CHAPTER SEVEN: HOOKED ON SEX

(THURSDAY MAY 29^TH )

It seems that laser surgery has a brand new application. Nowadays, according to an interview I heard on the radio during the Thursday drive to work, laser surgery is no longer just a fancy and modern way of fixing your eyesight or getting rid of your skin blemishes. No, there’s much more to it than that.

A certain Dr Michael Pollock of Cincinnati University has been using laser surgery to remove certain parts of the penis. (I was about to say that, when they announced the topic on the radio, it caused me to prick up my ears, but then I decided not to say that. How about that for self-restraint eh?)

Anyway, Dr Pollock has been busily (and meticulously) lasering off bits of the penis, but not on human males – that would probably be illegal, certainly at the moment. He’s been doing that surgery on fruit flies, known formally as Drosophila melanogaster. Now I must admit that I did not know much about the sex life of fruit flies, apart from the fact that there is a lot of it. They are a very fecund species much beloved for their reproductive abilities by geneticists, and much hated by householders - since flies appear in vast numbers from nowhere and hover around the fruit bowl - for exactly the same reason. Anyway, it seems that female fruit flies are not very interested in sex. They like to chill out, presumably just dreaming about decorating the kids’ room, trying new places to have dinner etc. So the males have great difficulty in getting the females interested in copulation, which is, in evolutionary terms, a very bad thing for the species. That, actually, sounds like a pretty useful line which human males could use whenever they’re not doing well in a singles bar. (It suggests an approach such as “Hey darling please come to bed with me, it’ll be good for the species.”)

Anyway, in the Drosophila species, the male apparently just mounts the female without any foreplay, buying flowers, romantic dinner etc. Naturally, the female is not wildly enthusiastic about being mounted, though nobody actually knows the fruit fly language for ‘that’s all you want me for’.

Having started copulation, the male keeps it going for a very long time, sometimes four or even more seconds, while the female just grits her teeth. That is, if fruit flies actually have teeth, which I think they don’t. I guess she just grits her proboscis and thinks of England, or the fruit fly equivalent thereof.

It seems that zoologists have long been puzzled by how it is that the male manages to keep the procreation process going for all those seconds, despite female indifference. So the zoologists studied the anatomy of the male fruit fly, and they found that that the fruit fly penis is equipped with a pair of hooks. Yes, hooks. Not only are these hooks very very very small, but they are also quite widely variable in shape from species to species. It seems that they are almost as varied in design and form among the fruit flies as automobiles are among us humans. One fruit fly species possesses the equivalent of the Chrysler penis-hook while another goes for the Cadillac, presumably with cruise control and air-conditioning. Maybe the designs of the penis-hooks are not only species-specific but also date-specific – perhaps they change the model every January, who knows?

Anyway, Dr Pollock did something amazing: he took some male fruit flies and used laser surgery to cut off their penis-hooks. Painlessly and under anesthetic, of course – this is science, not sadism. Actually it seems that fruit flies are quite easy to anaesthetize. At first I thought that the scientists would have to train other fruit flies as anesthetists and to dash around with very small masks and tiny cylinders of nitrous oxide for the patients (and goodness knows how they would get the consent form signed pre-op). But no: anesthesia in the fruit fly world is a simple matter of carbon dioxide. Apparently, you just pass a whiff of CO₂ into the box and presto the flies all fall asleep while you go ahead with the laser surgery.

But there’s another factor that needs to be taken into consideration too. The fruit fly is very small, and the fruit fly’s penis is even smaller: a LOT smaller actually - despite the bagging that goes on at Drosophila parties. Furthermore the hooks on the very small fruit fly penis are even smaller still. In order to be able to remove said hooks without removing any of the more essential stuff, Dr Pollock had to do the operations while the fly was anesthetized and asleep under the microscope.

So with effective carbon-dioxide anesthesia, excellent lighting, superb microscopy and a steady hand, Dr Pollock removed the hooks. Guess what happened then? Well, I’ll tell you: once the penis-hooks had been removed, copulation was a total failure. The Act would last less than one second, and then the hookless penis basically fell out. A case of premature ejection, perhaps.

One way or another, Dr Pollock had basically invented coitus interruptus for the fruit fly. Even more amazingly, as we heard during the radio interview, it turns out that those hooks are really really tiny. In fact they are only fifteen microns long. Let me give you a sense of scale here. If something is fifteen microns long, it means that it is only as long as long as the diameter of two human red blood cells pressed together (well, two and a bit perhaps). That’s it: that’s the length of the hooks we’re talking about. An appendage that is no longer than the diameter of two red cells makes the difference between good sex and bad sex for the fruit fly.

Doesn't that just prove the old adage: size isn’t everything.

But let’s not stop there. Isn’t there another message in the Drosophila conjugal anatomy? Wouldn’t humans benefit from the equivalent of penis-hooks? Of course, these are politically charged and deep waters. There are many submerged reefs of political incorrectness waiting to destroy the unwary, but, even so, isn’t there a message here about the ties that bind us?

