to two or three minutes at a time.

\n\n

Peter’s full-figured physique and military bearing supported a large rounded head, for the most part smooth and a little shiny, though partly ringed with a band of rigorously disciplined dark hair. Peter’s clean-shaven faced delightfully enhanced his tendency to flush dramatically: the merest ‘Peter’ exclaimed within earshot would result in his head radiating a remarkable red, almost the colour of claret, with a warmth enjoyed by all in proximity.

\n\n

Peter prided himself on being able to do everything perfectly. One morning, during a Consultant Ward Round, always a solemn event, Peter and his trail of acolytes: Nurses, IMSs, Interns, and Surgical Registrars, came to a halt at the bed of a patient who was completely obscured beneath a light blue cellular blanket. The blanket was rising and falling a little and emitting gentle snoring sounds as the occupant of the bed slept on, serenely oblivious of the small crowd of people now gathered around him.

\n\n

Peter looked briefly down at the concealed form, and then reached over and delicately folded down the top of the blanket, revealing the head and shoulders of a skinny, weathered-looking man. Short brown crinkly hair covered the man’s scalp, while tattoos and wound scars adorned his olive skin. The patient was shirtless, but his knobbly thorax was swathed in bandages from which, on one side, protruded a drainage tube, which snaked its way over the side of the bed, down into a glass bottle resting on the floor below. The bottle was half full of collected blood.

\n\n

“One of last night’s stab chests,” remarked the Registrar laconically from the foot of the bed, as he flipped through the notes on a clipboard which dangled there.

\n\n

“So it would appear,” concurred Peter slowly, with a minimal nod of his head, which began reddening immediately.

\n\n

For a moment longer Peter gazed down at the partly exposed gentleman, still snoring softly in innocent oblivion. Then Peter leaned over and tapped the sleeping man smartly on one shoulder. The man’s eyelids shot open, revealing small startled black eyes. His palpebral fissures widened further as he stared up at the large round red head hovering just above, and further still when he took in the small crowd of faces surrounding his bed. The patient glared briefly up at Peter, following which he pulled the displaced coverlet protectively up to his neck as he wriggled himself a little upwards into a more defensible sitting positon.

\n\n

“Good morning,” Peter greeted him brightly. “And how are we doing this morning?”

\n\n

The man’s dark eyes grew even wider as he stared back at Peter some more, but he said nothing.

\n\n

“I think,” said the Registrar, “you will find that this gentleman speaks Afrikaans, of a sort.”

\n\n

“Ah, yes,” said Peter, rubbing his hands together, “of course.”

\n\n

Peter turned back to his quarry, holding aloft one index finger.

\n\n

“Goy-yuh morah,” said Peter concentrating carefully, his enunciation an impressive display of how nearly complete was his recent, rapid mastery of the Afrikaans language.

\n\n

The patient continued to stare at Peter, his brows furrowing and his eyes narrowing a little.

\n\n

“Hoo gann dit met joe?” Peter added, his tone faltering almost imperceptibly.

\n\n

“Hoe sê?¹” blurted the man, his head tilted a little to the side, in an enquiring manner.

\n\n

Peter’s head reddened rapidly. He turned abruptly to the Registrar and in clipped tones requested a translation.

\n\n

“He said ‘What did you say?’ more or less,” said the Registrar.

\n\n

Peter retracted his head, frowning erythematously.

\n\n

“Please ask the patient how he is currently feeling,” Peter requested.

\n\n

In response the registrar strode to the head of the bed on the opposite side. Grasping and shaking gently one shoulder of the perplexed patient, the registrar enquired, “Hoe gaan dit man?²”

\n\n

“Nee-wat, dis goed, dankie,³” the man in the bed replied, a relieved looking grin brightening his expression, his smile exposing missing front teeth.

\n\n

The patient turned his gaze upon Peter’s still much reddened features, following which he lay back and pulled the blanket back up over his head, covering himself entirely.

