Neurosurgeon...and Mum! (6 page)

‘I see that Dr Rivers prescribed you some medication,’ he said. The usual first-line treatment was anticonvulsants, originally developed to treat epilepsy but found to be useful in treating trigeminal neuralgia. ‘Can I just check that you have been taking it regularly?’

She nodded. ‘Dr Rivers told me they didn’t work like painkillers and I had to take them all the time, not just when I felt the pain. He said we’d wait until I was free of the pain for three weeks, and then we’d start to taper it down to the right dose for me. But it just hasn’t worked. And it—’ She broke off, scrabbled in her handbag for a pack of tissues, sneezed into one, and then winced, clearly in pain. ‘This time of year, it’s always bad.’

‘Hay fever definitely doesn’t help,’ Tom said sympathetically. The slightest movement, even a gentle breeze, could cause shooting pains for someone with trigeminal neuralgia; the uncontrollable sneezing that went with hay fever must be agonising. ‘I can do something about the hay fever, but I’ll need to refer you to the neurology department for more help. As medication hasn’t worked, they’re likely to suggest surgery to stop the nerve sending pain messages.’

‘I don’t want to go into hospital.’ Her eyes widened with fear. ‘I know it’s stupid, but my aunt went in for a hip operation last year and she ended up catching that sickness bug. It set her back for months and now we’ve had to put her in a care home because she can’t manage on her own. Before she went in, she was absolutely fine.’

‘I’m sorry your aunt had such a bad experience,’ Tom said gently, ‘but it doesn’t mean that you will. For a start, this is summer, so it’s very unlikely you’ll come into contact with that particular bug. Besides, depending on what kind of surgery they suggest, you might be able to be treated in Outpatients rather than having to stay in for a couple of days.’ Given that Amy was on sabbatical, he knew it wouldn’t be fair of him to ask her to come and have a chat with his patient. Though Mrs Cooper was clearly suffering from her condition and anxious about the possible treatments, and, as her GP, Tom needed to give her as much help and support as he could. So maybe she would at least talk to him about the possible treatments. ‘I might know someone who can give me some more information about exactly what to expect and if there are any other alternatives to surgery,’ he said.

‘Really?’

‘I can’t make any promises, but I’ll have a word with her and see what I can find out. But in the meantime, let’s try a different drug to see if that helps.’ Sometimes antidepressants worked where anticonvulsants didn’t. He sorted out a prescription and talked her through the medication change. ‘We’ll need to reduce the dose of your other prescription gradually—if you stop taking it all at once, you’re likely to get some nasty side effects.’ He wrote down the doses she needed to take for the next week. ‘Come and see me this time next week so I can see how you’re doing, but give me a ring if it gets any worse.’ He flicked into the computer to schedule another appointment, and wrote it down for her. ‘I’ll refer you to the neurology department as well, because we might as well get the ball rolling—I don’t want you to have to wait in pain any longer than you have to.’

‘Thank you, Dr Ashby. I’m so sorry to make a fuss.’

‘You’re not making a fuss at all. This kind of pain’s pretty nasty and you’re doing really well to cope with it as long as you have. I’ll do my best to help you beat this,’ he said softly, and her eyes filled with tears. He reached over to squeeze her hand. ‘Try not to worry.’ And he’d talk to Amy tonight.

About his patient.

And the other problem they needed to sort out.

Tom clearly went straight from his surgery to doing house calls and then the school run, Amy thought, because she didn’t see him again until half-past three. She’d just made herself a mug of coffee when Perdy ran into the kitchen, positively glowing, and gave her a huge hug. ‘Thank you for making cupcakes with me, Amy. Everyone said they were really scrummy! And Alexis has invited me to tea on Wednesday. Can I ask her to tea here on Thursday, please?’

‘Better ask your dad. It’s his decision.’

‘If he says yes, can we make some more cakes?’

So much for not getting involved. Faced with Perdy’s earnest, shy smile and seeing the little girl begin to blossom…how could she say no? Amy smiled back at her. ‘Sure we can.’

She glanced at Tom; his expression was slightly dazed, and then she realised where he was looking.

At her mouth.

Was he remembering that kiss this morning?

The thought of it still made her blood heat and desire coil in her belly. And she really hoped she wasn’t blushing. ‘Tom, what do you think about Amy having her friend over on Thursday? It’s my turn to cook, but I don’t mind if it’s OK with you. As long as I know what Alexis does and doesn’t like to eat, that is.’

‘Sure.’ He still didn’t look particularly with it. ‘Um, can I have a quick word with you a bit later?’

‘No problem,’ she said, trying to sound casual, but her heart rate had speeded up.

She knew exactly what he was going to talk to her about.

That kiss.

In London, maybe she would’ve suggested having a mad affair to get it out of their systems. But here it was different; it was a small community, where people noticed what was going on, and Tom had Perdy to think about. So, however strong the attraction between them, they couldn’t act on it.

She’d just have to keep taking cold showers and reminding herself that she didn’t need the added complication of a love life—she was meant to be using this time to think about her future and what she wanted to do.

A
FTER
Tom had checked that Perdy was settled in bed and kissed her goodnight, he headed downstairs. He could hear a piano playing softly; he followed the sound to discover Amy reading in the conservatory with the stereo on.

‘I like this. What is it?’ he asked.

‘Einaudi. I love the simplicity and elegance.’

‘It reminds me of the sea,’ he said.

She smiled. ‘Not surprising. It’s called “
Le Onde
”—The Waves. The first time I heard it, it reminded me of walking on the beach here on a calm summer evening, with the waves lapping at the shore.’

‘I was just going to get myself a glass of wine. Would you like to join me?’ he asked.

‘Thanks, that’d be nice.’

