REAL AND VENEREAL
by Dr. Shaila Anne Silva
Dedicated to my family
CONTENTS
1 ) The company director , Chlamydia and obstinacy
2 ) Crabs and scabs and drips and drabs
3 ) Ignorance , arrogance and patient harm
4 ) The teenager , warts , and depression
5 ) The tragedy of drugs , rape , and STIs
6 ) The legal eagle , herpes , and suspicion
7 ) The schoolgirl , warts , and vicarious anxiety
8 ) Urethritis , cervicitis , and happy families
9 ) Keratitis , syphilis , and lifelong monogamy
10 ) Herpes genitalis and serious mental disability
11 ) Drugs n sex n rock n roll and the UK infertility epidemic
12 ) Serial date rape and a dope on dope
13 ) A nappy rash without nappies , and a nodule in a delicate place
14 ) If it itches , it isn't syphilis
15 ) Spotted dicks , painful pricks , and sundry cock-ups
16 ) Random reminiscences ( actually , raves and rants )
INTRODUCTION
People with sexually transmitted infections ( STIs ) are , not surprisingly , stressed and anxious .
British clinics dealing with patients who think they might have caught an STI or actually have one , are called Genito-Urinary-Medicine ( GUM ) clinics , and treat patients confidentially , sensitively , and non-judgmentally .
These true stories of patients attending such clinics are variably humorous or tragic , poignant or memorable . Others are simply odd .
The telling of these emotive tales is not intended to pander to voyeuristic leanings ; rather , I hope they instruct as well as entertain .
It’s sad but true , that what is after all normal human behaviour -- indeed a basic biologic urge -- can result in an outcome that can attract stigmatization . I hope this work will help attenuate this stigma , indeed engender feelings of sympathy or even empathy for victims of STIs .
For obvious reasons , the real names of people and places are not revealed .
The company director , Chlamydia , and obstinacy
It was a warm September day in the first year of the new Millennium and I reflected that the colours - the browns , yellows , and orange-reds in trees and shrubbery around me - were warm too . It was only 11:30 when I returned to the building that housed our Clinic in the grounds of the Millham General Hospital ( MGH ) and took my chair behind the large ugly desk in the consulting room .
The morning Clinic had finished surprisingly early , and looking forward to an early lunch after some fairly routine paperwork , I picked up the dictaphone to quickly finish a few letters .
But just before I could begin dictation , there was a tentative knock on the door . “ Come in ,” I said .
It was Sister Judith , frowning . “ Shai , I’m afraid this patient has just walked into Clinic, complaining of abdominal pain .”
“ Okay , lets see what’s the matter .”
“ But there’s something you need to know .” She sat down .
“ Yeah ? ”
“ She’s demanding treatment without tests or physical examination ! ”
“ Did you have time to discuss the various issues that could arise from such a request ? ”
“ Yes , including the possibility that we might refuse to treat her . In fact , just before coming to us , she attended A & E ( Accident and Emergency ) where they wasted no time telling her to piss off .”
“ All right Judith , send her in .”
Awaiting the patient , I glanced at the file that Sister had handed me . Company Director , it informed me , age forty-nine . Puzzling . I wondered how someone apparently this mature , and presumably educated , could be so unreasonable . But don’t be judgmental , Shaila , I reminded myself .
*****************
Putting up my feet , I sighed , took a few deep breaths . At this stage of my career I was relatively content with my lot .Years ago I’d passed the stringent qualifying examinations ( the Royal Colleges are mean and tough : two of their more pleasant traits ) and at last scored my goal - to be an NHS Consultant .
No apologies for a little trumpet blowing : it was a more uphill task for me than for some others , perhaps ; because I’m a British Indian and because I’m a female .
This brief locum spell at the MGH was bringing in the money we needed for Vikki’s ( our son’s ) private school et cetera et cetera . The workload was acceptable and the pay handsome .
*********************
I snapped out of my reverie when Sister got Mrs. A-J into the consulting room and closed the door behind her . I stood , grabbed a chair and seated the lady . “ G’morning , Mrs. Allason-Jones , I’m Dr. Silva . How can I help you ? ” We shook hands .
Attractive and well dressed . She reached into her handbag and pushed forward a couple of sheets of paper . “ This is a download from a prestigious health website . If you look at the highlighted section , it describes the treatment for Chlamydia with intravenous antibiotics for people with my symptoms . I have Chlamydia and so can you admit me into the Hospital straight away for this intravenous treatment ? ”
“ We don’t function like that , Mrs. Allason-Jones . I’m not dismissing that you may well need such urgent and aggressive treatment . But before embarking on any treatment , I need relevant information . Now I’d like to ask you some questions if that’s alright . We do want to help you , you know .”
It transpired that while abroad in Europe about five months ago she had had a brief affair lasting a couple of weeks , breaking it off when she noticed a vaginal discharge .The man had denied knowing that he had any kind of Sexually Transmitted Infection ( STI ) at all . She saw a specialist in Zurich who had taken genital swabs and informed her that she had contracted Chlamydia . Having no faith in Conventional Medicine , she waited a few days till she returned to the UK and saw her usual Alternative Medicine doctor , a herbalist who prescribed a herbal medicine . This didn’t work , so she saw him again , was given another herbal prescription , to no effect .
“ And now I have tummy pain , Doctor , for the last fortnight or so .”
