Goodness Gracious Me!

A short story by Dr TAE Nichols, April 2004

A patient of mine died last Winter.

I met Mr Charles Bolton in 2002 when I first joined the practice. He had been looked
after by my predecessor – the late (and great) Dr Herbert Montgomery (Monty to his
friends). Although technically he was one of my patients, my first encounter with him
was when I attended his wife who was poorly with a chest infection but unable to
attend the surgery because she also had a broken leg.

It was a lazy winter evening, cool but with no wind at all. I found my way to the
farmhouse down a winding country road, quite beautiful with avenues of weathered
poplar trees lining my path. He welcomed me in, calling me “doctor” (I always
secretly take pleasure when people call me by that generic term – it comes from
having aspired for it for so many years), and led me up to her.

She was lain up in bed with her leg in the air. A light airy room, with floral patterning
on the walls and an elegant four poster bed of dark wood. She was relieved to see me,
and said as much in her soft anglicised Spanish accent. Now in her late forties, she
was someone who had clearly been stunningly attractive in her youth. Thick dark
hair, with doe eyes and a pleasant manner – the photographs on the side of the bed
confirmed it.

Having talked to her at some length - she was chatty and entertaining, a good historian
and gave me most of what I needed to know without prompting, I examined her. Her
fingers showed no signs of splinter haemorrhages, no clubbing, her palmar skin
creases were not pale, and she had no palmar erythema. Her pulse was raised at
around 110 beats per minute, but it was a regular tachycardia and not overly
concerning. I noted the shape of her fingers as I examined – they were rough and
calloused from the farm-work that she did, but not unpleasant.

I examined her eyes – no jaundice, no eyelid pallor and no Arcus Corneus, just a deep
brown iris – the same as her wooden bed. Her tongue was dry, and her lips and mouth
made a clacking sound as she opened them, but she was not centrally cyanosed.

“I need to examine your heart and lungs, and have a feel of your tummy” that
was my line. At one time I had been annoyed with myself for saying the same thing
time and again – from time to time my regular patients would say it to me first to
make me blush. Now I had just accepted it, and rattled it out.

Mr Bolton as if taking his cue, and left the room. She loosened her silk shirt, and it
fell to the sides as I fished out my stethoscope.

“Take a deep breath all the way in” – I let my hands rest on the sides of her
chest “and out”. I squeezed the chest wall “and in again” – good bilateral expansion.

Percussing her chest around her lacy white bra, I was unable to avoid noticing a dark
brown nipple underneath, before carrying on, trying not to pause at my unintentional
invasion of her privacy. I listened to her lungs and heart at the front – entirely normal
– vesicular breath sounds and no murmurs. As I was doing so she said something to
me, which I couldn’t hear because my ears were stuffed full of stethoscope of course
– I took them out.

“I said: when I was young, I had fantastic breasts you know”.

My eyes must have been directed towards her breasts as I examined her, but in fact
had been glazed over as I concentrated on my auscultation. Feeling self-conscious
because of my earlier observation, I nearly choked, and said quickly

“Oh – don’t worry, there’s nothing wrong with your breasts.”

She gave me a wry smile as if unconvinced, and I felt uncomfortable before digging
my own grave once more

“I’m sure there are many young men who would pay good money to have
girlfriends with your breasts” I said, and then mentally kicked myself in the shins.
She gave me a surprised look, and I realised my blunder. While this silly lady had
started flirting with me, it was dangerous for her to lose control of it. My impulse was
honest – to reassure her in an area of her appearance she was protesting to be insecure
in, but when people say improper things like that, people like me always come a
cropper. I took refuge in professionalism, and met her stare head on

“Can I get you to sit forward so that I can listen to the back of your lungs”

She did so, but now that it was such a big deal in my mind that I couldn’t help notice
her cleavage over her shoulders (where I was safe from her accusing vision). My
superficial and silly comment might have been said out of a desperate attempt to keep
the words rolling, but she did indeed have fantastic breasts. I blushed.

Lying her flat again, I examined her stomach. The years of being a farmer’s wife had
kept her fit, and it was a real relief to examine someone who wasn’t obese for a
change. One actually had a chance of palpating an organ through the abdominal wall,
as opposed to a thick layer of skin. Once again she confounded my perturbed brain –
her stomach was beautiful to look at, and pleasant to examine. No masses, normal to
percussion, no organomegaly and non-tender. All things considered I decided not to
complete with a Per Rectal examination (my consultant would have scolded “No
abdominal examination is complete without examining the hernial orophices and
rectum” but I don’t believe he would have done it himself in the circumstances).

There was no evidence of peripheral oedema of the left leg, and the right was in a
cast, with warm, well perfused toes with a capillary refill of less than 2 seconds.
Incidentally there was no leg hair, but I did not feel that this was likely to be due to
chronic arterial ischaemia – there was no history of it, and I found it more likely that
she waxed her legs. These things are not to be taken for granted I had been taught.

“I’m just going to do some writing before I forget everything”

She was quite unwell, but things didn’t add up for the supposition of a chest infection
– she didn’t have a temperature for one thing. Her chest was clear and although she
was short of breath, she wasn’t producing any phlegm. That horrible heart-sink
feeling built as infection became less and less likely, and that other sinister cause of
shortness of breath became more likely.

Mr Bolton returned at this point, and after much debate they agreed to let me remove
her leg cast (which I reasoned with them was due off soon anyway) and, amongst the
pale and flaky skin, sure enough she had a swollen painful calf underneath it. A good
4 centimetres increased in diameter over the opposite calf, and somewhat tense.

I explained to the Boltons that I was convinced that the extended period of bedrest
and the intrinsic nature of healing fractures making one prone to clotting had led to
her developing a Deep Vein Thrombosis of her calf, and that small bits of clotted
blood had been breaking off and travelling into the lungs – Pulmonary Emboli,
causing loss of blood supply to small parts of the lungs and thereby damage to them.

Being people of good health although he a good ten years the senior, they took it
pretty hard. He reported to have never been in hospital in his life, not even at birth, he
had and only met a doctor professionally twice - Dr Montgomery both times on home
visits. He didn’t want his wife going into hospital – he didn’t trust them, and felt she
needed to be where he could look after her. She was more conciliatory, but deferred
to his judgement. There was an awkward silence as I considered what I needed to say
to get her in without worrying them overly.

The pause was broken by the entry of their only child - Miss Bolton, through the
bedroom door having returned to the house from town. If Mrs Bolton proved
stunning in the photographs of her youth, Miss Bolton was an improvement –
something to do with genetic blending and repair I suppose. Having thoroughly
examined Mrs Bolton, I was primed for the contrast with her daughter – I was struck
at first by her hair. The thick, straight continental hair of the mother had been blended
with the curly Celtic mop of the father into a mid-brown hair with long gentle waves
rolling down the side of her head onto her shoulders – I might have described it as
cascading. Aged in her early twenties, she was wearing a summery yellow dress
revealing the shoulders, arms and legs bare, and had toes poking out of a pair of suede
sandals.

She initially looked at me with a slight frown – somewhat challenged by my presence,

and not necessarily too impressed with my stare. There I was, a bearded young man
in her mother’s bedroom with her in pyjamas, her mother looking flushed in the face,
and me flushing rapidly as I realised how intently I had been staring at her. She then
noted the stethoscope casually slung round my neck (which is as casually cool and
blasé as it is absolutely practical), and realised who I was. Stepping forward as I
broke my gaze forcibly, she spoke quickly, with her mother’s Spanish twang but in a
milder form. Her frown had softened a little, but still made it difficult for me to look
at her directly.

“Doctor – thank god you are here. My father refused to call you for
days, but I couldn’t let her go on getting worse. I called the surgery and asked them
for you to come – do you know what is wrong with her? How can she have a chest
infection if she has no cough?”
 “Clots in the lungs he says – from her calves. Wants her to go
into the hospital, but I told him it was out of the question. I can’t look after her in
there, and they’ll not care for her.” Mr Bolton was gruff and unconvinced.

I cleared my throat

“I believe she has a thrombosis in the veins of the calf and that she has had
multiple small pulmonary emboli – lumps of blood passing up from those clotted
veins and wedging in the arteries that supply the lung”.

Her frown disappeared to a blank expression as she forgot my presence in the face of
what I was saying.. She went pale and looked nervously at her mother. Both of her
parents avoided making eye contact with her. Her mother was staring at her husband,
who in turn held his chin in his fist, leaning on the side of the armchair, looking at the
foot of the bed. She returned her attention to me.

“But you can treat them right? What does it mean?”

“What I hope is that we can prove the diagnosis by her going into hospital and
having a scan – after that it would be a question of her taking warfarin for six months
to thin the blood in a controlled way, breaking down the clots and preventing them
from coming back.”

“Now he wants bloody rat poison!” he said, shaking his head. I

looked round to make eye contact with him, but he was still staring at the bed. Mrs
Bolton had now closed her eyes, and in the absence of their focus, I ended up talking
to Miss Bolton.

