The devil wears a hospital gown

Doctors are renowned as being terrible patients. That may be true, but if I might voice my own opinion, I would say that doctor’s mothers are no “day at the beach” either! I first formulated this opinion when I treated Mrs. Durst in the Emergency Department late one evening only a few months after graduating.

The encounter is emblazoned in my memory, as that particular afternoon was absolute pandemonium in the ED – every bed was full, there was an endless queue of patients in varying degrees of infirmary waiting impatiently to be seen by medical staff, and ambulances relentlessly dispatched a barrage of the local sick and injured into the semi-organised chaos. Every single doctor on duty was juggling several patients – all of whom seemed to harbour particularly complex problems – so when an ambulance brought in Mrs. Irene Durst, the senior consultant assigned me to the case. Strolling into the cubicle, I was presented with an absolutely tiny, yet buxom lady, who I guessed to be in her early sixties, and who bore an uncanny resemblance to a gargoyle. Perched precariously on the examination bed and sporting the biggest pair of gold earrings I had ever seen, which competed in amongst a huge crop of died blonde hair (I had seen carpet stains more natural than her hair), my patient lay on her stomach with flesh spilling over both sides of the stretcher. My first instinct was actually to laugh; despite only taking up just over half the length of the bed, Mrs. Durst had positioned herself so her head jutted forward over the edge of the stretcher as if suspended by an invisible string, her mouth wide open and her eyes focussed on the entrance to the room. If there was to be any action, she was going to be the first to know about it.

Startled by the movement as I entered the room, her eyes suddenly came to life, darting erratically from side to side before quickly focussing on me and eyeing me up and down. I was just about to introduce myself and launch into a medical history, when Mrs. Durst obviously decided to take the bull by the horns:

DARLING!” she cried, almost at screaming pitch in a thick European accent, “You must be the baby doctor the nurse was speaking about. Bruno is it? Brian? No… Ben, of course darling, that’s it. Listen darling, I know you’re not very… how shall I say… experienced, but I don’t want to be in here all night waiting for some Professor to take care of me. After all darling, it’s only a scratch. So you’ll have to do darling. Do you think you’re up for it?  Well, do you?”

“I’ll certainly do my bes..”

“Course you will won’t you darling!” cried Mrs. Durst, warming to the conversation, both the pitch and volume of her voice steadily increasing.

“I know what it’s like darling. My son’s a doctor, oh a simply splendid doctor. You’ve probably heard of him darling – Dr Durst, Dr. Robert Durst. Oh he’s a brilliant man. All his patients think the world of him, darling, love him they do. He’s always booked out. He’s a genius darling. Have you heard of him?”

“No sorry Mrs. Durst, I’m sure he is an excellent doctor but the name doesn’t ring a bel…”

 “Oh, don’t they teach you anything these days darling? He’s so well known my son is. Oh, such a fabulous doctor, and years of experience too. I always like to see a doctor with plenty of experience darling. You baby doctors these days get taught all this gobbledy fancy new research darling, but give me experience any day – just like my Robbie. And do you know darling, after all these years he hasn’t lost the common touch. He always looks after his Mother, he does. If only he wasn’t on holidays darling, he would have been over in a flash. Make sure you do that darling won’t you. Don’t forget your poor Mum when you’re a doctor. Look after her just like my Robbie has over the years.”

“Of course, Mrs. Durst, I will I will” I stammered. “Now what has brought you in here toda…”

“Irene darling, call me Irene. Mrs. Durst makes me feel old darling, and I don’t feel old at all. My Robbie says I don’t look a day over 50 darling and he should know. Oh the ladies in his practice just adore him darling. Actually, you’re not bad looking yourself darling (my failsafe ability to charm the oldies coming to the fore I thought with a wry smile), but my Robbie is such a good looking boy.”

