Mick came to us about seven o’clock one evening complaining of a lump in his throat. He was probably in his late fifties, scrawny, unshaven and unkempt. Nicotine stains were abundantly evident on his fingers and he displayed a degree of agitation. But he was pleasant and cooperative. The lump, he said, had been present for about a week, was getting a bit bigger every day and was uncomfortable but not painful and did not get bigger or more painful when he ate.
He did not have a fever and denied felling unwell. The lump was quite solid, could be moved about under the skin and was only mildly tender. It was located under the jaw rather than in the throat. I suspected it may be a blocked sub-mandibular salivary duct. The main glands that produce saliva are situated in the face just in front of the ears but there are other, smaller such glands under the jaw. Apart from being underweight there was precious little else to find when I examined him. His liver was not enlarged – which surprised me.
I went around to the staff room where I knew a few nurses were having their evening meal break. I had seen some lemons in a bowl on the table earlier and, fortunately, a couple remained. I took one, cut it into four and took a quarter back to Mick. He didn’t question me when I asked him to suck on the quarter of lemon. The sour, acidic juice caused a grimace and his lump became a little more painful and a little more pronounced. I felt that was sufficient to diagnose a sub-mandibular salivary calculus or stone blocking the duct leading from the gland to the floor of the mouth.
I explained it all to Mick and gave him a request form for an ultrasound of the lump to be done in our x-ray department next morning. I asked him to get it done and return to ED and I would see him again with the report. He was most emphatic that he would do as I asked and be back next morning, “…without fail.” Next day, the morning came and went but Mick did not.
I was disappointed, got his notes out and called his phone number. No answer. No message machine. Damn! Nothing more I could do.
Late one morning, about a week later, Mick’s name appeared on the screen. I immediately put my name against his and got him into the department as soon as I could. I was about to berate him for failing to attend as arranged but the huge swelling under his jaw precluded beration. There was a huge, rock solid, very tender mass under Mick’s jaw and tender glands in the front of his throat below it. I arranged an urgent ultrasound and they managed to squeeze him in about an hour later. The report was disconcerting to say the least. It was most likely an abscess and urgent CT scan was advised. This was done and confirmed the presence of an abscess. There was no evidence of a stone anywhere in the region.
This, suddenly, had become a life threatening situation. Sub-mandibular abscesses are notorious for causing sudden death by obstructing the breathing passages or rupturing to pour pus into the throat. (This condition was once described as Ludwig’s angina but it has nothing to do with heart pain also known as angina.)
I explained my concerns to Mick and advised him that he required urgent surgery. His concept of urgency did not coincide with mine. He explained he could not have surgery for four or five days because he had some marital legal affairs to attend to including a meeting with his lawyer next day. That, in Mick’s opinion, could not be avoided. Try as I might I could not get him to accept the seriousness of his situation.
By this time it was late afternoon and we were very busy. I rang a teaching hospital and explained the situation to the facio-maxillary surgery registrar. He agreed we had an emergency situation and advised we send the patient in immediately and by taxi, not ambulance, because the ambulances were ramped at his hospital. Nothing unusual about that! He would await Mick’s arrival with a theatre on standby. And when I enquired I was informed the ambulances were refusing to take our patients “up the road” anyway because they would become immobilised with a patient on the ramp! Back to Mick; back to square one; but eventually, somehow, he began to grasp the seriousness of his condition. The best compromise arrangement I could get to was that Mick would drive himself home, pick up his tooth brush and toiletries then drive to the teaching hospital.
Mick left and I slept little that night worrying if he had followed the plan, had he survived the trip without harm to himself or to others and was he, I fact, still alive. I had no way of knowing. Next day I rang the teaching hospital but the registrar I had spoken to was not available. Then, other patients, other issues, other priorities pushed thoughts of Mick into deep recesses of my mind to emerge from time to time but to no avail – I could not devote the time to pursuing Mick’s fate.
A week passed then, one morning, there was a hand-written enveloped addressed to me in my pigeon hole mail box. It contained a note from Mick, written in block capitals on blank paper, and reads (verbatim):
“Ken, I always thought I was bullet proof. I am not! If not for your tenacity of making me do what you told me to do I could be dead. They were waiting for me when I got to xxxxxxx. I did not realise how serious it was! And I can not thank you enough for your care and concern. Mick
I reproduce it here not seeking kudos but as a sort of gesture of appreciation. This sort of thing always brings a lump into my throat and sometimes even a tear to my eyes. Mick is a rough diamond but took the trouble to put his thoughts into writing and express his appreciation for my puny efforts. That letter will always occupy its own small space in a file in my desk at home. I hope that when the time comes my family, especially grandchildren, will read it and understand it meant a great deal to me.
But Mick was not finished with me. He re- appeared in the waiting room about a fortnight later. He proudly displayed the healed surgical scar under his jaw and explained he just had to shake my hand and thank me in person. Then he left and I have not seen him since.
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