Grumble and the tramp

Regular readers may have read Dr Grumble's tale about a bag lady he encountered on his way into work earlier this week. She had been sleeping in the ladies' toilets and Dr Grumble suggested that security was called. Grumble knew that security would throw her out onto the streets. Comments following the post suggested that the NHS might be better off if they looked after patients like the bag lady to prevent her getting frostbite or pneumonia. Dr Grumble used to think the same. But you develop a thick skin if you work in a hospital. People you try to help quite often let you down and it is for this reason that hospital staff can sometimes appear a little uncaring.

Many years ago Dr Grumble worked as a medical registrar in a small teaching hospital in London. The main hospital block was on the other side of a small park from the nurses' home where Dr Grumble had his on call room. In those days you worked all night and all day. You snatched sleep when you could day or night. Often Dr Grumble would have to walk on cold nights alongside the park from one building to another. Sometimes it was bitterly cold. Most nights on one of the park benches Grumble would see a tramp curled up fast asleep. He had only one leg.

One night when Grumble was on call it began snowing. Cold weather portends more admissions so Grumble was not pleased. He needed his sleep. Emergency admissions, for some inexplicable reason, always seem to begin to peak at around bedtime but by about two in the morning on that night all those years ago there was a lull and so Dr Grumble trudged through the snow past the park on his way to the on-call room for a few hours sleep. That anyway was what he hoped. As usual the tramp was on his park bench. This time he had a few sheets of cardboard over him to help keep out the cold. The wind was bitter. Even Grumble felt it in his bones as he hurried through the snow from one building to another. He felt utterly exhausted and prayed for at least a little sleep. He consoled himself with the thought that his life of constant day and night work was not quite as bad as the life of that poor tramp on the park bench.

Grumble climbed into bed. The room was not as warm as usual and the sheets felt cold. Dog tired though he was he couldn't sleep. Patients do not know how much their doctors worry about them. But doctors worry a lot about lives that they are responsible for. Grumble had done his best for the day's medical admissions but he was still worried about some of them. He ran them over in his mind wondering what rare diagnoses he might have missed what test he might have forgotten.

Just as Grumble passed into the land of nod he awoke with a start. Was he dreaming that his bleep had gone off? He often did that. He would ring switchboard only to find out that he had not been bleeped at all. Those days were tough. Always on call. Always worrying that the telephone would ring or that a shrill bleep would cruelly terminate the Grumble reverie. But this time it was real. There was a very sick patient in what was then known as casualty. Grumble quickly pulled on some clothes and went out into the dark night. The wind seemed even colder. He tugged his white coat around him tightly to try and keep out the cold. The tramp had gone. The night it seemed was too cold even for him.

Dr Grumble arrived in casualty. There were the usual drug addicts lying around. The staff weren't worried about them. They were regulars. Once their heroin had worn off they would be on their way only to return the following night via casualty's ever open revolving door.

Grumble asked where his patient was. He was in room 3. Room 3 was used for the VIPs. Earlier in the day Dr Grumble had seen a noble lord in just this room but this was not the time of night for lords or ladies. And it was even a bit late for the drunks. There was usually a bit of peace at between 3 and 4 a.m.

The casualty officer had done the usual crap cursory clerking. Even in the days when doctors had more experience the casualty staff never seemed to be thorough. They knew that somebody more senior would have to see their patient anyway so they didn't really try. Doctors who do not really try do not learn. It's like that more often now. Junior doctors know that a consultant will soon see the patient so they don't really try. It's bad. Very bad.

Dr Grumble went into room 3. He shouldn't have been surprised but somehow he was. There on the trolley was the tramp with one leg. They had put him in the VIP's room because of the smell. Nobody had yet cleaned him up. It was Dr Grumble's job to try and work out what was wrong with him despite the stench and the filth and the scabies.

The diagnosis was actually quite straightforward. A chest radiograph had been done. The patient had middle lobe pneumonia. There was loss of the right heart border.

Doctors will have spotted that this cannot possibly be the
tramp's radiograph but it does at least show the silhouette sign.

Dr Grumble's patient was not at all well and there were other quite dangerous problems such as his low body temperature. Younger doctors would be surprised to learn that despite the severity of his illness Grumble treated him with intravenous benzylpenicillin. It used to work well in lobar pneumonia and Dr Grumble's patient got better.

Now in those days doctors, even junior doctors, had some leeway. If you felt a patient needed a bit more time you could keep them in hospital a little longer. If you felt that they needed to stay in while social issues were sorted out you could do that. And that is was Grumble did. He felt sorry for the tramp. He told the consultant, a somewhat dour Scot, that he was going to find him somewhere to live. "You're wasting your time, laddie," said Dr Blunt. But he didn't interfere. And that was how the tramp ended up with his own small flat to live in.

The winter that year was cold. On countless nights Dr Grumble went back and forth in the night between the hospital and the nurses home. And each night Dr Grumble felt good because the park bench was empty and he knew that the smelly one-legged tramp was now tucked up warm and clean in his own bed. Until one night when Dr Grumble was walking back from casualty he glanced into the park. And there he was. The one-legged tramp was back on the very same bench covered once again with cardboard. "I told you you were wasting your time, laddie," said Dr Blunt.

Dr Grumble sees his former self in his junior colleagues. They fail to understand why Grumble kicks tramps and bag ladies out of hospital. They want to help these people. It is only natural. That's what medicine is about. Sometimes Grumble lets them because he knows that they need to learn the hard way - just as Grumble did all those years ago.