The true story of a night call sets the scene and is used to show why GPs, like everyone else, must be educated for life and not merely trained.
MY NEW TRICK
I've just fallen asleep when the telephone rings. Not so deeply asleep that
it takes me an age to realize what the noise is, but enough to give me that
sickening feeling of being dragged back to reality. I reach across and
fumble for the receiver, craning to see the glowing figures of the clock on
the far side of the pile of half-read books on the bedside table. Quarter to
midnight. It feels like half-past two.
Almost all the tiny part of my brain which has woken up is
concentrating on finding ways of staying in bed, not to mention going
back to sleep. The whole of this meagre brain power now focuses on the
patient's apparent willingness to go to casualty. An appropriate reply is
necessary. Think, man, think.
"He's lying on the landing in agony. He can't move the knee and it's ever
such a peculiar shape."
"I see..."
I do see, that's the funny thing about it. Already, in spite of my
sleepiness, I've got quite a clear picture in my mind of the scene on the
stairs, complete with a provisional diagnosis and a plan of what I ought to
do about it.
I wonder momentarily whether I could talk her through reducing
it herself, then immediately reject this as a silly idea. On the other hand, it
is hard to justify a fifteen-mile ambulance journey and then hours of
waiting in casualty. And then getting home again. I know perfectly well
what I'm going to do.
"I don't know... There's the baby as well..."
"I see..."
"I'm terribly sorry to disturb you, doctor."
"All right. It's OK. I'd better come and see him."
"I'm terribly sor..."
"OK. - I'll be along in a few minutes"
Jersey and trousers on over pyjamas, hunt for socks, check the
bleep is on, receive wifes sympathy, step over the dog on the stairs,
through the front door, open the garage, feel for the keyhole in the dark,
open the door, start the car. Gales of laughter from all around as some-
late night Radio Four comedian shouts the second half of what must have
been a joke. Listen numbly to the puns as I drive through the familiar
streets past people who dont seem as anxious as me to be in bed. I find
the house with the light on and the right number. The laughter is snuffed
abruptly as I switch off the engine and coast to a halt. Left hand grasps
visiting bag, right hand swings open the door, I pivot on to my feet and
stumble into action, pyjama collar flying.
No need to ring the bell, a young woman in a neglige opens the
door as I approach.
"Upstairs?"
"He works as a chef, you see. He's only just got home."
I climb the stairs. The chef/husband is lying at the top of the stairs
in an agonized heap. He appears to have nothing on except a blanket. His
entire being seems focused on his left knee, which he is clutching with
both hands as it lies flexed under him. I go straight to it and he reluctantly
relinquishes his grip. Exactly like my mental picture - the great, hard
lump stretching under the skin on the outside of the joint, with the
peculiar dent on the front of the knee where the knee-cap ought to have
been.
Trying to appear more confident than I feel, I start doing what I
have been rehearsing in my mind on the way - straightening the leg is
the key. I grasp the knee with one hand and the ankle with the other. I fix
my eyes on the patients face. I tell him firmly to relax. To let the leg go
loose. Not to worry if it hurts - which his face tells me it does.
Monitoring his expression, I begin slowly to extend the knee. I feel the
tension coming out of the patella tendon, and the kneecap slowly yielding
to the pressure of my cupped hand as it begins to ride up on to the ridge
of bone it will have to cross in order to return to its groove on the front of
the knee.
Picture for a moment the dramatic scene. The silent, midnight
struggle focused on the knee. The patient, the physician and the wife,
variously attired and grouped in a powerful composition. Two, perhaps
even three of the characters struggling to keep bridled an almighty
scream.
But suddenly, instead of a scream... a "pop"!
Like magic, the patella is back in its proper place and the knee is
its normal shape.
I breathe out thankfully and sit back. The patient takes a little
longer to realize what has happened. He gazes incredulously at his
transformed limb and gradually the tension begins to leave his body. In
turn, his wife, who is bent over us, senses the relaxation and begins to
straighten up her face showing the beginnings of a sobbing laugh of
relief. The patient tries out his knee and finds that it will move. I
encourage him to stand up. (He is wearing underpants after all.) I tell him
to walk. He walks...
