THE CULPRIT
Amod Saxena
The
Royal Ipswich Infirmary had just hired me as a young doctor in
Nevertheless, we had a lot of fun also. The hospital provided us meals and a place to live. We had maid service to bring our tea, clean our rooms, and make our beds. In the dinning room, we had butlers and chefs. They tried to please us by cooking their version curry, rice and kebabs. The nurses and sisters were kind. They taught us most of the practical aspects of clinical medicine.
At the Infirmary, all junior house officers lived in a row of several rooms next door to the children ward. We could hear children’s voices from our rooms. Our Common Room was large and bright: we spent a lot of time here when not busy caring for our patients. It was bright and sunny during the summer. It had a large window and looked down at the courtyard of the hospital. The black and white television was a big box and sat on the floor. To the left of the television was a large fireplace. A porter would bring fresh supply of coal each morning and we would light the fire keep us warm. There was no central heating in the hospital.
On first day of my job, I arrived in the afternoon and went to the room given to me. It was small with bare white walls. A narrow bed was set against one of the walls. The heat came from a small gas heater set in the wall next to a sink with a round mirror over it. This would be my home for the next six months. When I first visited my room, I began to wonder my situation in a strange place far from my homeland.
I had brought a few personal possessions with me, most stored in a small suitcase and a few in a plastic shopping bag. I put the suitcase down on the floor and threw the shopping bag on the bed. I crossed the room and looked out of the window. A maroon Bentley and a black Jaguar was parked on the hospital courtyard below. The Jag, I discovered later belonged to Mr. Whitepark, the chief hospital surgeon. I was to work with him during my stay at the hospital.
During my trip to the town that morning, I realized that most people around me had difficulty understanding my thick accent. I tried to speak slowly and often translate my thoughts from Hindi to English first before uttering them to others. This made things worse.
I missed my family
and my friends. I missed the heat and dust of my childhood. I missed the smell
and the sounds of birds singing. I wanted to close my eyes and transport myself
right that instant to my hometown. With no funds and no means to support myself,
I could hardly think of that luxury. There
was also a question of my pride. I did not want to go back without an education
behind me. Going to
I turned around and sat down on the narrow bed. I laid down on it without changing my clothes and soon fell asleep. Somehow, sleep would free me of my feelings.
I woke up next day early in the morning to the sound of people in the children ward. I took a quick bath, got ready and reported to the male surgical ward on the fifth floor of the hospital. I had no idea about my duties. No one at the hospital oriented me about my schedule. I felt the butterflies in my stomach just as I had felt them on my first day at school a long time ago. I went directly to the “sister’s office” as the chief nurse’s office was then called. The room was small and seemed crowded with a desk in the middle with two chairs facing on each side of the table. As one entered the room, a bookshelf occupied its right wall. Several surgical and non-surgical books lay on the shelf arranged rather loosely. I saw two women sitting across each other at the desk. Both were Staff Nurses as I found out later. They wore white uniform with gray strips and white nurse’s cap. The woman with dark hair and black rimmed glasses was talking softly to the nurse sitting opposite to her. The first woman was the night nurse who was handing her charge of the patients over to the day-nurse. The latter had a slim body and red hair. She raised her head and looked at me. Our eyes met for a moment then she quickly went back to taking notes. I just stood there and said nothing. I did not know what to do. The two women continued with their work.
After several minutes that seemed an eternity to me, the red-haired nurse suddenly stood up and looked at me; I kept standing there without saying anything.
“Coffee?” she asked and came to stand besides me. She was thin and about five feet two inches tall. She had a narrow waist made narrower by a tight black leather belt.
Still conscious of my difficulties with language, I kept quiet. The single lighted bulb from the ceiling hanging above exposed her sharp nose and large eyes. Her face was thin and long. She had freckles and blue eyes. Until then, I had not seen a person with freckles, blue eyes and red hair at such a close range. I was used to seeing black hair, dark eyes and dark faces. Her freckled skin was smooth with a reddish hue. She seemed young probably in her twenties like me.
