[This stand alone story serves as a sequel to a previous story about Dr Scrooge and thus contains a couple of spoilers to that previous tale. In the unlikely event that there is someone who is foolish enough to want to read that story before this one, its beginning can be found here. As with that former tale, any similarity here to real people or events is entirely deliberate. Names, however, have been changed to protect the contentious.]
A Tale of Two Patients
In which Dr Ebenezer Scrooge finds some meaning in the seemingly meaningless and determines to keep on keeping on – at least for a little longer yet.
It was a little after eight in the morning and Dr Ebenezer Scrooge was sitting at his desk, looking at his computer screen. He watched as, with every passing minute, the list of patients he had to call lengthened. He was the only doctor in the practice that morning as his partner, Dr Robert Cratchit, had phoned in earlier to report that, since his six month old son had developed a fever overnight, he’d have to self isolate and work from home pending the result of the Covid swab that he’d organise to have taken later that day. Though frustrated, Scrooge didn’t blame Bob. He knew his colleague wasn’t one to avoid work and understood that the practice had to be seen to comply with government guidance on limiting the potential spread of the coronavirus, even if the actual risk from his partner coming in to work was small and far less than that posed to patients as a result of their care being compromised by his not being at work.
Scrooge reflected on how he’d never been so dissatisfied with his working life as he was now, more dissatisfied even than he had been, three years previously, when the spirits of General Practice Past, Present and Yet to Come had made their life changing nocturnal visits to him. A lot had happened since then. Bob, who had been a registrar at the time, had completed his training, joined the practice as a partner and even found time to marry one of the admin staff and have a child. But then Covid-19 had arrived on the scene and, as well as all the suffering and death it had caused, it had also had a significant effect on the provision of primary care.
Scrooge was alarmed by how fast the vision brought to him by the Ghost of General Practice Yet to Come was now becoming a reality. More and more consultations were being undertaken remotely, a trend that, though perhaps necessary for a time, had been welcomed by much of the profession and was one that seemed set to remain. Scrooge though, a man so old fashioned he’d yet to switch to a height adjustable desk, was less enthusiastic. To some this contactless life might be considered to be ‘the new normal’ but, in Scrooge’s eyes at least, whilst new, it was in no way normal.
Furthermore Scrooge found himself constantly asking if the response to the coronavirus might not, in the long term, do more harm than good. He understood, of course, that steps had needed to be taken to control the spread of the virus, but wondered if perhaps the right balance hadn’t quite been struck.
In the early days of the pandemic he had been informed that, as a GP, he’d be responsible for providing end of life care to patients with the coronavirus. He’d been told it was likely he would have to explain to many of them that, due to a lack of ventilators, it would not be possible for them all to be admitted to hospital and that a good number would, instead, have no option but to take their chances at home.
Scrooge had of course found all this deeply concerning, but when he started being asked to contact all his vulnerable patients and discuss with them their end of life preferences he sensed something wasn’t quite right. This feeling grew when he did a few calculations and realised that, were there to be 50,000 deaths in the country, a figure the government had suggested as a worse case scenario, he himself could expect to lose just one or possibly two of the 1800 patients on his own list. And though it would be no less sad for those who grieved their passing, those most likely to succumb to Covid-19 would be those who were already drawing to the end of their lives and might, therefore, not unreasonably be expected to die this year even if Covid-19 had never existed.
What Scrooge knew for sure though was that nearly six months on not one of his patients had actually died, only two or three had been hospitalised and he hadn’t seen anyone remotely unwell with coronavirus for months.
And in addition to all this Scrooge kept hearing about all the consequences of the measures taken to tackle the pandemic: the tens of thousands of non-Covid related deaths due to patients not receiving sufficiently timely treatment for their conditions, the hundreds of thousands of additional deaths that were likely to occur as a consequence of the lockdown having so badly damaged the economy, and the millions of people who would find themselves joining the queue of those unemployed or those waiting for NHS treatment.
It was, thought Scrooge to himself, the worst of times, an age of foolishness and an epoch of incredulity – with absolutely no positive side to it. Still, his was not to reason why, his was but to do and, almost certainly, not die. And with that Scrooge realised that he’d better stop wondering how long he could continue working as a doctor and start instead phoning the numerous patients who’d already requested urgent contact with him that morning.
