Further Confessions of a GP

Betty Ferrari

I was working in A&E again. As I arrived for my shift my heart sank as I spotted the queue of ambulances sat at the entrance. Each paramedic crew was patiently waiting to offload their patient into a department that was already completely full. Barry was in charge today, and he was looking very flustered as he tried to move trolleys in and out of cubicles in a gallant attempt to make space when there was none. The phones were all ringing at once and it felt like a scene from a disaster movie.

At times like this, each new patient being brought in feels like an extra mouth to feed when there is already not enough food to go round. The doctors and nurses collectively groan as they witness each new admission being wheeled in. The poor patient sitting on the ambulance trolley needs help, time and care, but this can often be lost when the staff are in such a flap simply trying to manage the impossible task of fitting 50 patients into a department with 30 beds.

‘There’s a bed crisis,’ one of the nurses mouthed to me as if to try to explain the madness that I was walking into. There was a time when a bed crisis was considered to be a rare, traumatic event, but now we just seemed to run on the assumption that there was always a bed crisis, which makes the phrase meaningless.

Fortunately for me, I wasn’t responsible for managing the bed issue. I was simply there as a foot soldier. My job was to see and treat the patients as effectively and efficiently as I could. I blanked out the noise and chaos and picked up the medical notes of the next patient to be seen. To my surprise it was a patient I knew very well and, if I’m honest, was probably my favourite patient at my practice. One of the odd perks of being both a GP and an occasional A&E doctor is that I sometimes meet my primary care regulars when they have an emergency and end up in casualty.

Betty was a great character, well known to all the staff at my practice. She had a loud cackling laugh and called everyone ‘darling’. She made sure to buy the practice a bottle of sherry every Christmas and would flirt outrageously with any man aged between 16 and 100. Betty had worked the boards as a cabaret performer for years and I loved visiting her flat and seeing the old black-and-white photos of her from the late 1940s looking glamorous. Her stage persona was Betty Ferrari, which sounds like the name of a drag act now, but back in the late 40s, she assures me, it was alluring and exotic. ‘I was married to the stage and I was monogamous!’ That was her way of telling me that she never settled down or had children. With no family, Betty was lonely. I visited as often as I could. If we had medical students attached to the surgery I would bring them to meet her. I told them she had an interesting medical history but the real reason for the visit was because she loved the company and revelled in performing a few of the ‘old numbers’ for a new audience. Unfortunately, these days her bad lungs mean she rarely finishes a song without being interrupted by a coughing fit.

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.