“Are
you the new doctor? We knew you were coming.” She said matter of fact manner. “I am Peggy; just call me Peggy; that is what
my parents call me. Sister Reed is on
holidays and I am in charge here. Say! You are not a bad looking man,” She said
inspecting me closely. “Once you take
that mustache off, you would look even better. What do say,
“Let’s get going, we have a lot to do this morning; you better start cracking right away. We had a new admission earlier this morning. He has not passed water since yesterday. Go see him; I have the catheter tray ready for you. You need to put it in his bladder and relieve him from his misery.” She spoke rapidly stringing her words in a rapid succession. I only caught a few words of what she said.
She took hold of my right arm and led me to the fourth bed on left side of the ward. The ward was a long room with few windows looking out. Thirty-two beds were set against the two opposing walls, sixteen on each side. Patients occupied many beds but a few were empty. The empty beds were made up neatly. A dull light brown curtain hung from the ceiling around each bed for privacy. The patient on the fourth bed was lying propped up on two pillows under his upper torso. A white sheet covered the rest of his body.
“
Without waiting for a reply, she left me with the patient. Later that morning I found out that her name was Elizabeth Mary Ann Ryan; Peggy or Peg for short.
Mr. Cleland was a sixty-six years old and a retired coal minor. A local ambulance had brought him to the hospital very early this morning because he had not passed urine for the last several hours. He had been drinking at a local pub when he complained of pain in his lower abdomen. He went out to urinate but could not. He went back in the pub and had a few more rounds of beer. When he walked out of the pub in dark he fell down on the ground and could not get himself up; that is where a bobby found him and brought him to the hospital.
He was a thin man with prominent collarbones
and a narrow neck. The veins in his neck filled up quickly with every breath.
He had deep wrinkles on his face. He kept a thin mustache and probably had not
shaved for a few days. Several of his upper and lower front teeth were missing.
He raised his right hand to greet me but said nothing except to give me a
smile. I immediately noticed the first two fingers of his right hand. They were
deeply stained and looked yellow. He
probably smoked heavily and these were nicotine stains. When he did speak, his
voice was labored, hesitant and hoarse. He coughed constantly in between his
speech. I found it almost impossible to understand him and was having hard time
taking his medical history.
“Go
wash your hands and put a catheter in his bladder so the poor man will feel a
little better”. She said. During my
medical education, I was taught that one should not put a catheter in a man’s
bladder without first trying simple methods to relieve urinary obstruction. A
catheter may introduce infection in the bladder that may later affect the
kidneys leading to their failure. Other complications might arise from this
procedure. In my faltering English, I tried to explain to
I put my right hand on patient’s abdomen and could feel a firm swelling filling his lower abdomen. The swelling went all the way up to his belly button. I put my left hand on it and percussed it with my right middle finger.
“Thud, thud, thud” I listened closely. The dull “thud-thud” sound was obviously a bladder full of urine.
“Ah” The patient winced obviously with pain and then gave me a rueful smile. There was a sweet odor from his body typical of a person with uremia- a sign of failing kidneys.
I
asked Cleland to lie on his left side and pull up his knees to touch his
abdomen. In this position, I could do an
examination of his rectum and feel his prostate gland.
I
tried to explain to him as simply as I could that it was common for men at his
age to get in this situation. I told him that swelling of prostate gland comes
with advancing age. I tried to comfort him that with surgery he would be all
right. I did not want to tell him that men had died from this disease if not
taken care of soon. I looked at Mr. Cleland to see expressions on his
face. Suddenly he developed a coughing
spell and became breathless. He put his hands over the front of his chest to
stop his cough. His face got flushed and his neck veins popped out like thick
bamboo stems.
I
looked behind.
“Well?” she asked.
“I
want him to lie in a hot water for about half an hour.” I said remembering the
chapter on prostate gland in “The short
practice of surgery” by
She did not say a word.
She
got Cleland up and led him to a room next door. This was where a large bath had
been set for the patients. Once inside, I heard sound of running. I then went
back to the nurses’ office and found a cup of coffee lying on the table with my
name scribbled on a piece of paper. It was
I sat down on the chair at the table to write down the medical history of Cleland’s recent illness and findings of my physical examination.