“That’s lovely Irene, what seems to be the proble…”

“Darling, darling, you’ve got to stop this chatter. It’s time we got me sorted out. Oh, I know what it’s like darling, my Robbie has trouble like that. He’s just so nice to everyone, he gets terribly behind in his schedule. But his patients don’t mind darling they love him for it. It’s my back darling… my back. Oh I am a… how-do-you-say… butter fingers? I was painting the kitchen darling, a beautiful shade of duck-egg blue; it’s fabulous darling. My husband can’t stand it darling, but I didn’t marry him for his taste. Yes, I was painting the roof of the kitchen darling, but I tripped and fell through the kitchen window darling. I thought I was done for darling, I thought it was the end. I work too hard darling, too hard. I’m tough though darling, and it looks like a made it. I’m just so mad darling that I didn’t finish the roof before I fell. Oh, and I must tell you this daring, when that charming ambulance man – very experienced he was, just like my Robbie, Oh I do love dealing with experienced people darling – wheeled me outside, I could see Gina, my neighbour darling, staring at me. If only she was in ear shot darling I would have given her what for. You’ve no idea what she’s like darling, her husband not ten minutes dead and already flirting with the postman. She brings the tone of the whole street down darling!”

And on it went.

Irene didn’t seem to stop for breaths. Eventually I managed to get a word in and attempted to salvage the remnants of a medical history.

“That’s fine Irene. Just before I have a look at your back, do you have any other medical conditions I should know about?

“What about allergies darling? My Robert always says you should ask about allergies first. Oh and he should know darling?”

“So… do you have any allergies Irene?” I stammered, clearly now on the back foot.

“Allergies? Of course not darling – a sign of weakness if you ask me. No I’m fit as a fiddle darling, never been better.”

 Admitting defeat, and satisfied that I had at least gained some remnants of a medical history, albeit unconventionally, I decided maybe an examination of the injuries would be in order. Explaining my intentions, I undid Irene’s gown amidst a relentless barrage of conversation revolving around her son, to discover a series of nasty lacerations on her back, seeping blood and obviously requiring some serious suturing to repair. As I completed a secondary surbey looking for any other injuries, quite amazingly – considering the nature of her fall – the back proved to be the only site of damage.

There was at least two hours of stitching required here, I estimated, to rejoin the jagged edges of the lacerations on Irene’s back, and as I considered what the the next two hours held in store, I think at that point, something inside of me died!

This was going to be one for the diary…

“Can you see what I’ve been through today darling?” Irene wailed as I finished my examination, “I’m going to need stitches darling, do you think you can handle that? My Robbie is so good at stitching darling, I’ve never seen him leave a scar. That’s experience for you darling. Well let’s get it over with then I haven’t got all day darling; this injury has already consumed my life darling, I’ve missed a hair appointment this afternoon and it’s so hard to find a good hairdresser these days don’t you think”.

“Quite, Quite,” I mumbled, attempting to collect my thoughts in amongst Irene’s unrelenting tirade and the chaos of patients around me. “Just relax here while I find the equipment and then we’ll get started”.

“Whatever you say darling, whatever you say. I’d use size 4 nylon myself – Robbie always says that gives the best results and he should know darling. Oooh he’s such a good doctor, never leaves a scar….”

Nearly running from the room now, I was some distance away from the cubicle before Irene’s ranting finally fell out of earshot. Taking a few deep breaths, I made myself a quick cup of tea before hunting down the equipment I would need to sow Irene back together – suturing set, local anaesthetic, size 4 nylon (who was I to go against Robbie), surgical gloves and gown; unfortunately no ear plugs were available. A quick check with the consultant confirmed my view that the wounds were superficial enough to stitch and none warranted further attention, then taking some deep breaths I prepared to head back into that cubicle. This was going to take a while.

Irene’s voice hit me like nails on a chalk board, several metres from the entrance to the room.

“Surely she can’t be talking to herself” I thought, as I pulled open the curtain, preparing for round two. Irene wasn’t talking to herself; she was venting her spleen on a very skinny, greying man who was sitting next to the bed, holding a beautifully crafted wooden walking stick.