I thought to myself , what wonderful hypocrisy , so why are you here , could it be because you know the NHS is probably the best health service in the world ; and want to claim your National Insurance privilege anyway .
I elicited a detailed description of her lower abdominal pain .
This lady was reluctant to be examined or to have swabs taken and when I pointed out that I really couldn’t offer her treatment based on her history alone , she wept .
“ What has the NHS come to ,” she sobbed , “ when people cannot get the treatment they deserve unless they’re forcibly tested or examined ? ”
It was useless , my trying to explain to her that it might be dangerous to her health for us to accede to her demand without some tests plus physical examination . She was disconsolate .
I put a gentle hand on her shoulder , and escorted her through the door to Sister’s room . Seating her , I told her there might be a way to help her .
Sister was in the female examination room with the auxiliary nurse and I beckoned her back to my consulting room .
“ Judith , this is a tough nut to crack ---- ”
“ Nut is probably the right word .”
I smiled . “ I’ve seated her in your room again . She broke down unfortunately . I want to offer her treatment , but conditionally . Have another chat with her , once she’s calmed down . Tell her that if she’s unhappy to have an ugly metal speculum up her vagina , would she mind a simple blind swab -- bloody hell , she could take her own sample if she wants ! You know what specimens anyway . I definitely have to examine her abdomen though , even if she still refuses tests .
“ If she will not comply with even these concessions , send her away . If she agrees , we’ll treat her . But Judith , please don’t forget to take a written disclaimer from her after telling her of the risks to her health of refusing comprehensive tests and physical examination .”
“ But Shaila , wouldn’t it be safer - for you , that is - to simply refuse to treat her ? Just get rid of her . Well within your rights , too .”
“ Yeah , but you know that’s not my style , not the way I work . Thanks a million for your help .”
While Sister busied herself with Mrs. Allason-Jones , I phoned a very senior and respected colleague and sought his comments on this difficult patient .
“ All ready ,” Judith called . “ She’s on the couch . You were right . She chose to take her own swabs . Refused speculum insertion . She’s consented to abdo exam but not an internal .”
When I examined her , she had calmed down and our subsequent chat back in the consulting room was less antagonistic .
“ I’m glad to say that all I could find on abdominal examination was a small area of tenderness , that is , slight pain on pressure .You really don’t need inpatient treatment . Have you any questions for me ?”
“ Thanks . Feel a bit better now . Sister was quite kind compared to the A & E staff . What happens now ? ”
“ We’ll give you a two week course of antibiotics and I want to see you in two weeks’ time . If you have problems , we can see you earlier ; but please be courteous enough to give us a ring , rather than just turn up .
“ Please finish the entire course of antibiotics even if you’re much better quite quickly .
“ It’s important you do attend on that day because we want to test your blood for three infections .”
“ What infections ? ”
“ Syphilis , Hepatitis B and HIV .”
She was visibly alarmed when she heard those names .“ Are you saying I’m at risk of them ? ”
“ All I’m saying is that this is what we do , and with good reason . Now I’ll take you through to Sister , for the tablets .”
Having done that , I left , walked to our allocated Staff apartment , just a couple of minutes within the Hospital grounds . Sigh of relief ! Little did I know - - - -
**************
We’d been given the use of the apartment for five days , the duration of my stint as a Locum in this Hospital . The Staff Residences at MGH are small but functional and comfortable . Hungry , I lunched quickly and relaxed watching television with my husband Krishna .
“ Morning Clinic alright ? ” he asked .
“ Sort of . Thought I’d be lucky to have an early lunch but there was a hiccup , got delayed but never mind .”
Just then , at about 1: 45 p.m. the BBC announcer made a “ Breaking News ” interruption --- and our lives changed forever .
We gaped at the scene on screen , smoke billowing from one of the twin towers of the World Trade Center in New York . “ The seriousness of the accident is unknown since it only took place within the last few minutes or so , but apparently an airplane has crashed into the North Tower .”
It must have been in another two or three minutes that the same voice said : “ Apparently a tourist was able to catch the accident on his video camera and we can shortly show viewers .”
Silent and uncomprehending , we waited and soon enough were shown the impact , unclear , but readily recognisable as some kind of plane hitting the building quite high up . We watched in amazement as the screen continued to show the stricken tower , smoke dense and continuous near the top , the South Tower beside . Alternating occasionally with the two second clip of the tourist’s video shot of the impact .
“ Surely most people must have escaped already .”
“ I’m sure you’re right .”
Then the unbelievable happened , except that we had to believe our own eyes ! Surely the Media weren’t playing a macabre trick - it was the eleventh day of September , not the first of April , for Heaven’s sake !
On the right side of the TV screen a plane appeared , and barely had our subconscious registered this as an artefact , something incidental , in the background sky perhaps , when it disappeared into the other Tower , bang and flash , flame and smoke , explosion , all in one second .
After we’d both been watching , mouths open , hardly daring to blink for maybe five minutes , Krishna turned toward me .“ You know what this is , don’t you ? ”
I gasped , snapping out of what felt like a bad dream .
He was shaking my shoulder . “ What a coincidence ,” I replied . “ How horrid , maybe people below the impact can escape but what about those above ? ”
“You don’t get it , do you ? ”
“ What do you mean ? ”
“ No coincidence . Those were suicide attacks by fanatics : you know , in the last few years , American targets in different countries , and now , in America ! Can’t believe it ! ”
“ I remember Vikki saying something about his name , the fanatic’s name the last time he attacked - he said the name sounded funny . That’s right , he called him bin liner . ”
“ Close enough . I think it’s Bin Laden .”