“My concern is that although it is unlikely, there is a risk that the whole clot
will become dislodged at once, and if it were to do that, the blood supply to a whole
lung, or even both lungs could be lost…. it would be immediately life threatening.”

“Then she goes in and has her scan and her rat poison – whatever you
have to do.” Mr Bolton looked up at his daughter to protest, but seeing his daughter’s
focus realised his futility in the face of necessity and went back to moping glumly.
Miss Bolton went to her mother, and sat on the side of the bed. “Mama – you must go
in. This could kill you”. Mrs Bolton agreed, and Mr Bolton’s assent was gained.

I fished around in my bag, and retrieved a vial of Enoxaparin – a fantastic drug that
has revolutionised the whole process of anticoagulation – a once-daily Low Molecular
Weight Heparin that does not need monitoring because it is more predictable than
Heparin and can be given sub-cutaneously with revolutionary ease – no need for
definitive venous access, no need for blood tests every four hours. At the sight of the
needle, Mr Bolton left the room, and Mrs Bolton shivered.

“They are ridiculous the pair of them. Give them an animal and they
will stick a needle into its backside no matter how loud it squeals, but when it comes
to humans they go weak at the knees”.
I knelt by the bedside as I drew it up, flicking the ampoule to get the air to the top,
then breaking it open and drawing the fluid carefully into the syringe, now flicking
the syringe like they do in the movies to allow me to expel the air. It is utter nonsense
of course, because a small amount of air being injected sub-cut makes no difference at
all – in fact it might even speed the absorption by physical pressure gradients, but I
wanted to impress for some reason, and that meant flicking like a professional actor.
Mrs Bolton had raised her pyjama shirt once more, and exposed her stomach, but
winced in anticipation of the injection.

Miss Bolton reached over me to reassure he mother. In doing so, her arm brushed
against my cheek – soft warm downy skin against my face (a part spared of facial
hair). She muttered an apology to which I assented. In her sudden movement, I
caught a waft of her smell – its funny that body odour is sometimes not only not
unpleasant, but in some cases (and what I am getting at is in this case) her smell was
like a caress. Gentle and relaxing – I liked it. It was the first time I had ever felt that
about body odour, and having spent my second job in Breast Surgery, which involved
routine examination of the breast (and armpit lymph nodes) I had plenty of exposure.
It had never bothered me while at work in the way that it might if I was on a crowded
bus. It never occurred to me to take offence in the same way that a pathologist
dissection the bowels at post-mortem forgets to find the mixed smells of
decomposition and faecal matter offensive.

“Sharp scratch then” I gently pinched the abdominal wall, injecting the drug
just under the skin. She didn’t actually notice the discomfort, so small was the needle,
partially masked by the discomfort of my pinching the skin around it “All done”.

“Is that it?” Miss Bolton exclaimed “Mama you wet kipper”

I blurted out a laugh at her silly turn of phrase – the colloquial English didn’t fit with
her Spanish accent, and Mrs Bolton opened one eye, only realising that it had been
injected already as she saw me store the needle in a small Sharps Box I carried in my
bag. I called the hospital and arranged for her to be admitted. The daughter was to
drive her in. I said my goodbyes to Mrs Bolton, who remained a little stunned and
clearly not looking forward to her hospital stay.

“Thankyou so much doctor – I can’t believe they left it so long. I

knew there was something wrong like this, but they wouldn’t listen to me. You don’t
really think that this clot is going to shoot off do you?”

“There is a chance, but it is small, and I have already started the treatment
with that injection. It’s just important to get her in”.

“Yes yes – I will take her myself. Thankyou again doctor. Before you
go…”

“yes?”

“Can you help me bring some things in from my car? I will need the
space.”
 “er…certainly.”

I didn’t quite know why she was asking me, when her father was inside, but I was in
no great hurry, and more than a little curious about what might be in her boot. It was
laden with canvasses, a substantial amount of artwork that she had produced and was
bringing home. As I carried an armful towards the house, I lost my grip on their
awkward shape, and one tumbled from my grasp onto the ground. The canvas fell off,
and I saw a skilfully painted lanscape - a valley with a supernatural sunset receding
below the horizon. I was full of admiration. I have always been a scientist, and
creativity in my eyes is enviable – I have always been self-conscious about my work,
and hate for other people to see it. I couldn’t reach down for the canvas because I was
still laden with others. Miss Bolton heard the event, walking briskly back to the
scene, she quickly cast a green canvas sheet over them to conceal it from my vision.
She was frowning again.

“Don’t you know not to look at an artists work before it is complete?” she
questioned angrily.

“I’m so sorry.” I was confused. Why didn’t she want me to look at

them? She was asking me to help her, and must have known they were open to see.
Besides, they looked quite finished to me. I felt horribly guilty as I helped her carry
them into the house, the weight of my double transgression nauseating me. I had
dropped her work, and violated it with my perusal.

“Please just leave them here” she declared as I accompanied her inside,
placing her load on the table. Our second trip was carried out in silence. Once the
labour was complete, I retrieved my bag and coat.

“I’m sorry I dropped your..”

“It’s okay – it wasn’t damaged” she cut me off in mid sentence.

“Goodbye then.”

Demoralised, I marched back to my car, cursing fate but knowing that I only had
myself to blame for trying to carry too many paintings. Then I heard the crunching
sound of footsteps on the gravel path, and turned to see Juliet jogging towards me.

I stood, doctors bag in one hand and Mrs Bolton’s notes in the other, and was helpless
as Miss Bolton stopped short of me and kissed me on the lips before turning back and
jogging into the house. There was nothing I could do about it but accept my
punishment. I wasn’t quite sure how to take it. Was it an apology? Was it gratitude?
A cultural thing no doubt was behind it. They give kisses all the time on the
continent, and if the mother was anything to go by with her comments about her
breasts, uncomfortably forward behaviour was part of that household.

I drove away feeling odd. I felt the weight of the intrinsic reward of picking up a
serious problem and doing my part efficiently and well, and the personal reward of
the two interesting ladies I had met, particularly the latter. Practising medicine is
intrinsically physical, personal contact with the bodies of others, from things as small
and controlled as guiding a needle into a vein, to as intense and dramatic as sprinting
to a cardiac arrest. It is a real bonus if the contact ends up being pleasant, but I was
left with an unpleasant feeling of guilt at the same time, guilt that I couldn’t quite
place.

For the next two weeks, from time to time I thought about the Boltons, and in
particular Miss Bolton, whose gentle curls and angry frown wove their way through
my mind, and every morning or afternoon surgery I wished that the next patient
would be her. My work had been routine and unrewarding – low key clinics with
common complaints needing little of my clinical skill to assess and manage (apart
from the one case of Dermatomyositis, whose Shawl Sign was the first I had seen in
clinical practice). My idle mind needed something to look forward to, and the
Boltons, being my last interesting case kept coming back to me.

When the hospital’s Discharge Summary was sent to me by post, I was horrified and
taken aback. It seemed that Mrs Bolton had been admitted without event, they had
preformed a pulmonary angiogram by Computer Assisted Tomography promptly and
confirmed that yes she had multiple small emobli, but on the way back from the
scanner, she became acutely unwell with piercing right sided chest pain associated
with a cough productive of small amounts of blood. Her oxygen saturations dropped,
her pulse rose, and her blood pressure plummeted. Once stabilised in A&E, she was
rushed back to the CT suite where they confirmed that she had suffered a further and
this time massive embolic event. She was taken to the Intensive Therapy Unit,
deteriorating all the time into worsening Type 1 Respiratory Failure despite receiving
100% oxygen through a High-Flow circuit. They thrombolysed her successfully – the
clot was broken down, and she bounced back quickly. After only twenty four hours
they successfully took her off the ventilator and she spent many days on the ward, as
the warfarin levels in her blood built up - now she was discharged back to my care.
My pulse raced as I read the summary. I paused to absorb this onslaught of
information.

My eyes scanned down to the discharge arrangements. The note apologised for the
slightly late discharge summary (the doctors had changed teams and the writer had
never met Mrs Bolton, instead piecing together the details of the admission from her
medical notes) and informed me that the initial reports of the CT had been given
verbally, and the full formal report although produced only a few days afterwards,
was only reviewed by the new houseman on the firm. Necessarily imaging the whole
chest, and in the calm of the reporting room, the other structures of the chest had been
screened and considered. The images demonstrated an area of microcalcification in
the soft tissue of the right breast, a radiodense stellate lesion centrally, several small
malignant looking lymph nodes in the axilla, a possible metastasis in the liver (the top
of which had been caught in the lung fields scanned because of its intimate anatomical
association with the right lower lobe of lung). The conclusion was that she probably
had an area of Ductal Carcinoma in Situ with a central invasive malignancy, lymph
node and liver metastases. An advanced breast cancer that had spread locally and
distantly.