“I hope you don’t mind doctor. The nurse showed me in while you were away,” the man spoke very quietly in a thick English accent, his wrinkled face radiating friendship and appreciation, as he stood up to shake my hand with military bearing. “Thank ye so much for helping out me wife – I was right worried when I saw her fall through the glass.”

“Harold!” Irene erupted as if her husband had just issued an obscenity, “Don’t bother the doctor. He doesn’t have time to waste on you. I’m the one who almost died today… and missed a hair appointment. My nerves are shot to pieces. I’m booked in to have my eyebrows done tomorrow and if I can’t make it… well I just don’t know how I’ll cope”.

“Yes of course dear” said Harold, giving me a long-suffering smile and sitting back down immediately.

“Now darling” cried Irene at a deafening volume, “let’s get moving, yes? Which one shall we stitch first; I think that cut on the left will need about four stitches. Robbie always says they should be about 1cm apart for best results, and he should know darling, oh, such an experienced doctor”.

Donning my gown and gloves, before I began the process of injecting local anaesthetic, I quickly checked that Harold was comfortable to watch the procedure, and didn’t, for example, faint at the sight of blood.

“Don’t you worry Doctor” he assured me, “I fought in the Great War and I’ve seen worse than this in my time”

“He’ll be fine darling. It’s me you should be worried about” cried Irene.

“Just one question doctor” interjected Harold softly, as I filled my syringe with the local anaesthetic lignocaine containing adrenaline (added to help prevent bleeding), “Will it be very painful?”

“Oh Harold don’t be so ridiculous” shouted Irene, “I’m not worried about a little sting. Although my Robbie never hurts anyone darling; his patients don’t feel a thing.”

“Actually Harold”, I said “The actual stitching process shouldn’t hurt at all, but to be honest, injecting local anaesthetic can be a bit unpleasant. It’s likely to sting for a couple of seconds before it starts to go numb”.

That took the smile off Irene’s face, and quietened her down for a few minutes, and as I held up the syringe and squeezed a few drops out the end, I was sure I could detect the faintest twitches of a smile appearing at the corner of Harold’s mouth. He was no fool I though to myself, and as he leaned back in his chair and folded his arms, his face said it all: after years of living with Irene now was his chance, even if only for a few minutes, to gain the upper hand.

And so it began. Amidst Irene’s assertions that I was injecting at a different angle to Robbie, which explained the unnecessary stinging sensation (that every patient receiving local anaesthetic inevitably experiences), I infiltrated the first laceration with local and waited a few minutes for it to take effect.

Unlike the vast majority of the new doctors I studied with, I am actually very confident at stitching. So many of the skills that medical students were expected to gain experience at (plastering, taking blood, putting in drips etc) required so much effort for me to master – or at least gain some semblance of competence at. However for some strange reason, stitching seemed to be second nature to me. I have thought at times that I missed my true calling as a seamstress or dress maker, as I could be presented with a jagged, dog-eared cut, and by the time I finished it was a barely discernible line. I first discovered this in the Emergency department as a third-year student when a consultant asked me to stitch up a builder who had lacerated his arm. When I explained that up to that point I had done only two stitches – both of them on fake skin – and had never injected local anaesthetic, she simply gave a laugh, said “you’ll be right”, and locked me in a room with the builder. I was absolutely sure this would end in, at the very least a medicolegal disaster, possibly the permanent loss of function in this poor builder’s arm, and the outside chance of amputation. Fifty minutes later however when I emerged – sweating profusely and with an incredibly sore back from leaning over the patient –  the consultant couldn’t believe I had transformed that gaping, bleeding mess into a perfectly even, neat line. News spread fast, and from that time on, whenever there was a stitching opportunity and I was on duty, it was automatically left to me.    

