The Lieutenants, However…

This happened one Christmas an age ago, in another galaxy.

I had repaired to my office with a copy of the Annual Proceedings of the Medical Protection Society – a bulky document with an appropriately black cover – to read a few salutary tales of medical mishap, misadventure, miscalculation, misbehaviour, missed diagnoses, and occasional miscarriages of justice.  A large number of the episodes described had occurred in hospital emergency departments.  We were a high risk area.  These vignettes were post-mortems, metaphorically and also sometimes literally.  They resembled the reports of a civil aviation crash inspectorate; by their detached regard for the truth, they could be brutally frank.  And ‘pilot error’, of one sort or another, was a recurring theme.  I read the reports and would feel a familiar crawling sensation in the pit of my stomach.  I would think to myself, “I’ve done that.”

One particular report I found almost unbelievable.  And yet the details had the starkness of authenticity about them.  A thirty year old man had come to a hospital emergency department complaining of chest pain.  He had been seen by a young doctor who had made a diagnosis of ‘dyspepsia’.  The patient had been given some antacid, and discharged. Shortly afterwards (the scene had been reconstructed following the hearing of evidence in a court of law) two hospital orderlies had approached the young doctor.  “Hey doc, remember that young guy with the chest pain you sent home?  Well, he’s dead.  Collapsed behind the steering wheel of his car a couple of hundred metres up the road.  But don’t worry.  We’ve turned his car around.  It looks as if he’s driving towards the hospital, not away from it.”  So the doctor had gone ahead and destroyed all evidence of the patient’s visit to the hospital – demographics, patient file, chest X-ray, ECG, lab results.  The memory banks were erased.  The patient no longer existed.  He had never existed.

I developed sweaty palms when I read that, and I thought about that wretched young doctor.  Had he conducted himself honourably he would, no doubt, have been rapped over the knuckles.  He would have been censured by the General Medical Council, perhaps severely.  He might have incurred public humiliation.  But he would have survived.  Not now.

There was a soft knock on my office door.

“Come in!”

Delegation of two.  Mike Ruddell and Sandra Cunningham, two orthopaedic house surgeons.  “Sorry to interrupt.  Could we ask your advice?”

“Take a pew.”  Was this a clinical matter?  I noticed they weren’t carrying any notes or X-rays.  I knew them vaguely as two first year doctors who worked on the same team together, and I had an idea they were an item.  They were both about twenty three.  Mike was dark and studious looking, while Sandra had shoulder length red hair, freckles and mischievous eyes.  For a moment they looked as if they sought counselling.  Perhaps they needed the morning-after pill.  I said, “What’s up?”

“We need your advice on a ‘turf’.”

My interest waned.  “Oh yes?”

“Which service in this hospital looks after cellulitis?”

“You ask difficult questions.”  I closed the MPS disaster file.  “Let’s see.  Mondays, Wednesdays, Fridays… orthopods, unless there is no evidence of bone or joint involvement, in which case it goes to the general surgeons.  Tuesdays, Thursdays, Saturdays… plastics.  Sundays alternate.  If, however, there is evidence of an underlying disease process, for example diabetes, it would go to the physicians.  Then there are special cases.  A periorbital cellulitis generally goes plastics.  But if there is ocular involvement, it would go to the ophthalmologists.  On the other hand, if there were cerebral involvement, it might go to the neurosurgeons, but some of these patients are so sick they end up with the Intensivists.  Simple.  What’s your problem, exactly?”

Mike and Sandra exchanged glances.  “Can we run the case by you?”

“Go ahead.”

Mike presented the case.  “We admitted a twenty five year old man on to the ward last Wednesday.  A Mr Cart.  Ronald Cart.”  The hint of a smile played on Mike’s lips.  “A motor mechanic.  He presented with a hot red right upper limb and a temperature of 38 degrees. Examination revealed a large cellulitic area over the flexor surface of the right arm extending from mid-forearm to ten centimetres above the elbow.  His hands were the typical hands of a mechanic, dirty, callused, with cracked fingertips in various stages of disrepair.