In contemporary society of course we don’t really need devices as obvious and overt as penis-hooks, because we have all kinds of existing devices that bind us together such as joint-mortgages, in-laws, Christmas with the family and other indestructible links between partners. But wouldn’t the evolution of penis-hooks add something to our relationships? Given what Dr Pollock found among the species of Drosophila, human penis-hooks could become a new and promising expression of individuality and creative design. Perhaps they could become a sort of anatomical cod-piece a new fashion statement and a must-have accessory.

Maybe the next year’s sex manuals will be discussing the implication of this research in great detail: at least it’d be something for us males to get our hooks into, wouldn’t it?

CHAPTER SIX: A COUNTER-PHOBIC COFFEE BREAK

(WEDNESDAY MAY 28^TH 11.45)

OK.

So now here I am in Houston, four weeks into my temporary job at St Helen’s, sitting in the cafeteria waiting to tell Dr Beadle about my brilliant clinical acumen, when I suddenly find myself in the cross-hairs of Dr Bernard Hoffbrand, Chief of Medical Staff. This is not good. As I see him – and instantly see that he sees me, too - my anxiety level shoots up to astronomic heights. That’s not just the effect he has on me: he has the same effect on everyone. But speaking for myself, when Dr Hoffbrand is anywhere within a radius of about ten yards, I become so flustered that I know for certain that I am about to fall victim to an outburst of counter-phobic behaviour.

As you read this, you probably don’t know what counter-phobic behaviour is, do you?

That’s all right, neither did I, until a psychiatrist explained it to me.

Counter-phobic behaviour is the phrase that psychiatrists use to describe what happens when people try so hard not to say or do something that they involuntarily end up saying or doing exactly that thing anyway.

In plain language it’s usually termed ‘blurting’. A classic and widely used example (and I heard this from a real practicing psychiatrist, so it must be true) is what happened when a family invited the local church minister for Sunday tea.

This particular minister had an extremely large, long and prominent nose. It was a combination of beak and beacon, apparently. So, before he arrived, the children were all sternly told by their parents not to mention anything to do with noses, snouts, beaks, nozzles, elephants’ trunks, hoses, ant-eaters, or anything that could be construed as having reference to or analogy with noses. Otherwise there would Serious Consequences for the child who broke this rule e.g. the stopping of the weekly allowance, being grounded for the next six years etc etc

So everybody was on their Best Behaviour, and the Minister had just been given his tea in the Best China cup, when the very nervous youngest son proffered the sugar bowl and said “Would you.. erm.. like some.. umm.. sugar in your nose, Minister?”

That, so I was told by the psychiatrist, is an illustration of counter-phobic behaviour at its rolling, destructive best.

Unfortunately, Bernard Hoffbrand is precisely the kind of person who puts everyone he meets into counter-phobic mode. He is one of those people who talks and moves so fast and is so brusque and bossy and almost manic that you are always one step behind and out-of-sync. Without exception, everyone around him becomes flustered and behaves self-consciously – counter-phobically - while trying to keep up.

Furthermore, he is so toxic and so busy firing on all cylinders in all directions that you never get the feeling that you’re having an actual conversation with him. You feel more as if you are a member of his audience at a private performance. Without sounding too psycho-social about this, there is never any dialogue - no interaction, no actual connection. Talking to Bernard about anything that matters to you is like having a philosophical discussion about humanistic philosophy during the Renaissance with a billiard-ball. Only less fun.

Basically, he is what is called ‘a Type AA personality’. As you may recall, the Type A personality is a competitive, multi-tasking, over-achieving, and obsessionally time-constrained person: the kind of man who would flush the toilet before finishing peeing. The Type AA personality is twice as fast as the Type A, and twice as intense. In fact, Bernard Hoffbrand would probably have flushed the toilet before he even got into the washroom, if he could.

To make matters worse, he mistakenly thinks that’s he is a brilliant team-maker and leader, and is an enormously skilled people-person. Apparently he spent a year on a management course and came back with an MBA and a whole bunch of catch-phrases like “Let’s play ball” or “What’s the deal here?” or “Talk to me” or “Let’s get down and dirty on this one” and even a winsome “Tell Uncle Bernard.”

He clearly believes – and is completely mistaken in that belief – that these catch-phrases are a type of charming and winning aw-gee-shucks slogans which will instantly enchant anyone who hears them, and turn them into willing recruits and disciples.

Mind you, it has to be said that his ability to say these things – even though they mis-fire – did undoubtedly facilitate his rise to the top of the medico-political tree at St. Helen’s. Right now, as Chief of Medical Staff, he basically tells everyone else what to do and when to do it: a task made much easier by the fact that he oversees all the departmental budgets.

He is not a tall person, but moves fast and waves his hands a lot, so that people tend to pay less attention to his height. In short, he is quite short. And the fact that he is quite short only seems to give him a stronger urge to appear ultra-dynamic. In other words, I think he has a mild form of the Short Man Syndrome, but even if he doesn't, his general rapid-fire speech and movement is somehow more pronounced because he is a tad vertically challenged.

Apparently this syndrome – of reduced size and above-average energy and speed – is comparable to what goes on with planetary bodies, i.e. stars and suns, in most galaxies as they get older.