Consequently, I began stitching up the large wounds in Irene’s back with vigour, constantly assessing where to place the next stitch so as to avoid puckering at one end of the wound, which significantly decreases the cosmetic result. Irene, however, was not going to let this prime opportunity to educate the next generation of doctor pass, and now out of pain, she really opened the throttle with a stream of educational comments:

“Darling, darling, Robbie puts the needle in much further from the edge of the cut than that. You don’t want the stitch to pull through darling”;

“My Robbie never does two loops when he ties his knot darling, and I’m sure that’s why he never leaves a scar”;

“Darling, that cut could obviously use another stitch, no?”

Through this unrelenting barrage from Irene, I plodded along, anaesthetising each laceration and carefully stitching it together. I was actually amazed at Irene’s flexibility and endurance; she was able to lie on her stomach with her neck craned almost at 180 degrees to view the progress and pass  judgement. No amount of subtle encouragement would convince her to lie down and relax for a while. After the first hour, I found myself wishing that the infamous Robbie might actually show up and relieve me, but unfortunately it was not to be. Harold too, must have thought that Irene was becoming a little overzealous with her commentary, as he decided to try and stick up for me:

“Irene dear, don’t bother the nice doctor. Let him get on with his work. I think he’s heard enough about Rob”.

“Don’t be ridiculous darling” came the instantaneous reply. “I’m helping him darling. We wouldn’t have got nearly this far if I wasn’t here. He’s not a real doctor you know”.     

Two hours and 118 stitches later, I tied my final loop and stood up, exhausted, to survey my handiwork. Stretching my aching back, I looked with satisfaction at the lines of neat stitches the transversed Irene’s entire back. Irene looked like a patchwork quilt, but at least she was in one piece. As I covered the wounds with waterproof dressings, and confirmed that Irene was up-to-date with her tetanus vaccination, I explained to Irene and Harold the logistics of having stitches:

“Now Irene, the stitches will need to be left in for at least 7 days, and you can get your son or your local doctor to remove them. In the meantime, you have to keep the area dry. Also, if you notice any bleeding, you need to apply firm pressure and ice for at least 20 minutes. Should the bleeding continue despite this, which is extremely rare, you will need to return immediately to the Emergency Department. Also, if you notice any signs of infection – redness, swelling, discharge, pain – you will need to see your local doctor or come back here to get some antibiotics.”

I wrestled in my mind whether to ask the question that ended most clinical encounters, particularly in view of what I had endured through the last two hours, but in the end my morals won out…

“Do you have any questions?”

This was like waving a red rag to a bull, and I could see Irene about to leap into action, when Harold stepped in, obviously deciding that enough was enough. Summoning the courage that enabled him to leap from the trenches inFrancesome 60 years go he said quickly:

“No that’s fine doctor, I’m sure my wife understands that information. Thank you very much for all your time. We both really appreciate it and I’m sure you’re going to make a wonderful doctor. Irene… we’re leaving.”

“But Harold…” cried Irene, in more distress now than at any other occasion throughout the encounter.

“No, leave the poor doctor in peace. I’m surprised he hasn’t stitched your mouth closed!”

I could have hugged him right then and there. Instead, in a rare moment of self-control, I simply shook his hand, wished Irene all the best and left the cubicle.

 As I walked briskly towards the staff room, satisfied that I had done the job to the best of my ability, I should have known it was too good to be true. With a force that would have measured on the Richter scale, I was almost deafened by a high-pitched voice that thundered through the entire Emergency Department:

“Robbie takes his stitches out after five days darling. And he always says real doctors should wear a tie to work. You should think about that… after all, he’s very experienced!”

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About Ben Kirkland

An apple a day... I am a young Doctor currently specialising in Internal Medicine and working full-time at a tertiary Hospital in Australia. In my day-to-day dealings with patients, I never ceased to be amazed at the extraordinary courage displayed by ordinary people in face of tremendous adversity and sometimes insurmountable health challenges. I am inspired to share some of these experiences - some are funny, some emotional, some heart-warming, some unjust... all true. I also hope to share with world my passion for medicine and perhaps even enlighten a few people on the organised chaos that is modern hospital medicine. Enjoy...
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