Benjamin Daniels - Further Confessions of a GP

Back in those original photos the cause of her current suffering could be clearly seen. In each picture she was holding a cigarette holder with the cigarette itself shrouding her in a swathe of smoke.

‘We used to think we were so sophisticated,’ Betty told me, ‘and I loved the sexy husky voice the smoke gave me.’

‘You could still give up,’ I often told her.

‘Too late now, darling,’ she would reply with her husky laugh.

It was no real surprise that Betty was here in hospital. She had been in and out of the emergency department seven times in the last six months. Each admission was for the same complaint. Her lungs just couldn’t get enough oxygen into her blood stream. On each occasion she was admitted for a few weeks, given oxygen, steroids and antibiotics and then sent home. She had all sorts of inhalers, but despite everyone’s best efforts, an infection would cause her lungs to deteriorate again and she would be back in hospital. We couldn’t give her oxygen in her flat as she still smoked and so the risk of her accidentally igniting the oxygen supply and blowing herself up was too high.

Betty was sitting up on the trolley leaning forwards. She was struggling to breathe and had an oxygen mask tight round her face. She was in a hospital gown that covered her front but was left open at the back displaying her ribs and shoulder blades protruding through tired pale skin. Betty was so short of breath that she couldn’t really answer my questions. She had been sitting in this cubicle for the last two hours waiting for a doctor to come and see her. As the mayhem increased around her, Betty’s breathing had become steadily worse. All alone, unable to shout or call for help, she was simply focusing all her attention on trying to get enough air into her lungs to stay alive. When I walked in I saw the recognition on her face. She tried to tell me something but the effort was too much and instead she gently shook her head and grasped my hand.

Betty had been short of breath ever since I’d known her, but I had never seen her look this bad. Watching someone unable to breathe is horrendous. How it must feel for the poor sufferer I can’t imagine and I was finding it difficult to watch Betty suffer so terribly in front of my eyes.

The department was chaotic, but Betty was sick and needed expert help. I started her on a BiPAP, a machine that helps the patient to breathe more easily, and called the doctors from intensive care. Betty was too sick to go to a ward. She needed to go to intensive care where they had all the equipment and expertise to get to grips with her breathing and possibly even put her on a ventilation machine. The specialist intensive care doctor clip-clopped into the department in her high heels. She was South African and looked impossibly young and elegant. Tall and slim, with perfect hair and make-up, she was a stark contrast to us dishevelled A&E staff wearing faded scrubs and grubby trainers. I carefully told her Betty’s history and observations.

‘I don’t think she’s 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?’

‘It’s not that she’s not sick; it’s 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. ‘You’ve barely even waved your nose in front of her and you’re 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. ‘I’ll have a chat with my consultant and get back to you, but I’m fairly sure he’ll back me up on this one. I think she needs palliative care rather than intensive care.’

I went back into Betty’s cubicle and grabbed her hand. ‘I’m having some trouble with the specialist team but I’ll get you to ICU, don’t 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 you’d 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, I’m sure she knew I was there. When I couldn’t 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.

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.

‘You’ve got to help me, Doctor, the smell is repulsive. It’s 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. I’m sure everyone can smell it: the woman who sits next to me at work, people sitting behind me on the bus. I just can’t go on like this any more.’

‘And it’s not a flatulence issue here? I mean, you don’t 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 haven’t 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 wasn’t 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 it’s not the sort of thing that you actually ask someone is it. “Can you smell my bum?” I’m sure they can all smell it but are just being too polite to say. I’ve not had a girlfriend for years because I’m terrified she’d 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 you’re right, but how many of you reading this have a job that involves placing your nose in the close vicinity of a naked man’s 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 John’s 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.