THE MORNING AFTER THE unit meeting started for Goldblatt as a perfectly blameless Tuesday and continued in that vein for about two minutes, which was the time it took for him to walk into the doctors’ office, take off his coat, glance at the Book of Time, feel his heart sink at the sight of four names vying for a maximum of two available beds, come out again and walk past the occupant of bed eight on his way to his morning admissions colloquy with Sister Choy.
‘Doctor!’ shouted the man from bed eight. ‘Doctor! Doctor!’
Goldblatt stopped.
‘Doctor!’ shouted the man again.
‘What?’ said Goldblatt, unwillingly taking a very small step towards him.
Even as he did it, he knew it was a mistake. Patients who shouted ‘Doctor!’ across the ward were usually asking for a bedpan. If not, they were wondering what had happened to the tablets they were supposed to have been given an hour ago. Or when they were going for the test that had been booked for them. Or what had happened to the breakfast they were supposed to have been given. Or they had some other question concerning one of the thousand omissions, substitutions, and alterations that occur on a ward every day, and which only the most naive patient could genuinely imagine that a doctor would be able to answer. As anyone ought to know who has been in hospital for more than ten minutes, nurses run their wards in accordance with secret and impenetrable cultic rites that are as much a mystery to doctors as they are to patients. It follows, therefore, that any doctor who is foolish enough to give in to a patient’s request for assistance will have to spend ten minutes finding, interrupting, and irritating a nurse. Or to put it another way, patients who call out to doctors are shamelessly exploiting the supposed helplessness of their situation in order to substitute the doctor for their bedside buzzer, which as everyone knows serves a largely ornamental purpose.
But Goldblatt had stopped now, and responded.
‘Are you a doctor or not?’ demanded the man who had yelled ‘Doctor!’, as if he had some kind of a right to know.
Goldblatt gazed at the man. He had sallow skin, a black moustache, and a few long strands of dyed black hair plastered unconvincingly across his skull from a parting half an inch above his left ear. To top it off, he was wearing purple mock-satin pyjamas.
‘That depends,’ said Goldblatt at last, adjusting the stethoscope that was hanging around his neck.
‘On what?’ demanded the man sarcastically.
‘On who’s asking,’ Goldblatt took the chart off the end of the man’s bed, glanced at the unfamiliar name, and said: ‘No, I don’t believe I am.’
‘What’s your name?’ demanded the man.
‘Dr Goldblatt,’ replied Goldblatt.
‘But you said you’re not a doctor!’
‘My parents had high hopes for their children and thought they’d give us a head start. You should hear what they called my brother.’
‘You are a doctor,’ said the man.
‘True,’ said Goldblatt. ‘But there’s one important fact you have to consider.’
‘What’s that?’
‘I’m not your doctor.’
But Goldblatt was his doctor, as he predictably discovered fifty-four seconds later when he found Sister Choy and she informed him that Dr Morris had admitted a new patient overnight. Sister Choy needn’t have bothered even telling him the name. After his conversation with the man who yelled ‘Doctor!’, there was only one possibility. Fate works like that.
Mr Lister was a short, surly fifty-six-year-old who claimed never to have had an ill day in his life. He did some kind of manual labour in a mattress factory, smoked twenty-five cigarettes a day, and drank a minimum of two pints a night. Three months earlier he had started to have sweats. At first the sweats came on at night and he drenched the bed, which upset his wife. Then they started coming on when he was at work, which upset his boss. He felt tired, drained, washed-out, and irritable, and his desire for cigarettes diminished. That upset Mr Lister, and he finally decided to go to a GP. The GP gave him a course of antibiotics and told Mr Lister he’d be smoking again in no time. He lied. He gave Mr Lister another course of antibiotics and ordered a chest X-ray. Nothing happened. The antibiotics didn’t cure him, and neither did the X-ray. Mr Lister was still having sweats. The GP sent him to his local hospital.
At this stage, having had a fever regularly for more than six weeks, Mr Lister had officially become a Pyrexia of Unknown Origin, or PUO. Infections and inflammatory illnesses are two of the main causes of PUOs. Cancer is the third.
