Sunday, 9 January 2011

In Memoriam

In Memoriam
This is a factual account, written about some years ago, with the details slightly altered and the name of the patient changed to ensure anonimity and confidentiality
In general practice, the accumulation of years inevitably leads to a steadily growing mental catalogue of personalities whom one has met, sometimes come to know well, and for one reason or another have moved on again - to another county or country or, all too often, away from this mortal coil entirely.
Kenneth was one of these. He "adopted" me in my green years when I was newly arrived at my practice, over a quarter of a century ago. And while he certainly had the avuncular air about him - with which I felt comfortable enough - he was clearly a vulnerable and wounded man. Relapsing depressive disorder had been a part of his life since his own youth. He was anxious to discover just who had replaced my predecessor in the practice, and anxious to know how I would take to him. We quickly became comfortable with one another. For he was not a "demanding" patient in the sense that we GPs tend to use the word. Appointments never went over their time. He seemed happy enough to know that I would continue to see him once a month for an update, a chat about things in general, and his repeat prescription. At that time he was on a monoamine oxidase inhibitor, sticking to the prescribed regime obdurately in the manner that slightly obsessive people tend to do. "Ah, it’s Kenneth next" I would murmur to myself with a sense of relief when I was tired or running a little late. For I knew that, if the occasion required it, he would not delay with me. "I can see you’ve had a busy afternoon, doctor."
He learned very quickly that I had a young family. "What they need, of course, doctor, is plenty of fresh vegetables". And he left a bag of the most delectable purple sprouting broccoli from his allotment, at the reception desk the next day for me. I don’t think the children were quite into the brassicae in those days, but that night my wife and I feasted upon it.
"Do you enjoy gardening, doctor?" he enquired the next time he called. I told him I was something of a novice, but yes, I did enjoy it. But our garden, being in the city, could only cope with a modest display of annuals. I was a potato and tomato man myself, but space simply did not permit it. I don’t think "grow bags" had arrived at that time. And that was the gist of our conversation.
"What about an allotment?" He asked next time. I told him that I would love one, but in those days there was something of an allotment craze, and the waiting lists could be years long. "Don’t worry about that, doctor. I’m on the Committee!"
A month later he was helping me to dig the couch grass out of my newly acquired patch, leased to me at a rental of about £3.50 a year.
Life got busier with the children growing and the increasing professional demands. I had taken up postgraduate teaching by then, with its inevitable intrusion into my time away from the surgery. Kenneth said to me "You need to watch out, doctor" and went on to enlarge "I see your ground’s not looking its best. Could be a problem there." I agreed, sheepishly. "Problem is, doctor, the women". I did not understand what he was on about. "It’s women - on the committee! Cor, they want the whole site to look like it’s been manicured!" He did what he could to help me. But things went from bad to worse, and one August we returned from a holiday to find that it had been "requisitioned" as Kenneth put it, by a fit retired couple with plenty of time on their hands. I never saw it looking so pristine. But the soul had gone out of it, I thought.
This unfortunate turn of events coincided with a deterioration in Kenneth’s health. He developed a bowel problem which worried me a bit and him a lot more. I told him I’d like him to see a specialist. I don’t think I fully appreciated the anxiety this suggestion provoked in him. At his appointment he was told he would have to have a barium enema, for this was in the days before lower intestinal tract endoscopy was the almost routine matter that it is now. He was terrified at the prospect. Not the thought of the procedure itself, but by the horror of the notion that it might cause him to be incontinent when he got home, and soil the carpet. He was not to be reassured. He quickly relapsed into profound depression, so profound that I feared that he might go so far as to make an attempt on his life. The bowel problem was put on one side, and an urgent psychiatric referral set in motion.
"Do you think they’ll give me the electric shock treatment, doctor?" He was utterly changed from the man who had helped me weed and sow on those sunny evenings the previous spring. "I do hope they will. It really brought me through the last time ..."
All this took place at a time when electro-convulsive therapy had slipped from favour. Pressure groups claiming to champion the "victims" of psychiatrists were in the ascendance. Doctors had been sued.
His appointment came through very quickly, to our mutual relief. But when he saw me the next day he was in a state of near despair. "They say they don’t do it now. They want me to start some different tablets".
The following morning, when I was away at a conference, one of my partners was called to the block of flats where Kenneth had lived to certify him dead. "He was very dead" she assured me, visibly shocked, that afternoon. "His brains were splattered all over the floor of the basement."
The Coroner said that because it could not be certain that he had intentionally thrown himself down the stairwell from his fifth floor flat, he would record a verdict of accidental death. His wife was grateful and relieved about that. But I did wonder, as I have often wondered since, if we really do have an accurate idea of the incidence of suicide, and whether the denial of what is pretty self evident really serves to help people with mental illness. It is certainly clear that it provides a modicum of comfort for their grieving families.
From time to time I am called to that same block on visits to other patients. The heavy steel hand rail on the stair case at the ground floor still bears the indentation where Kenneth’s head made its final and catastrophic impact with it, and cascaded its contents on to the floor below. And I think of his honest, gnarled hands as he helped me to lift the first crop of new potatoes from the good earth on a warm summer evening twenty years ago. And I think of all the things he did for me, and of all the things I was never able to do for him.

Dona eis requiem sempiternam

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