We stared at each other , not really understanding what we were witnessing . How could this happen ? I stumbled to the kitchen and brought cups of tea to the tea table . “ Wait a minute , don’t touch your cup yet . Too hot .”
Over the next few hours we learnt of the successful attack on the Pentagon , the unsuccessful one on Washington , D.C .
Holding hands , we wept unashamedly as the massacre unfolded , live . Fire , smoke , black dots ( men in black suits ) jumping from windows , paper fluttering , the sky darkening on a bright morning .
Krishna blurted , “ They ought to clear the ground of people for miles around , you know .”
“ How come ? I’m sure they’ll put out the fires .”
“ Don’t think so . Sorry , I meant it would be really difficult . What if the Twin Towers come down tomorrow ? Poisonous gases , mayhem . Some wise guy should get everyone far away from there .”
“ How can you say things like that ? Towers coming down ! ”
“ Hey , I’m only a bloody architect , remember ? Only thinking out loud . Didn’t it occur to you ? ”
“ Yes , for a second . Blanked it out as incredible .”
*********************
Just over a month later I was back at MGH , only a two day Locum spell , but this time I was alone . Mid morning , things were going well . While looking at a patient’s file prior to calling him into the consulting room , I was interrupted by a knock on the door and Sister Judith came in .
“ Remember Mrs. Allason-Jones from last month - the Chlamydia lady who wanted treatment without examination ? ”
“ How could I forget ? ”
“ She’s back . Walked in a few minutes ago , saying she’s in agony .”
I frowned . “ Oh dear . I distinctly remember asking her to phone us first . But I shouldn’t really be surprised .”
“ She’s in my room . Do you want me to get her in here ? ”
“ Sure . But do me a favour . Can you ask Matt to see a few of my patients ? ”
Dr. Matthew Sims is our Clinical Assistant , a lovely guy , knowledgeable , reliable .
Sister sat Mrs. Allason-Jones down at my desk and left .
“ What happened ? ” I asked .
The lady did look ashen and haggard and had her hand pressed to her lower abdomen . “ It’s been quite sudden , about five days , the pain is awful .”
The whole story unfolded slowly . She’d taken the antibiotics given to her five weeks ago , but because her pain and discharge had promptly gone away , she had stopped after seven days , just half the course . She was fine for another couple of weeks but the pain had then returned , mild at first . After a couple of days she consulted her own herbal therapist and took the prescribed treatment - to no avail . Now the pain was very severe indeed .“ I’m in agony .”
“ Mrs. Jones , I’d like to examine your tummy , but would be grateful if you could agree to let my colleague Dr. Sims give his opinion as well , he’s a very experienced doctor .”
She assented , and I asked one of our nurses , Georgina to prep her on the female examination couch and to check her vital signs .
A glance at Nurse’s entries in the patient’s notes told me that her pulse rate and blood pressure were normal but she had a mild fever . Halfway through my palpation of her abdomen , Matt came in , and as I finished my task he was introduced to her .
In the time it took him to see her , I returned to my seat and made notes in her file . Soon Matt was back with me .
“ Thanks a ton for helping me out here , Matt , what do you think ? ”
“ No problem , Shai , there were just a couple of simple cases . As for this patient , I’m not at all sure what we’re dealing with here .”
“ Me neither .” I briefly gave him her salient historical data . “ My plan , Matt , is to give her intravenous treatment , in view of her recent nausea and vomiting , to cover Pelvic Inflammatory Disease ( PID ) .”
“ Shai , I also think she needs a laparoscopy , urgent .”
“ Mind reader ! ” I pointed at my case notes which showed the same intent .
“ Let me know the outcome , Shai .”
“ Sure thing , thanks again . ”
I discussed this with the patient , who looked worse if anything , having been examined twice in quick succession .
“ Mrs. Jones , looks like you’re going to get the intravenous antibiotics you wanted a while ago , after all . The difference being that this time it seems you do need them .”
“ Oh , so you’re thinking Chlamydia .”
“ Both Matt - - Dr.Sims that is , and I think you may have Pelvic Infection ; however we are also both in agreement that you need an urgent laparoscopy . This involves looking directly into your tummy with a flexible telescope like instrument .”
“ Why ? Don’t you know what’s wrong ? ”
“ We are not sure . That’s why we want a gynaecologist to peep inside ; if they find something , treatable either medically or surgically , we can then try and fix it . Hopefully , you will then make a speedy recovery .”
“ Surgery ! Are you saying I need an operation ? ”
“ No , all I’m saying is that we don’t want to take any chances with your health , and a laparoscopy would reassure both yourself and us that there’s nothing sinister going on .”
Reluctantly she agreed , I soon busied myself arranging her immediate care . Dr. Mal Price is an excellent colleague and I was confident that she was in capable hands .
The rest of the day flew by , and the drive home to Carvill was unexpectedly long thanks to a traffic jam . Exhausted , I slept like a log that night .
*****************
Several days later , there was a brief but welcome lull in my Clinic at Carvill
and I took the opportunity to ring Sister Judith at MGH . Luckily she was free and we exchanged pleasantries .
