The naive detective

Medical education provides those lucky enough to receive it with knowledge that allows them to see into the lives of others. It must be wielded with care.


During a brief foray into infectious disease medicine, I saw my virology consultant enter the lab in a quandary. In her lunch hour (they do exist, I have seen them) she noticed some blisters in the ear of a shop assistant. The consultant looked carefully, bought her shoes, thought about saying something but in the end held back. She was sure the assistant was brewing a case of Ramsay-Hunt syndrome*, a form of shingles which if left untreated can lead to hearing loss, facial paralysis and ocular problems. She asked us what she should do. Was it any of her business? What should she say, how should she broach it? Perhaps she was wrong. On the other hand the thought that this unsuspecting young lady might go on to suffer more, and for longer than was necessary, felt intolerable. My consultant went back next day…but I never did hear what happened.


As I acquired medical knowledge I began to make diagnoses on the street. It was exciting. I could practise the Holmesian trick of deducing conditions and partial life stories from signs that others might overlook; rashes, palsies, postures, gaits… The young lady with an oddly shaped face, blue lips and grossly clubbed fingers who used to walk slowly along the high street – I wondered how her life had been affected, and how much time she had left to her, having been born with an abnormal heart. The boy in the local park with a large port wine stain** on his face; I reflected on the toll that an associated tendency to epileptic seizures must have had on his parents. Was that a look of strain I saw on his Mum’s face, over by the swings? Such disembodied diagnoses, and the fanciful extrapolations that followed, reflected nothing more than privileged information. They served nobody. Better perhaps not to know such things outside the hospital or surgery.


There are of course occasions when knowledge is helpful. Most medical students keenly anticipate situations in which they might come to the rescue in a good Samaritan scenario. I listened in awe to the story of the cardiology conventioneer who decompressed a fellow airline passenger’s pneumothorax with a catheter over a coat hanger. Now that was cool! In my case I came across a motorcyclist with folded limbs, a sore stomach and the features of haemorrhagic shock. My emphatic description to the 999 dispatcher resulted in a HEMS helicopter being called in. They wrote to me a few weeks later, and let me know that his ruptured spleen had been removed as soon as they landed.


Good Samaritan situations are not always so clear cut. One night, just off Leicester Square, I spotted a woman slumped in a doorway. I ran over and assessed her level of consciousness. With my girlfriend standing behind me I checked the woman’s response to pain by pressing a knuckle into her sternum. Ten seconds later she came to and screamed at me drunkenly, just as a policeman arrived on the scene. He grabbed my arm and told me to get off her. My girlfriend and I left them to it. I have since walked past many inebriated forms in the shadows of the West End without rushing to their aid. I might watch discretely for thirty seconds, just to make sure that their chest is moving, and that they have not swallowed their tongue.


Even the most alarming diagnoses cannot bring me to transgress the boundary of privacy. Unless the person is my patient, unless they have been referred to me, I cannot justify whispering advice into their ear, or giving them a gnomic warning. The thin man with little red stars on his face*** and a subtle tinge of jaundice, standing at the bar… I know he runs the risk of developing liver failure unless he abstains, but I stand silently by, waiting for my pint. He probably knows. He has made his decision. What would he say anyway? He would probably, and quite rightly, tell me to ‘F___ Off!’. But…but…what if he has never been told that his liver is damaged? My uninvited words might open his eyes, drive him to his GP, and start him on the road to recovery.


But no.




* reactivation of the chicken pox virus, Varicella Zoster, within the geniculate ganglion. Treatment within 3 days of blistering with anti-viral medication can reduce the severity of the illness.
** Sturge-Weber syndrome; a vivid facial birthmark with underlying damage to the surface of the brain on the same side.
*** Spider naevi, dilated capillaries on the skin, suggestive of cirrhosis.


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