I
realized that I did not have details of his medical history because of my
difficulty to understand him. I found
I ordered a dose of sedative and for a completel bed rest. A sedative would, I hoped relieve his anxiety; a hot tub bath would encourage him to urinate by himself. This would avoid a need for the tube that might introduce infection. At the back of my mind was the fact that I did not want to put a tube in his bladder if I could help it. I had only performed a few of this procedure and did not want to admit my discomfort. Nevertheless and as I learnt later, many older Englishmen in those days carried rubber catheters in their pocket and would insert the tube themselves when obstructed.
“How long are we going to waste our time with this man?” she said sharply. “You have to go to the operating room in a few minutes to help Mr. Whitepark with surgery. Do you want me to put the tube in his bladder? I can’t stand house officers who think they know every thing.” She said impatiently.
Obviously
my recommended treatment had not worked.
“Listen, I am just trying to help you and your patient, it is not my place to catheterize men. You fellows should know your work; at least learn to listen to the nurses. They do have experience. I hope you will remember that.” She said in a quiet but firm voice. Her face was red that seemed to have deepened the color of her blue eyes.
I kept quiet; I swallowed my pride and without looking at her left the room for the operating room.
I
returned to the ward well after
I
noticed a glass bottle on the floor next on the right side of his bed. A
reddish brown rubber tube was inserted in it. The tube was attached to a
catheter that drained his bladder. The straw colored urine was clear and had
half filled the bottle. I saw no trace
of blood in the bottle. I felt relieved.
“Hello, doc; done with your cutting?” Cleland said cheerfully. He had already shaved and looked well groomed.
“My woman will be coming here soon. Would you like to meet her, doc? We have been married good forty years. You will like her, doc.” He said putting away his newspaper.
I smiled back at him and asked him if he felt better. He gave me an affirmative nod. I lifted his bed sheet to put my right hand on his stomach. It was flat and soft. This time he smiled as I touched his abdomen. Again, he asked me if I would come back later and meet his wife. I declined. I had a lot of work ahead of me.
Just then, he started to cough. The fit lasted for about a minute; his face became flushed and then turned bluish gray. The muscles of his neck became taught; the veins popped out. I could hear a wheezing sound as he tried to exhale. The eyes bulged out of their sockets and became red. He sat up and put his both hands over the front of his chest trying to suppress his cough. I suddenly recalled a similar attack of cough earlier in the morning. I did not pay much attention to it then. I looked at his fingertips closely; they seemed thick and the nails were curved like a boat. They had bluish tinge to them. Such shape of ones fingers is a clue to a serious lung disease.
His bare chest was shaped like a barrel, typical of a person with emphysema. A large amount of trapped air reduces the breathing capacity of the lungs. This causes the chest to become round and narrow. After a while, his cough abated and he became quiet. I asked him about his smoking habits.
“Not much now. As a young lad, I did my share of smoking; sitting in those bunkers during the war got boring; so you smoked. The woman is always carping. Don’t got pennies to burn on them cigarettes now.
On
the table next to him was a packet of Navy Cut ‘Capstan’ cigarettes laying half-empty.
He also had a pint of
In
I went back to the nurses’ office to look at Cleland’s chart. It was lying on a rack next to the main desk. Peggy had written about his prostate problem and had not missed his emphysema. Her notes were neat and concise. On her own, she had asked for a chest x-ray, which I had forgotten to order that morning. I wondered if she noticed my stupidity. No doubt, she had covered for my oversight and saved me from embarrassment.
The X-ray and laboratory results were in Cleland’s chart. They all showed signs of kidney failure and emphysema with low hemoglobulin and eosinophilia.
I looked at my morning notes on his chart. My final diagnosis inscribed with such a confidence that morning now needed revision to include emphysema.
I wanted to examine him again. I made him sit up. I did not want to miss anything on my examination this time. I was relieved to find nothing new.
The
evening went by rather fast. I had a number of new patients to take care of.
Several patients were going for surgery next day and they needed preoperative
orders. By the time, I completed my work it was already past
I grabbed a big piece of cheese and some crackers lying in Sister’s office. I ate them quickly; I found bottle of milk in the refrigerator and drank it. I was deadbeat. I went to my room, got into my bed and before I knew it, I was fast asleep.