“ Hey . How’s tricks ? ”
“ Bril . How’s you ? ”
“ Great . Just a quick word , Jude , wanted to know how Mrs. Allason-Jones is doing .”
“ Oh , she’s just fine , but she nearly drove Dr. Price mad with her antics .”
Mal happens to be an unflappable kind of guy , so I listened with more than a little interest at what Sister had to say .
Apparently Mrs. Jones had questioned Dr. Price at length about the procedure she was to undergo . She had then informed him that no matter what he saw in her pelvis at laparoscopy , he must not operate . She did not believe in surgery , all she wanted was to know the diagnosis .
Once she knew what was wrong , she would obtain herbal treatment . Dr. Price had tried to explain that many conditions were actually curable by appropriate surgery , but she would have none of it . In the end , she had agreed to surgical intervention in only one specific scenario .
That is , if there was an accident during the laparoscopy itself and a complication ( for example a blood vessel being cut ) , then she gave permission for lifesaving intervention . She was adamant that only in these circumstances ( procedural complications ) would she permit surgery . Dr. Price , like us , was very careful to take her signature on a disclaimer statement to protect his own ass .
“ Phew ! So what did they find ? ”
“ Just as you and Matt had suspected - appearances compatible with pelvic infection . The intravenous antibiotics worked like a treat and she went home in just two days .”
Thanking her , I put down the phone and thought : “ There’s nowt so queer as folk .”
Here was a lady with blinkers firmly in place , even willing to risk her life rather than take them off . This , in spite of being cured by our system of Conventional Medicine . I do hope she does not suffer in the future because of her stubbornly held beliefs . Just regret that I couldn’t bring her around to thinking more clearly about some conventional concepts of healthcare .
Crabs and scabs and drips and drabs
It was approaching the turn of the millennium , late 2000 . At Carville Royal Infirmary ( CRI ) , the gang of inveterate gossipmonger smokers , at the altar of the giant cylindrical cigarette bin ( courtesy CRI management ) were huddled together in the cold .
Jenni was looking at me . “ Is that a food stain ?” Pointing at my sleeve . “ Very unusual for you , Shai , you’re normally so neatly turned out .”
I grimaced . “ Must’ve been when I was packing my lunch . Mushroom curry . Oof , very hot . Krish makes a wicked dry mushroom curry . Made me cry . Haven’t cried in years .”
“ You lucky swine . Do you ever cook ?”
“ Of course I do ,” I said indignantly . “ But not very well . Fair to middling . Of course Krish is an Angel in the kitchen .”
“ Is he also a Devil in bed ?” laughed Louise . The others were smirking and laughing too . Soon their din would touch danger decibels .
“ Shush ,” I said , feeling myself blushing . “ Why do your filthy little minds always drift south of the belly button ? I would’ve thought we have enough crotches at work .”
“ Talk of crotches ,” said Hillary . Hillary is one of our Charge Nurses . “ I saw the worst case of crotch rot in years just the other day . The swelling and the redness and the pus and the sores were awful but the worst thing was the smell .You won’t believe this but the patient actually asked me if I thought there was a risk of it dropping off .”
“ You’re putting us off our lunch !”
“ Sorry . Talk of food , I had the most amazing lamb biriyani yesterday .”
“ Can you do biriyani , Shai ?” asked Jenni .
“ Easy peasy ,” I said . “ But I’m reminded of the best chicken curry I have ever tasted --- excepting of course , Krish’s .”
“ Where ? Here in Carvill ?”
“ No . On holiday in India would you believe . We went climbing up to this fortress on a hilltop near Poona ( now Pune ) . And back down , pleasantly tired .
“ Decided we deserved tea before the hour long drive home . Krish’s sister Devi who runs a computer business in Poona decided a takeaway was a good idea .
“ We asked the waitress for chicken curry but she said it would be at least a half hour . So we waited . It was an open air joint , rustic and quaint . Vikki and I wandered around to one side of the restaurateur’s house , just aimless meandering .
“ There we saw many chickens running around in the open , pecking at the ground . Then we saw this woman come from the back of the house , chasing a chicken . The one she chased got away , but she made a lightning grab for another one and it was curtains for that one , then .
“ There was hearty laughter when we told the others . No wonder the waitress said half an hour . That night we had what I thought was the best .”
“ Well , you can’t get fresher than that .”
“ Vikki was a bit squeamish , having seen the chicken alive and kicking , literally , just before . But once he tasted it , no stopping him .”
“ We must have some of Krish’s curry soon ,” called Hillary’s voice as I was about to re-enter Clinic .
“ That’s a promise .”
*********************
The fifteen year old boy Robert was tall for his age but had a cute round baby face . He was accompanied by his mother who appeared tense .
There was a niggling worry in my head . Sometimes the parent-child situation like this one can make for a rough time for all three of us . Occasionally , even the finesse and the intuition and the years of experience can fail in the face of anger and embarrassment . I braced myself .
“ Good Afternoon , Mrs. Philpot . And how are you , Robert ? I’m Dr. Silva .”
“ Good Afternoon . Can you tell us why we are here ?” spake Mum .
“ Let me check . Did your Doctor do a little note of referral to us ?” I dug around in his case notes . “ Yes , here it is .” I had found it tucked away in the little pocket in the back of the notes .
