My main worry with Nigel is that one day he might get very paranoid and kill somebody. It is very rare for somebody with mental illness to commit murder, but it does sometimes happen and when it does, the debate on how we should manage people like Nigel is reopened. The finger is pointed at GPs, psychiatrists and politicians and then everything blows over and not much changes. Today we can’t lock up Nigel because he isn’t harming himself or anyone else. I am scared that if he smokes enough dope, he might get sufficiently paranoid to harm someone, but my fears aren’t a good enough reason to lock him away. Nigel does have a designated psychiatric nurse, who is very nice but struggles to keep track of him. There are only so many times the nurse can wander the city centre looking for him. If she finds him, she buys him a coffee and tries to persuade him to stop smoking weed and to take his medication. Then she leaves and Nigel goes back to his chaotic paranoid existence. There are community support teams and services available to help people like Nigel, but when he is out of hospital he doesn’t really have much interest in using them.
Nigel will always have a difficult, chaotic life, but it would be nice to think that we had the services available to keep him and everyone else safe. At the moment we don’t. If he did take his medication regularly, he would probably stay fairly well. The problem is, like many people with mental illness, he just won’t take it voluntarily. One option is to consider paying people like Nigel to take their antipsychotic drugs. It is a controversial idea but every time Nigel is admitted to hospital it costs the NHS thousands of pounds. If Nigel were paid ?20 per month to come and get his injection of antipsychotic medication, it would probably be enough incentive for him to take it and he would almost certainly remain well. This would save thousands of pounds in hospital admissions and also reduce the harm caused to Nigel and those around him every time he becomes unwell. Many are against this idea, feeling that it degrades people with mental health problems. There are many stable, well-supported people with schizophrenia and other types of mental illness who take their medication readily without the need for financial incentives. Unfortunately, there are also an awful lot of Nigels.
Memories
I see about 40 patients a day and have been a doctor for several years. As you can imagine, over the years I have seen many thousands of patients. For the duration of their time with me, each patient has my full and undivided attention. But once they leave the room, my recollection of them fades quickly and they are filed into a grey blurry part of my memory somewhere between the names for the small bones in the hand and the West Ham team of 1985.
I’m sure many patients forget me as rapidly as I forget them, but I’m still surprised by the impression I can sometimes make as a doctor. I once got stopped in the post office by an elderly lady who greeted me as if I was her long-lost son. ‘Dr Daniels! It is you, isn’t it? It’s me Rita, Rita Lloyd. You saw my husband Roger in A&E about four years ago.’ I had absolutely no memory of her at all. Even digging deep into my brain, I pulled out Tony Cottee and Frank McAvennie (1980s West Ham legends) but no Rita and Roger Lloyd. ‘You helped save my husband’s life!’ I was really racking my brain now. I should’ve recalled something. I endured many long and arduous shifts in A&E but it was rare that I ever helped save anyone’s life. ‘Roger had a tummy ache and everyone said it was just constipation but you examined him and said you thought there might be a more serious cause for the blockage. You sent him straight to the surgeons and they operated that night. He nearly died on the operating table but thankfully he pulled through.’ ‘Oh yes,’ I said. I now had the names of nine West Ham players and two hand bones (although one of those might actually have been a foot bone) but still had no memory of Roger and his tummy pain. ‘How is Roger doing now?’ I asked. ‘He died nine months later from the bowel cancer that was causing the blockage, but we are all so grateful for that extra time you helped to give us.’ She gave me a big hug, shed a tear and left me to carry on in the post office. It’s not often that I get a warm fuzzy feeling like that but it really was a vintage year for West Ham…and it’s nice to think that I occasionally make a difference as a doctor.
Fighting
Tommy has a proper West country ‘ooarr’ accent that never fails to entertain me. He’s not particularly blessed in the brains department and has a very high TTT score. TTT stands for tattoo to teeth. The rule is that if a patient comes in with more tattoos than teeth, they are probably going to have a fighting-related problem. This may seem like another unfair prejudice made by snobby middle-class doctors, but it is in fact a frighteningly accurate clinical sign.
‘’Allo, Doctor. I’ve come about my nose. It’s sniffing, see. I can’t sniffs on this side. And I can’t sniffs on the other side, neither.’ Tommy demonstrates with a long and unsuccessful attempt to breathe in through both nostrils in turn.
‘See, Doctor — I can’t sniffs nothing. I snores like a bear and I can’t even smells my own farts.’
You didn’t have to have a medical degree to spot the problem with Tommy’s nose. It was clearly big to start with, but had unmistakably been broken on several occasions and now pointed in several directions at the same time. Judging from his multiple tattoos and missing teeth, I imagine that Tommy’s nose has probably been punched out of shape, but it seems unfair to jump to conclusions.
‘So, Tommy, it looks like you’ve broken your nose. Was that a sporting injury, perhaps?’
Tommy gives me a big toothless smile.
‘No, Doctor. I broked it fighting. I broked it this way fighting in the pub and then my wife broked it the other way when we was rowing at home. Just the other day I think I might ’ave broked it again when I fell over pissed.’
I send Tommy off to the facial surgeons but warn him that they have quite a job on their hands.
I myself am pleased to say that I have never been hit. Although my nose is big, I am relieved that I have at least managed to keep it straight and I’m rather keen it remains that way. A recent report suggested that up to one-third of NHS staff have been physically assaulted at work. One of the reasons I have avoided violence during my years as a doctor is my natural tendency to exhibit cowardice at every possible opportunity. This was most clearly demonstrated when a fight broke out between two drunk patients one Friday night in the A&E department. When looking back at the CCTV footage with the police, several small nurses could be spotted bravely moving towards the action and attempting to break things up. Meanwhile, I could clearly be seen running away in the opposite direction towards the door.
I have been threatened on several occasions and it is easy to feel quite vulnerable when you are alone with an angry patient in a confined space such as an A&E cubicle or a GP surgery consultation room. People can get angry and aggressive when they are in pain or scared about their own health or the health of their loved one. Sometimes their aggression is part of an illness such as schizophrenia or dementia. Sometimes they are just drunken arseholes looking for a scrap. I have a simple rule. If someone is unnecessarily aggressive and abusive towards me, I won’t see them. On one occasion in A&E a man was needlessly abusive and threatening towards one of the nurses. He was a little drunk but that was no excuse. He was shouting and swearing in front of young children and elderly people in the waiting room and, towards the end of a long and tiring shift, I decided that I was not going to put up with that sort of behaviour and I refused to see him. This made him more angry and he ended up kicking off big time and getting arrested. I could have probably resolved the situation peacefully by placating him verbally, making him a cup of tea and letting him jump the queue to be seen. But why should I?
When I made the decision not to see that man, I was in a busy A&E department with plenty of porters and a couple of burly security guys on hand to help protect me from getting a beating. Had I been less well protected, my cowardly instinct would have kicked in and I’d have happily treated him immediately as long I knew that it was going to prevent me ending up with a nose like Tommy’s.
Class