\n\n

“He says he’s good,” said the Registrar.

\n\n

“What was the difference,” demanded Peter, “between what you said, and what I said?”

\n\n

“Well nothing, really,” said the Registrar with a little shrug.

\n\n

“Then why could the man not understand me, whereas he had no problem understanding what you said?”

\n\n

The Registrar hesitated before replying:

\n\n

“Well sir, I think it may have been in the inflection.”

\n\n

Peter frowned briefly at this before moving on to the next bed, his glowing red head a visible beacon to us all.

\n\n

My colleague Phillipa was another Final-Year Illustrious Medical Student allocated to Peter’s firm. Phillipa was softly spoken and possessed a contemplative expression, partly obscured by her large round spectacles. Phillipa favoured the then fashionable garb of the student political activist: colourful ankle-length woven skirts, leather sandals, and closely-cropped hair.

\n\n

One day the Registrar asked Phillipa and me to assist in the Operating Room. Peter and the Registrar were due to perform a Popliteal and Tibial Artery Bypass Graft, a daunting and delicate procedure. The prolonged surgery would involve dissecting out obstructed arteries in the patient’s leg and replacing them with veins harvested from the other leg.

\n\n

Phillipa and I were tasked with holding thin silicone loops which had been threaded around slender exposed arteries. These tiny elastic tubes retained each artery in a particular position as required by the surgeon. The thin catheters also occluded the artery, thereby preventing blood squirting from any severed branches. The two of us had to stand frozen in posture for hours on end, holding the ends of the catheters just so, while Peter performed the painstaking micro-surgery…

\n\n

“Doctor?”

\n\n

A Nurse had entered and interrupted the quiet flow in the Operating Room. Peter was head down, deep in concentration, his eyes obscured by black cylindrical magnifying loupes attached to the lenses of his spectacles, throwing his round face into an alien relief. Peter did not respond.

\n\n

“Doctor,” the nurse repeated, a little louder.

\n\n

“Yes, what?” Peter grunted, not looking up.

\n\n

“There is a group of students outside. They say you’re late for their tutorial. They want to know how much longer you’re going to be.”

\n\n

“Fuck,” replied Peter under his breath.

\n\n

“I beg your pardon,” said the nurse. “I didn’t catch that.”

\n\n

“Tell them to go away,” said Peter.

\n\n

“When should they return?”

\n\n

“Never,” said Peter, his face reddening rapidly, contrasting vividly with the baby blue of his paper bonnet and surgical mask.

\n\n

“Oh, right,” said the nurse. “Sorry.”

\n\n

“Fuck,” repeated Peter, again under his breath, his mind seemingly settling back on the task in hand.

\n\n

Peter cut delicately through a small branch of an artery.

\n\n

“They just want to know when you’re going to be able to teach them,” said Phillipa.

\n\n

Peter glared at her, the visible portions of his head now so red we could feel their radiating heat. Phillipa’s words died away uncomfortably amid the ensuing silence.

\n\n

The deathly quiet seemed to trigger a moment of anxiety for Phillipa, for her hand twitched - the hand holding one of the silicone loops, a loop which just happened to be holding firm the artery whose branch Peter had just severed. The loop slackened its grip on the artery, loosing a needle like jet of pressurised blood from the its cut branch. As the jet of blood sailed obliquely across her line of vision, Phillipa pulled on the catheter, cutting off the spume, but not before it had planted a single drop of blood in the middle of Peter’s forehead. Phillipa cast a look of horror at the red droplet, her eyes widening rapidly, the effect enhanced by her specs.

\n\n

“What are you staring at?” hissed Peter, as Phillipa’s gaze remained focused on Peter’s now extremely red head. Phillipa appeared mesmerised by the small scarlet blob, adhering seemingly miraculously, to the crimson background of Peter’s sweaty forehead.