I was barely able to decipher the handwriting . It was from a chap I’d briefly trained last year , Dr. Eccles . Itchy pubis and groins two weeks , it said . Maybe scabies -- unsure .
“ You saw Dr. Eccles ,” I said . “ What did he think , did he say ?”
Mum replied on her son’s behalf . “ He wasn’t sure whether it was scabies or not . But why didn’t he treat it ? Why send us here ? This is a VD Clinic .”
“ He didn’t treat because he wasn’t sure . He must have been concerned that if the wrong treatment was given , Robert might suffer for longer . He knows me from having a training update with me last year and has sent Robert for another opinion . Is that alright with you , Robert ?” I smiled at him . “ If you prefer to see a male doctor , I can try and fix that up for you . We do try to give people a choice .”
But Mum wouldn’t let go . She was getting more and more irate by the minute . “ Doctor , you haven’t answered me . Why the VD Clinic ?”
My patience is profound , but was being tested . “ Mrs Philpot , this is a Department that deals with venereal as well as non sexually transmitted conditions . Many of our patients have ordinary non-venereal conditions . So Robert being treated here is perfectly normal .”
With difficulty , she seemed to compose herself . “ Robby , do you want to see a male doctor ?”
He had looked at me but looked away now . “ I can see a male doctor .” I smiled at him again . “ That’s quite alright , Robert , just fine . Please wait here .”
I went to fetch Dr. Dodds . There was a slight wait as he was with a patient .
“ Hi , Don .” I explained the situation and offered to see one or two of his patients . “ No need ,” he said cheerfully . “ I ’ve just finished .”
Introducing him to the couple , I said : “ I’ll be in the staff room if you need me , Don .”
Sipping warm water with my feet up , I heaved a sigh of relief . Mrs. Philpot’s kind of frustration is quite common . Patients want instant solutions ; they are almost by definition anxious ; being ping-ponged from place to place and /or from person to person is annoying and unpleasant ; combine this and other factors with the “ stigma ” of attending a certain kind of clinic .
You have here a recipe for a confrontational situation which can turn nasty , including violence . Compared with some other Departments we are lucky ; still I had been tense , and just a few minutes ago wondering how to react if the lady had lashed out . Relieved now that the problem was apparently defused .
But not for long .
Don came along shaking his head ruefully .
“ Couldn’t tell what it is . You better have a look .”
“ Did the lad agree ? He’s probably shy .”
“ I particularly asked him . He said alright . But you’re right , he’s shy , kept his underwear on , did not want to expose his bits .”
“ Great . Do you wanna come along .”
We marched slowly back and I waited while Don got the boy ready to be re-examined . I went around the screen and had a close look .
Lots of scratch marks , scattered scabs --- that was all . No signs of specific conditions that might give me a clue about why he was scratching . Things like eczema , dry skin , psoriasis , sweat rash , fungal infection , scabies , seborrhoeic dermatitis , folliculitis , et cetera .
To buy time , I got a lamp and a hand lens , and used them to magnify features in stronger light .
Thus far , I knew neither head nor tail of the diagnosis ; but peering closely at his groin through the lens , I saw two tiny pinhead size oval things stuck to the hair shaft . Nits ! But I was looking for more .
In half a minute , I saw it : not head or tail , but a brownish black , barely visible square shaped body stuck to the skin , looking like a spot or a flat mole or a blemish , barely visible . It wriggled , probably irritated by the heat of the lamp .
I showed Don , he nodded and left .
With Robert dressed and seated , I looked at one , then the other , and said : “ Robert has pubic lice .”
“ What are they ?”
“ Similar to head lice you know , like kids catch from school , but these infest the groin and pubic area .”
Robert : “ Have I caught it in school , then . Some of the smaller boys in school had head lice a long time ago .”
At last he had spoken on his own initiative . “ No Robert , not from school ,” I said . “ They are usually caught from having sex with someone , or very occasionally from clothing or bedding .”
Mrs. Philpot was outraged . “ Nonsense . I won’t have any of this !” And away she stomped before I could say anything , almost dragging poor Robert along .
I started : “ Wait , we need to talk ------ ”
But she interrupted : “ How dare you ?” and slammed the door shut .
Helpless , I continued Clinic after making careful entries in Robert’s notes .
Later in the day , Louise came up to me and said that Mrs. Philpot had telephoned the Clinic and spoken to her .
“ We had a chat about crabs , and she asked me if another opinion was permitted . So I dug out the notes , took consent , and having seen your entries , explained that she had a right to an opinion , but it was a waste of time as you had actually seen the crabs .
“ She didn’t seem to register what I said because she asked which other doctors could diagnose Robert’s problem . Then I explained again , slowly , in words of one or two syllables .
“ At last it sunk in , and she wants to see you again .”
“ Fine , just fit him into Clinic . The poor boy is scratching his skin out .”
************************
That evening the three of us were relaxing , watching TV . Supper was a long way off because Krishna had indulged his great culinary skill . So at tea time we had a special treat .
I wonder how many nationally well known architects were also capable Indian Cooking master chefs . This concoction was delectable . Vada is a scrumptious dish , rice and lentil balls shallow fried . The twist was his own savoury signature masala and herbs . He deserved special thanks tonight .
The screen showed starving kids in Africa in the milieu of war , famine , AIDS , and a squizzilion other problems . I switched the TV off , unable to stomach the suffering of kids . Adults I can be brave about but the thought of innocent children suffering drives me bananas .