He quickly dealt with the first couple of calls which involved patients seeking advice about minor upper respiratory tract infections. He hated himself both for prescribing antibiotics (‘just in case’ due to his not being able to see and assess them properly) to patients who almost certainly didn’t need them, and for then going on to advise them that the whole household would now have to self isolate pending the symptomatic family member having a Covid swab. He knew that the former went against all he had tried to teach patients regarding how antibiotics were unnecessary for self limiting viral infections and that the latter would threaten the livelihoods of families but was nonetheless deemed essential even though, ever since his patients with possible Covid symptoms could have a swab taken, not one had come back showing a positive result.
The morning continued in similar fashion though soon, amongst the physical problems that were being presented, a number of cases relating to the mental health of patients required triaging. The isolation of lockdown was now getting a lot of people down and many more were experiencing high levels of anxiety. For many the concern was about catching the coronavirus, even amongst those for whom there was very little risk of their coming to any harm were they to do so – for others it was the threat to their livelihood that was causing them to lose sleep. Scrooge tried to support them as best he could but knew he’d be able to do it so much better if he could see a few of these folk face to face. Even then, however, the requisite plastic apron, latex gloves and face mask would make meaningful conversation on sensitive matters difficult.
At mid morning there was a knock on the door announcing the arrival of one of the reception staff with a cup of coffee and a selection of biscuits. Scrooge accepted them gratefully and munched on a custard cream whilst signing the prescription handed to him by the receptionist. It had been requested urgently by a patient who was currently waiting for it in reception.
Brushing the crumbs from his lips, Scrooge looked back at his computer screen and noticed another call had come in from an elderly man who’s problem had been flagged simply as ‘back pain’. Pleased to have such a straight forward call to deal with, Scrooge picked up the phone and dialled the patients number. Within a few rings the patient answered.
‘Hello, is that Mr Carton? It’s Dr Scrooge, how can I help?’
‘That was quick doctor, I hadn’t expected you to ring back so quickly, I know how busy you all are, what with this virus and all. But don’t worry about that with me, it’s just my back that’s the problem. It’s kept me awake all night it has – I’ve never before experienced anything like it.’
Scrooge asked a few more questions and didn’t sense that anything particularly concerning was going on other than the fact that Mr Carton, a man not prone to call for help unnecessarily, seemed quite agitated by the pain and that he’d not had any relief from even his wife’s reasonably strong painkillers. Scrooge decided that he had perhaps better see his elderly patient after all. He felt guilty for doing so since the guidance was so insistent that all patients should be managed remotely wherever possible.
‘I’d like to see you Mr Carton, but before I do I need to ask a few more questions. Have you developed a new persistent cough lately?’
‘No doctor, it’s just my back, it’s like …”
‘Or a fever?’
‘No doctor, as I was…’
‘And have you lost your sense of smell at all’
There was a pause on the end of the line as Mr Carton clearly struggled to understand the relevance of such a question to his clearly stated problem of back pain. Eventually he answered in the negative and Scrooge asked him to come down to the surgery but to wait in the car park until he was ready to see him. He’d ring in 15 minutes and say when it was safe for him to enter the building.
Whilst he was waiting Scrooge dealt with a few more telephone calls including one from Enid Gray. Mrs Gray was terminally ill and had been so for some while. She had survived longer than had been expected despite, on Scrooge’s advice, repeatedly ignoring the letters sent out under his name inviting her to have a repeat blood test to determine if she were still pre-diabetic. But now she was undoubtedly losing her battle with cancer and was very definitely going rapidly downhill. He picked up the phone and was soon speaking to the patient he’d become very fond of ever since he’d invited her to share Christmas Day with Cratchit and himself a few years previously.
‘Hello Mrs Gray, how are you? How can I help?’
‘Oh I am sorry to bother you Dr Scrooge. It’s just that I feel so tired at the moment. Since I came out of hospital I’ve simply no energy at all’.