It seems that many stars get very big and go through a phase in which they are called Red Giant stars. I’m informed that this will happen to our very own sun (the big star of our own solar system of course), which will expand and get hotter and hotter and eventually scorch all of its planets, including Earth, to cinders before swallowing them up entirely. The good news is that this will not happen for a few billion years, so you don’t need to rush out and buy sun lotion with a Sun Protection Factor of 68,000,000 yet.

Anyway, after stars have been Red Giants for a few billion years, they then start shrinking into White Dwarf stars: a process that involves their becoming smaller, faster and denser as time goes on.

Hoffbrand is very definitely into the White Dwarf star phase, though it is not certain whether he ever was a Red Giant.

Perhaps one of his most off-putting attributes is the way he treats his own opinions and pronouncements (he’s an endocrinologist) as if they were the words of the Gospel - only more widely known, a bit more reliable and more respected.

I was initially taken in by his manner of speaking and I really wondered whether he was some worldwide respected authority in endocrinology. So, after I’d been at St. Helen’s for a week or two, I Googled his name, searching for his academic publications. I expected to find that he had published very few landmark papers in his area, but was astonished to find nearly two hundred major articles listed.

Which is when I realized I had inadvertently typed in ‘Bernard Hoffbrann’ in the Google search box. It turned out that Bernard Hoffbrann is apparently a leading gastroenterologist at Massachusetts General Hospital, and has published very many scholarly articles mostly about diarrhea and serum citrate levels. When I corrected that error, and typed in ‘Bernard Hoffbrand’ I got nothing.

Those problems aside, it is actually his private life that really generated major interest and hostility at St Helen’s.

As I heard it from one or two long-term staff members (well, all of them actually) Bernard’s first wife, Catherine, was a demure dark-eyed paediatric social worker who left him after four years of marriage basically because of Bernard’s other major character flaw: infidelity. In fact, according to local legend, Bernard would pursue and seduce anyone with two X chromosomes (the female genotype): human if possible, but other primate species would be considered (so it was said) if it was a slow night.

His current wife, Jacqueline, is, so I was told, an exceptionally beautiful woman who is more than twenty years younger than him, i.e. in her late thirties, and she works part-time as a personal trainer. Everyone agreed that she is also a very nice person. Too nice for Bernard, it is universally agreed.

In summary then, Bernard Hoffbrand is a big fish (admittedly a short-but-big fish) in a small pond. As has been said of many local dictators and small-town Stalins, or parochial Pol Pots, Nowheresville Napoleons, regional Robespierres etc etc Hoffbrand has an international reputation that extends over a radius of more than two hundred yards. All the way from the out-patients’ entrance at St Helen’s over to the visitors’ car park.

To make things even worse from my vantage point, it was also known that he particularly resented any form of change to the status quo. To be specific, he disliked New People. Among whom of course he would include the newest recruit to the E.R. team i.e. me.

Which is why, as Hoffbrand headed towards my table undoubtedly in order to talk at me for as long as he wanted, I felt my anxiety rise and I prepared for a surge of some type of counter-phobic behaviour to overwhelm me. Which is exactly what happened.

He sat down and did his characteristic opening line:

“Right. Ferguson. So. Fine. What’s going on? Talk to me. Start now.”

I was absolutely determined not to talk about Roger’s case (I wanted to save that for Dr Beadle) but Hoffbrand so unnerved me that the counter-phobic urge hit me like a water-cannon and I heard myself blurt:

“Well actually Dr Hoffbrand, since you ask, I think I’ve just seen a case of a possible phaeochromocytoma.”

Despite the fact that this wasn’t the topic he had decided to talk about, he was clearly a bit interested – particularly since he is an endocrinologist and a phaeo is a tumour that definitely belongs in the endocrine category.

“Right. OK. So what makes you think that? Talk.”

“Well, actually he’s a forty-five year old Australian who got a headache after sex this morning, and the pain got worse when he was peeing. Of course I've ordered a CT which he’s having right now to rule out a sub-arachnoid, but I’m also doing the tests for a phaeo – the urinary VMA and catecholamines.” (These are the correct tests needed to make the diagnosis of a phaeo. As every nerdy medical Sherlock knows.)

Hoffbrand was clearly troubled by something in this story, and narrowed his eyes and said ‘hmmm’ but in a huffy kind of way. I immediately assumed that I’d done something wrong in handling the case, and quickly said that I’d arranged to get the tests done as soon as Roger came back from the CT department.

Somehow even that didn’t make Hoffbrand any more tranquil.

He mused for a moment:

“Australian, you say. About 45. Having sex mid morning. Today.”

Then he seemed to collect his thoughts.

“Yes. Right. That’s it then. Fine. I agree. It could be a phaeo. Possibly. Yes. I like the thinking there, Ferguson. Good job.”

Did he just say ‘good job’? And to me, a New Person? Goodness gracious, would wonders never cease?

But they did cease. At that moment.

Bernard snapped back into his Type AA mode, quickly looked at his watch, “Right. Enough chit-chat. Medical executive committee meeting now. (Looks at wrist-watch.) And I mean now. Nice talking to you. Have to run.” Then he got up and ran.

I finished my coffee and, since there was still no sign of Dr Beadle, I left the cafeteria and went back to the E.R.

When I got back to the E.R., the result of Roger’s CT scan was back: it was completely normal.