I sat back in my chair, miserable and demoralised. Sometimes when things make
sense to you, it is a rewarding thing, and at other times it drags you into despair
because the realisation is of such gravity. She had a metastatic cancer of the breast, a
highly significant risk factor for developing venous thrombosis – it had been tipped
into clinical exposure only because of the additional risk factors - the leg fracture and
immobility. Our breast screening program didn’t start on people of her age because
the pickup rate isn’t great in younger people on account of the relatively dense tissue
of the breast. As I mulled things over in my mind, the other possible link occurred to
me – the fracture of her leg had a legitimate explanation – she had been thrown from
her horse but it was all too possible that she had a bony metastasis of the leg that had
weakened it and caused a pathological fracture from relatively mild trauma – it hadn’t
been a bad throw from what I understood, and she was rather surprised to have broken
the leg. These things are usually picked up by the Orthopaedic surgeons because the
bone looks sclerotic and weak, but if the deposits were small and the x-rays not
reviewed on a light-box with scrutiny they might have missed subtle changes.

The last piece of the jigsaw clicked into place. During my consultation with her,
whatever its mechanism it was true to say that she had deliberately drawn my
attention to her breasts. At the time I was disturbed by it because she was beautiful
lady, and I had been attracted to her (in quite a benign way) – what I was scared might
have been flirtation at the time made me very embarrassed because it threatened my
professionalism. With that wicked thing retrospect, I scolded myself that if I hadn’t
been more deeply professional, then I might have taken her cue without being self-
conscious, and considered the breasts objectively… perhaps I might even have
examined them (not a matter of routine for someone with a suspected chest infection,
but would have been if actively screening for Risk Factors for embolic disease). My
morose contemplation was tempered by the fact that even if I had found it there and
then, it might have got her reviewed in hospital, but that at this advanced stage a few
days delay in diagnosis meant nothing to her overall prognosis. Early metastasis
before any symptoms are apparent is typical of a high grade, poorly differentiated
tumour growing fast.

How subtle the human brain is! I doubt she had even been aware of what she was
doing. Certainly I had been thinking about her ever since – my brain had been trying
to make the connection and going back over my visit time and again, but inevitably
being distracted by the personal involvement. The image of the beautiful Miss Bolton
had pervaded my mind every time I though of it, stunted my imagination (or
redirected it). Now the medical jigsaw had been completed, I was left with a different
kind of gap – if Mrs Bolton’s apparent forwardness had been falsely interpreted in
what I attributed to be flirtation, then I had to question my assumption about the
nature of Miss Bolton’s forwardness and its motives. Shaking the thought from my
head, I received my first patient of the morning – a young boy with a bladder
infection. He giggled as I examined his testicles (they always do, poor fellows) –
both present and descended (I documented in the notes), and sent him home with
some antibiotics.

The morning dragged on forever. There was one thing I had to do most of all, but
couldn’t because of my other duties, and I felt frustrated. Mrs Bolton didn’t know
that this had been found in her breast, and it was going to be up to me to break the
news to her. The efficient Houseman who had read the report had copied the
discharge summary to the Breast Clinic who would be sending her out an appointment
to attend the clinic by first class post – she would probably receive the letter the
following day if my reckoning was correct, and the cat would be out of the bag in an
uncontrolled and insensitive way.

The afternoon came, and I drove out to the Poplars. There was still no wind, and their
borders drooped calmly, breaking the sharp winter sun into a scattered pattern on the
road – quite beautiful.

My heart was thumping as I was greeted at the door by Miss Bolton, dressed smartly
in a two piece Burberry suit, hair tied back, revealing the maxillary bones nicely. Oh
who am I kidding… she had nice cheek bones that I hadn’t focussed on before. She
smiled warmly and welcomed me in. I was told that Mrs Bolton was doing well, still
very tired, but the leg was much better. Mr Bolton, I gathered, was out. I was polite,
but I must have looked a little white, and her conversation began to tail off a little as
she realised that something was wrong, and that my visit had not simply been out of
curiosity, or an excuse to visit (at least I hoped she had made that assumption). I
wanted more than anything to chat casually to this lady, but was stifled by my
pressing duty. I accepted the cup of coffee offered, and asked if I could see Mrs
Bolton. Proceeding with what I interpreted as a little disappointment, she showed me
out to the veranda where Mrs Bolton sat reading a newspaper, legs tucked away under
a tartan rug. Though her smile was broad as she saw us approaching together, I was a
little taken aback to see her. She looked pale and a little wasted – she looked ten
years older than she had a few weeks before, and when she talked it was not in
complete sentences – she paused to catch her breath every now and again.

I listened attentively as she recounted her experience of events, this time picking up
the human perspective – the sheer terror and agony of a near-death experience. I
asked her how she was doing since leaving hospital, building up to what I had to tell
her. There is no right way to do these kind of things, and people need news broken in
different ways, but I default to being straightforward and honest, and had certainly
had not the mental strength to be evasive with this woman.

She and her daughter listened intently to what I had to say, completely silent. I
explained the findings of the scan and then what it meant. I paused, but was urged to
go on by Mrs Bolton – she wanted the whole spiel. The original source of the cancer
was beyond the point of being removable by operation. Radiotherapy could be to
treat local symptoms only if they occurred in the future, but we could offer
chemotherapy to try and extend her life, and a hormone tablet that might suppress the
growth of the cancers or even shrink them to a certain extent. There followed a long
silence, and she maintained eye contact with me. I heard Miss Bolton swallow, and
shifted my glance to her, finding in return a carbon copy of her mother’s brown eyes
welled up with tears. I turned back to Mrs Bolton, who closed the originals slowly,
causing two large tears to fall onto her tartan rug. She talked to me with eyes closed.

“I saw my mother die of the breast cancer you know. She was
fifty years old when she finally went. I wondered if I was meant to outlive her – she’s
got the better of me by a good year from now, and now you save my life from one
thing to kill me with another.”

I was caught in the emotion round the table, and felt that horrid flushing of the face as
the autonomic nervous system kicks in and prepares you for a good blub. The
tingling of my face and the lump low down in the throat. I had been here many times
before, but although it is easier over time and blinking frequently to avoid the tears
welling certainly helps. I can never remain unaffected by these kind of discussions,
and in a way, I hope I never will, painful though it is. When it had first happened on
the wards, I was worried about the idea that my feelings were false – it wasn’t my
relative after all. Lately, I was happy to realise that it’s just about seeing the pain of
others, and sharing in the misery of mortality.

After leaving a time for the news to sink in, I presented a plan for them. My initial
suggestion that she should attend the hospital breast clinic appointment when it
arrived was rejected. I stressed that the importance would be that they could take a
tissue biopsy of the lump, which would tell them if it would be amenable to
chemotherapy, or to the hormone treatment. Once again, I found myself threatening
her with hospital and in-patient medical care. How easy it is when you are a doctor to
forget how dramatic going to hospital is for the lay public. The only way I can feel it
is to be sensitive to their reaction when I tell them, but I can never quite get there. I
remember as a child hearing about how so and so “was in hospital” – it was a place of
disease and death. I suppose it still is to me, but disease and death aren’t strangers to
me any more.

Even Miss Bolton wasn’t keen on the idea of hospital, and I realised I would have to
fight my own battle on this one. Eventually, I suggested that I could take the a fine
needle sample myself – I have done it many times working on the breast unit, and
although I didn’t have the neat little kits, I had a needle and syringe of an appropriate
gauge, and I could pass by the pathology department of the hospital on my way home,
giving them the sample to process. A little unorthodox, and it would only be cytology
rather than histology, but it was better than nothing, and would probably provide
receptor status to assess the possibility of hormone therapy, and suggest a grade of
cancer to help prognosticate.

We solemnly proceeded into the house, and to the bedroom. She undressed, and took
of her bra. I was long past the embarrassment that had plagued me previously
surrounding her breasts. Slapped forcibly back in the doctor role, my training and
routine came back into play. The words of the stern Professor Lennard came back
into my head ”When inspecting the breast – always think TIT” (queue giggles from
the third year medical students) “Tumour, Inflammation and Tethering”. The only
visible sign was a slight discolouration of the skin on the upper outer quadrant of her
right breast which would had previously been covered by her bra on my respiratory
examination, but when I examined it, there was indeed a large hard lump – craggy and
irregular, pulling the tissues towards a central point in a violent disruption of the
otherwise soft breast. There were several large lymph nodes palpable in her armpit,
consistent with the scan’s interpretation. I prepared my syringe to take the sample,
and Miss Bolton sat on the opposite side to me, holding her mother’s hand.

I was about to take the sample, when she grabbed my arm, halting the progress of my
needle.

“Tell me again why you are taking this”

 “When we look at it down the microscope, we can see whether it will respond
to chemotherapy, and whether it will respond to the hormone therapy.” I paused. “It
will also tell us roughly how long you might have before serious complications arise”.
I left it for her to read between the lines exactly what I meant by that.

“And if I don’t want chemotherapy? And if it won’t respond to the

hormone therapy?”

I paused.

“Then I would probably give you the hormone therapy anyway, because
sometimes the sample gives a slightly unreflective picture and some of the cancer
might be responsive. Nobody would want you to have chemotherapy against your
will of course...”

She held my arm.

“I don’t want chemotherapy.”

