I dont think shes really appropriate for the intensive care unit, she said curtly after listening to my referral.
What do you mean not appropriate? How sick does she have to be?
Its not that shes not sick; its just that I think her outlook is poor. She has end-stage lung disease and everything points to there not being much room for improvement.
I was fuming. Youve barely even waved your nose in front of her and youre condemning her to death. How bloody dare you
Slightly taken aback by my response, the impossibly elegant doctor looked down at me in surprise. I think you might have got too attached to your patient, she retorted. Ill have a chat with my consultant and get back to you, but Im fairly sure hell back me up on this one. I think she needs palliative care rather than intensive care.
I went back into Bettys cubicle and grabbed her hand. Im having some trouble with the specialist team but Ill get you to ICU, dont worry.
Betty shook her head and gestured for me to turn the noisy BiPAP oxygen machine off.
With the machine quiet, she mustered up all her energy to say, No, darling. Thank you but let me go. This really is my final curtain call. With that she attempted a smile and held my hand. I was surprised to find a tear running down my cheek and to my annoyance realised that the intensive care doctor was right.
Is there anyone youd like me to call?
Betty shook her head and now it was her turn to shed a tear.
With the noise and chaos of the busy department engulfing us, I managed to sit quietly with Betty for 10 minutes holding her hand. Our little cubicle, with the curtains drawn, was like a tiny oasis of reflection, and although Betty had her eyes closed, Im sure she knew I was there. When I couldnt justify leaving my colleagues to face the constant onslaught any longer without my help, I gave Betty a kiss on the cheek and said goodbye. She was admitted to the respiratory ward and slipped away that night.
Smelly bum
John was absolutely convinced that his bum smelled. So much so that this was his fourth or fifth visit to see me with the same problem.
Youve got to help me, Doctor, the smell is repulsive. Its repugnant. It follows me everywhere.
Do you wash it regularly?
Yes, Doctor, of course I wash it. I scrub it every morning and evening. Nothing I do makes any difference. Im sure everyone can smell it: the woman who sits next to me at work, people sitting behind me on the bus. I just cant go on like this any more.
And its not a flatulence issue here? I mean, you dont just need to cut down on the cabbage and beans?
John looked at me as if I was a complete idiot. No, Doctor! It smells all the time. Not because I fart or havent washed. Every minute of every hour of every day I can smell it and it stinks!
I was at a bit of a loss. I had sent samples of his poo to the lab to be tested and ordered all sorts of blood tests. I even put my finger up his behind to make sure that there wasnt some sort of anal tumour that was giving off the smell. The last time he was in I even tried a Google search of smelly bum, but other than getting a list of some very odd and unsavoury sites not appropriate for workplace internet browsing, I was still at a complete loss.
So has anyone else actually ever commented on the smell?
No, but its not the sort of thing that you actually ask someone is it. Can you smell my bum? Im sure they can all smell it but are just being too polite to say. Ive not had a girlfriend for years because Im terrified shed just dump me because of it and then tag a photo of me as smelly bum on Facebook.
Although John had seen me on numerous occasions about this problem, on each occasion I had simply ordered another test and sent him on his way. This time I had run out of tests and really I needed to do what I should have done the first time he came in.
John, I need to smell your bottom.
Excuse me?
If you really feel that your bum smells this bad, but only you have smelled it, you need me to smell it and tell you if this really is a problem or not.
This is how I found myself in a scenario I never imagined I would have to face. Some of you may feel that doctors are overpaid and perhaps youre right, but how many of you reading this have a job that involves placing your nose in the close vicinity of a naked mans bottom? John was leaning over the couch with his trousers and pants around his ankles. He was holding apart his bum cheeks and as I kneeled down on the floor, I wondered how close I would actually have to place my nose to his anus to satisfactorily complete the examination. I was doing my very best to suppress my oversensitive gag reflex and feeling bitter that of all the doctors working at this practice, John had chosen to come to see me. As I got closer to Johns anus, I realised I was instinctively holding my breath, so had to consciously make an effort to open my nostrils and take a big whiff.