For some reason, we medics always call a normal result a ‘negative’ result – which, as many patients have pointed out, gives entirely the wrong impression. Anyway, Roger’s scan was negative and normal, and it showed clearly that he had not had any form of stroke or haemorrhage.

This was actually very good news all round, and it meant that the tests I was now going to organize to see if he had a phaeochromocytoma – the urinary VMA and catecholamines - were going to be even more relevant. Perhaps.

But when I got back to Roger’s cubicle in the E.R. to tell him the glad tidings, to my surprise, Roger had already left the hospital. Probably to have some more sex.

I must say that his abrupt departure was a bit of a downer. The potential proof of my whole brilliant theory had basically just disappeared. It was like being a fledgeling Sherlock Holmes, and then having the murder victim get up from the library floor saying “See? I wasn’t really dead after all”.

The light of my true genius would obviously have to remain under a bushel. For the moment, anyway.

CHAPTER FIVE:

IT SEEMED LIKE A GOOD IDEA AT THE TIME

(FRIDAY JANUARY 3rd)

My temporary job at St. Helen’s may seem to you like a pretty dumb career move on my part – and, in retrospect, perhaps it was – but it did seem like a smart decision at the time.

I don’t think I’m unique or even unusual in this behaviour – i.e. in going along with something that seems to be a brainwave, but which later turns out to be not a rolling wave of brain activity, as much as a tsunami.

I think almost all of us suffer from this syndrome at some time in our lives: we get a sudden flash of inspiration, and only later realize the potential downside by which time it is too late to abort the plan. Just like the man who (it is said) invented a liquid acid so corrosive that it could dissolve any known substance (a brainwave), and then couldn’t find anything to keep it in (a tsunami).

I first became aware of this syndrome – let’s call it the ‘It Seemed Like A Good Idea At The Time’ (ISLAGIATT) syndrome - when I was about twelve years old. I heard a man on the radio tell the story of how he was a collector of antique cars, and how he had spent a long time painstakingly restoring a 1930s Rolls Royce.

After a complete mechanical make-over and test-drive, he had then spent a further six months painting and chroming it, and then decided to finish the final clean-up by vacuum-cleaning the gas tank (brainwave). He said that, as he thrust the nozzle of the humming domestic vacuum-cleaner into the gas tank, he suddenly had a vision of the last drops of gasoline in the tank being sucked up into the vacuum-cleaner’s electric motor, where sparks would cause a huge fire. He was right: they were, they did and there was. Worse still, not only did his car and garage catch fire, but the garage was attached to his house which also burned to the ground (tsunami).

He said that he was going to start all over again, and restore to perfection a vintage Chevrolet, but this time he wouldn’t use a vacuum-cleaner to clean the gas tank. I think he said that this time he was going to use a blow-torch. I guess he’d learned his lesson.

Another example of the same phenomenon cropped up in a report I had read a couple of weeks previously about a brainwave that an Italian couple had had about their wedding. The idea was this: after the actual ceremony, the bride’s bouquet would be immediately transferred to a single-engine light airplane and flown up over the bridesmaids, to be released and then caught by The Next Lucky Girl.

Nice idea, eh? And so much more restful than having to go to all the effort of throwing it over your shoulder.

Sadly, the brainwave had some unexpected consequences. When the pilot released the bouquet, it was immediately sucked back into the engine which stalled instantly, causing the pilot to make an emergency crash-landing in a nearby field. Tsunami.

No-one was hurt but it was not recorded whether The Next Lucky Girl was quick enough to catch the engine as it fell. Though maybe that wouldn’t have been such a good idea after all.

The terrible thing about these moments is that in retrospect you simply can’t remember why it had ever seemed like a great idea.

Why was New Coke ever thought to be an improvement? Why did Decca turn down the Beatles? What was it about Monica Lewinsky that once seemed so alluring? Why did the script for Waterworld ever seem like box-office gold? What qualities did Sarah Palin ever have that the Republicans thought they needed?

Well, my decision to work at St Helen’s was a bit like that.

In my case, the ISLAGIATT decision actually had its beginnings over six months previously. It had started back in England during the previous winter when I was impressed by the example of a doctor colleague of mine, Sidney Thompson, one of those whiz kids who spent most of his time telling everybody how good he was at whizzing.

Sidney and I were both Medical Residents at St Gulliver’s, a teaching hospital in North London. Both of us wanted to be cardiologists (and medical Sherlocks as well, actually) but Sidney was quicker off the mark than me and he realized that, in order to really get ahead of the crowd, an aspiring British physician needs a special degree called a BTA which stands for ‘Been To America”.

Sidney was absolutely certain that if you could get your BTA you would instantly and greatly increase your local value upon your return. And he was (and is) right. He went ahead and applied to be a clinical Fellow in the cardiology training programme at the Texas Heart Institute in Houston, and, guess what, he got in. He bragged about it endlessly and kept saying that all prophets are without honour in their own land, so they should go and spend some time in someone else’s land and then pick up as much honour as they want when they get back. That was the idea, anyway.