I re-sheathed the needle, and kneeled back a little, waiting to hear her out.

“I saw what it did to my mother before she died – I don’t want

chemotherapy. If a fox is wounded in a trap, it will try and bite its own leg off to
escape, and bleed to death in the process. I don’t want to bite my leg doctor – it will
hurt, and I don’t want to spend the rest of my life bleeding from it.”

I saw the sense in her argument, and so did Miss Bolton. Her mothers experience of
chemotherapy might have been a lot worse – we had far more powerful anti-emetics
to deal with the nausea and vomiting associated with chemotherapy, but the agents she
would need to make an impact were substantial. I couldn’t honestly council her about
whether to have it or not. In these kinds of situations, you just have to let people
decide. I knew she would fight to avoid a protracted in-patient stay, and I anticipated
that it might require one for effective treatment. My pulse was no longer racing, as I
packed up my things, and she dressed herself again. A pale cloud had come between
the farm and the sun, the dulling of the atmosphere was entirely in keeping with our
moods.

She asked to be left alone - Miss Bolton and I went downstairs . She tried to talk to
me, but her emotions would hardly let her. She sat opposite me on a chair in the
lounge. Her face crumpled and she looked at the ceiling, bloodshot eyes. She
covered her mouth with her fingers, almost praying. She had her mothers fingers –
almost exactly the same, but without the callus. I let her cry for a while, and tried not
to notice her heaving chest. In the privacy and intimacy of the tears, I was getting
involved on that other level again. My duty as a physician to my patient done for the
time being, I was faced with the duty as a person to her daughter to comfort her. In
truth I had a duty to myself not to ignore the growing feelings I had for her. My heart
was mixed with pity and admiration for this sobbing lady in front of me. There was a
conflict between the need to be benevolent, and my almost overwhelming desire to
put my arms round her and return the kiss she had given me previously. I basked in
the joy of being near her in this intimate way, selfishly detached from her misery.
Her sobs slowed, and her arms fell to her knees, hands bridging the gap between us.

“How..” she struggled to swallow some unexpected saliva at the back

of her throat, waiting to choke her as she tried to talk “…long will it be, doctor?”

The pain of being called Doctor was awful. I had never felt it before, but the
formality which I made my staple was turned on me cruelly, and put up a barrier
between us again where my thoughts had been more personal.

“It is very difficult to say – it could be months or it could be years”.

Her face crumpled again, and I reached out to her, holding her hands in mine.

“There’s nothing you can do then?”

“There are always things we can do. The first thing is to give her the hormone
treatment. I can prescribe it now, and the chemist in the village will be open until 7
tonight – she can start it today as an empirical treatment. She has no symptoms of the
cancer at the moment, and that is the most important thing – any symptoms she does
get we can always treat. The breathing will improve the further from the clot she
gets”.

I reached into my bag and filled out the prescription, tearing off the top copy for Miss
Bolton. I handed it to her

“I don’t know your first name…”

She looked up at me

“Juliet”

With her accent it came just a little like “shoolieta”.

“Ben”.

I shook her hand, and we managed smiles.

“She should take one of these every morning. It doesn’t have to be with food,
and she doesn’t need to avoid alcohol. Does she have enough warfarin, or does she
need some more?”

“No she had plenty thankyou. She is going to see your nurse in two
days time to have another blood test for it.”

As I left this time there was no kiss. We had arranged for another home visit the
following week, and for Mr Bolton to be there so that he could talk to me.

Now nothing but the Boltons filled my mind. I dreaded the meeting with Mr Bolton –
as I knew he would. I longed to see Juliet again. I racked my brains to come up with
something else to offer Mrs Bolton. At night, our encounters went round in my head,
and I woke with a sore neck where my head wouldn’t relax.

I avoided noticing the Warfarin Clinic list on the day I knew she was coming, but that
didn’t save me. I had finished my morning clinic, and was reclining in my chair,
British Medical Journal in hand, ready to read about the latest evidence suggesting
that in asymptomatic derangement of Liver Function Tests where Non-Alcoholic
Hepatic Steatosis was suspected as a general rule we should be more aggressive in
doing liver biopsies, when one of the secretaries came in.

“Sorry to bother you Dr Lovell, there is a relative here to talk to

you about Mrs Bolton of Poplars Farm– do you have time or should I ask them to
make an appointment?”

Mr Bolton. I completed my painful swallow of the coffee in my mouth which was

still uncomfortably hot, and assented. I was unprepared – the right things to say to
him hadn’t yet been contemplated… I would just have to wing it.

It was Juliet who came into my room, not her father. She was looking radiant again –
all of the misery gone (hidden beneath the surface no doubt), and an air of intent focus
carried her to me, and she sat on the edge of the patient’s seat.

“I want you to examine my breasts”.

There was no escaping fate. Bolton breasts were meant to be a part of my life. Her
request was legitimate - she had a positive family history of relatively early, and high
grade breast cancer, and although she wasn’t one of my patients, there was no hope of
refusing her. The ethic attempted a clash with my morals. Could I examine the
breasts of a woman I was infatuated with and retain my professionalism? The thought
that someone else less trained in breast examination or less interested in doing a
thorough job might be asked to perform the task and miss a treatable cancer in this
woman clinched it for me.

“Alright. First show me your fingers.”

I went through my drill as per usual. As I had noticed before, her fingers were very
similar to her mothers. No nail changes, no skin crease pallor, no palmar erythema.
Her pulse was… significantly raised at around 140 beats per minute, but it was
regular. She had a pronounced sinus arrhythmia – the pulse rate varying as she
breathed in and out as is often the case in young healthy people. A physiological
response to Adrenaline I thought… it occurred to me that there was a similar
neurohormonal response going on not so far away. I wondered what my pulse rate
was, and whether it would beat hers.

No eyelid pallor, moist mucous membranes, no supraclavicular lymph nodes. I pulled

the curtain over the door, and tilted the shutters as I always did for examinations.

“Can you take your shirt off for me please? If you are wearing a bra, you can
leave it on for the moment.”
She was wearing a bra. A white one, plain at the bottom, but with lace at the top. She
took a deep breath. She sat straight as I held her ribcage while it expanded, pushing
her breasts to the sides as it did so. Equal and good chest expansion. As I percussed
her, she swayed gently with the impact of my finger drumming. I fumbled a little
with my stethoscope as I put it to her back to listen to the lungs, passing the
diaphragm just inside her bra strap near the catch to listen to the bases properly. She
flinched a little as I put the diaphragm on her skin.

“Sorry – it’s just a little cold”

“Oh yes… sorry. I forgot to warm it.”

“Don’t worry it’s fine…it was just a surprise.”

Damn… not only had I listened to the back of the lungs first (which I never do), but I
had not warmed my stethoscope before applying it to the chest. I had been too
impressed with her back, and was distracted. The reason - her hair fell down and
caressed her shoulderblades, and its curls rolled with every slight movement of her
head. In addition there was an fascinating trough between her Erector Spinae muscles
running from her mid-thoracic spine down to her sacrum where it flattened out into
the small of her back. From there the skin spread laterally to her shapely hips in turn
atop her thighs, which were slightly pressed out as she sat on my chair in her black
trousers. As if that wasn’t enough, her white underwear that matched the bra was just
visible as the belt-strap of her trousers bulged slightly at the back, tracing a course to
secret areas. I realised that I had been auscultating the same section of lung far longer
than was necessary. To cover my error, I asked her to take some deep breaths
(implying that it had been her fault to throw her off any scent), but only closing my
eyes could I recover and note the vesicular breath sounds posteriorly and absence of
wheeze.

Then to the anterior chest, noting Corrigan’s Sign of carotid pulsation in the Anterior
Triangle of the neck, and the chest wall literally thumping with the exertion below
from the force of the heart’s contraction. A broad hand placed over the upper chest
found no evidence of a Fluid Thrill or a Cardiac Heave. Long gone are the days when
I make the blunder of telling a patient that I am feeling their chest “for Thrills”
however – that lesson was learned the hard way. An examiner might nod and score a
point on his chart, but the patient tends to take it the wrong way. The only other
palpation phase of examination for the heart was to feel for the apex. A broad hand
placed over the fifth inter-costal space in the mid-clavicular line was necessary, and
always, after placing my hand there (necessarily using the side of my hand to advance
the breast superiorly, my other hand was placed on the patients left shoulder to
stabilise them as I pushed gently on the chest wall. The apex was felt to be non-
displaced, but more fascinating was the feel of her shoulder muscles. The skin was
smooth and the muscle firm. Her ribs moved gently as she breathed in and out, quite
heavily. As with the Corrigan’s sign, the heart was clearly beating with some force,
and fast.

At the best of times, breasts and bras are a nuisance to cardiac auscultation, but my
drill worked as usual – I lifted the lower part of the bra slightly from below to listen to
the cardiac apex below her left breast (recently established to be in the 5th ICS, MCL
by my palpation), and listened to the pulmonary and aortic areas above the bra. Sod
the Tricuspid area – it wasn’t worth the hassle or disruption to the examination to
screen for Tricuspid Regurgitation in a healthy asymptomatic person. Normal heart
sounds, but with the persistent tachycardia.