\n\n

“Um…” said Phillipa, raising slowly the index finger of her free hand and pointing toward the offending droplet.

\n\n

At that moment a nurse appeared fleetingly in our vision. She darting across from the side of the room where she had been counting swabs which had been removed from the surgical field,and crossing them off one by one on a writing board. The nimble nurse applied a piece of paper towel, deftly removing the blood from Peter’s forehead.

\n\n

“Just a bit of perspiration Doctor, not surprising, hot afternoon and all that,” the nurse explained lightly.

\n\n

With a grunt Peter lowered his head and returned once agaon to his field of operations. Phillipa gave the nurse a grateful glance.

\n\n

Several hours later Phillipa and I were released, as Peter and the Registrar began to close up the soft tissues and skin over their newly implanted arterial grafts. It was a relief to step outside the theatre, and be able to move and rub our stiffly aching limbs.

\n\n

“That was close,” said Phillipa quietly. “Thank goodness for that nurse.”

\n\n

“Yes,” I agreed, “she was superb.”

\n\n

That same saintly figure had returned often during the procedure and wiped our own foreheads, surreptitiously pressing barley sugar sweets behind our paper masks into our mouths. I think there must be a special heaven for such people.

\n\n

While on our surgical rotation the time came for the entire hospital to move. A vast rectangular glass, steel, and concrete monolith had been constructed in front of the old hospital. The original airy Victorian building, with its high ceilings, and iron bedsteads lining the walls of long rectangular wards, had been supplanted by this new modern structure, designed for efficiency.

\n\n

As in the old building, offices were allocated to the medical staff serving on each ward: the Interns had been given a small shared office, with a sign on the door which read ‘INTERNS’. The Registrars now had an office each, each office door adorned with the word ‘REGISTRAR’. The Nurses had a rectangular area in the centre of the new ward, bounded on all sides by waist-high counters, affording them a three-hundred-and-sixty-degree view over the entire ward. A sign attached here proclaimed proudly: ‘NURSES STATION’.

\n\n

Peter, being the Consultant, had his own office too, of course, though, for reasons unknown, his door had no sign. Several of my fellow IMSs, Phillipa, Petra, and Helena, stood aghast at the sight of Peter’s naked door. After several minutes muttering to each other about the unfairness of this neglect, the three of them set about correcting the deficiency, making use of a length of printer paper and a box of coloured marker pens. The result of their labours was a colourful paper banner, about five metres in length.

\n\n

Their ‘sign’ was far too large to fit on Peter’s door. Making use of pink sticking plasters appropriated from the ward, Phillipa, being the most nimble, stood on a stool and taped the sign to the wall above, stretching it out evenly on either side of the doorway. Then they stood back, fingers on chins, considering their handiwork.

\n\n

“It’s a bit confusing,” said Helena. “It’s so long, that it almost reaches the neighbouring doors.”

\n\n

“True,” said Petra, “but Peter’s door is right in the centre of the sign.”

\n\n

“I think we should add a few arrows, just in case,” Phillipa said, her tone earnest.

\n\n

“Arrows,” the other two chorused, “an excellent plan.”

\n\n

They retrieved more paper from the printer and constructed several sizeable red arrows of variable length. These were placed beneath the sign, along much of its lower edge, each angled arrow pointing to the top of Peter’s office door.

\n\n

“That will do nicely” said Phillipa, standing back and gazing upwards to appraise the result.

\n\n

A little later Peter arrived in the ward, leading a delegation of besuited gentlemen: Professors and Surgical Consultants all. As we were to learn a little later, these eminent individuals hailed from many parts of the world, . They were all renowned surgeons, visiting our hospital to attend an International Surgical Conference concerning the latest advances in vascular surgery. Peter had apparently brought them to his office for an Important Meeting. As the group approached, Peter nodded curtly at us, blushing mildly.