Vikky was annoyed . “ Hey , Mom , I was watching that .”
“ Sorry , Sonny , another time . Maybe you want to play scrabble or Nintendo or something .”
“ It’s okay . India isn’t as horrible as those places , is it ?”
“ Yes and no . Some places are bad . But not as bad as you just saw . You’re older now , and both times we went to India you saw loadsa poor people , didn’t you ?”
“ Oh yeeaah , but we had fun too .”
“ Wish I had as much fun as you at your age .”
“ Whatsat mean . We went round in a car and everything .”
And everything . He always said that . All the kids did . “ Vikki , I said at your age . When I was a kid we were almost poor if there‘s such a thing as almost poor . We were happy enough but didn’t have all these comforts .”
“ Poor . Poor . You mean like on telly just now .”
Luckily or unluckily Vikki is intelligent , and articulate for his age . And unlike some peers , he doesn’t have the attention span of a drunken bumblebee .
“ No , not like on telly . I said almost poor which sounds silly . Not starving to death or simply killed off for reasons you and me don’t understand .”
“ Does almost poor mean the poverty line like they say on TV ?”
“ Yesss . Tell me . How many bedrooms do we have . And how many toilets .”
“ Four bedrooms and ------- er , three toilets .”
“ And a small garden .”
“ Yes , but why are you talking about that . I already know .”
“ We were talking about poor people .” Is it possible Vikki isn’t as clever as I think he is ?
“ Oh yeah .”
“ When I was your age , we lived in a one room flat in Bombay .”
“ What . A one bedroom flat .”
“ No , Sonny , only one room . No bedroom .”
“ Gross .”
“ Stop that “ gross ” business . One room , eight people living in it .”
“ Gross ! Eight people in one room and no bedroom .”
“ There was Mom and Dad , that’s two . Then us three kids . Me , your auntie Vijaya and your uncle Kumar , that’s five .” Each time I splayed my fingers so he could keep track . “ Dad’s Ma - Gran , that’s six . And two “ uncles ” , not Dad’s brothers but his cousins . That’s six plus two equals eight . Eight people in one room .”
“ Naahh , you’re joking . What about food , and toilets .”
“ No joke , Vikki .” He sensed my sombre mood , was quiet .
“ We had a small kitchen , enough for two people to squat in . And a shower room in the kitchen , a shower room without a shower .”
“ How ’s that .”
“ No shower . Remember a couple of years ago both showers didn’t work here . We had to pour water from a bucket over ourselves . That’s what we did . It’s called ablution .”
“ What about the toilet .”
“ The toilet was outside the flat in the backyard . We shared the toilet with neighbours . In the morning , there was a queue outside the common toilet . People had little pails of water to wash their bums after their poo .”
He was shocked . “ What about toilet paper , Mom .”
I could sense he was panicking . “ None . India was , and still is a poor country and no one except the rich had toilet paper then .”
Now the coup de grace .
“ Imagine a small girl or boy in the queue , bum-tight . Difficult to talk about the weather or Cricket or anything with a turtle-head poking out , eh ?”
Poor Vikki’s eyes filled with tears . I held him close .
Didn’t mean to upset you , Sonny .
Kids are great . Particularly ours . He was suddenly quiet . “ Mom , what about a wee-wee . How could you do that ?”
“ Can you guess ?”
“ In the shower in the flat .”
Yup . He‘s smart .
*************************
The next morning Mrs. Philpot came in with her son in tow .
I’d mentally prepared for another unpleasant encounter of the Nt/h kind , so was surprised that she appeared becalmed . At the previous consult she had looked ugly with the facial distortion that accompanies emotional disquiet . She looked nice , and did not fire the expected salvo .
We exchanged G’mornings and sat comfortably , but I tend to err on the side of paranoia and was alert to nuances that might spell danger .
“ I’m glad you’re back ,” I said . “ The longer you wait , the longer Robert’s horrible itching tortures him .”
“ I’m sorry I lost my temper , I was shocked and upset about your diagnosis of an STI .”
“ Not to worry . I have a son and I can not only sympathise , but also empathise with you . If something like this happened to Vikki I suppose I’d be pretty upset too .”
“ We looked at some websites last night and non-sexual pubic lice was mentioned .”
“ I did mention that yesterday .”
“ Did you ? I don’t remember .”
“ That’s entirely understandable . Quite natural for an upset mind to focus on the dark side and fail to register every damn detail contextually .”
“ I remember you saying clothes , doctor ,” said Robert . I smiled at him encouragingly . I liked his face and manner . He should come out of his shell , I thought . A bit difficult if one is overtly or otherwise dominated .
“I’m sorry . The online blurb says it isn’t always venereal . Robert doesn’t have a girlfriend so that means he got it from clothes , right ?”
“ I don’t know . What’s important is that we kill the lice with this cream .” I turned to Robert . “ I can see you in a week or two to make sure we’re on track . You can come alone or with Mum .”
This was my attempt to try to speak to him alone , confidentially . The problem is , people lie about sex . They lie before sex , after sex , and during sex . If I was to fulfil my duty to Robert , I had to offer tests IF he had had sex . Mum’s presence may or may not have affected the truthfulness of his answers to my direct questions .
But we can’t always have it our way .