So, I followed Sidney’s example: motivated by a complex mixture of altruism (comprising perhaps five percent of my motivation), a desire for academic excellence (three per cent) and major personal envy and jealousy (ninety two percent). Thus motivated, I applied to the Texas Heart Institute in Houston and they were kind enough to say (roughly) ‘any friend of Sidney’s is a friend of ours’. Early that January they offered me a Fellowship in their world-class cardiology training programme for three years starting July 1^st.

I’d already passed the relevant international exams for clinical practice in the U.S. and I had the certificates to prove it, so all I needed to do now was to apply for my Texas medical license. This usually takes about six months to be processed, I was told. So, by the end of January, I was feeling pretty relaxed and On Top Of Things. So far, so good.

Which is when the waste material hit the fan.

My problem was simply that my Texas medical license actually came through in early April – three months earlier than expected – and I was stupid enough to tell the Texas Heart Institute that I was ahead of the game.

Whereupon they immediately e-mailed me back and asked whether I would help them out please, pretty please, by working on their behalf as a temporary E.R. physician in one of the smaller hospitals linked to their Institute and to the Baylor Hospital: a place called St Helen’s, in a part of Houston called the Downtown Core. Which sounded very grand. As indeed a bit of it was. And a lot of it wasn’t. Anyway, hey, it was just for the months of May and June, so how bad could that be? Furthermore, Sidney Thompson e-told me that he was going to be on a two month exchange course away from Houston in Stanford during that time, so even if it I made a dog’s breakfast of my time as a locum, at least Sidney wouldn’t find out about it. (I was wrong on both counts unfortunately – I did, and he did.)

I must say that I was a little bothered by the name of the hospital, St Helen’s. I can’t remember (although I’m sure they told me) whether the erupting volcano was named after the hospital, or whether the hospital was named after the erupting volcano. Either way, both entities represented a slight hazard to human life in the vicinity, as we shall see.

But at that moment, I didn’t let the name put me off. At that instant, I was so elated with the way things seemed to be going, that I immediately said yes, hoping to garner a large number of brownie points with my willingness and enthusiasm.

Now, looking back, I realize that saying yes to the St Helen’s job wasn’t a very wise decision, but, as they say, It Seemed Like A Good Idea At The Time.

CHAPTER FOUR: MAYNARD’S MEANDERINGS

(TUESDAY MAY 1^ST)

Now in order to get a clear picture in your mind of what I was hoping for, you need to know a bit about what Dr Maynard Beadle is really like.

Maynard is actually a very nice guy, as everyone at St Helen’s agrees, but his main problem is that he never finishes his sentences. He isn’t stupid. Far from it. In fact, he’s a really bright man, but he has so many thoughts coming into his mind at one time, that he never finishes explaining the first idea (or instruction) before going on to the second. Listening to him is the aural equivalent of watching three fat men trying to get through a narrow doorway at the same time.

To help you realize what it was like meeting Maynard for the first time, I need to give you a bit of context. I was introduced to him on my first day at St. Helen’s while I was being given the “Grand Introductory Tour” of the E.R. conducted by Maureen The Amazing Receptionist.

Every successful hospital unit has got the equivalent of Maureen The Amazing Receptionist. I’ve now worked in about six hospitals and got to know maybe two dozen units such as the E.R., the O.R. (Operating Room), the I.C.U. (Intensive Care Unit) etc. and every single one of them that works really well has a figure like Maureen at the wheel (whether or not they are truly acknowledged as the helmsman).

So I felt very good and secure as Maureen walked me round the E.R. for my orientation tour. She showed me the layout of the place, and how the patients were brought in from the ambulance bay into cubicles or, for serious cases, into the Rapid Response Area (a.k.a the crash room) and how, when there was a serious case on the way, the ambulance crew could alert the hospital in advance so that red warning lights would flash all over the department. Apparently, when that happens, everyone automatically becomes very military in their behaviour and they all say “Incoming!” loudly and strut around purposefully, getting ready for action.

Maureen also showed me where all the prescriptions and consultation forms etc are kept and then (a very important bit) how to log on to the hospital computer system and use my new I.D. number and password. Then, as the final stop on the tour, she led me over to an imposing bit of the central desk station where Dr Beadle was busy communicating with the computer.

As well as having a major problem with finishing his sentences, Maynard Beadle also has the disconcerting habit of punctuating his monologue with what he clearly hopes will be a reassuring and winning smile. It is neither. Because he never parts his lips when he smiles, and he only smiles with the bottom part of his face, the facial expression which he hopes will be a reassuring grin comes over as an uncontrollable and bizarre tic, like a mild and intermittent case of strychnine poisoning.

Let me try and give you a rough impression of what Maynard said to me when Maureen introduced us to each other on that first day:

Maureen: Dr Beadle, this is Dr Ferguson – he’s filling in for two months instead of Dr Atkins.