“That’s all fine” I declared, my standard reassuring phrase. “I need you to

remove your bra so that I can examine the breasts.”

‘The breasts’. How funny that my drill (my idiosyncratic turn of phrase developed
over many hundreds of examinations to try and objectify the process in its formality
and make it easier for the patient and myself) in this case seemed to have the opposite
effect and heighten their prominence in my mind. They had become the climax of my
examination. The point of doing them last was to avoid missing the other
rudimentary parts of the examination. Who would remember to look at the fingernails
if they didn’t do it first? The breasts…

She removed her bra, they sagged gently as she did so, and she rested the bra on her
lap. Magnificent. Oh Lord I hope I didn’t say it out loud. I believe it to be the
objective truth that she has the best formed breasts I have ever seen. Her look told me
my mental thought hadn’t manifested itself in vocalisation, probably thanks to the
paralysis of my vocal cords rather than any controlled inhibition on my part. I asked
her to raise her arms out to the sides ‘like a chicken’. She burst out a little nervous
laugh. At last part of my drill had it’s desired effect– it was designed to release some
of the tension involved in an intimate examination while communicating to the patient
to move Pectoralis Major, thereby demonstrating any deep tethering. TIT. How could
he do that to me? What a horrible word he had put in my head to describe the sight
that faced me now. Maybe that was his way of remaining professional.

Examining with the flat of my fingers, there was nothing to feel in the left upper
inner, lower, outer lower or upper, behind the aroelar complex, or in the axillary tail
on either side. Just soft breast tissue. No, I thought, there was no indication to
examine them a second time just to be on the safe side, and it might be taken the
wrong way.

“There’s nothing to feel, everything’s fine” I reassured her, in my usual voice.

She nodded assent, and reached down for her bra.

As she put it on, I prompted her to dress while I turned to the computer to tap “Breast
Examination: Asymptomatic and Normal; +ve family history with two 1st º relatives”,
but then I realised that she wasn’t on the system – she wasn’t actually my patient. I
had managed it though. Just. The examination I mean. I hoped my cheeks weren’t
too red.

She was composed again, harnessed and focussed.

“Thankyou Ben.” She declared and stood to leave.

I stood with her, but the chairs were a little too close, and we nearly bumped each
others heads as I did so. We recoiled slightly
 “Oh.. sorry” she said, and laughed.

The tension was broken. Her face flushed with relief, the colour came to her cheeks,
but it was too much. It crumpled again as before, and her shoulders drooped, arms
limp as she tried futilely not to cry. I don’t remember how she came to be in my arms,
but there she was, crying gently.

“Hey… don’t worry. There’s nothing there. You’re going to be fine”.

She held her breath and I felt her arms slowly embrace my back. Whatever my pulse
was before, it was steady now. Fast and steady. I had never been held by anyone like
that before, and I never wanted it to stop. My repressed doctor’s fists relaxed, and my
fingers extended over her back, pressing gently into her shirt and her skin below. She
felt so good. Her hair right next to my face, I could smell her scalp. The same as her
body odour I had noticed before – a sweet, slightly malty smell that was far from
unpleasant. At that moment in time it seemed to be what my nostrils were there for.

She stopped crying, and pulled her head back from me. I couldn’t make out what her
expression meant. It was slightly aggressive, and I feared the worst. Her arms drew
back from me. What had I done? But it wasn’t my fault! Her hands cupped my jaw,
and head came forward to kiss me. First a gentle peck on my lips, and then our lips
and more were joined. She was like intravenous morphine to me – powerfully
analgesic and inducing euphoria. That was my last medical thought – my brain was
now empty, completely pure of jargon and drills for the first time in years. I was a
human again, not a doctor or counsellor. It felt good. Then it was over.

“I will see you next week, Dr Lovell.”

With that she turned and left, leaving me to fall back into my chair. Full circle now, I
had never been so pleased to be Dr Lovell in all of my egocentric years. It was the
way she said it, that restored the title to its former glory in my mind. I reached for a
clock, feeling my carotid pulse with my index finger estimate my pulse rate at 146
beats per minute. She had been calmer than me.

After a while I wandered through to the nurse running the warfarin clinic. She looked
at me disdainfully.

“Oh it’s you is it? What do you want?”

I was relieved to have someone giving me some abuse – it brought me back to the real
world. I laughed

“What have I done now?”

“Oh just the Bolton ladies – elder and younger. You would
think you were a movie star the way they go on about you.”

“Oh really? How is Mrs Bolton then?”

 “Just the same I reckon. Skinnier than she used to be, but
otherwise alright. She says her breathing improves by the day. Her daughter looked a
little peaky though. She was all pale out there in the waiting room before she came in
to see you.” She looked down at her paperwork and started writing again. Something
about the way she said it made me panicky. She went on “looked like you brought the
colour back to her cheeks as she left though… was she worried about her mother?”

“Erm… yes. Something like that… well wouldn’t you be?” I ventured. She
looked up briefly, looking keenly at me, clearly trying to glean something from my
demeanour. I took a deep breath, trying to appear casual. I wasn’t sure whether she
had bought it. In any case she carried on writing.

“Yes I suppose I would if it were my mother. Gave me my life back

she says… bah… you make me sick”.

She fake retched at the paper with a good vocal impersonation that came out rather
like the sound of a toad being squashed. Nurse know how to imitate these noises well
– learnt through the experience of helping patients through their illness. It was so
good that I cackled hysterically. She had unwittingly given me a cue to release my
adrenaline, and my loss of control was embarrassing. She seemed to notice it, and
gestured for me to leave. She declared that she was busy and that I had better bugger
off before she spoiled her notepaper.

Working with people like her was good for me. I can’t stand it when people
compliment me. The problem inherent is that no-one can possibly have as high an
opinion of me as I do of myself. I don’t think it is really self love. I know that people
don’t think I am arrogant. I go to great lengths to avoid it. Arrogance by definition is
faith in one’s abilities above what they really are, and people find it obnoxious
(rightly so). I am not arrogant – I am great. I just happen to know it. It is this belief
that makes it so easy to avoid patronising people. Everyone is inferior to me in my
eyes – so they all get treated the same way. It means that I have a basic respect for all
people, be they Professors or street sweepers. I don’t expect them to be as great as
me, and they see my security in myself. I am not afraid to admit my mistakes when
they arise – of course I am not perfect, just damn good. They routinely mistake this
for true humbleness. It is humility I suppose, but not in the way that they think. I just
don’t care whether they see that imperfection, because I trust implicitly to the fact that
if they are worth their salt, they will see how great I am and appreciate me for it (and
they do mostly). They know that I’ll go out of my way to help them if I can, and that
the help will be effective.

Having gorgeous things like Miss Bolton throwing themselves at me only made
perfect sense – how could they not? The poor things. Only she had the upper hand
on me. I would do nearly anything to be kissed by her like that again… how did that
happen?

I had turned and was leaving the room, when the nurse spiked me with a parting
remark that chilled me to the bone.

“Pretty ladies those Boltons.”

I tried to keep a steady pace as I left, pretending not to hear. So she had got it out of
me. She knew. I began to worry again. Hitherto I had been becoming infatuated with
one of my patients, knowing the conflict of interest but putting it to one side. Now
someone else new. In fact, after the coffee room gossiping, probably the whole
surgery would know, or at least suspect my feelings towards her. I was troubled by it
all that morning, and struggled through my break. I would have to ask them to change
doctors. That was it! But would they take it the wrong way? How could I without
revealing my hand?

Two things in my mind were settled. Mrs Bolton was getting better, and I knew now
that Miss Bolton could not be ignored, that I had to do something about it.. That left
me with Mr Bolton. Somehow the edge had been taken off the issue. I felt confident
about the forthcoming consultation, and happy that I wouldn’t yet be exposed to his
scrutiny of my affections towards his daughter. I would spend some time over the
weekend figuring out how to put things to him. I knew he wasn’t the sort of fellow to
want too much information about the future of his wife’s illness, but I needed to
prepare him for what was to come. I had read a research paper from 1961 where they
took 160 patients in a hospital all going for operation. Half they told the process of
operation, and the nature and likely duration of pain after the operation. The other
half they only told them as much as they specifically asked about. The difference was
huge. Mental preparation not only reduced their subjective score of pain on a chart,
but the doses of morphine they required, and indeed their length of stay in the
hospital. It was an elegant study demonstrating the importance of routing the
synapses ready so that the reception of painful stimulus wasn’t as hard to cope with.

Unfortunately I blew it by delaying too long. On the Saturday morning, I was still in
my pyjamas when the doorbell rang. It was Mr Bolton, with a large carpet bag in his
hand, looking sombre and red-faced. Behind him I saw Juliet in the driver’s seat of
the car she had driven him to me in. She made eye contact and gave me a smile, teeth
breaking through.

“Can I come in then Doctor?”

“Of course”

He did not want to sit.