“We stuck him on the ward and put him on intravenous antibiotics.  The temperature came down overnight.  Ordinarily, at this stage, we would have sent him home on oral antibiotics.  But we noticed some abnormal neurology of the right arm.”

“What abnormal neurology?”

“Wasting of the intrinsic muscles of the right hand, with some motor loss, about four-fifths.  Proximal muscle bulk seemed okay – maybe a subtle power loss.”

“Perhaps related to pain?”

“Well, that’s the funny thing.  The cellulitis wasn’t painful.  Mr Cart demonstrated this by pinching the area.”

“And he didn’t feel it?”

“He felt it.  It just didn’t bother him.”

“Anything more on that?  What had Mr Cart himself noticed?”

“Actually,” said Mike, “he had a rather strange complaint.  When he went into the fridge for a cold one he had to use his left hand.  If he used his right, he couldn’t decide which beers had been chilled.”

“Interesting array of symptoms and signs!  What did you decide at the morning ward round?”

“Unfortunately,” said Sandra, chipping in for the first time, “the boss didn’t see him.  We had sent him for a repeat X-Ray of the right arm because we thought we could see a foreign body in the cubital fossa.  So Mr Cart was down at X-ray during morning rounds, and the boss missed him.  Actually the X-ray was normal – the ‘foreign body’ was just an artefact.”

“So what happened next?”

“Well, on the basis of what we told him, the boss decided to hold on to Mr Cart and investigate him.”

“Who’s the boss?”

Mike mentioned a name.

I gave a low whistle.  “The Incandescent Light!”  It was absurd to feel intimidated by the mention of a name, but I had an image of a small, compact figure swaggering down the main hospital corridor with the glaring, crazed eyes of the occupying dictator marching down a deserted Champs-Elysees.  “If you think The Incandescent Light is ferocious now,” elderly Charge Nurses used to tell me, “you should have seen him twenty years ago.  Remember the time he beat up his House Surgeon because he couldn’t remember a patient’s haemoglobin…”  Of course, I realised, The Incandescent Light would investigate Mr Cart.  He would, if necessary, bleed Mr Cart dry to get to the bottom of Mr Cart’s problem.  He would not hand Mr Cart over to another service unless it was absolutely necessary and in particular he would not ask for nor expect any input into the management of the case from the physicians, for most of whom he had scant respect.  Poor Mr Cart!  Which was the lesser of two evils, to put up with a dodgy limb or be subjected to the full brunt of The Incandescent Light’s investigative and therapeutic zeal?  I silently transmitted my thoughts to the patient.  “Mr Cart, I don’t know you, but self-discharge now, while you have a chance.  Take to the hills – with a chilly bin of cold ones.  You can still gauge the temperature with your left hand…”

I said, “So what investigations have you done?”

“Full blood count, ESR, blood cultures, urea and electrolytes, liver function tests, calcium, phosphate, alk phos, urate, albumen, Rheumatoid Factor, Antinuclear Factor, Anti-DNA antibody, urinalysis, syphilis serology, you name it.”

“Turn up anything?”

“Everything is essentially normal.”

“How about radiology?”

“Upper limb normal.  Chest X-ray normal.  Cervical spine, normal.”

“Did you get thoracic inlet views?”

“Looking for cervical ribs?  Yes, we did.  No extra ribs.”

“So what else have you done?”

“The Incandescent Light came to see him on Friday, but unfortunately he missed him because we had sent him for some electrical studies.  Myography.  He left instructions for him to have a CT – head and neck – at the beginning of the week.”

“So has he gone home for the weekend?”

“No.  Incandescence wanted him to stay on the ward, in case he was developing a cervical stenosis, and ‘went off’.”

“How has he been over the weekend?”

“Much the same.  Three to four on five global right upper limb power loss with associated muscle wasting.  Sensory changes.  Loss of reflexes.”

“Signs all unilateral?”

“Yes.”

“Any neuro signs higher up?  Bulbar palsy?  Horner’s Syndrome?  Balaclava helmet sensory loss?”

“No.  What are you thinking of”

“He’s got classical dissociative sensory loss – loss of pain and temperature sense, with preservation of light touch and, presumably, proprioception.  I don’t say it’s pathognomonic, but you have to consider syringomyelia.  What does The Incandescent Light think?”