Maynard: (looking up from computer work Station): Ah!..Yes… Ferguson. Right….(realizes that this is a first meeting, so stands up and does the half-smile) So, you’re the new….Good. (Puts his hand forward as for a handshake, then changes his mind and claps both hands together in what he clearly thinks is an encouraging and motivating gesture) Right, then…(peculiar half-smile) Well, as Maureen has probably shown you…(points vaguely round the whole E.R.) And for cardiac arrests… So if there’s ever…(looks towards the cardiac resuscitation area) OK? And the flashing red light (indicates the ‘incoming alert’ signal light)… yes. And the bells. The bells… (Sounding a bit like a poetry reading now) Yes, the bells. Right…. And if you ever need…(puts left hand with fingers spread to left ear imitating a phone, then another half-smile) And I really mean any time….So! (Another half-smile) Right! You’d better start by… (waves vaguely towards the cubicles awaiting the patients) But don’t forget to…(mimics writing by signing the air) And also, never….Yes. Right... And one other thing…If it ever happens that… so always make sure you…so they can’t say you didn’t…that’s most important. And also….hmmm…ummm…you….yes… you can take your lunch break at 12.30. OK? Right. (Does the half-smile again, claps his hands together and turns back to computer work-station)

That was what Maynard was like when I first met him, and now four weeks after that introduction, I had, at long last, a really interesting story to tell him. So I looked round the cafeteria contentedly, hoping to sight the benign Dr Beadle.

Instead of which, I saw striding into the room the one person in the hospital that nobody liked: the Chief of Medical Staff, Dr Bernard Hoffbrand.

At that moment I would rather have been anywhere on earth – even the North Pole – than in the cafeteria in St Helen’s Hospital, Houston, within ten yards of Dr Hoffbrand. So perhaps this is a good moment to explain how I actually came to be in Houston in the first place (and not somewhere more welcoming and comfortable such as the North Pole). It’s a rather strange story.

CHAPTER THREE: NO SHILLY-SHALLY SHERLOCK

(SIX YEARS AGO)

The whole problem has to do with the way we doctors are trained.

In medicine, a person’s reputation and career can be made on the basis of a single brilliant diagnosis of a very rare condition that is causing a symptom which is quite common. All of us, from our very first moments in medical school onward, hanker longingly for that moment of brilliant deduction when we prove that, in this particular case, the diagnosis is not the usual and ordinary Condition X but actually a very rare and unexpected form of Condition Y.

It’s rather like the denouement in the final pages of every Sherlock Holmes story. Sherlock always manages to create a chain of inexorable logic, proving at the last moment that “this wasn’t a case of suicide after all, but was actually murder, because only the real killer would have known that the 3.42 train to King’s Cross was running nineteen minutes late that Monday, which gave him just enough time to bludgeon the vicar to death, put the brass candlestick in the victim’s hand and still make it to the railway station in time.”

Well, most doctors, deep inside, want to be like that. We all have a deep desire to reach a brilliant conclusion when the rest of the world (or Scotland Yard if you’re Sherlock Holmes) is baffled.

Let me give you a few examples of the type of Sherlockian brilliance that we physicians all seek.

Here’s one: the fluid that circulates round your brain (the cerebro-spinal fluid or CSF) may, under exceptional circumstances, leak out through your nose and cause a drippy, running sniffle. This very rare condition is called CSF rhinorrhea, and although the patient may seem to be suffering from no more than a common-or-garden runny nose, the rare diagnosis of CSF rhinorrhea can be made by testing the nasal fluid for the presence of protein. That’s because CSF has got a fair amount of protein in it, and ordinary snot hasn’t. So, like many nerdy doctors and wannabe Sherlocks, I’ve had endless samples of routine snot tested for protein and have never – not ever, not once – diagnosed a case of CSF rhinorrhea.

Here’s another one. There’s a very rare cause of kidney failure called angiokeratoma corporis diffusum (known to its friends – of whom it has precisely none – as Fabry disease). This condition also causes a red spotty rash on the skin, sometimes on the buttocks only. So, if you want to be a brilliant medical Sherlock, you carefully examine the buttocks of every patient with kidney troubles, in the hope of one day seeing Fabry’s spotty signature there. I've done that dozens of times and never found a single case.

Also, there’s a really rare cause of the symptom of losing your sense of balance and starting to stagger when you walk, due to problems in the area of the brain called the cerebellum. Very very rarely a type of cerebellar disorder can be caused by a chemical found only in red grapes in Italy. So, only Italian red-grape-treaders ever get this particular occupational hazard. It’s called Machiafarva-Bignami disease. In the hope of making that astonishingly rare diagnosis, I’ve always asked anyone who has difficulty in keeping their balance and walking in a straight line whether they have ever worked as a red-grape-treader in Italy, in the hope that one day a patient would reply ‘funny you should mention that, doc, but yes, that is the job that I did for nigh on twenty years’ and I’d win the gold medal with an open-and-shut case of Machiafarva-Bignami disease. Guess what? It has never happened.

Then, there’s a very rare benign glandular tumour called a phaeochromocytoma – usually referred to by the abbreviation ‘phaeo’ (probably at the suggestion of the Endocrine Tumour Marketing Department).

Anyway this tumour, the phaeo (pronounced faye-oh), can cause the patient to have episodes of high blood pressure, sometimes causing headaches. So if the doctor wants to seem like a real genius, he’ll order a couple of special chemical tests on the urine for any person who has high blood pressure, hoping that, one day, the tests will show that the diagnosis is actually a phaeo. At which the whole world will be stunned by (and deeply envious of) the physician’s utterly Sherlockian brilliance. This would be even more brilliant if the phaeo happens to be located in the wall of the bladder (as happens even more rarely) when it may cause a release of blood-pressure hormones as the bladder contracts down during the act of emptying, thus causing a headache that worsens towards the end of the urination process.