\n\n

On arrival at his office door, Peter seemed at first not to notice anything amiss. However, as he stood before the portal, his gaze was drawn upwards, and a shadow of consternation passed over his face. He blinked and shook his head, and then looked up again, reddening further, following which his mouth hung open, briefly.

\n\n

Above the door frame, resplendent for its full five-metre length, ran the colourful banner: “DOCTOR PETER, CONSULTANT SURGEON”, each large letter proudly displayed in a different bright primary colour, with an exuberant background of butterflies, birds, flowers, trees, and clouds, and a bright, yellow, smiley-faced sun. As Peter stared upwards, it appeared as though the red arrows had been aimed with purpose, their points converging directly over Peter’s bright red head.

\n\n

Peter turned around and glared at the group of girls gazing at him expectantly.

\n\n

“Who placed that sign there?” Peter demanded, his voice a stoccato whisper, forced out between tightly clenched teeth.

\n\n

“I did,” replied Phillipa, a trifle hesitant, her hesitation tinged through with a tangible pride. “Do you like it?” she added, beaming an angelic smile at Peter.

\n\n

“Remove it,” Peter commanded curtly through pursed lips, as he pushed open the door, before stepping aside to allow his bemused looking colleagues to enter.

\n\n

During the two months in which we served as Peter’s minions, we benefitted from several academically exacting tutorials presented by Peter, who had become our erudite mentor. Peter seemed always able to dredge up some obscure bit of his encyclopaedic knowledge with which to interrogate us. As our time in surgery drew to a close, we were all seated before Peter for a farewell tutorial.

\n\n

“Well now, Phillipa,” said Peter, smiling, and flushing mildly. “Where will you be spending your Internship next year?”

\n\n

“I have a post at CMH⁴,” Phillipa replied.

\n\n

“Of course you do,” said Peter.

\n\n

Phillipa glared at him. Peter’s grin broadened, as his head reddened further.

\n\n

“So tell me, Phillipa,” Peter continued, an ocular twinkle gleaming through his spectacles “how do you treat snake bites?”

\n\n

“Um,” stammered Phillipa, her eyes widening behind her spectacles at this side-ball question. A rare moment of befuddlement clouded Phillipa’s usually calm gaze. “Uh, that is,um,” her voice petered out. “That is, actually, I don’t know,” Phillipa finally admitted.

\n\n

“What?” cried Peter. “You’ve been a medical student at the Illustrious Medical School for over five years, and you haven’t yet learned how to treat snake bites?”

\n\n

Phillipa stared at Peter, suffused in silence, her own face reddening now, redolent of horrified anguish and inner turmoil.

\n\n

“What’s going to happen next year?” demanded Peter, with obvious relish, “when you find yourself in that rural bush environment of the far Eastern Cape. Just imagine, you’re all alone in the Emergency Unit, and they bring in a little farm urchin with a snake bite on his foot? Are you going to look at the little tyke and say, ‘Um, I’m so sorry, but you see, I’m from the Illustrious Medical School, where they don’t teach doctors how to treat snake bites, so I don’t know what to do.’?

\n\n

“Or what about when you’re visiting your Aunt Mabel,” Peter continued, getting into his stride now. “You’ve just finished Sunday lunch and you’re settling down for some of Aunt Mabel’s delicious home-made chocolate cake. Aunt Mabel turns to you and says, ‘So, my dear, you’re a doctor now, tell me, how do you treat snake bites?’”

\n\n

Phillipa didn’t reply, as her own face reddened further.

\n\n

“Are you going to say, ‘I don’t know’?” Peter harangued. “And then Aunt Mabel is going to be astounded,” he continued. “‘What kind of medical school is this?’ she’s going to exclaim. ‘Where they don’t even teach doctors how to treat snake bites.’ That’s going to do a world of good for the reputation of the Illustrious Medical School, isn’t it now?”

\n\n

“But we have never been taught how to treat snake bites,” Phillipa pleaded.

