On the theme ‘A case I’ll never forget’, Dr Charlotte Luke writes about consulting from the comfortable, distraction-free environment of a patient’s home
‘Doctor, my side keeps swearing.’
‘Swearing? I’m not sure I understand?’ It’s a bad line, the patient is out walking his dog.
‘Sweating, I mean sweating.’
‘Oh, okay. Well, that makes more sense… I think.’
This is how the last phone call of the day often seems to begin. The problem seems odd, or perhaps not even a medical problem at all.
It’s the call you’ve left until last, either because it doesn’t seem incredibly urgent, or because you are fatigued and out of clever thoughts for the day, your energy consumed by urgent requests for zopiclone and discharge letters comprising lists of tasks rather than useful information.
‘Okay, Mr P. Tell me more about this. When did it start?’
‘Well, I’ve had a bad back for a few months, and now I have a sweaty patch on my side.’
‘How sweaty?’ I wonder out loud.
‘I’m soaking the sheets at night, it’s driving my wife mad.’
Suddenly the case starts to seem more interesting and I pull up some recent blood results from a hypertension review.
Mr P hopes his cholesterol has improved. He tells me that he’s lost half a stone from walking the dog a bit further. I’m tired at this point and don’t really know what’s going on, so I offer to pop in and take a look on my way home.
‘That’d be great, doctor. I’ll be home in 10 minutes.’ Inevitably, it takes me quite a bit longer to tidy up and get in the car.
I arrive at Mr P’s house. It’s been snowing today and when I arrive he’s been out with a shovel clearing a space on his drive for me. Sometimes it’s easy to forget patients are generous people. On the way in his wife presses a bourbon biscuit upon me and tells me to sit in the comfy chair by the fire.
Suddenly I’ve entered a completely different reality, in a warm house far away from total triage and misbehaving printers.
He’s obviously lost quite a bit more than half a stone: his trousers are loose; he looks tired. From the shovelling, he says.
He lowers himself on to the sofa very slowly and lifts up his shirt. There’s a perfectly demarcated wet patch on his left flank, glistening in the light of the TV. It’s a dermatomal distribution. Bad news, I think.
I examine him. There’s midline tenderness over his lower back and the sweaty area of skin but nothing else to find.
We have a chat and I explain that I think one of the nerves in his back is misbehaving and sending the wrong signals to his skin. It might be being pressed on by a disc in the back, I tell him. But given the weight loss, we need to take it seriously in case it’s something more sinister.
I arrange A&E admission and the next day look up his results. It’s myeloma. A big deposit in his spine, and some worrying looking bloods. After some radiotherapy, he’s back home with the local haematologists providing follow up.
Many months later, things are worse. He’s probably at the end stage but in good spirits. I’m back in the comfy chair despite my protests. A nice chat, a biscuit, an A&E referral. It didn’t really feel like work, compared to ticking off a list of closed questions over the phone.
Sometimes being sat in the comfy chair makes things a lot easier. Away from distractions. No emails or letters to read. No total triage. No remote consulting.
Just the patient, who has all the information you need, and biscuits.
Dr Charlotte Luke is a GP Partner in Wigan, Lancashire