I was woken suddenly by a light flashing on my face. I opened my eyes and saw Peggy standing by my bed with a flashlight in her hand pointing at my face. She was in her uniform and looked fresh and alert. She had a notebook in her left hand. I jumped out of my bed. I was in my pajamas and I felt bashful with a woman in my room at that hour. I looked for my white coat. Peggy had already grabbed it from the hook on the door. She then handed it to me and motioned for me to put it on.
“Cleland
is ill. You should go see him right away,” She said. She was breathless and
spoke rapidly; she caught my right hand and pulled me towards the ward. I shook
her hand off and ran in front of her. When I reached patient’s bed, I found the
night sister standing next to the bed.
I looked at the clock on the wall. It was thirty-five minutes past six in the morning. Outside of the window, the sky was beginning to lighten. Peggy had come to the ward a little earlier than usual to say hello to one of her nurse friends on night duty. That is when all the commotion began.
Cleland
woke up at about five-forty that morning with a spell of cough. The noise
disturbed the rest of the patients in the ward.
When the nurse arrived, she found him sitting up in his bed gasping for
breath. His face was blue and he looked distressed. He pleaded for help. She
quickly called for the night nurse-in-charge and the house officer on call to
come immediately. Every one was there within a few minutes. They inserted a
needle in his left arm and started giving him intravenous fluid. Someone had
quickly brought an oxygen tank and had put a breathing mask over his nose and mouth.
Nothing seemed to help Cleland. The house officer, John ordered an injection of
a drug to open up his lungs with no luck. It was then that
I kept looking at the man on the bed with shock and dismay. This was my first patient in this hospital and my first death under my care. No one said any thing. The mask was taken off the man’s face. Some one came and put wet cotton wool on his eyes to close them. The curtain was already drawn around him and a white sheet was now put over his body to cover him completely. All one could see was the bed and shape of a body lying on top of it covered completely by the white sheet. Slowly, every one walked away. No one looked at or said anything to me. I began to walk towards my room. The door of my room was wide open; the curtains were drawn open and there was a cup of hot tea lying on the lamp table next to my bed. The housemaid, Lilly had brought the “bed tea”. I took off my white coat and threw it over the chair. I then lay down across the bed with my legs hanging down from its side. My head rested against the back wall of the room. I folded one of the pillows on itself and put it under my head.
The whole incident puzzled me. What might have caused his sudden death? Could I have expected his death? Did I miss something? Why did I let him die? If I knew this would happen to Cleland, could I have done things differently, I kept asking myself.
When
I went back to the ward later that morning, I saw that another patient had
already occupied Cleland’s bed. Every thing seemed normal and business like as
if nothing had happened there. Cleland’s chart was lying on the nurse’s desk.
On top of it, was a handwritten note? It said that there would be an autopsy on
Cleland’s body later that after
At three in the afternoon, I arrived at the autopsy room. Cleland’s body was lying on its back on the tabletop. Its eyes were closed and the arms were by its side. Cotton wool plugged his nostrils. Image of him in the hospital bed talking to me would not leave me. The face had few wrinkles and the skin had waxen appearance. The stench of formaldehyde was unpleasant. Reeder, the pathologist was standing nearby in his white surgical gown; he wore brick red rubber hand gloves. From his posture and behind the mask I guessed his age to be in forties. He seemed short and rotund with a big belly. A large loose mask over his face covered his mouth and nose. Through a pair of thick black rimmed glasses, I could see his dark eyes. I introduced myself as one of the young doctors.
“How do you do? Give me a short medical history of this man.” He said in a business like manner. Cleland’s medical chart was already lying on a wooden stool in the room. I picked it up and told him all about his recent history, as I knew it. I recognized Cleland’s recent chest X-ray hanging on the lighted view box on the wall behind me.
“What do you think caused his death?” Reeder asked me. I tried to explain that the patient had enlarged prostate gland obstructing his bladder opening; and he also suffered from chronic emphysema but it seemed to be under control.
“Then what killed him so suddenly.” He demanded. I had no answer.
“You just told me that he developed a sudden spell of cough. He hungered for air and went into a shock before he died. Can you think of any cause of sudden death in a patient with such a history?” Reeder was now challenging my clinical insight. Again, I had no answer. I froze in my thoughts. I kept quiet.
