Further Confessions of a GP

David

I don’t think it will be a great surprise to any of you to hear that a reasonably high number of the patients who come in to see me leave my room without receiving a definite or immediate diagnosis from me. The great advantage I have in general practice is that time is by and large on my side. The patient in front of me is usually not severely unwell. They may well be in discomfort, worried and upset, but they are very rarely just about to expire before my eyes. This means that there is a bit more time for me to work out what is causing the aching legs, funny rash or tiredness that my poor patient might be suffering from.

However, working in the emergency department, time is often at more of a premium.

When the paramedics brought in David, barely conscious and with slow breathing, I really needed to work out quite quickly what was going on. I couldn’t rouse him enough for him to tell me anything, so I was left with the tricky task of trying to deduce the cause of his comatose state from hundreds of possible causes.

The best place to start was with the information that the paramedics already had at hand. They told me that David was 31 years old with no past medical history of note. He had been looking after his two-year-old daughter while his wife was working her shift as a nurse. He was absolutely fine when she left for work, but when she arrived home she found David lying unconscious on the sofa. Fortunately their daughter was unharmed and happily watching CBeebies, apparently unaware of her father’s poor health.

Why had a young, previously healthy man suddenly gone into a stupor? I started trying to work through some of the more common causes. I began with diabetes, but his blood sugar was normal. There were no signs of infection and no signs of a head injury that might have knocked him unconscious. His breathing was slow, but his lungs seemed clear. I was hedging my bets that something was going on in his brain and so was sure that the CT head scan I had just ordered was going to throw up some answers. Top of my list of suspicions was that an aneurysm in his brain had popped, causing a type of stroke. We managed to get the CT scan done pretty quickly, but to my surprise it came back completely normal.

Nearly 45 minutes had now passed and I still had absolutely no idea why David was unconscious. He was stable, but although he wasn’t getting any worse, he definitely wasn’t waking up. His wife had managed to find someone to look after their daughter, so was at his side, looking understandably upset and worried. I felt under huge pressure to work out what was going on. What was I missing? Barry the charge nurse wandered back from his break and took a glance at David. ‘Sure he’s not overdosed on something?’ he asked.

‘He doesn’t look like a drug user,’ I responded.

Barry gave me a sideways look. ‘Come on, Ben, you’ve been doing this job long enough to know that doesn’t mean a thing. He’s a youngish bloke, unconscious with slow breathing. We both know the most common cause of that.’

Because David didn’t fit my stereotype of a drug addict, I hadn’t even considered drug overdose as a possibility. Whereas, even before my other patient Kenny introduced himself as Crackhead Kenny, it wouldn’t have taken a genius to suspect that he might be a user: his clothes, his hair, his tattoos and even his smell… everything fitted the stereotype of the archetypal drug addict. David had a young daughter and a wife who was a nurse working at this very hospital. He lived in one of the nicer parts of town, and this was a Tuesday afternoon, not a Saturday night. He couldn’t have been taking drugs, could he?

Barry was never one to turn down the opportunity to get one over on me. He grabbed a pen torch and shone it into David’s eyes. Both pupils were tiny. Next he grabbed David’s left arm and pointed out to me the needle prick mark on his forearm. We had taken blood and put in a cannula in his right arm, so the needle prick must have already been there when David arrived at hospital. Without saying a word, Barry went to the cupboard, pulled out some naloxone and injected it into David’s cannula. Naloxone is an antidote to morphine and heroin. It reverses the effects almost instantly. Within a minute David was awake, pulling off his oxygen mask and asking where he was.

Barry was trying to catch my eye so that I would notice his smug smirk, but I was too preoccupied with David and his wife. Her relief at his recovery was very quickly replaced with tears of hurt and anger. As a nurse she knew the significance of his sudden improvement following the naloxone. Through her tears she kept asking him why. David only seemed to be able to answer, ‘I don’t know.’ It turned out that he had spent a period of time injecting heroin regularly in his early 20s but had kept away from it for years. For some reason, today his previous addiction had got the better of him and he’d tried to inject himself with the quantity of heroin that he used to take as a regular user. After such a long break, his body was naive to the drug and he accidentally overdosed.

Russell Brand talks very eloquently about the power drugs have over an addict even after years of staying clean. For some people the pull of that ‘high’ is something that hangs over them for ever, however settled and happy their drug-free life might seem on the outside. I learned that day that I had to leave my stupid stereotypes behind. Clearly, anyone can suffer from drug addiction.

The hardest part of the day was telling them that I was going to have to contact social services. I’m sure David was a great dad, but he had taken drugs when he was responsible for looking after his young daughter. Despite David’s pleas, I just couldn’t ignore that. I spent a lot of time with David and his wife, and we talked about getting help and support for them both. David had beaten drugs before, and there was no reason why he couldn’t again. He had so much to stay clean for.