I was prepared for the worst but to my surprise, Johns bum smelled fine. It didnt smell like spring meadows or an ocean breeze, but there was certainly not the horrendous reek that he had been describing. Having never actively smelled any other mans behind, I was lacking a benchmark for comparison, but to my part relief and part annoyance, there was absolutely no reason why I needed to have my nostrils in such close proximity to his anus.
John was overjoyed when I told him his bum didnt smell. He did need some convincing and at one point seemed to be suggesting that I check again, but fortunately he did eventually take my word for it. Having managed to belatedly resolve the dilemma of the phantom smelly-bum syndrome, I had two options: I could of course simply wave John on his way having cured him of his complaint, or I could take the professional and appropriate option, which was to sit John back down and delve deeply into his inner psyche, to try to establish what previous trauma had culminated in his long-lasting and deeply disturbing delusional paranoia about his bottom.
John was overjoyed when I told him his bum didnt smell. He did need some convincing and at one point seemed to be suggesting that I check again, but fortunately he did eventually take my word for it. Having managed to belatedly resolve the dilemma of the phantom smelly-bum syndrome, I had two options: I could of course simply wave John on his way having cured him of his complaint, or I could take the professional and appropriate option, which was to sit John back down and delve deeply into his inner psyche, to try to establish what previous trauma had culminated in his long-lasting and deeply disturbing delusional paranoia about his bottom.
I thought about it for a millisecond
Bye, John. Glad weve sorted this all out for you. All the best.
As far as Im concerned, smelling Johns bum was already beyond the call of duty that afternoon. His 10 minutes were up and the opportunity to explore his inner psyche would have to wait for another day.
Tarig II
It had been a few months since I had last seen Tarig and failed yet again to persuade him to agree to take HIV medication. Unexpectedly, I had a request to urgently phone his wife. I didnt know Tarigs wife well as she rarely came in to see me, but I often wondered what she made of his decision to not treat his HIV. She herself had tested negative to the disease and had, on the surface at least, stuck loyally by her husbands side. She must have known that his decision not to have treatment was effectively a choice to commit suicide.
Doctor, please come. Tarig is confused and unwell.
As I arrived, his wife greeted me at the door.
Doctor, please dont mention the HIV in front of the children. They dont know, she whispered.
Tarig was in bed looking pale and unwell. He was saying some words in a language that I took to be Arabic, but his wife assured me that he was confused and making no sense. It was clear that Tarig was really sick. Once the immune system becomes very weak, numerous types of infection can take hold and I wasnt sure which one was making Tarig so unwell. Severe forms of pneumonia and meningitis are common, but regardless of which infection had taken hold, he clearly needed to go to hospital. In any other circumstances, I wouldnt have thought twice about calling an ambulance for such a severely unwell man in his 40s. With Tarig, though, we had spoken on numerous occasions about his specific wishes not to be treated for his HIV. In hindsight I wish we had put together some sort of living will or something in writing to prepare for this very situation. We hadnt, so I had to make a decision. Tarigs wife and two teenage children were in floods of tears. There was no way that I could leave him at home to die. He was now too confused and unwell to refuse hospital admission, so I went against my patients previously expressed wishes and dialled 999.
These decisions are really tricky. If a person is actively suicidal and threatening to jump off the nearest building, they can be sectioned (compulsorily detained in a psychiatric hospital) and incarcerated against their will for their own safety. Tarigs refusal to take medication to treat his HIV was equally suicidal in its nature, but he wasnt mentally unwell. He fully understood the implications of his actions and although most people would feel that this decision was wrong, there is no law against being wrong. The alternative to leaving him to die would be to lock up Tarig against his will and to hold him down and force him to take medication every day. Ive seen this done in psychiatric units and it is frightening and brutal to watch. Severely mentally ill patients are only forced to take medication for a short period of time because they are so unwell that in their psychotic state they have no concept of what is real and what isnt. They dont have the ability to weigh up decisions rationally. The same couldnt be said for Tarig. He had been calm and rational during our previous conversations and well aware of the implications of the decision he was making. Right now, though, he wasnt well and as he had lost the ability to make a rational decision, I made one for him.
I worried about the ethics of that decision for some time afterwards. However, after spending some time in hospital, Tarig was discharged home and to my amazement he was voluntarily taking HIV medication. I had a lot of time to think in hospital and I decided that God wasnt ready for me to die just yet, he explained.