“I mean to be concise Doctor. I can’t abide those as mince their words,

and I know you are a man of straight talking. I understand you meant to visit us again
next week, but I am coming to tell you it won’t be necessary.

They tell me what is going on with the breast, and I know enough to do
what I got to, and that’s all I need to know. She’ll take her tablets and have done with
it. I’m no big believer in them myself, and I told that old bastard Monty as such, but I
am a believer in you Sir. Without you, she would have died a month ago, and by my
reckoning it was you that you saved her life. She’s on time borrowed her by God now
– every day I have with her is a blessing from him through you, and I will never
forget that.”

He clearly didn’t want to be interrupted, so I just nodded recognition.

 “I can’t repay you in kind, notwithstanding to offer you the life of my
best pig as substitute.”

The carpet bag was laid carefully on the table, the contents presumably the late beast
he was talking about.

“The girl suggested it, and I couldn’t think of a better fate for the fella’.
He comes from good stock, and belongs in the stomach of someone that deserves him.
I raised him by my own hand, the only one of his kind, and was worth a pretty penny
if sold so I don’t give him lightly, not least because I loved him. Furthermore, as
afore mentioned, I said it won’t be necessary for you to come tell me what’s what next
week, on account of this conversation. It would however be my pleasure to entertain
you on Sunday evening as my guest, when Mrs Bolton will be preparing what of him
I didn’t bring to you today, for dinner.”

I chose to ignore his liberal sense of the word conversation, and declared that I would
be delighted. I hoped he had no idea quite how delighted I was. I watched from the
window as she started the car, and drove off. To see her, even from a distance was a
huge reward for me. The encounter was a good one. Mr Bolton and I had been
overdue a talk, and clearly he could not wait for the rendezvous. He had prepared a
spiel to me as good as any I could have come up with to address him, and I was
grateful to him for saving me the trouble.

In the carpet bag were several home-cooking tubs with the “little fellow’s” various
parts in them. They had been cut with the hand of experience, and each tub was
labelled with the name of the cut – I cannot remember what they were, save the one
with the trotters in it, with a hand-written copy of a family recipe detailing how to
jelly them. I wondered what it would be like to jelly my first trotters. Or to eat them
for that matter. I had been a little more squeamish about eating extraordinary things
since my life threatening anaphylaxis to snails. At the hospital they were dismissive
of the idea, instead treating my allergy generically and accepting the allergen was
never to be identified. It was only an Haematologist with a special interest in Atopy
in the Newcastle General Hospital who sent my blood to a small lab in London who
confirmed the allergy, with a possible crossover to other Molluscs. Jellied trotters
would have to be tried however, if for no other reason than professional courtesy. I
gave his wife the medicine of my experience, he provided me with his best pig, neatly
chopped. I had to trust him. Putting the tubs into my freezer reserving the trotters, I
noted fresh Parsley on my shopping list.

The following day was a time of great peace for me. No weekend duties and the meal
to look forward to, I lounged in my back garden, and admired the blossom on the
neighbours’ trees. My own garden was functional – green and lively, but with no
character or flare. I could have invested the time in it, but frankly I had not the
inclination. I bathed in the winter sun (in my jumper) and waited from Spring to
come. It wasn’t long before I returned indoors, realising that despite the sun Spring
was not likely to arrive that afternoon, and it had become a little chilly.

I arrived for the meal at the prescribed time, and the flowers were well received by the
Bolton ladies. I was immediately instructed not to ask how Mrs Bolton was – she was
very well thank you, and her breathing was much improved (as evinced by her
presence at the dinner table. Juliet served me from the kitchen with the meal Mrs
Bolton had prepared – it was indeed exquisite. There is little that improves on fresh
food cooked with care.

Throughout the meal, I was unable to keep my eyes of Juliet. She looked stunning in
a deep red dress that hugged her figure and made my heart race. She chatted about
what she was doing at the college where it transpired that she was doing a course in
art. She tended towards landscapes which she did mostly in and around the area, but
from time to time drew a portrait to test her ability.

The conversation drifted slowly, Juliet expressing herself with intelligence on various
topics that came up. She had strongly held opinions whenever there was something
complex, and I relished the chance to talk with someone in a deep way. It had been a
long time since I had held what I call a proper conversation. Mr Bolton talked
relatively little, prompting us from time to time talking about things that were
important to the family, and Mrs Bolton asking me about work and my life. Having
become distracted by Juliet as she served out the dessert, I was blissfully unaware that
I had drifted far from what Mr Bolton was saying, until I was snapped back into
consciousness by Juliet’s unexpected pause with the custard, and the family going
quiet.

“Are we talking about the same Harold Shipman, Benjamin?” Mr Bolton

proffered.

I suddenly realised that I hadn’t been paying attention to the question and apologised,
acknowledging that I hadn’t a clue what had been asked of me. It was apparent to me
from their looks to each other that Mr and Mrs Bolton seemed to have a fairly good
idea of why I had lost attention, and I tried a recovery. I told them about how I had
met the late Dr Shipman while a Medical Student in Durham. I told the story of how
the Home Office had taken my passport, verified my access request to accompany the
GP who was teaching me at his practice, and allowed me to visit HMP Frankland, one
of the small handful of high-security prisons in England. My trainer had an external
contract to provide Primary Care services to the prison, and visited once weekly to
attend to their coughs, colds and typically infectious diseases.

I recounted the tale of how it had taken me well over an hour of having my palm print
read, and double gates with cameras monitoring our every move to get from the front
entrance to the Medical Wing. There, I passed the ominous figure of the wicked
murderer, and tried not to notice the similarity of shade between his beard and my
own. I gave my assurances to them that I was not aware of having any homicidal
feelings myself.

At the table, the game was up. Mr and Mrs Bolton had confirmed in their minds what
was brewing between their daughter and I, and it was far from subtle when after the
meal they suggested Juliet show me her studio and then the rest of the farm. Having
helped carry some dishes to the kitchen from the table, Juliet and I were discharged,
and she led me up a spiral staircase into the attic of the farmhouse. It was lined with
several skylights on either side, making the room quite bright, and it was surprisingly
warm. The floorboards were a dark wood, bare but sanded down, with large gaps
between the spaces here and there. The room was well organised, with a section of
old artwork in one corner, and at the far end several works in progress were out on
easels, with the fall-out of paintdrops scattered on the floorboards.

My eye caught the landscape that I had dropped, propped against the wall, seemingly
complete. She and I stood silently as I surveyed her works, but couldn’t help but
notice her slight panting, having energetically climbed the staircase. I tried to make
some noise with my feet to avoid her being embarrassed, and looked intently.

“I love them. You’re really good”

“Thankyou”

“I can only see landscapes – you said you do portraits as well?”

“Yes I do.” She seemed a little hesitant, and I turned to face her. “I
wasn’t going to show you until it’s finished, but since you are here now…”

She reached behind to an easel slightly set aside, and brought out a canvas she had
started. It portrayed her mother’s bedroom, the scene that was still strongly
embedded in my memory. It was unique and fascinating to see it from her
perspective. Her mother was a ghostly figure lain in the bed, the details of her face
indistinct because of the texture of the paint (was it acrylic?), but the impression was
very much that of a dying person. It was a little while before I became aware of her
father, who was a dark figure in the chair, his faced turned away, sunken into the
leather upholstery, and part of the furniture. He was almost lost into the background
of the room – it was dark, painted in sombre colours, much darker than in my mind
and it was after all early afternoon. The light source was the window, with one
curtain drawn, but the light was falling onto my figure, kneeling beside her mother’s
bed. My arm extended onto the sheets, pointing towards but not making contact with
her hand. The light was bouncing off my white shirt, illuminating her mother who
was pale in her complexion, and there was stark contrast between my black
stethoscope and her bed linen, similarly my beard and hair contrasted against the light
window behind me. Apart from my skin, there was little colour in the picture; I
noticed fine dark hairs on my arms. There was only a small section left to complete, a
corner of the painting which would just be cupboards and a dressing table, roughly
sketched out in pencil.

“Wow…” I said, not really knowing what to say.

“You like it then?”

“Its so vivid. She looks so deathly… you must have been really scared.”

“I was terrified. I hope it didn’t show.”

“No not at all”

“I’m glad it was you that came that day.”

 “So am I” I declared, hoping that my enthusiasm didn’t come across too
strongly. I walked closer to get a better look

“It’s a little hot in here.” Juliet opened one of the skylights, and the
raucous noise of ducks came into the room. My attention drawn back to her, all I
wanted to do was be close to her. I joined her at the window, relishing the fresh air,
standing beside her as she rested her elbows on the windowsill. Her lips were bright
red. She turned to look at me, and I stared back not sure which eye to look into. She
smiled at me.

“Are you a good doctor then?” she challenged. I let out a nervous
laugh. I wanted desperately to impress her, and at the same time not sing my own
praises, which to me is a repulsive trait.

“I’m very dedicated. I care enormously about what happens to my patients,

and do everything I can for them.” She seemed satisfied.