Mrs Gray had been admitted the week before having taken a fall at home. She had been discharged precipitously under the guise of it being too dangerous for her to stay in hospital in the middle of a global pandemic. Little thought seemed to have been given, however, to the risk of her living alone without an adequate package of care. Mrs Gray did not have a smart phone so there was no possibility of Scrooge doing a video consultation with her. Despite this, and though he hated himself for even thinking it, were Mrs Gray to die, since she’d been seen so recently in hospital, Scrooge knew he wouldn’t have the unnecessary nuisance of having to liaise with the coroner about her death, not under the new guidance that had come out on the issuing of death certificates during the pandemic. Even so, Scrooge looked up the results of the tests taken during Mrs Gray’s hospital stay. He noticed that she’d been found to be a little anaemic and so Scrooge suggested that he write Mrs Gray a prescription for some iron tablets and arrange for the district nurses to check a further blood test later in the week. Mrs Gray seemed happy enough with this plan but Scrooge nonetheless stressed that, should she feel any worse, she could call him again at any time.
By the time he’d done this he noticed that it was time to see if Mr Carton had arrived. He called him on his mobile and learnt that he was indeed waiting in the carpark. Scrooge invited him in saying he’d meet him in the waiting room. He then donned his PPE being careful to tie the plastic apron about his waist before putting on his gloves, experience having taught him that with gloves on it was nigh on impossible to tie the apron effectively. Mask applied Scrooge then went to the empty waiting room pending Mr Carton’s arrival. As he sat there, perched on the radiator, he surveyed the carefully spaced seats that so few people these days sat on. It saddened him that this was no longer a place where people gathered waiting to be seen, somewhere one might bump into an old acquaintance that one hadn’t seen for years and with whom one might catch up on each other’s news.
A few minutes later Mr Carton arrived accompanied by an obviously very anxious Mrs Carton. It was becoming something of a trend now but once again Scrooge found himself hating what he was doing as he asked Mrs Carton if she wouldn’t mind waiting outside. ‘Because of the Coronavirus’, he added by way of explanation. Walking together toward his consulting room Scrooge paused by the waste bin in the corner of the waiting area and, by holding his apron close to the container, indicated to Mr Carton how that which was now supposedly protecting him from a deadly virus, was made of the exact same material as that which now lined the bin. It always amused Scrooge to point this out to patients even if by doing so it served only to make him feel even more rubbish about himself.
Back in his consulting room, and having run over the symptoms again, Scrooge asked Mr Carton to pop up on the couch. Scrooge had noticed that the agitation that he had sensed in his patient on the phone was apparent speaking to him in the flesh, Mr Carton was finding it difficult to stay still. Up on the couch Scrooge noticed something else – a pulsatile mass in his abdomen which could be nothing other than an abdominal aortic aneurysm.
After explaining the seriousness of the situation and calling for an ambulance, it wasn’t long before Mr Carton was being led away by two paramedics to the emergency vehicle that was now parked outside the front doors of the medical centre. Scrooge walked out with them and caught site of his patient’s increasing worried wife. Stepping over towards her, Scrooge explained what was happening to the man she’d been married to for more than fifty years.
‘I’m afraid you won’t be allowed to go with him, Mrs Carton. The hospital aren’t allowing any visitors at the moment you see.’
‘But he will be OK?’, she asked, ‘I will see him again won’t I?
Scrooge wanted to look her the eye but found himself unable to meet her gaze. ‘I’m sure he’ll be fine’ he said, trying to sound confident before adding, more honestly, ‘At least, I hope he will’. With that Scrooge went back inside, removed his PPE and placed it in the bin. Along with all that was being used both by him and the rest of the practice staff, he pondered how long it would take for all of it to biodegrade. He thought how insignificant his previous use of the odd plastic straw now seemed in comparison to environmental impact of all this discarded PPE.
The day continued in similar vein and when he eventually finished the day’s work shortly after 7.30 he noted that he’d completed 86 individual patient contacts made up of telephone calls and face to face consultations. In addition there had been the day’s post to read and act on, blood results to deal with and many, many repeat prescriptions, requests for sick notes and other sundry other administrative jobs. It hadn’t been the busiest of days but it was somewhere close to it. And yet he thought to himself, if the posts he had seen on social media were anything to go by, many people out there felt that GPs had reneged on their duty throughout the coronavirus crisis.