Which is why, when Roger Mulholland came in with a report of high blood pressure and a headache, I did two things. First, I arranged an immediate CT scan of his brain to find out if there had been a small haemorrhage in the brain, either of the type called a sub-arachnoid haemorrhage or possibly a small stroke. That’s the ordinary standard procedure that has to be done anyway in those circumstances. But second, and in true Sherlockian style, I also arranged for a bunch of urine tests to be done, as well as routine blood tests, after the scan, in order to diagnose (brilliantly) a phaeo.

So while Roger was in the imaging department getting his CT scan done, and because there was a temporary lull in the stream of the Walking Wounded, I decided to take a ten-minute coffee break, in order to savour the way I had handled Roger’s case, and to speculate about how good I would look if it turned out that the CT scan was normal and if the tests for a phaeo happened to come back positive.

But what I was REALLY hoping for was a casual meeting in the cafeteria with my boss, the Head of the E.R. Department, Dr Maynard Beadle. I was hoping to bump into him so that I could oh so casually mention the case of Roger Mulholland and show Maynard how brilliant I was. Without really trying to, of course.

CHAPTER TWO: THE WALKING WOUNDED OF THE DOWNTOWN CORE

(WEDNESDAY MAY 28^TH MID MORNING.)

I was still unaccustomed to Houston. I was still surprised by how ludicrously hot it gets, even before six o’clock in the morning, even in May. In England, the summers would often begin in mid-July and end six hours later. When I was a kid, if we had three sunny days in a row, we used to think we must have done something to offend the gods e.g. coveting our neighbour’s ox or something equally serious.

In Houston it was the opposite. It seemed to be sunny and hot most of the time (apart from the occasional flood, so I was told). Which is why nobody really minds getting to work early. That morning I was on the day-time shift which began at six, and even by then the heat was going at full blast. Just crossing the car park was enough to make you sweat as if you were a human colander i.e. as if your body had suddenly been turned into a hundred boiled Brussels’ sprouts which were being drained, through your skin into your shirt, before serving.

Muttering and cursing in true British style, I went through the Emergency entrance into the E.R. (or ‘Emergency Room’ if we’re being formal) where at least it was cool and pleasant. And pretty well empty, as it always is during the midweek mornings at St Helen’s.

Basically, the Walking Wounded of Houston’s Downtown Core district like to rest up most Wednesday mornings, in order to gather their strength for Friday evenings. So, for the first part of that morning in the E.R., my physicianly job was relatively light, and I unhurriedly assessed a small number of people who had nothing really wrong with them, a group known in most E.R.s as ‘The Worried Well’.

Then, just before lunch time, a man strolled in with a note from a nearby walk-in clinic asking us at St Helen’s to assess him because he had suddenly had a severe headache and they had found his blood pressure to be very high.

His name – and it wouldn’t be a name blazoned across the front-page of the Houston Chronicle for at least another month – was Roger Mulholland.

At first sight, Roger was one of those rather good-looking people in their mid-forties who look so confident and comfortable (and well-dressed) that almost everybody gets a little pang of envy when they see them. Well, I did anyway. Casually Roger told me, in his obviously Australian accent, that he’d had a really bad headache which came on very suddenly at the climactic moment when he was having sex about two hours previously.

I must say that my envy of him escalated astronomically right there and then. Mainly because he was a well-dressed, good-looking man who had been having sex at 9.30 on a Wednesday morning. In Houston for goodness’ sake.

Maybe it was because he was Australian and not Texan, but in any event there was a lot to be very jealous of.

He said he’d got out of bed a few minutes later and the headache suddenly got even worse while he was peeing, so he got dressed and, still feeling headachy, went to a nearby walk-in clinic. In the clinic, they’d found his blood pressure was very high. They’d given him a bottle of Advil capsules (or, to give the drug its formal name, ibuprofen) for the headache, and a referral letter to St Helen’s. He’d taken a couple of the Advil, and had then driven over to St Helen’s, by which time his headache had disappeared completely.

This was a fairly unusual and rather impressive story compared to the average chronicle of constipation, or whatever, that we usually hear at St Helen’s, so I showed due medical diligence and asked him a whole slew of questions about the headache. My last question was (because we modern doctors are supposed to get a brief overview of the patient’s social and family support) what I thought was a simple and reasonable one. The conversation went like this:

Me: “Was your wife concerned when you got this pain after sex?”

Patient: “I don’t know.

Me: “Ummm…you don’t know?”

Patient: “She wasn’t there. I suppose she might have been concerned if she’d known about it. So I’d say ‘potentially, yes, she might have been concerned.”

Me: “Ah!”

Then there was a short pause. Followed by a longer pause.

I was thinking – as every good physician should – that there are several things that can cause serious health problems as a result of sex. Furthermore there are some published reports that have shown that health complications are actually more common if the sex in question is adulterous. For the most part, the medical problems are heart-attacks and strokes, except in Chicago where research studies have shown that the frequency of adultery is statistically correlated with the incidence of gunshot wounds.

Still doing my due diligence, I checked Roger over very carefully including taking his blood pressure and doing a full neurological examination to make sure the headache hadn't been caused by a stroke.