“If I was ill, would you take care of me then?”

“As if you were my only patient.”

“Good.” She declared, nodding her head, and gesturing down to the
yard. “Let me show you the rest of the farm.”

The sun was still shining in the clear sky, although it was low, a mottled red bathing
us warmly as we walked into the open courtyard. The air was still, as it had been each
of my visits to the house – probably the valley it was in, or maybe the trees, but it
must have been cool because it showed our breath nicely. She was wearing a long red
woollen coat with black buttons, tied at the waist, with a white hat on and Wellington
boots. She politely showed me the pigs, the horses and finally we came to the duck
pond. A sole lazy mallard was swimming in circles, glaring at us indignantly for
disturbing him before plunging his head to the bottom once more, posterior in the air,
doing whatever it is that ducks do when their head is below the surface.

“I can’t imagine he will find anything that tasty at the bottom there”.

“You would be surprised”.

Our eyes met, and we stopped walking. She drew in her breath, hunched her
shoulders slightly (pushing her hands against the inside of her pockets) and exhaled a
sigh, looking at the duck and hoping to throw off my stare, which was still on her
when she stole a glance at me seconds later. She rolled her eyes, and thrusting her
face slightly forward, she declared very matter-of-factly:

“I think you’re amazing, okay?”

I had been waiting for a cue of any kind, and grabbing her arms before she could pull
them from her pockets, moved to her and kissed her quickly on the mouth, pausing to
gauge her reaction lest I had transgressed. She withdrew her hands and fed them
inside my jacket, embracing my waist, and kissed me back. For many minutes we
stood there embraced, and afterwards, she laid her head on my chest and shoulder.
My heart fluttered for some time before I plucked up the courage to say it to her, and I
paused with full lungs before I whispered

“I have never met anyone like you. You are the most beautiful and interesting
person I have ever met. Since I met you the only time I have felt whole is with you.”

She put her palms flat on my chest, pushed me away and looked intently at my eyes,
broke into a huge smile, teeth bared at me and then ran off up the farm as best she
could in her Wellington boots with arms stabilising herself against the resistance of
the mud, laughing.

“Wait!”

My shoes were not meant for trudging through farmyards, and I had difficulty
following her as she lead me up the side of the valley, through a small copse, and into
a small clearing, where she finally stopped, panting, her breath making large and
dramatic plumes of condensation in the air ahead of her. She pointed over my
shoulder at the setting sun, low in the sky between the relatively steep sides. The
view of the cleft was magnificent, the water reflecting the fading sunlight back up at
us, artificially lighting the area with its reflection. The valley was lined on either side
with foliage and lush grass.

“This sun is for us today”.

I suddenly realised that it wasn’t Déja-vu that I was experiencing – it was a true
memory of her painted landscape. The sunset wasn’t supernatural after all – it really
did look the way that she had painted it. She led me over to a large fallen tree, pushed
me down on it, and lifting her coat out of the way, sat sideways on my lap, facing the
sun. Her breathing slowed, and she eventually turned to face me, opening her coat
and folding it around my back to keep me warm, prompting me to put my arms
around her waist. My arm found a small gap between her top and skirt by accident,
and a single finger made contact with the skin of her stomach. I paused, and then
advanced my hand into the space, holding her skin in my hand, squeezing it as hard as
I dared without risking offending her.

“You are falling in love with me, Doctor.”

She leaned her head forward, a few strands of hair that had worked loose falling over
my face, and tickling me. I wrinkled my nose in protest, and blew them to the side.
She grinned and pecked my nose with a kiss. I proffered my lips, and we kissed
more.

After a time, we ambled down the hillside, as the sun sank behind the horizon and the
temperature dropped. Back in the cottage, I discovered that Mr Bolton had made
himself scarce once more – under the preface of feeding some creature or other that
wanted feeding, but more likely wanting to avoid the lovers returning from their tryst.
Juliet addressed her mother.

“He loves me and we are to be married in a week, Mama”

Mrs Bolton caught my unease stance, but I felt no stammering excuse coming forth –
the idea was not so alarming to me as I might have suspected.

“Juliet! You tease! Well it couldn’t happen to a nicer man.

Don’t say anything Dr Lovell. You will only encourage her nonsense.”

After a cup of tea I departed, arranging to see her the following day after my morning
clinic, for lunch.

The following months were a happy time for all. Mr and Mrs Bolton travelled to
Spain to see her family there, and she returned full of stories about them, but tired. I
saw Juliet increasingly often, I went with her as her work was exhibited at a local
gallery, and had the privilege of buying the Diaspora of my first meeting with her, her
first paying customer. She visited me at my surgery from time to time without
warning, brightening my day, and making those last few hours of the day drag in the
wait to meet her after work. Eventually she agreed to live with me, and moved in
some months later. She brought me out of my shell, like a breath of fresh air in my
life, uncluttering my mind from petty complaints.

Meanwhile, throughout the Autumn Mrs Bolton grew slowly weaker. She lost her
appetite, and grew pale and cachectic. I had long since formally transferred the
Bolton’s medical care to one of my colleagues at a nearby practice, but my informal
care for her continued in a more fundamental way now that the medical was taken for
granted. Mr Bolton, ever dedicated to her, took on more help, and waited on her hand
and foot – never demoralised or morose, he and she spent precious hours alone
together. Their acceptance of her fate had been the most remarkable I have ever
witnessed. They fell into the last group of three groups with different reactions to
terminal illness. The ones who accept rapidly and completely do the best, actively
fighting the disease and limiting its psychological impact, those who completely
denied its presence, and those who could never accept it. The latter two have worse
outcomes, and the last the worst. The strength of character of the Boltons was
formidable. I had come across that in farmers, but never been involved first hand
before. Without it, fast though her deterioration was, she would had declined much
quicker.

It had been a particularly hot day, and I had not seen Juliet or the Boltons for a few
days - Juliet was staying at home to focus on some work. The clinics had been filled
with sick people. They were dehydrated and poorly, and I had many home visits to
them, with a record number of consultations resulting in admission to the hospital for
the whole district. There seemed to be no rhyme or reason to it – it wasn’t one
complaint over and over, it was all different things as if a bad spirit had passed over
the town, dropping ill health randomly on the locals.

That night, at 2 am I had a phone call. I wasn’t on duty, so it came as a shock to the
system – that old adrenaline jerk I used to have when I was a houseman kicked me in
the guts and made my heart pound as if it were my bleep going off for a cardiac arrest.
I was wide awake as I answered the phone. It was Juliet.
 “Ben. I need you to come quickly – I think she has had another clot in
the lungs, but they won’t let me call an ambulance.”

Within two minutes I was dressed, and in my car before cursing and returning to the
house to retrieve my emergency bag, driving at speed towards the Poplars. As I
pulled up, Juliet was standing at the door, waiting for me.

“She hasn’t been taking her warfarin.”

I was confused. I was aware that Juliet had been collecting Mrs Bolton’s
prescriptions, but it transpired that not only had she been omitting her warfarin
intentionally, but when her INR blood test was phoned through and she was advised
to increase her dose, she had mis-documented it in her yellow Anti-Coagulation
Record book to conceal her omission from Juliet and myself. The awful part was that
she hadn’t been taking her hormone therapy either.

The leg was swollen again, and she had the same symptoms as her pulmonary emboli
in the Summer. When I arrived, she was limply holding a tissue in her hand, stained
with the small specks of blood that she had coughed into it. She was deathly pale now
just as Juliet had painted her, and her head lolled towards me, managing a smile.

“I didn’t want to carry on, and I left it to God to choose how

and when I should die. I’m sorry if you are disappointed Ben.”

Her smile faded and she closed her eyes, clearly in pain from her chest.

“I’m not disappointed, I just want to help.”

I rapidly took my kit from my bag, and started a basic assessment. Her hands were
cold and shut down – I blanched the blood from her fingers, but it took far longer to
return than it should. Her pulse was irregular – clearly an erratic rhythm caused by
the physiological pacemaker in her heart failing. In effect it was a normal pulse rate
but it shouldn’t be. I took my grandfather’s sphygmomanometer from my case, the
first time it had been used in a while. It was a beautiful mahogany affair – the banned
kind still filled with mercury that was now 80 years old. Although I had replaced the
cuff, the mercury within its column had pulsed to the heartbeat of my grandfather’s
patients, and held enormous sentimental value to me. I couldn’t help but think of how
most of the patients it had pulsed to were now long dead.

The pressure of her arterial blood was low, dangerously low. She should had a
significant tachycardia and high blood pressure as her system struggled to meet her
oxygen demands by pumping the blood faster and stronger – her heart was clearly
failing in its impossible task. Her eyelids were normal, and her trachea central.
Turning her head slightly to one side, I could see that her venous pressure of her blood
in the jugular vein was huge – it tracked all the way up to the angle of her jaw – the
clot was stopping its drainage into the right side of the heart and the back pressure
was built up from the lungs all the way back.

