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15 August 2016

Every doctor has ghosts – one day, one of mine came back to help me

Patricia came in for a consultation six weeks ago. Just turned 70, she remembered her back hurting when she twisted at a dance.

By Phil Whitaker

Len came to me many years ago. A tall, lean retired miner, he’d been erecting a garden shed when he’d felt something go in his back. I see hundreds of cases of back pain a year: the vast majority are termed “simple mechanical” – to do with muscle strains, or wear and tear in joints – and Len’s story fitted this perfectly. When I examined him, all I could find was spasm in the muscles. We agreed some pain relief and to return in a fortnight for review.

When he came back, things were a lot better, but he still had a nagging ache. I suggested that he give it a bit more time. When that didn’t work, I referred him to physiotherapy, thinking their input might help settle the last vestiges. But given how much progress he seemed to have made, I wasn’t unduly concerned.

It was about three months later when the physio called. The department was under huge pressure and so Len had only just had his appointment. The therapist thought she’d better ring me because he looked very unwell. I went round that day, and was shocked by what I found. He was gaunt, in substantially more pain, and pale from anaemia. On top of that, he had signs of pneumonia. I admitted him straight to hospital.

He never made it out. His lungs were ravaged by a form of aggressive bacteria which went on to cause his vital organs to fail. And the reason he had such an unusual infection was that his immune system was no longer functioning.

The cause of his back pain was now apparent: Len had developed a cancer of the white blood cells called multiple myeloma. A single clone of antibody-producing cells starts to multiply uncontrollably, infiltrating the bone marrow and obliterating normal blood and immune cell production. Myeloma also causes weakening of bone, particularly in the vertebrae, leading to pain and even unprovoked fractures.

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The prognosis for myeloma sufferers was poor in those days, and Len had an advanced case of the disease, so it may not have made much difference to the outcome if I’d picked it up. But I felt awful. Len had evidently been deteriorating at home but hadn’t made a further appointment, hanging on to see the physiotherapist I’d told him would help.

I learned some hard lessons: to treat new back pain in the elderly very warily, not to be fooled by even the most apparently clear-cut mechanical onset, and to keep arranging reviews until I was certain that nothing sinister was going on.

Patricia came in for a consultation six weeks ago. Just turned 70, she remembered her back hurting when she twisted at a dance. Again, it seemed very mechanical, and after a couple of weeks things had resolved, but still I drummed into her to return if the problem recurred.

A fortnight later she was back, in much more pain. I took blood tests there and then, and requested an X-ray. Even before she’d had that done I received the results from the lab – a pattern of abnormalities characteristic of myeloma, the first new case of this relatively uncommon cancer I’ve seen since Len.

I called her back in with her husband, Cliff, another patient of mine whom I’ve known for years. I talked them through the diagnosis and explained the fast-track system that would get her seen in hospital within a fortnight. Although they were shocked to receive the news, I was able to offer hope: treatment for myeloma has been revolutionised in recent years by a slew of new drugs, and most patients can now expect to live for many years with the disease controlled.

At the end of the conversation, Cliff shook my hand and thanked me for getting on to it so swiftly. Privately, I knew I deserved no credit. All doctors have their ghosts – haunting memories of patients for whom things went wrong and ended badly. Len is one of mine, and the similarities between his case and Patricia’s was the reason I moved so decisively and quickly to investigate her pain. We live, we learn, and strive always to do better. 

This article appears in the 10 Aug 2016 issue of the New Statesman, From the Somme to lraq