There were no problems. In fact his blood pressure was now completely normal, even though the doctor at the walk-in clinic had found it to be very high. However, you need to understand that I – like many keen and nerdy junior doctors - wanted to make a Brilliant Diagnosis Of An Incredibly Rare Condition Causing A Common Symptom. And Roger’s case was the perfect place to try my hand.

Allow me to explain (NOTE TO READERS: If you want to skip the following explanation, please do go ahead and jump over it and we’ll meet again at the bottom of page 10. OK?)

But for those of you who want the full tour, please follow me into the next chapter.

CHAPTER ONE: TOO MUCH SEX CAN KILL YOU

AN ANALYSIS BY DR SEAN FERGUSON

(WEDNESDAY MAY 28^TH 5.45 a.m.)

Apparently, too much sex can kill you, even if you are a healthy teenager. This news came as a major surprise to me because I grew up, as did most English schoolboys, with the belief that in real life there was no such thing as too much sex. It was simply a matter of knowing the threshold for even the slightest harm, and staying well below that limit. Which, for our entire generation, was never a problem. By an extremely wide margin unfortunately.

So I was very surprised when last year, a few weeks after I’d arrived in Houston, I happened to read a report from Nuremberg about the sudden death at the age of nineteen of Mike, a father of twelve children, after a prolonged sex session with three females named Fara, Tiffy and Soda.

This was an important and very troubling item of news, and it raised many questions. For a start, what was the actual cause of Mike’s death? Could it have been the fact that one of his girlfriends was called Soda? Was it the shame?

Or was it the fact that he was nineteen years old and had twelve children and was worried about child support? Or was it the fact that, according to the report, he weighed 630 pounds?

Of course, his body weight in itself could have been a major predisposing factor for all kinds of heart and lung problems, but there is another aspect that has some bearing on Mike’s case: Mike was a sea lion. As it turned out, Mike was the first sea lion ever to die of too much sex.

Yet Mike’s fundamental sea lion-ness raises other questions.

I found myself wondering what it means to be nineteen years old if you are a sea lion. Are sea lion years like dog years, i.e. you just multiply by seven to get the human equivalent? In which case Mike the sea lion would have been the same biological age as a human who was 133 years old.

And if you are 133 years old and a sea lion, is a body weight of 630 pounds a lot? Would that categorize you as slightly overweight? Or might you be in the category of the morbidly obese – meaning that the excess weight posed a serious health problem? I mean if the average senescent sea lion is nicely skinny (for a sea lion) and weighs, let’s say, a mere 510 pounds, then wasn’t anyone at the Nuremberg zoo concerned when Mike first tipped the scales at 540 pounds, and the following month weighed in at 570 pounds and so on? Wasn’t anybody worried? I assume that sea lions don’t have a waist line or anything that makes them self-conscious about getting a bit tubby, but even so, why didn’t somebody do something?

On the other hand, was Mike’s weight really above the average for an elderly sea lion or was it actually below the mean? Does the average father-of-twelve sea lion usually weigh around 900 pounds? In which case, was Mike anorexic? If that was the case, then maybe it was the sex itself that did for him - even if he didn't have a cigarette afterwards. Which in itself would have been quite difficult, what with the water and everything, and trying to hold a ciggy in your flippers.

In the end, I just couldn’t get rid of the mental image of Mike, at the age of 133 and weighing 630 pounds, having sex for three hours and then dying suddenly ‘of nothing serious’.

I asked myself: what is wrong with this picture? And immediately I answered my own question: there is nothing wrong with this picture at all. This is precisely the manner in which many of us would like to meet our maker, pop our clogs, slip off the plate, drop off the twig or however you want to phrase it.

But, I asked in a supplementary question to my own answer to my own question: was it, even so, a fair and equitable use of resources?

Was it good for the planet? For the species? For the visitors at the zoo? For Fara or Tiffy?

All of these major and complex philosophical issues just kept on going round and round in my mind for the whole of my drive to work that morning. It was only while I was parking the car in the hospital parkade that I concluded that yes, dying of sex over the age of 133 and over the weight of 630 pounds was actually a pretty desirable exit. Even if your last partner was called Soda.

I’m only telling this story because it’s an example of how my mind gets so easily and totally clogged up with trivia and oddities. Mental flotsam and jetsam seem to become lodged inside it, just like those tiny grains of sand that get inside an oyster’s shell and gradually get bigger and bigger until eventually each one turns into a colourful plastic imitation of a pearl, and a real bargain at $4. So I’m told by street vendors anyway.

In any case, on that Wednesday morning, four weeks after I’d started my job as an E.R. physician at St Helen’s I found my mind occupied in cogitating the implications of Mike’s sudden death. It was of little reassurance for me to remind myself that (a) I am not 133 years old, I’m only 28 (b) I am not obese and (c) I am not a sea-lion. Oh, and also (d) I am English – although in Houston (as in any part of Texas) that’s rarely a source of reassurance at the best of times.

Anyway, having my mind involuntarily clogged with thoughts of the lethal potential of sex actually turned out - by extraordinary coincidence - to be an entirely appropriate start to a most peculiar day. As was pointed out in court subsequently.