“Everyone at this party isn’t as young, fit and single as they’re making out. Yep, let’s face it, we’re all falling apart piece by piece. Doesn’t matter if you’re single or in a couple: You. Are. Going. To. Die”
In this scene from the TV comedy Peep Show (S1E3, ‘On the Pull’), Mark is a reluctant guest at a house party full of vibrant young revellers. On visiting the bathroom, he decides to check out the contents of a small cabinet above the sink. Unsurprisingly, he comes across a variety of self-medications for a multitude of ailments and makes the above contemplative statement to himself in the mirror.
We will all self-medicate for a variety of self-limiting conditions throughout our lives, but at some stage the grim reaper will come for us with his scythe usually in the form of a fatal illness, invariably preceded by an initial symptom. We just have no idea when.
Sometimes we are faced with a new symptom which we have to process. Essentially this involves trying to work out whether or not it is something that we should be worried about. In the middle of winter when every man and his dog seem to have some kind of galloping consumption, it doesn’t take a medical degree to work out that symptoms of a sore throat and runny nose most likely represent a self-limiting and more importantly non-fatal cold (ignoring the recent Covid-19 pandemic). Occasionally though on the cricket pitch of life the predictable and easily dealt with fast bowler will deliver a difficult googly to contend with, and in this analogy that is the symptom that creates doubt about our longevity.
I can imagine no greater nightmare than contemplating one’s own potential death. In this latest Halloween instalment, I describe a googly bowled at me earlier this year and the symptom in question was insidious in onset. It all started with a vague intermittent occipital headache. Although I don’t usually suffer from headaches, I initially put it down to a combination of factors. These included: the early starts to avoid the rush hour on my commute; the lack of any annual leave remaining; the long hours of darkness associated with my latitudinally compromised geographical location; an unexpectedly high tax bill from HMRC (a.k.a. Lord Voldemort); working in an overstretched and underfunded NHS (for almost 30 years); the stress of teaching my teenage daughter to drive (and a pervasive dizziness from continuous parallel parking); I could go on… In essence, there were a multitude of reasons for a potential tension headache.
However, as spring approached and the daylight hours improved along with all the other presumed precipitating factors, the headaches persisted and became worse. They remained occipital, but now appeared to radiate to behind my left ear. I still didn’t dwell on it much as they were not particularly severe. I decided to take the rather drastic step to cut out all caffeine. Although not excessive by any means, it was the only modifiable cause I could think of. The headaches persisted and I had put myself through an unnecessary torture. What was more alarming though was that my headaches were becoming worse and occasionally waking me from sleep at night. I could hear vague symptom alarm bells starting to ring. I tried to ignore them.
A temporary alleviation to my stress was in sight though. I had a week booked in the sun in Malaga, Spain for the start of April. Surely that would improve my headaches along with a carafe or three of sangria. “I’m just a-walking in the sunshine, leave your troubles all behind you,” Buster Bloodvessel once sang with Bad Manners, and I imagined that would be me on the beach too. It wasn’t. On the first two nights after arrival in Spain, I awoke with bad headaches in the middle of the night.
By Monday morning the symptom had clearly reached the worrying stage of “OK, have I got a brain tumour?” I war-gamed the potential options. Any pathway through the NHS or private healthcare back in the UK to obtain an MRI brain scan would take some time, with the first limiting step being an appointment with the GP. With either option, a wait of some degree was inevitable, but I was impatient and wanted an answer quickly. On a quick Google search, I discovered that a private MRI scan could be obtained in Malaga for only 200 euros. After a brief exchange of emails, an appointment was surprisingly easily arranged two days later.
My own interpretation of my MRI brain - normal crystalline lenses.
On arrival at the radiology department, I was full of trepidation and an underlying fear that this imminent investigation would unmask an underlying malignancy. It wasn’t helped by the fact that I had only very recently read the famous Neurosurgeon Henry Marsh’s autobiography Do No Harm (2014), describing in detail the many ‘horrendomas’ that he had operated on.