\n\n

“Well may I suggest, Phillipa Dear,” said Peter, “that you find a good textbook and read it up, before starting work next year, or, for that matter, before visiting your Aunt Mabel again.”

\n\n\n

\nPractitioner I

\n\n

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

\n\n

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

\n\n

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

\n\n

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

\n\n

“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.

\n\n

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

\n\n

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.

\n\n

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.

\n\n

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.

\n\n

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.

\n\n

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

\n\n

An alumnus, I was pleased to see.

\n\n

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

\n\n

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

\n\n

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.

\n\n

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

\n\n

“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.

\n\n

“Uh, hi,” I said, a bit taken aback.

\n\n

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

\n\n

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

\n\n

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

\n\n

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

\n\n

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

\n\n

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

\n\n

“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.

\n\n

“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.”

\n\n

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.

\n\n

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

\n\n

“Yes Doctor,” came the reply.

\n\n

“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.”

\n\n

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.

\n\n

“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?”

\n\n

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.”

\n\n

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

\n\n

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.

\n\n

“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.

\n\n

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

\n\n

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

\n\n

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

\n\n

He jabbed the intercom button.

\n\n

“Next please,” he instructed quickly.

\n\n

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

\n\n

‘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.

\n\n

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

\n\n

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

\n\n

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

\n\n

“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.”

\n\n

“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.

\n\n

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

\n\n

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

\n\n

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’.

\n\n

“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?”

\n\n

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

\n\n

“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.”

\n\n

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

\n\n

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

\n\n

This unexpected interrogation reduced me to stammering.

\n\n

“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.

\n\n

“Why do you say that?”

\n\n

“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?”

\n\n

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

\n\n

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

\n\n

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

\n\n

“Next please,” he called.

\n\n

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

\n\n

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.

\n\n

“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.”

\n\n

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.

\n\n

There followed a moment of expectant silence

\n\n

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

\n\n

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

\n\n

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

\n\n

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

\n\n

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

\n\n

“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?”

\n\n

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

\n\n

The Doctor tried again.

\n\n

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

\n\n

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

\n\n

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.

\n\n

“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.”

\n\n

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

\n\n

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

\n\n

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

\n\n

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

\n\n

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

\n\n

“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.

\n\n

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

\n\n

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

\n\n

“To see if she is all in one piece.”

\n\n

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

\n\n

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

\n\n

“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.”

\n\n

At this she released a brief, enigmatic smile.

\n\n

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.

\n\n

“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.”

\n\n

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.

\n\n

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

\n\n

“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.

\n\n

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

\n\n

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.

\n\n

“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.

\n\n

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.

\n\n

“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.”

\n\n

Aunty-Mother looked grimly satisfied.

\n\n

“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.

\n\n

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

\n\n

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

\n\n

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

\n\n

The office door opened and the flowery reception lady appeared.

\n\n

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

\n\n

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.

\n\n

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

\n\n

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

\n\n

“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.

\n\n

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

\n\n

“Terrible, Doctor.”

\n\n

“And your shoulder?”

\n\n

“Oh Doctor, bad, very, very bad.”

\n\n

“Not to mention uh, your ribs?”

\n\n

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

\n\n

“Let’s check your blood pressure.”

\n\n

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.

\n\n

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

\n\n

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

\n\n

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

\n\n

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.

\n\n

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.

\n\n

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.

\n\n

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.

\n\n

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.

\n\n

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.

\n\n

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

\n\n

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

\n\n

“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.

\n\n

“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.”

\n\n

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.

\n\n

“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.

\n\n

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

\n\n

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.

\n\n

“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.

\n\n

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

\n\n

“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.”

\n\n

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

\n\n

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

\n\n

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.

\n\n

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

\n\n

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.

\n\n

“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.”

\n\n

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

\n\n

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

\n\n

“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.

\n\n

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

\n\n

“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.”

\n\n

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.

\n\n\n

\nRule One

\n\n\n