Mike nodded.  “He thinks it’s got to be syringomyelia, too.  Just on the basis of history alone.  He still hasn’t seen the patient.  He came in to-day, but we got the chance of fitting Mr Cart in for the CT this afternoon.  Radiology offered us a slot.”

“What did the scan show?  Was it helpful?”

“Equivocal. The head scan was normal.  The radiologists thought there was cervical enlargement and maybe evidence of a syrinx, but they weren’t prepared to be categorical, and they said it could all be within normal limits.”

Sandra said, “That brings us up to the present.  He came in on Wednesday.  To-day is Sunday, and we think it’s time he was turfed from our service.”

I shrugged.  “So turf him.  Turf him to the neurosurgeons.  What he needs is an MRI scan.  You need to know whether he’s got an Arnold-Chiari malformation.  Get the scan, confirm the diagnosis, and get him across to neurosurgery.”

Mike and Sandra looked at one another.  Mike said, “Thought you might say that.  That’s what we think.  That’s what The Incandescent Light thinks.  There’s only one problem.”

“What’s that?”

“It’s Mr Cart.  He doesn’t exist.”

*

Ronald Cart was a little Yuletide diversion that had got out of hand.  His name was a bastardisation of Rene Descartes, the French Philosopher and mathematician who had attempted to establish a solid foundation for all human knowledge based on the cogito.

Cogito ergo sum.

There was collateral invested in Ronnie.  Mike had bet Sandra one bottle of fifteen year old Laphroaig single malt whisky that he could present a figment of his imagination on the ward round of Thursday, December 19th, and keep the figment alive until Christmas morning.  It had been planned that, during the customary Christmas ward revelries, Mike would reveal to The Incandescent Light that Ronald’s empty bed had always been empty, and that Ronald had never been to X-ray, Myography, CT, or any of the other venues to which he had been hurriedly despatched whenever The Incandescent Light was sighted on the ward.  And they would laugh – this at least was the plan – at the recollection of how the morning round had repeatedly assembled with due gravity round the foot of Ron’s bed, studying the factitious temperature chart.

It was a good, imaginative scam.  It would have been easy if the boss had been a physicianly elder statesman who spent large tracts of his week out on the golf course.  The Incandescent Light could, of course, be as much of an absentee landlord as any of the other eminent wise men of the hospital, but he was not, as far as I knew, a golfer.  I knew he was a workaholic whose whole life was tied up in hospitals, theatres, wards, clinics, and medical committees.  He started early in the morning and worked late into the night.  His movements were unpredictable and he was often seen prowling the hospital corridors in the wee small hours.  He would have taken in all the information he had been given on the airy Mr Cart, he would have forgotten none of it, and, if asked at any stage, he would have been able to tell you what particular investigation was pending, and what the likely diagnostic possibilities were.  It occurred to me that specialist registrars and nurses on the ward must have been brought in on the act.  The Incandescent Light would quite likely have phoned the ward at three o’clock in the morning to ask how Mr Cart was progressing.  So how would he take it when he found out he had been duped?  I couldn’t imagine.  I had never seen The Incandescent Light smile.

I said to Mike, “I wouldn’t care to be on your ward on Christmas Day when you tell the old man, but now that he’s sanctioned an MRI scan, I should say your Laphroaig is in the bag.  Merry Christmas.”

But Mike was shaking his head.  “No, no.  You don’t understand.  I’ve already conceded the Scotch to Sandra.  We need to turf Mr Cart.  We need to get rid of him and we need to get rid of him now!”

“Why?”

By way of reply, Mike delved into his pocket and produced a wad of computer printout paper.

“What’s that?”

“It’s the monthly budget for the ward.”  He flicked through some pages.  “This is the cost of the investigation of Mr Cart thus far.  If you add up hotel services, treatment for the cellulitis, lab work, scans etc. etc., you reach this figure.”

It was a substantial five-figured number.

“If we go ahead with magnetic resonance, we arrive at this figure.”

It was a very substantial five-figured number.  For the second time during the conversation, I gave a low whistle.