Everyone at the hospital expected Mr Lister to have a nice straightforward lung cancer. His smoking history made the odds ten to one on. It was just a matter of finding the tumour, and in no time at all he’d be on his way out again with a diagnosis, an appointment at the Radiotherapy clinic, and six months to live. The chest X-ray that was ordered, however, was normal. Then everyone remembered his GP had already done a chest X-ray, and that had been normal as well. Unwilling to give up on the prospect of a neat conclusion to the affair, the consultant ordered a CT of the chest, looking for a tiny little cancer hiding in some out-of-the-way bronchus behind the heart. No luck. Things were starting to look complicated.
By now, the results of various blood tests were coming back without giving any clues to the cause. Nonspecific changes, nothing more definite. Blood cultures didn’t grow any bacteria. The consultant told his registrar to try another chest X-ray, perhaps hoping that the radiation from the earlier X-rays might have produced the cancer that was supposed to be there. Still no luck. They tried an ultrasound of the liver and gallbladder without having any definite idea what they were looking for. Nothing. More blood cultures: negative. Echocardiogram: normal. Abdo CT: unremarkable. Lumbar puncture: clear.
Over a week had passed. Mr Lister was growing restless and increasingly irascible with his fever. At ten o’clock every morning he started to shiver, his temperature rose towards forty degrees, and by eleven-thirty he was drenching the bed as his temperature fell again. Another week of unrevealing tests went by. This was getting beyond the competence of the consultant, his fellow consultants, and of the investigations that the labs in the peripheral hospital could run. In fact, it had already got beyond them. At the end of the second week, Mr Lister told the consultant he was going to leave. The consultant thought this was an excellent idea and told him that he had heard of a very clever new doctor who was especially interested in cases like his.
‘And what kind of cases is that?’ asked Mr Lister sceptically.
‘Difficult cases,’ said the consultant, speaking with many layers of meaning.
‘Is he here?’ asked Mr Lister.
‘No, he’s at another hospital.’
‘When can I go there?’
‘Tonight,’ said the consultant. ‘I hope.’ And he walked off to call Dr Morris, whose fame as the local sink of all medical conundrums, like a ripple on a pond, was relentlessly spreading.
Dr Morris’s response to the consultant’s description of the case consisted of one word. Fascinating! His three beds on Professor Small’s unit were full, with the earliest discharge set to take place in three days, but Dr Morris wasn’t going to let that get in the way of a prize as delectable as a PUO that defied diagnosis. His alternate existence as the pseudo-Sutherland gave him opportunities of which other consultants could only dream. The Sutherland unit was on call that night, so every empty bed in the hospital, theoretically, was his. But only for emergencies, not for elective admissions from other hospitals. Dr Morris’s incurable inventiveness found a way. First, slyly adopting the guise of the pseudo-Sutherland, Dr Morris rang the bed coordinator to find out where he could get a bed. Second, having reserved the bed for a Sutherland unit patient, he rang his latest locum Sutherland registrar to arrange a transfer into it of his patient on the Prof’s unit who was going to be discharged in three days. This was the key step in the chain. Utterly illicit, but difficult to detect, and sparklingly brilliant. The last step was easy. Having freed a bed on the Prof’s unit, the pseudo-Sutherland turned back into Dr Morris and rang the consultant at the other hospital to let him know that he could send Mr Lister in to the bed that was being vacated. The whole procedure ran like clockwork, and by nine o’clock in the evening Mr Lister had arrived to find Dr Morris personally waiting to admit him.
It was one of the slickest pieces of bed manipulation that Goldblatt had ever come across, and he would have been proud of young Dr Morris if it hadn’t been such a dumb thing to do. Why, he asked himself, couldn’t Dr Morris use his awesome powers for good – getting rid of patients – instead of evil?
He would have stopped it, Goldblatt knew, if only the call from the other hospital had first come to him. He didn’t know how, but he would have stopped it. Often, in later weeks, listening to Mr Lister pour out his endless complaints, Goldblatt knew that somehow, somehow, given half a chance, he would have blocked him.
Goldblatt examined him that morning. So did Dr Morris, for the second time, as well as Emma, and the HO. Ludo said she’d get around to it after she finished her Dermatology clinic. Mr Lister was thin. His ribs stood out when he took off his purple mock-satin pyjama top. Everyone asked him the same set of questions, and he finally exploded when Goldblatt asked him if he itched.