My own quiet now disturbed me. Did I know the answer? I must know the answer. With every second passing, a sense of personal failure began to descend on me. I searched deep for an answer. My thoughts were empty. I felt like a drowning man in deep water, sinking and no place to go but down and no one to rescue me.
“Think
man, Think, clear your mind. How could it be such a difficult problem”? I told myself, “In medicine, one must pick a
major symptom or a physical finding as a starting point and then systematically
go through a list of different causes of that syndrome. Then try to link every
symptom and physical finding of the patient by a single disease process? I remembered reading somewhere that “a physician who can explain most symptoms of
his patient by a single diagnosis will be correct most of the time”.
I must not fail, I told myself. I searched for a central problem of Cleland’s illness before he died. It was not his prostate problem and certainly not his chronic emphysema. He died of a sudden coughing spell at the time of his death. This was the central cause of his death and I must build my case on this syndrome. I locked my eyes on the gray ones behind the dark rimmed glasses. Reeder was looking at me intently and waiting for an answer.
“The patient died from a sudden death either of a heart or pulmonary failure. The question is which one preceded the other.” I said cautiously.
“Excellent reasoning but you have not answered the core question yet. What caused his sudden death?” Reeder said with a little more fervor. Andrews in the mean time had begun to saw the Cleland’s chest right in the middle to expose his heart and lungs.
“The patient died of either a massive heart attack, a sudden large busted artery in his chest flooding his lungs with blood or a large pulmonary embolism; emphysema by itself would not cause a sudden death without warning” I said loudly to myself but wanted Reeder to hear it.
In spite of an absence of a history of heart disease, he could still have had a massive heart attack. That was a definite possibility. I did not think that he had any reason to bleed profusely in his lungs. Therefore, I settled my diagnosis on either a big heart attack or a large pulmonary embolism as most likely causes of his sudden death.
“It is one of two things,” I said rather confidently. “Heart attack or embolism”
Heart attack occurs when suddenly a clot of blood blocks one of the big arteries of a patient’s heart or when heart’s big muscles go into a sudden arrhythmia. The oxygen to that part of the heart stops and the heart muscle ceases to function. Lung embolism is due to a blood clot in one of the veins. It can escape and lodge itself in the main arteries of the lungs, thus blocking the flow of blood to the lungs. Patient then dies suddenly of shock and respiratory failure within a few minutes.
While I was explaining my diagnosis to Reeder, Andrews was busy cutting the dead body.
“Careful James.” Reeder suddenly turned his attention to Andrews. He continued, “The young doctor suspects a pulmonary embolism or a heart attack in his patient. I am sure he would be upset if you did not let him have a look for the culprit inside the chest”.
Who was the culprit? I was now anxious to find out. Heart or the clot?
Andrews acknowledged Reeder with a nod and continued to work on the body silently.
“What do you expect to see in his heart and lungs here, doctor?" Reeder asked. I now realized that I was in front of an excellent teacher. I learnt later that most young doctors had no patience to listen to him or were too busy and tired to come here. As for me, I was getting a total attention and good clinical teaching, one on one!
Self-confidence now replaced earlier dread. I methodically described to Reeder what I might find in the chest. I had hardly finished talking to Reeder when I saw Andrews split open the heart and the lungs to expose the pulmonary artery and the chambers of Cleland’s heart. I could clearly see a large worm like reddish brown clot of blood lying inside the cut groove of the right pulmonary artery. It occupied the whole lumen of the big vessel.
This was the culprit, big, red and ugly. It cost Cleland his life in a hurry. His heart showed no sign of an attack. I began to muse over the details of my conversation on the evening before his death to try to remember any clues about his impending death. Was there any indication that he might have harbored thrombus in his legs? Did I miss a simple diagnosis just as I had missed his emphysema?
Repeatedly I went over Cleland’s case during his short stay in the hospital and before he died so suddenly. I came up empty handed every time.
I looked up to the pathologist. He was still looking at me. I thought that we had found the answer and could now conclude our search for the cause of my patient’s death. I was quite satisfied and wanted to go to my room before my evening round of other patients begins.
“Not so soon, doctor. We are not finished yet” Reeder said to me.