“ Dr. Silva , I asked you whether he got it from clothes .” She seemed to be getting hot under the collar again .
“ And I answered you . I said I don’t know ,” I said to her as gently as I could . “ Mrs. Philpot , you’re a mature lady . You know about doctor - patient communication privacy . One of the duties of this Clinic is to obtain a patient’s sexual history , so that we can do the correct tests at the correct time to detect infections properly .
“ That is why I have to now formally ask your permission to let me talk to Robert alone . May I ?”
“ But he’s only fifteen and I’m his mother . Is it really any business of yours about someone’s sex life ?”
“ Good question . Yes and no . Yes , we need to ask so we can offer tests for STIs appropriately . And no , we can’t force people to divulge things they do not want to .”
The next step would have been for me to ask Robert whether he wanted to talk to me alone . This would possibly set Mum on the warpath again .
But young Robert came to my timely aid . Probably fed up of the amicable exchange between us , he spoke out : “ Dr. Silva , I never had sex .”
I was mighty pleased . I could now wrap this up quickly , and get on with pending work . Smiling gratefully at him , I said : “ Thank you , young man . Now I would like to ask you about something else .”
“ But he just told you ,” said Mrs Philpot . Why can’t you keep your ugly snout out of this , I screamed silently . But I smiled sweetly : “ This is general questioning .”
And turning to Robert : “ Within the last two months , have you had friends sleep over at yours or did you sleep over at their homes ?”
He thought for a bit . “ No .”
“ Have you slept anywhere other than at home ?”
“ Yes . School trip to France nearly two months ago , for a week .”
“ His school is boys only ,” said Mum . “ They normally stay in a hostel .”
“ Thank you , Mrs. Philpot . Now Robert , tell me , were the sheets always clean in those hostels ?”
“ Yes , except one , the bed was dirty and smelly . Two days there but I didn’t complain .”
“ I ’ve seen this happen before ,” I explained . “ If someone with crabs , sorry , pubic lice sleeps in a bed whose sheets aren’t washed before the next person sleeps in it , infection can spread that way .”
Mrs. Philpot : “ So it was the bedding after all .”
“ Madam , I couldn’t say for sure . All I will say is that it is likely .”
“ So the sexual history as you called it wasn’t necessary after all .”
“ We all have a job to do . I would be grossly negligent if I didn’t ask the questions I’m supposed to ask .”
“ Thanks for your help , Dr. Silva . What next ?”
“ Our Specialist Nurse will see Robert and issue the prescribed anti louse cream . I’ll see Robert in a couple of weeks , just in case the cream isn’t working as well as it should .”
I studiously avoided the topic of drug resistant lice , fearing it might lead to more time wasting aimless chatter .
I passed them on to the Specialist Nurse , having first discreetly warned her to tread cautiously .
Robert was quickly cured , bless him .
But about a month later , I was surprised , but not so surprised , to find that Mrs. Philpot had attended Clinic for a checkup , because she had been unfaithful to her husband .
***************************
That morning , after I had treated Robert , Clinic was really busy , Mrs. Philpot’s theatricals had infringed seriously into other patients’ time . So I was relieved to have no medical students to teach .
I love teaching , but it invariably slows things down , especially if the student is ignorant or not very bright .
No break this morning , I thought as I worked through the list . Again , luckily , all the patients had straightforward problems and I whizzed through and actually caught up with appointment times .
The last but one patient was in his early forties , pleasant enough but looking rather worried .
“ Mr. Benton , what can I do for you , sir ?”
“ I have this whitish patch down there . Been there about three years .”
“ Is it itchy or painful , is it getting bigger ?”
“ None of that . D’you think it could be cancer ?”
Aha ! There it was , no wonder the worried look . “ Don’t worry , it doesn’t sound like it , though , to be fair , I haven’t examined you yet . Any other health problems ?”
“ No .”
“ So you’re not on tratment for anything at all , tablets , creams , inhalers ?”
“ Oh yes , I’m taking these tablets for my bladder problem .”
Sometimes you have to tease the information out of patients with leading questions , or else you can miss important stuff .
“ What bladder problem . And how long have you suffered with this ?”
“ About ten or eleven years . At night , I have to go and pass urine four or five times . No pain or anything , but it’s a bloody nuisance , not just me , the wife wakes up each time .”
“ Did your own doctor do tests ?”
“ Loads and loads of different urine tests . A scan of my testicles .”
“ Any other tests or did you see a specialist ?”
“ Yeah , where they inject a dye into your vein and look at your kidneys with an x-ray . And I saw this specialist who put his finger up my arse and even shoved this magic eye thingy up my penis to look at my bladder . Nothing showed up .”
He shivered at the memory .
“ Come through with me . I’ll have a look and take the tests .”
Back in the consulting room after the swab tests , I told him : “ That white spot on your shaft is called vitiligo . It’s not cancer .”
“ This website said something called pre-cancer .”
“ That is a different disease which can look similar , just forget the C word .”
Visible relief . “ What next , doc .”
“ Blood tests next door . Meanwhile , remember I showed you the little glass slide with some moisture from your urethra . I’ll study that under the microscope and tell you what I found . So wait outside , I’ll call you later .”
I was very happy with this chap . No bull , quick , easy .
The last patient was a thin guy in his mid twenties . I introduced myself .
“ How can I help you , Mr. Chapple ?”
