A Troublesome Cough

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My experience working as a solo doctor in the Maniototo taught me a deep respect for the people who live in this remote farming community. It also helped me to develop my ideas about the effectiveness of medical treatments. The incident I describe touches on both of these aspects. It is also, at least in retrospect, is one of the funniest things that has happened to me in medical practice.

 

A Troublesome Cough

I have never really believed in medicines. I don’t take them myself and I don’t like prescribing them for others. Even the strongest ones don’t seem to make enough of a difference. These days, such a lack of belief wouldn’t matter. Our profession is presenting itself as more of a science and less of an art. I could say I was practising evidence-based medicine, and talk eloquently about therapeutic indices or numbers needed to treat. But I have to admit that my aversion to pharmaceuticals has always for me been more of a personal preference.

In the small farming town where I first worked as a GP, this was not too much of a problem. I had a busy obstetric practice; there were various injuries to deal with; at one stage I even went away to distant courses and tried to learn acupuncture. It also seemed to be important, in the consultation, in our relatively remote session, rather than prescribe an ineffective remedy, to pick out those patients who needed referral to more specialised help. Some people of course just wanted to talk. Everybody wanted to talk. Some of the conversations I steered in the direction of getting people off regular sleeping pills or stronger painkillers. I prided myself, as a doctor, on avoiding what I saw as the usual unhelpful ritual of treating illness as recurrent antibiotic deficiency.

All of this must have irritated the local pharmacist. I think he made more money from selling fishing gear and souvenirs. In those days, there was a good margin in dispensing pharmaceuticals from prescriptions, but I didn’t write that many. The pharmacy was only open during the week. There was no supermarket and the local general store did not stock, as they would be allowed and expected to do nowadays, a supply of over-the-counter medicines. We kept a range of these medicines on the shelf at the practice – paracetamol and nonsteroidals for pain and fever, opiates for cough, decongestants for runny noses. These were mainly syrups and were dispensed by the nurses. They had a habit of recycling the empty bottles. When women came in for antenatal checks, for example, they would be asked to transfer a urine sample into one of the bottles for testing.

It was not a bad place to work. We had a good team, at the medical centre – a receptionist and three nurses who knew the community. There was also a small hospital that did a good job of caring for the sicker patients. People were generally supportive of each other and of their doctor. For most of the locals, illness when it happened was an inconvenience, something to be tolerated rather than suffered. When things got too bad, people would come to the doctor with the expectation that they would get some treatment that would immediately allow them to return to work.

I was the only doctor in the area. Sometimes this was a strain, especially when I wanted to get away or had something important to do. Personal sickness could also have been a problem. Fortunately, I kept myself relatively well. In other ways, working alone made my work easier. I got to naturally learn a lot about people over time. Also, many people were related to each other; knowing the relationships between them helped me to understand more about their lives, and to have a better handle on what was going on.

The town was in the middle of a large open basin surrounded by distant mountains. In winter, the hills were covered in snow. Animals found shelter where they could from the cold. Farmers would be busy feeding out hay. The evenings and weekends were spent skating and curling. In summer, it was hot and dry. The countryside was bare and brown, apart from the occasional irrigated paddock. On hot afternoons we would head as a family for the shade of a nearby pine forest for walks through the trees and picnics by the lake.

Most people made a living from agriculture. The soil was poor and most of the farms were large. Traditionally, there had been a lot of intermarriage, which seems to have been less about romance and more about preserving the size of the family holding. As one lady memorably explained to me, prior to me examining her husband that afternoon, “you should understand that we choose our husbands by the acre, not by the inch”. As a young doctor, I found it an interesting and useful lesson. Many of the farmers had been in the region for generations. Other patients, mainly shearers and farm workers, were more itinerant. There were a few visitors and tourists. There was a sprinkling of professionals – teachers, nurses, a dentist – but some of these people also had other connections to the area.

I can’t remember the name of the guy with the cough. He was from somewhere in the North Island. He was a typical shearer: hard working; hard drinking; heavy smoking; constantly swearing; didn’t expect too much from his doctor. He had a few days’ work coming up, as it happened, for the husband of one of our nurses, who had a few thousand sheep due to be shorn. My patient wasn’t sure if he would be able to manage his part of the work, as he had been unable to sleep. I carefully examined him and couldn’t hear anything unusual. We talked about his smoking. Against my better judgement, I went into the nurses’ room and got him a bottle of cough suppressant to take at nights.

Cough suppressants, I’m pleased to know now, are turning out to be probably ineffective; you can’t stop someone coughing without a serious risk of also stopping them breathing. Expectorants are even less useful; you can’t produce a physical change in someone’s lungs by putting something into their stomach. More importantly, cough is only a symptom. With my shearer patient, someone I had not seen before and might never see again, I should at least have been thinking about asthma, reflux, cancer, even tuberculosis, and taken a much better history.

It was a busy afternoon. It is always busy when things go wrong. I may have already been running behind time when I saw him. He may not have booked an appointment, and I had had to squeeze him in. I may have been called to the hospital to deliver a baby. I may have gone out to a car crash or some other emergency. I may have been up all night looking after a patient. Or maybe I had just been having one of those long conversations with an earlier patient about the meaning of life and the disadvantages of taking regular tranquilisers, and been running late.

I’m not sure when we noticed my mistake. Probably it was when the nurse who was on that day returned to tidy up and wondered what had happened to the urine sample she had left on the shelf, in its medicine bottle, after testing. Certainly we heard about it a few days later when the other nurse returned from looking after the shearers. Our man had been fine. He had got through his heavy shearing work without incident. He was recommending my excellent care to the other shearers. The syrup I gave him off the shelf had cured his cough. It “tasted like piss” he said, but it was the best cough medicine he had ever had.

– Trevor Lloyd

Trevor was born in rural Southland. He has been a GP and rural hospital doctor in Vanuatu, Central Otago and Northland, and now works at Dunstan Hospital in Clyde. He and his wife, Joan, have three children and live on a small farm near Bannockburn.