‘Why does everyone ask me if I itch?’ he demanded angrily. ‘Do you think I’ve got lice or something? I don’t itch. I never itch!’
Goldblatt couldn’t believe that. ‘You must itch sometimes.’
‘Never!’ declared Mr Lister.
‘You mean you’ve never had an itch?’ asked Goldblatt, genuinely intrigued. He wondered if he was looking at the makings of a case report for the Lancet. ‘A Mattress-Maker with PUO Who Never Had an Itch.’
‘No, Dr Goldblatt,’ retorted Mr Lister irritably, scratching at his thigh. ‘I’ve never had an itch.’
‘Then how do you know what the word means?’ enquired Goldblatt.
Mr Lister peered at Goldblatt. He glanced at the HO, who was standing beside him.
‘Of course I know,’ he said at last. ‘Everyone knows.’
Goldblatt nodded. ‘Look, Mr Lister, I know we’re asking you a lot of questions, and I know you’re worried about what’s going on. Our job is to find out what that is. If we’re going to do that, we have to know as much as we can. We’re not asking you these things to upset you. There may be a detail you may not realize is important, but which we need to know about. For instance, the reason we ask you whether you itch is because there’s a certain disease that sometimes makes people itch. It also gives them fevers and sweats, like you’ve been having.’
Mr Lister frowned. ‘What disease is that?’ he asked quietly.
‘It’s called Hodgkin’s disease, and—’
‘That’s a cancer!’ cried Mr Lister. ‘My uncle had Hodgkin’s disease. He died of it!’
‘We just need to cover all the possibilities,’ said Goldblatt. ‘I’m sure you don’t have Hodgkin’s disease.’
‘How do you know that? My uncle had it! How can you be sure?’
‘Well, we’re not absolutely sure yet. But I’m pretty certain. Besides, you don’t itch, do you?’
Mr Lister thought about that. ‘I don’t think so.’
‘What about after you have a hot shower?’
‘I don’t have hot showers.’
‘All right, what about after cold showers?’
‘I have baths.’
‘Cold?’
‘Hot.’
‘Do you itch?’
‘When?’
‘After hot baths.’
‘No.’
‘There you are, then,’ said Goldblatt. ‘Most people with Hodgkin’s disease do. Now let me look at your knee.’
Dr Morris thought he had been able to detect a slight swelling of Mr Lister’s right knee, and wondered whether he had stumbled across the clue that would unlock the mystery of Mr Lister’s illness. Goldblatt couldn’t detect anything. He called Dr Morris, who admitted he hadn’t been absolutely certain he could feel a swelling, but if there was even a possibility of excess fluid in the joint they would have to extract it for analysis. Goldblatt went back to put a needle into the knee and draw off the fluid that Dr Morris may – or may not – have felt.
The HO came with him. She had never seen a joint aspiration. Goldblatt asked Mr Lister to roll up his pyjama trousers, and he examined his bony knees for the second time that day. Then the HO followed suit, trying to copy Goldblatt’s technique. She thought she could feel a swelling on the left.
‘The left?’ asked Goldblatt.
The HO nodded.
‘Not the right?’
The HO glanced shiftily at Mr Lister’s thin white knees. ‘What did Dr Morris say?’
‘Never mind what Dr Morris said,’ said Goldblatt. ‘Where did you feel the swelling?’
The HO gazed at Mr Lister’s knees. ‘The right,’ she blurted out abruptly.
‘Wimp.’
‘Where did you feel it?’ she asked.
‘Me?’ said Goldblatt, peeling the wrapping off a needle and attaching it to a syringe. ‘I couldn’t feel a swelling at all.’
Mr Lister was staring at the needle in Goldblatt’s hand. ‘What are you doing?’
‘I’m going to take some fluid off your knee.’ Goldblatt swabbed the inner aspect of Mr Lister’s right knee with iodine. ‘If you’ve got some fluid in there, we can check it out in the lab and it may tell us what’s wrong with you.’
‘From the fluid?’
Goldblatt nodded.
Mr Lister gazed down at the sterilizing yellow stain that had been spread across his skin.
‘Will it hurt?’ he asked.
