Anthony, my registrar, took an out-of-hours call from a care home. One of the residents, a 25-year-old named Daryl, was complaining of pain in his nether-regions. The nurse said his testicles looked very swollen. It sounded like a straightforward infection, and Anthony was happy to go on his own. However, as part of the box-ticking necessary to complete his training, he needed his proficiency in male genital examination to be witnessed and signed off. This would be a perfect opportunity, so I came along, too.
The care home is tucked away in a nearby village – I don’t have any patients there of my own, but I’ve sometimes visited out of hours. The front is an Edwardian house, but there’s a sprawling 1950s block at the back, with wide, echoey, linoleum-shod corridors leading to several dozen residents’ rooms. These are people with complex disabilities that render independent living impracticable: paralysis following spinal trauma, severe multiple sclerosis, motor neurone disease. They have precious little autonomy left, and the care staff have made great efforts to cheer up the austere institutional surroundings – each bedroom is chock-full of personal effects and mementoes.
Daryl had been paralysed below the waist in a motorcycle accident. He’d also sustained a brain injury that left him with a mental ability akin to that of a five-year-old. I watched patiently as Anthony tried to gain his consent to be examined. Just like a young child, Daryl was scared of doctors. He kept interrupting Anthony, shaking his hand and asking him repetitious questions – where did he live? What was his favourite colour? – in heartbreakingly transparent attempts to divert the conversation on to safer ground. Eventually, with the help of Linda, a familiar and trusted nurse, Anthony managed to gain Daryl’s confidence, and set about confirming the diagnosis.
It wasn’t an infection. The apparent testicular swelling was because a huge mass in his perineum (the area behind the scrotum) was displacing everything forwards. Neither Anthony nor I had encountered such a thing before. The likeliest explanation was an abscess, but its texture felt ominously tumour-like. Either way, Daryl needed to be admitted to hospital.
Gaining Daryl’s consent to examination was one thing, getting his agreement to go to hospital quite another. Despite the best efforts of Linda and Anthony, he became increasingly stressed – shaking hands, wanting kisses, asking again and again about favourite colours. When a patient lacks capacity, doctors must take “best interest” decisions on their behalf. These are, quite rightly, subject to strict safeguards, and the process of admitting someone without consent can be complex and time-consuming. It’s also far from ideal for the patient.
I noticed a poster on the wall facing Daryl’s bed. It was a blow-up of a photo of him with two young women. I was intrigued to recognise the one on his left: a patient of mine, a lovely, gentle lass called Megan. I asked Daryl about the picture. “Megan is my sister,” he told me. “Amazing,” I said, “I know her really well; she often brings her kids in to see me.” We talked more about her: what a kind person she is, how funny she can be, how much Daryl loves her.
Within a short time, Daryl had visibly relaxed. I told him that, if Megan were there, she would want him to go to hospital to get help. He thought about this for a while, then – much to our relief – nodded and agreed that she would. He held my hand and kissed it. I’d seen enough of his way of connecting with people to be sure of my ground, so I gave his hand a kiss in return.
Fortunately, the tumour, though rare, turned out to be benign. After a short spell in hospital, Daryl returned to the home. How much more distressing the admission would have been for him, had it not been for the poster on his wall, and the chance presence of a doctor who happened to recognise his beloved sibling.
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