I looked at him with a little impatience. What did he want now? I kept quiet hoping he would explain what he was looking for. No such luck. He wanted to know why a patient should get a pulmonary embolism unexpectedly. I gave him several causes of pulmonary embolism. None satisfied him.
“Can you think of a syndrome that causes extensive clotting in a patient?” He asked me in a friendly tone. He knew that I did not know the answer. He now took charge.
“Have you heard of Trousseau?” I had never heard of him.
“Trousseau was a French physician and in 1865 he described a number of patients who had an increased clotting in their veins. When he probed further, he found that most of them also had cancer. You told me that this patient had low hemoglobin and eosinophilia. Trousseau’s patients also had a low hemoglobin and high eosinophil count. In addition, they had cancer. Our patient had been a heavy smoker, according to you. And he worked in mines. He of course, had emphysema too.”
Before Reeder could finish, I saw his line of thought. Not to be left behind and caught up in his excitement I said, “Cleland had a lung cancer because he smoked and had emphysema”
“How could be, though; His chest X-ray was normal.”, I followed my own answer with the question.
“Yes, it is true but then a lung cancer can be very small and unseen on a chest X-ray. It is also possible that a lot of trapped air in his lungs from emphysema could have hidden a shadow of lung cancer. Well, we can always look at his lung now that we have them with us. That is one advantage we pathologists have over you clinicians. We can always find the truth by directly looking at the tissue.” Reeder was now animated and excited. He looked at Andrews who was waiting for a signal from his boss and did not need any prompting. He had already started to take out the lungs and began to feel the soft rubbery organs with his fingers and the thumb.
It did not take him too long; he grabbed one area of Cleland’s left lung and exclaimed,
“I got the bugger”.
And slit open a mass of a white looking round lesion embedded within his right lung. Reeder said that he had no doubt about the presence of cancer in that lung but wanted to wait for his final diagnosis only after he has looked at it under a microscope. He would then claim his triumph of diagnosing my patient’s cause of sudden death. Only then, he would find the real culprit.
Then he added, “Young man, to treat a patient is simple, to learn from a patient is often difficult but to treat and not pursue the truth to the end is a crime. You had found the road to the culprit but did not find the culprit. Good evening, doctor”.
I listened to him but paid little attention. All I could think of the previous night when I met Cleland; a living person who talked to me and touched me and wanted me to meet his wife. He was gone, my patient, my first patient. Without saying anything, I began to walk back to my room lost in my own thoughts. I became a doctor to make my patient well, not let him die. I had not wanted him to end up like this.
A gentle touch on my right shoulder startled me. I turned around and saw Peggy walking behind me. I continued to walk and she quickly caught up with me and began to walk besides me. She wore a light blue dress with small red and pink flowers. She also had a narrow dark blue belt around her waist. She had bright red shoes with pointed toes and high heels on. A red cashmere cardigan covered her shoulders. She held my hand, squeezed it lightly and guided me to the stairs to the right. We sat down on one of steps.
She had a white cloth napkin in her hands. She opened it carefully and brought out two small and round cakes, one chocolate and another vanilla.
“I am sorry there was only one napkin in our hall. The staff had already cleared the afternoon tea but I got these from the kitchen. Hannah told me that you were here and so I brought these for you. You must be starved. I am hungry too.” She said tenderly and offered me the whole bundle. Before I realized, I was eating chocolate pastry. She picked the other one and began to eat.
“This is your future life. Some patients will die on you, as they must. It is only a beginning in a long career. One never gets over such tragedies. It feels like a personal loss when your patient dies. I had known Cleland for the last three years and it hurts. I just talked to his wife about an hour ago. She was glad that she was with him last night.”
I said nothing. She did not know me. We both ate up the cakes quickly and sat there for sometime without saying much to each other. She then got up suddenly and brushed the crumbs off her dress with her hands.
“I got to leave now. I have to meet Peter in about ten minutes. I shall see you tomorrow morning. I hope you feel better.” She then suddenly turned around cupped my face with her hands and kissed me.
“Take that mustache off.” She said and was out of the building in no time.
I
was very hungry. I had missed my lunch again.
XXXXXXXX
THE END XXXXXXXX
Read to the
©Copyright
Amod Saxena