“ I thought I was seeing a white doctor .”
I was shocked , but pulled myself together pretty quickly .
Wanting no further development to this situation , and to avoid future hassles , I walked to the door , opened it , and waved my arm .
“ Please go back to reception and book another appointment .”
He looked confused . “ What do I say to them ?”
“ Your call , Mr. Chapple .” I stared at his face . If the police needed a photo-fit at some point in the future , I’d make no mistake .
I joined the smoking crowd , cup in hand . It was nice and warm outside , strange for September . Michael was rendering his usual tall stories . Mike is our senior most Charge Nurse . I love his style . He garnishes his “ incidents ” and makes the mundane sound hilarious . He’s crudely bombastic and coarsely loquacious .
“ So there I was , supposed to take swab specimens from this gay bloke because Dr. Dodds was overrun , you know how slow he is .”
He caught sight of me , grabbed my elbow . “ Not like this little filly here . You’re fast aren’t you , me darlin’ , very fast .”
“ Fast but not loose ,” I said .
He let go my arm , and said with mock shock : “ Didn’t mean that . But where was I . Yes , he was lying there , exposed , I turned around to get the swabs , only a minute to make sure everything was just so .
“ I turned back around , and the patient had this massive erection . I said nothing , just did the swabs really quickly . You can guess what the pain of the swabbing did . He deflated before you could say Robinson Crusoe .”
Everyone was shaking with mirth .
“ What a whopper . What a plonker . A whopping plonker ,” he continued . “ He had the good grace to apologise . I said no problem mate , I’m used to this . I’m flattered . My lovely arse attracts both sexes , all ages .
“ He’s got a good sense of humour , this lad . He laughed out loud . Broke the ice .”
I went to the side-lab to read Mr. Benton’s slide . One of the junior nurses had already focussed it , and sitting on the little stool I looked down the eyepiece . In seconds I saw the clumps of pus cells indicating infection .
Reseated in the consult room with him , I said : “ Two things . One , your skin problem called vitiligo . If you are a computer buff , get online info , we do not have leaflets about it . See your doctor , he may refer you to a skin specialist .
“ Two , that urethral moisture isn’t normal . That glass slide , remember . It’s infection , we call it urethritis . It may be the cause of your frequent peeing but I can’t be sure .
“ We’ll treat you and your wife .”
“ Why ? Bladder problem got something to do with my wife ? Her bladder’s all right .”
I repeated patiently : “ Mr. Benton , the infection is not in your bladder , it’s in your urethra . The leaflet will explain .”
In fact , he was cured of his frequency . How crazy can this be ?
Over a decade of suffering . Sleepless nights times two . Many , many thousands of pounds worth of medication and tests . All for want of a few pounds worth of tests and antibiotics . Talk of horseshoes and battles .
Later that day , the grapevine gossip was that the patient who wanted to see a white doctor had tried to justify his request . Apparently the last few coloured doctors or nurses that he’d seen had such thick accents that he couldn’t understand them .
*****************
It was a day of interesting encounters .
Strange how monotonous days or weeks go by , unexciting drudgery . Then a flurry of incidents , or interesting cases , or more rarely , a humdinger .
That afternoon saw yet another surprise . For me , at least . Maybe my upbringing had been too cloistered .
“ Mr. Parris ,” I called . The man got up from his waiting room chair and followed me into the consult room .
Seated , for the first time I noticed the thin white dog collar . A clergyman ! A quick glance at his notes . Occupation : Priest . He was in his late forties , but looked younger . Round face , rotund figure .
“ Good afternoon , Father ,” I said . “ What’s the problem ?”
“ Good afternoon , Dr. Silva .” He had a quizzical look . “ I think I’ve caught gonorrhoea .”
I gave him a quizzical look . Quizzical looks all round .
“ Go on .”
“ Three days ago I noticed yellowy pus discharge , with slight stinging .”
This sounded like it could be gonorrhoea . Usually though , they don’t say slight stinging , they say pissing razor blades .
“ Let’s take the tests , Father , come with me .”
He followed me into the examination room and I took his swab tests . Yellow green pus was dribbling out of his urethra in slow motion . A cloth he had tucked into his underpants was soaked .
“ Father , you are probably right . In about five minutes we should have a tentative , also called presumptive diagnosis of gonorrhoea .
“ We are able to do this by microscopy of the pus you saw me plate onto a glass slide . We do that in the side-lab next door .
“ The treatment is a tablet of ciprofloxacin which should cure it . I’ll see you in ten to fourteen days for a test of cure .
“ Have you any doubts , questions .”
“ Yes .” He was smiling . “ Why do you address me Father ? Are you a Catholic ?”
I smiled too . “ No , Father , I was born into a Buddhist family . I’m not a practising Buddhist though . But I went to Convent Schools in India for -------- er , fifteen years .
“ So it’s like a knee jerk reaction to address you Father . It was all I could do to keep from genuflecting . But if you have deep philosophical objections , I will stop calling you Father .
“ No misunderstandings , only understanding . No offence ?”
Now he laughed . “ As you like , Dr. Silva . I must say , you are a refreshing change .
“ I’ve had such problems before , no one has behaved like you .”
“ Thanks . How did you get this ?”
“ I met my ex-boyfriend last weekend and was weak .”
I didn’t bat an eyelid . “ You need to tell him tonight . You know the danger , don’t you .”
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