“If The Incandescent Light finds out about this,” said Mike, “there will be hell to pay.”

“But surely this is just a paper exercise.”

“No!  We have spent the money.  It’s gone.”

“Well where has it gone?  Who has it?”

“I have no idea.”  Mike’s understanding of the microeconomics of the hospital was as thin as mine.  “It seems to have vanished, down a great entropic sink.  So you see, Mr Cart mustn’t have that MRI scan.  We’ve got to cut our losses and run.  We’ve got to turf him.”

What an absurd predicament.  I idly fingered the pages of the black-covered Medical Protection Society publication I had lately been reading.  It occurred to me that Mike and Sandra’s little difficulty was exactly the opposite to the nightmarish case report I’d just read, concerning the young man with chest pain whose records had been systematically annihilated without trace.  There, it had been as if a man of real flesh and blood had been swallowed up and lost in an amorphous Soviet Gulag.  He had been a real patient of whom there was no record.  On the contrary, Mike and Sandra’s creation, the figment, Cart, was an imaginary patient with an embarrassing superabundance of annotation, an exuberant profusion of recorded data that had assumed an independent life and was now reproducing itself with promiscuous abandon.  All over the hospital, and throughout the connected network of the Area Health Board, the name Cart was steadily gaining substance as the laser printers spewed forth his credentials.  Could he be stopped?

I said to Mike and Sandra, “Do you like Soviet symphonic music?  Shostakovich?  Prokofiev?”  Mike gave me an impatient shake of his head.

“Prokofiev composed a symphonic suite based on the Russian tale of Lieutenant Kije.  Do you know it?  The Russian Tsar was reading a report from an army officer which contained a sentence beginning ‘Lieutenantki je…’, which means, ‘The Lieutenants, however…’  He misread it as ‘Lieutenant Kije…’ and took it to refer to the name of an army officer, Kije.  In order not to frustrate the Imperial pleasure, the Tsar’s military commanders-in-chief had to create a Lieutenant Kije, and furnish him with a biography, much as you have done with Mr Cart.  As a matter of fact, the army ended up in just the sticky situation you are in.”

“And what was their solution?”

“They killed him off.”

Mike pursed his lips.  “What are you suggesting?  A motor vehicle accident?  A fall?  A heart attack?”

“Definitely not.  That might go as far as the coroner.  There would certainly be a post-mortem.  No.  The solution is simple.”  I took a form of self-discharge from my pocket – I have the habit of carrying one around with me.  “Get Mr Cart to sign himself out, against medical advice…”

It was as if a cloud had suddenly evaporated from above Mike’s head.  His face broke out into a serene smile.  He said, slowly and meaningfully, “That is perfect.”

And it was perfect.  It was a perfect solution because if there was anything to make an archetypal psychopathic orthopaedic surgeon lose interest in a patient, it was a form of self-discharge against medical advice.  The Incandescent Light would quietly and irrevocably take offence.  If Mr Cart was not going to be grateful for the service offered, then he could bloody well take himself out of the hospital, and take his precious self-discharge form, and stuff it up…

And the bed clothes would be changed, the name of Cart erased from the blackboard in the doctors’ office.  The electronic record would be despatched with a click of a mouse to some virtual repository on cloud nine, and any paper notes sent back down to the bowels of the hospital records department.  With any luck, no inquisitive eyebrows would be raised at the cost of keeping Mr Cart for five days prior to his departure, and the alarming cost of Mr Cart’s upkeep would be lost amid the details and complexities of a host of other expenditures.  The Incandescent Light would deliberately and unforgivingly erase from his mind all thoughts of Mr Cart and his condition and, with any luck, that would be that.

Mike looked at me squarely.  “Thanks for that.  It’s a brilliant turf.  A self-turf, back to the community.  I owe you.”

“You do.”

Thus Mike and Sandra went off with the self-discharge form to forge the signature of Mr Cart, as it would be written in a hand that felt nor hot, nor cold, nor pain, thus to placate their Tsar.  And I returned to reading more Gothic medical horror stories, absentmindedly whistling the Troika from Lieutenant Kije by Prokofiev, who died on March 5th, 1953, the same day as Stalin.

 

 

 

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