Her lungs were clear as they had been before, but when I asked her to take a deep
breath, it caught her in pain, and she started coughing weakly, producing a small
amount of blood, which she spat onto her handkerchief. Her heart sounds were
normal, a slow irregular beat - it was dying.

“I’m not afraid of death, Doctor”

I was a little taken aback, because our relationship had moved on so far, but realised
that right now, I was her doctor again. Had she ever called me by my first name? I
couldn’t remember.

“We could take you to the hospital you know. We can give you oxygen to
make it easier to breathe, and medicine to stop the pain”.

“No. Not this time. I want to die at home, with my family, in my own
bed.”

Juliet was kneeling on her left side, I on her right. I looked across to her, silent tears
rolled from her eyes. I felt their pain far more acutely now that I knew them and
loved them so well. Mr Bolton was sitting in an armchair at the side of the room, his
arms resting on the side, folded on each other. There was not a hint of emotion on his
face, it was completely calm.

“I need to call her doctor” I declared and made for the lounge. My colleague
Dr Shrikrishnapalisury answered promptly in his refined Indian English accent. I
explained my assessment to him, and he listened solemnly. I was relieved to have my
intention sanctioned by him prophylactically before I could bring it up – “give her
some intramuscular Pethidine, and some Lorazepam – did you bring some with you?
Good… that should keep her comfortable until I get there. I’ll go to the practice and
bring the oxygen cylinder and a Graseby pump to set up an infusion for the rest of the
evening as I assume from what you have said that she will refuse my suggestion that
she goes into the hospital. There is no indication to call an ambulance here – wait for
me, it’ll take me about twenty five minutes.”

Returning to the bedroom, I talked to Mr Bolton directly. Mrs Bolton did not open
her eyes as I came in.

“She is she dying then, Benjamin?”

I was ready for his question.

“Yes.” I paused while he nodded. “but that doesn’t mean I can’t help her. I’ve
been here many times before, and there are always things we can do” he stirred, as he
wrongly assumed that I was going to push to have her admission – I cut him short
“and I don’t mean taking her away to hospital. Doctor Shrikrish is on his way, and he
is going to bring an oxygen cylinder to make it easier for her to breathe.” He relaxed
back into his chair. “I’m going to give her two medicines now as small injections, a
mild sedative to relax her, and some morphine. Morphine is a very good drug at this
stage of life – it will relax her, make her euphoric, ease the pain, and importantly, it
will stop the feeling of being short of breath. It won’t actually stop her being short of
breath, it will just make her forget about it. That will of course mean that her drive to
breathe will go down, as will her oxygen levels, but that is a consequence I think will
all be prepared to accept.” He nodded his assent.

I turned round, and Mrs Bolton’s eyes were open – she had been listening to me after
all.

“Please do it now, and don’t skimp on the morphine – it was wonderful

last time.”

As I gave her the small injections into the arm, she said to me

“It’s a good job you haven’t yet married, because this could be taken
the wrong way you know. Giving morphine to your mother-in-law? I’m sure they
would lock you up along with your friend Dr Shipman.”

I blushed slightly, becoming a little self-conscious as the monster of professional

ethics reared its ugly head at me, but it would have been wicked of me not to help her,
and there was no other moral option for me.

“Don’t worry, it will look fine. They can’t get me if I don’t charge you, and
the paperwork can be conveniently lost.” I managed irony.

As I withdrew the needle, she reached over to my arm again, gently holding it.

“If you take care of these two properly, I promise not to haunt you
forever” she declared.

Her words hit a nerve in me. I had indeed been haunted by those who had died under
my care, in the form of nightmares. There was never any guilt involved – they hadn’t
died because of my negligence, it was just that I was attached to them, and wanted the
power to save them so much that it felt like a failure to ‘lose’ them. In my dreams,
there were no antibiotics on the ward, or the oxygen ran out – things that were out of
my control.

“I only hope I can look after them better than I did you.”

“Nonsense. You did everything you could for me, but it is my choice
which medicines I take, and God’s when I should die”.

She was right of course, and I couldn’t easily flaw her choice, having seen the
suffering of patients with terminal cancer, particularly the personal and family anguish
of those vainly struggling for quantity of life over quality.

It was a matter of minutes until the effects really became apparent. Her respiratory
rate fell slowly, her breathing less laboured, and her face relaxed. Mr Bolton roused
from his chair, and sat on the side of her bed, taking her hand in his. She opened her
eyes halfway, and raised her hand to his cheek.

“I’m going to close my eyes now Charlie.”

He nodded, and after she did, he looked to me.

“It is just a small dose – once Dr Shrikrish arrives, he intends to put up a small
infusion to give her a steady flow of it.”

I turned away, and Juliet stepped forward out of the shadows, walking into my chest
just a little too abruptly and disrupting my balance. I held her, and we stood there,
watching her mother die. After a time, Dr Shrikrish arrived with the further medical
supplies, but by that time she was more or less moribund. He did a crude set of
observations on her – her pulse had slowed further, now to around 45 beats per
minute. He had the benefit of a pulse-oximeter, which registered 75% saturation
where it should have shown 99%, and its gentle beep tracked her ever-slowing
heartbeat.

She was not suffering any more, so he never actually gave her the oxygen or other
medicines, but stayed with us for those last few intimate moments. The beep slowed
further, and he turned it to a silent setting. Her breathing slowed almost to a standstill
and stopped, only to start again a few seconds later with a slow, shallow breath. Then
a good ten seconds, and after a long, stuttering inwards breath, she exhaled her last.
The pulse-oximeter registered a slowing pulse for a good minute afterward. Only Dr
Shrikrish and I were aware of it, a silent communication of her capillaries reporting
her last flickers of life to us. Mr Bolton and Juliet were by her side, Juliet’s head
buried in her lap, and Mr Bolton sat with her hand in his, eyes closed, silent tears
dripping from them. The pulse slowed inexorably and stopped – leaving a slowly
moving flat trace.

Shrikrish removed the monitor, and packed his other things away, save his
stethoscope, and his movement stirred the Boltons. He reached over, and slipping the
diaphragm of his stethoscope between her pyjama shirt, he listened for a good half
minute by his watch, feeling the pulseless carotid artery. It was the first time I had
ever seen someone else certify a body. I suppose we all have our own way of doing it
– I always check the pupils first, but he did it last.

He stood up straight, curling his stethoscope up into one hand.

“Mr Bolton” although gentle, his voice still made Mr Bolton

startle a little, and he looked up at him. “Mrs Bolton has died.”

It took several seconds for this news to register with us all. Of course we knew it, but
it was another thing to hear it said out loud. Mr Bolton nodded, and closed his eyes
again, gripping her lifeless hand tighter. Juliet held me tightly, shaking silently with
tears. Though I felt emotional, I felt very much the observer again – detached in a
medical way. I can never make sense of how my emotions responded to that
particular lady, to whom I owed so much in the birth of her daughter. I just had to go
with it. Shrikrish documented in the notes time of death, witnesses present, and a note
of the events leading to her demise. He transferred the batch numbers of the two
medicines I had administered, and asked me to countersign the notes, drawing my
attention to what he intended to put on her death certificate: 1A – Recurrent
Pulmonary Embolism 1B Carcinomatosis from Primary Breast Carcinoma
(Unspecified Ductal Type). He pointed silently to section 2 “Other significant disease
contributing to death but not directly related to cause of death” and raised his
eyebrows. I shook my head – there were none.

“The phone is in the hallway” – he would want to call the Coroner, who would
arrange to have her picked up that night.

Juliet and I followed him to the door, Mr Bolton remained. Some time later he must
have pulled her sheets over her head, and he joined us downstairs. The atmosphere
was calm and final. The mortuary technician arrived with remarkable speed, and after
a brief exchange, he and his assistant carried Mrs Bolton’s cadaver downstairs and
then she was gone.

Mr Bolton wanted to be left alone, and Juliet and I wanted to be together – it wasn’t
hard for us to leave him. He had well stoked a wood fire, and retrieved an ancient
looking bottle of Scotch whisky from the cabinet, a third full, and a single tumbler – it
wasn’t hard to take the hint, and we made an arrangement for me to drive Juliet home
the following morning.

In the car on the return journey to my house, the emotions welled in waves. I realised
that although I had certified no less than eighty-six patients in my junior doctor years
alone (before I stopped counting), she was only the second I had been present at,
futile resuscitations aside. I remembered the first, and how emotional I was after, and
been haunted by the drama of the cardiac monitor screaming the last moments of her
failing heart, and how similar I had felt then to losing Mrs Bolton that night, but on a
smaller scale. Not only had I lost a patient, for she remained as such despite my
technical transfer of care, but I had lost her, the original draft of my love whose genes
and nurture had raised Juliet to be the object of my affections, and whose ill-fate
brought us together.

As I lay in bed that night, Juliet lying inside my shoulder, I shed silent tears for her on
my own. The tears of a doctor for his patient.

A patient of mine died last winter.

That was my concluding remark when I spoke at our wedding as I raised a toast to
absent friends, and Mr Charles Bolton stood from his chair to deliver his speech. I
wonder if anyone will ever know that I meant by it.