‘It won’t take long,’ replied Goldblatt, who preferred to avoid giving direct answers that were likely to make patients behave unexpectedly when he was holding an unsheathed needle. Of course it was going to hurt. Hadn’t Mr Lister ever seen a needle before? Besides, as far as Goldblatt could tell, there was no excess fluid in Mr Lister’s knee. When there is, hitting the fluid is easy. Just slide your needle smoothly into the depression that marks the gap between the back surface of the kneecap and the femur behind, draw on the plunger, and watch the fluid flow. But a normal knee contains only a minute volume of thick, viscous liquid, which can be a lot more elusive to find. And there are a lot of sensitive structures in the vicinity that you’re bound to hit before you strike oil. In another second the needle in Goldblatt’s hand was going to be poking around inside Mr Lister’s knee, nosing its way into bone, ligament, and cartilage.
The kindest thing Goldblatt could do for Mr Lister, he knew, was to do it quickly, efficiently, and without fuss.
‘I’m just going to put the needle gently in,’ he said to Mr Lister. ‘I’ll tell you before I do it. You’ll feel a jab. Hopefully it will be over in a few seconds.’
Goldblatt pointed out the anatomy to the HO, showing her how to locate the point for the needle to enter. ‘OK, here we go,’ he said to Mr Lister, and slid the needle in. Mr Lister winced. Pulling back on the plunger to suck up any fluid on the way, Goldblatt advanced until he hit something, cartilage or ligament.
‘Are you all right?’ he said to Mr Lister, whose brow was starting to glisten with little beads of sweat.
Mr Lister nodded hurriedly.
‘Almost there. I’m doing it as quickly as I can.’
Goldblatt withdrew the needle partway, changed direction a little and advanced the needle again, still drawing back on the plunger. Eventually a drop of viscous, yellow fluid appeared in the barrel of the needle, stained with a streak of blood. Goldblatt pulled the needle out of Mr Lister’s knee, pulled down on the plunger to suck the droplet of fluid into the syringe, detached the needle, squirted the droplet into a sterile container, and handed it to the HO to label and send down for analysis.
‘Looks normal,’ Goldblatt said to Mr Lister, who was staring at him with horrified amazement.
‘I never knew you could put a needle into a knee.’
‘You’d be amazed where we can put needles.’
‘Don’t tell me, doc,’ Mr Lister said earnestly.
Goldblatt laughed.
‘Will you be doing other tests?’ asked Mr Lister, as Goldblatt put a plaster over the puncture hole in Mr Lister’s knee.
Goldblatt nodded. Dr Morris was planning a whole opera of investigations.
‘A lot?’ asked Mr Lister anxiously.
‘As many as we have to do,’ said Goldblatt. ‘Not a single one more. I’ll come back later and explain them to you so you’ll know what to expect.’
‘Are they going to hurt?’
‘That’s about as bad as it gets. There’ll be X-rays, and things that don’t hurt at all. Give me half an hour and I’ll come back and explain.’
Mr Lister smoothed down his wispy hair. He didn’t say anything else. He glanced nervously at Goldblatt and the HO, then looked back at his knee, where a plaster and a yellow stain were the only evidence that a needle had been sticking into it a couple of minutes before.
‘We’ll get to the bottom of things,’ said Goldblatt. ‘Don’t worry.’
And they did. Or tried to. Mr Lister’s blood would be assayed for antibodies, his bone marrow trephined for tuberculosis, his spinal fluid tapped for neurosyphilis, his skin biopsied for inflammation, his circulation injected with radioactive particles and his body exposed to X-rays and ultrasounds and CTs and MRIs with and without intravenous dyes and with and without guided needles to take biopsies of his tissues. And that was only part of it.
Was it a lymphoma hiding in the gutter between the spinal column and the aorta that was causing his PUO? Or a renal carcinoma tucked away under the cap of one of his adrenal glands? Or a VIPoma buried in the slippery, sliding wall of the gut? Or a tiny abscess loculated just under his diaphragm? Or inflammation of the microscopic leashes of blood vessels in his kidneys? Or another one of a thousand other possibilities?
They’d find out, eventually. The disease hadn’t been invented that could elude Dr Morris for ever.