It is the sort of moment when, in an earlier age, cigarettes would
have been distributed and everybody would have sat around in a state of
mellow, post-ictal contemplation. However, being enlightened, I make do
with sitting down on the edge of their bed and writing up the out-of-hours
visiting slip. I apply a probably unnecessary but proper-looking crepe
bandage. I give advice on what to do if the knee dislocates again in the
future.
"Very kind of you but no, thank you."
"We're so sorry we had to trouble you."
"Glad to be able to help."
Back inside the car and the cocoon of relentless comedy from the
radio. Five minutes home. Lock the car. Dog doesn't seem to check my
credentials as I climb over him on the stairs. Neither does my wife when I
get into bed and snuggle up. Nice, satisfying feeling about that visit. I
avoid thinking about whether there will be another call - I don't like
superstition but this is far too important a matter to leave to chance. I
have left my clothes draped over the bedside chair ready for instant
dressing for the same reason. Putting them away neatly is, I find, an
infallible method of making the telephone ring at one o'clock in the
morning.
I use my new trick for getting back to sleep. I concentrate my mind
on a phrase I like from the Pie Jesu in Faure's Requiem. I exclude
everything else ruthlessly. I sink into the music. I join in and become part of
it. I am asleep.
My new trick seems to work rather well.
UNDERSTANDING
When I do something really trivial in surgery I often joke with the patient
that it has taken years of training to perfect it. I sometimes tell children
that medical students have to sit for hours in classrooms learning to say
"Mmmm." And there is a grain of truth in the joke. There are so many
different conditions in medicine that you simply cant be trained to deal
with each of them individually. But when you encounter each one it
always seems that it would have been better if you had been specifically
trained in dealing with it. General practitioners are constantly meeting new
situations and what they do is to apply their broad knowledge and
experience to the situation and more often than not they come up with an
appropriate action.
As it happens, the incident in the true story I have just related was
the first and only time that I have reduced a knee cap in nearly twenty
years of medical practice. I've reduced fingers, toes, fractured wrists, and
am a wizard at pulled elbows; but I've never done a knee cap. I'm not
sure that I've even seen a dislocated knee cap before, or even a picture of
one. By no stretch of the imagination could I be described as an expert in
the field of reducing knee caps. And yet the extraordinary thing is that I
had a diagnosis and a provisional plan of action in my sleepy head within
seconds of the telephone ringing.
I take no particular credit for this, it is just the way all of our
minds work all the time. They create internal pictures so automatically
that it just doesn't occur to us to think that there is anything clever about
the process. But in this case I happen to know that I wasn't recognizing a
picture I'd seen before, and I wasn't following a set of instructions I'd
learned in my training - the two most obvious explanations. So what was
I doing?
What my subconscious must have done was allow the various facts
of the case to interact with the complex store of information and
experience hidden away in my mind to produce that mysterious
phenomenon which we call "understanding". In other words it produced a
model of the situation in my mind which fitted the facts as I knew them. I
then used that model - quite automatically - to work out a plan of
action.
And this model was no ordinary model. From my knowledge of
anatomy I could see the internal structure of the leg, complete with the
displaced knee cap and the stretched tissues. I knew exactly what the
ridge of bone and the empty groove down the front of the knee would be
like and in a very real sense I could actually feel them. Even as I was
imagining these things and trying out my solution in my model, I was
taking into account the distance from the hospital, the wifes anxiety, the
pain, the baby, the possibility that I was wrong, the need to be available
for another call in the middle of it all. All these things, and others no
doubt that I have forgotten or was never consciously aware of, were
included in my model of the situation. And all before I had put down the
telephone.
The point of this little story is to show that no amount of training
can prepare us for every eventuality in life and that what is needed is a
broad education and a free environment in which to use our common
sense - the extraordinary ability which we take for granted only because
it is common to us all.
by James Willis
Chapter One: Understanding"I'm terribly sorry to trouble you but my husband has just got
home and hes fallen up the stairs and seems to have broken his knee. I
wondered if I should take him to casualty or somewhere..."
"Well, yes, mmm..."
"I see... It sounds as though he's dislocated his knee cap."
"How are you going to get him into the car, if he's like that?"
"I'm really terribly sorry to trouble you doctor."
"Thank you so much, Doctor. Can't we get you something - a cup
of coffee?"