Previous reports from friends and patients had warned me that having an MRI scan could invoke feelings of claustrophobia. However, I found that whilst lying in the machine listening to the deep industrial rhythmic noises, I fell into a trance. The sound was similar to monotonous ‘deep house’ music, except I wasn’t in a night club and there were no euphoric vibes to be had. In the back of my mind, it felt as if the machine was deciding my fate. As the radiographer ushered me out afterwards, I tried to read her expression. Had she seen something on the scan? Was that pity she was showing me? I mulled it over for the rest of the day but eventually realised it was a pointless exercise. I resigned myself to wait for the scans to be reviewed.
When I finally received the written report, it felt like finals exam results day. Pass or fail, my future depended on it. I ripped open the envelope and quickly scanned the document. My eyes alighted on the words “… una normal configuración de la corteza cerebral…” Even without Google translate, I breathed a sigh of relief. However, there was the customary sting in the tail that I have come to expect. As I read further through the report it continued “…aislados focos hiperintensos en la sustancia blanca hemisférica, en probable relación con microangiopática isquémica crónica, no patológico para la edad.” Essentially isolated ischaemic white matter changes related to ageing and a brief nod to my own mortality. “Dammit!” as Jack Bauer would say [1].
The sense of elation which I felt from knowing that my headaches did not represent anything sinister made me reflect on my own role as a doctor. It may surprise you, readers, but on occasion I have questioned whether or not I make much of a difference in my work. For example, the numerous false positive new patient referrals who ultimately have no significant pathology; the stable return patients under annual review requiring no change to their management; and even the macula patients undergoing regular treatment, the majority of which seem to slowly deteriorate over time, masking any evidence of an impact from my care.
What I realised from my own relief, is that as clinicians, what we are able to provide to patients in our clinics is a sense of hope. For the false positive patients that I see who have been referred and have no pathology, they may have had a similar fear to me that there was something seriously wrong with them. Allaying that fear gives them hope again of a future without serious eye disease, vision problems or even a premature death if that was their concern. For the macula patients who are deteriorating over time, reassuring them that they are better off with treatment than without and explaining that we are trying to preserve their vision for as long as possible, gives them hope that they are doing everything they can to keep their vision and remain independent.
This hope that we give to patients in every consultation, whether it is for a future free from pain or blindness or any other incapacity, seems to be more effective than any medicine we can prescribe or surgical intervention we can perform. In his third memoir, And Finally (2023), where Henry Marsh describes his transition from doctor to patient with his diagnosis of advanced prostate cancer, he writes:
“Hope is one of the most precious drugs doctors have at their disposal”
Importantly for our patients though, as Aleksandr Solzhenitsyn stated in his novel Cancer Ward (1967): “Hope is the flame that keeps us going, even in the darkest of times.”
So, you ask, what happened to my headaches? Well, they seemed to settle over the subsequent weeks aided I believe from the therapeutic effect of the negative brain scan and the hope it gave me – that and my daughter passing her driving test. Fortunately, the car insurance fee did not precipitate any subsequent chest pain. I eventually came to a self-diagnosis of occipital neuralgia related to the occupational hazard of a chronically poor posture when examining patients at the slit-lamp. I have since made attempts to rectify this.
Returning to the episode of Peep Show, Mark’s mood improves when he bonds with a kooky teenage goth at the party. So much so that he states, “Yeah well you know… Everything is decaying. So, the way I see it, has there ever been a better time to save up for a very comfortable sofa?” Similarly, back in the real world my spirits are temporarily lifted as once more I have a potential future without a premature death. Until that is, on the cricket pitch of life, another worrying symptom is bowled at me. For the present, though, I live with renewed hope. I will leave the final words to the post-punk band Yard Act and a quote from their song 100% Endurance:
“Grab somebody that you love, grab anyone who needs to hear it, and shake ‘em by the shoulders, scream in their face, death is coming for us all, but not today. Today you’re living it, hey, you’re really feeling it. Give it everything you’ve got knowing that you can’t take it with you, and all you ever needed to exist has always been within you”
References
1. Jack Bauer is a fictional US counter-terrorist federal agent and the main protagonist in the TV series thriller 24, lasting a total of 204 episodes. His escapades saw him dodging explosions and bullets whilst saying his catchphrase, “Dammit,” when things went awry. However, his survival was never really in doubt given his plot armour – the necessity for his character to be protected for the plot to continue. Unfortunately, in the story of my life I don’t have plot armour. I need to speak to the script writers, if only I knew who they were.