As he logged off from his computer he noticed the four cold cups of coffee sitting undrunk on his desk, together testifying to how busy his day had been. What he couldn’t understand however was why there was never an accompanying pile of uneaten biscuits! ‘Another medical mystery’ he said to himself as he stood up, ‘but one that will have to remain unsolved for the time being. I’m off home.’
Scrooge locked up the building, got into his car, and set off for home. He tried to turn his thoughts away from the day, but as he drove the radio was playing Solomon Burke’s ‘Cry to me’. Hearing of how loneliness was such a waste of time, of how it made you want to cry, Scrooge couldn’t help but think again of Mrs Gray and so, having deviated from his usual route home, he soon found himself parked up outside her home instead.
Walking to the door to the stairwell of the block of flats in which she lived, Scrooge noticed a now faded rainbow that someone had painted on the adjacent wall. Underneath were written the ubiquitous words ‘Thank you NHS’. Scrooge averted his eyes, uneasy at what seemed to him as yet another shrine erected to an organisation that, whilst wonderful, was being deified in ways that weren’t helpful, by a population that was putting all its hope in an NHS that could not possibly deliver all that was being asked of it. He didn’t consider himself a hero of the pandemic, that particular label he felt, would surely be better applied to those who would lose their jobs and livelihood over all of this.
Scrooge pulled opened the door and climbed the steps to Mrs Gray’s flat. As he donned yet more PPE he noticed the piles of bottles filling the recycling box of the flat opposite that of Mrs Gray. Somebody was clearly doing their bit to support the local off-licence in these difficult times. Scrooge wondered if the young Mum who lived there, and who had called him several times this week regarding various minor problems, might be better served by a face to face consultation. Perhaps she’d feel freer to talk when she wasn’t being overheard by her partner, given how he was known to have problems ‘managing his anger’. He made a mental note to call her in the morning before turning back to Mrs Gray’s flat and ringing her doorbell.
Nobody came to the door and so Scrooge rang it again. Again there was no response. Trying the door and finding it unlocked, he gently pushed it open and entered the flat.
‘Hello? Mrs Gray? It’s Dr Scrooge – is anybody here?’
Scrooge made his way in the direction of the feeble voice that called out from the back room and found there Mrs Gray, laid uncomfortably on her bed, desperately pale, weak and laboured in her breathing.
‘Dr Scrooge, what are you doing here?’ Mrs Gray asked, barely able to voice the words. ‘I wasn’t expecting you to call round, I know how busy you all are at the moment. And aren’t you supposed to avoid visiting people like me?’
Scrooge looked down at his feet and felt ashamed at the thoughts he’d had when he’d spoken to her earlier that day.
‘Some would say so, Mrs Gray, some would say so’, he replied and, realising that Mrs Gray’s time was near, Scrooge did something else that he wasn’t supposed to do. He pulled off his mask and apron and, after slipping off his gloves, took Mrs Gray’s hand as he sat down next to her on the chair that stood by her bed
‘Enid’, he added, thinking to himself how nobody should be allowed to die without a friend present, no matter what anyone says, ‘I suspect that what I am now doing is a far far better thing than I have ever done. Of course I should be visiting you.’
Mrs Gray smiled at Scrooge, and Scrooge smiled gently back.
Thirty five minutes later, after a call to the local funeral director, Scrooge was back in his car. Picking up his phone he dialed the number for the hospital and was informed that Mr Carton had had his aneurysm repaired and, all being well, would be allowed home the following day. The vascular team had apparently had little else to do and so had wasted no time in dealing with what was the most interesting case they had had in weeks.
Scrooge smiled again, this time to himself. Perhaps his actions today hadn’t changed the world, but they had made a world of difference to at least one or two people he’d had the privilege of helping. Perhaps he thought, he would continue in General Practice, at least for a little while longer. And that, he decided, was cause for celebration. After all, as one whose income had not been threatened by the events of the last six months, he had much to be grateful for, not to mention a civic duty to support the local economy.
And besides, he’d had nothing to drink all day.
To read the full story of ‘A Primary Care Christmas Carol’, click here