He could see the wariness on her face and knew it was because he’d asked her to have a quick chat with him. Did she think he was going to bring up this morning? They’d have to talk about it at some point, he knew, but right now he wanted to pick her brains about Mrs Cooper—and he had a feeling that was going to be just as awkward a subject. If you’d had enough of your job, to the point where you were taking an open-ended sabbatical, the last thing
you’d want to do would be to discuss it. So it would be mean of him to ask.

Then again, wouldn’t any doctor in his shoes do the same thing—put their patient’s needs first?

‘Back in a tick,’ he said. He poured two glasses of pinot grigio from the bottle he’d left chilling in the fridge and took them back to the conservatory.

Amy accepted the glass with a smile and took a sip. ‘This is very nice.’

‘My vice,’ Tom said. ‘The occasional glass of decent wine.’

She laughed. ‘Not like in your student days, when you’d drink anything going?’

He pulled a face. ‘Thanks for making me feel middle-aged. I’ll have you know, I’m thirty-four.’

‘Same as me. Yeah, you’re middle-aged,’ she teased.

But despite her bantering tone, she looked strained.

Guilt flooded through Tom and his chest felt tight. Was he just about to make everything worse for her? And yet…maybe it would help her to talk. ‘There was something I wanted to talk to you about. Given that I’m trying to stick to boundaries, this is probably breaking the rules,’ he warned.

Amy was silent for so long that he was about to apologise and offer to leave her be, then she nodded. ‘Go on.’

‘If you had a patient, say,’ he suggested, ‘and it was a tricky case, and you had the chance to talk to someone who wasn’t going to be involved in your patient’s treatment but had much more expertise in that particular area than you did…would you take it?’

She blinked. ‘You want to talk to me about work?’

He nodded. ‘I know I’m asking a lot. But my patient is worried sick and I want to reassure her—properly, I mean, so she doesn’t think I’m just being bright and breezy and fobbing her off. I have no idea whether you know her, but
I’m not going to tell you who she is or give you enough detail to work it out for yourself, so I’m not infringing patient confidentiality. And I could really do with some advice.’

‘Uh-huh.’

He could see the struggle in her face. The doctor in her wanting to help, and yet the woman who was on sabbatical not wanting to talk about anything to do with work. ‘Amy, if you’d rather not, I do understand—it’s not a problem. I don’t want to make you feel uncomfortable.’

‘But you need to help your patient.’ She bit her lip, clearly torn; like him, then, it seemed she’d gone into her profession to help people and make a difference to their lives. ‘I’m not sure how much use I can be but, OK, tell me about her.’

‘She’s in her fifties, and has pain in her right cheek and upper jaw that she describes as feeling like an electric shock,’ he said. ‘The lightest touch makes it hurt and it doesn’t help that she has hay fever—every time she touches her nose or sneezes she’s in pain. She’s had X-rays from the dentist and everything’s fine there.’

‘Sounds like a classic presentation of trigeminal neuralgia,’ Amy said. ‘Though it could be neuritis, especially if she’s a diabetic. Is the pain constant?’

‘She says it’s not—and she’s not diabetic,’ he explained. ‘She’s been on anticonvulsants for the last six weeks and it hasn’t touched the pain; and she tells me she’s taken them properly, not treated them as if they were painkillers, so it isn’t that either. I’m referring her to the neurology department for tests. She’s a bit nervous about hospitals, so I wanted to know what the procedures are so I could run through them with her beforehand and give her an idea of what to expect.’

‘Without actually seeing her myself,’ Amy said, ‘I can’t
say what kind of treatment I’d recommend, but the neurologist will send her for an MRI scan to check if there’s an obvious cause for the pain—a tumour, or pressure on the nerve from a blood vessel—and run some tests to rule out any other diseases.’ She set her glass down and shifted in her chair so that she was sitting cross-legged. ‘Do you know if she’s had shingles?’

‘It wasn’t in her notes,’ Tom said.

‘It’s worth checking, because that’s a possible cause,’ Amy said. ‘Poor woman. I’ve known cases where the pain was brought on by brushing teeth, or even by going outside on a cold night.’

This was something Tom had missed deeply; he and Eloise had studied together as undergraduates, and he’d loved discussing medicine with her. He’d still been able to discuss things with his colleagues, but it wasn’t the same as relaxing after dinner and talking about medicine.

Amy must have enjoyed doing something similar at one point, he guessed, because right at that moment she looked more animated than he’d seen her before, even than when she’d been baking with Perdy.

‘So would we be looking at treating with a rhizotomy or microvascular decompression?’ he asked.

Amy grinned. ‘Did you look it up, or do you know the stuff already?’

‘Looked it up,’ he confessed. ‘I’ve only come across one case of TGN before.’

‘The condition’s not that common. It affects roughly one in a thousand men, and two in a thousand women,’ Amy said.

‘As you told Perdy you were a neurologist, specialising in pain management, I assume you’ve seen a few?’

‘Yes.’ She looked thoughtful. ‘So your patient is nervous about hospitals. You might have trouble persuading her
into microvascular decompression, then, because it’s open surgery under a general anaesthetic.’

‘So she’d be in for a few days afterwards.’

Amy nodded. ‘It can be a good bet because it works for around ninety-five per cent of patients, and ten years later three-quarters of them are still pain-free—though they do get headaches and nausea for a few days after surgery. The operation’s still a pretty big deal.’ She shrugged. ‘Mind you, so’s the pain. If she wants to know exactly what happens, we make a cut behind her ear, open the covering of her brain to expose the trigeminal nerve, and then move all the blood vessels and arteries that are compressing the nerve and making it hurt.’

Tom could’ve listened to Amy all day. She knew what she was talking about, got straight to the point, and didn’t try to dress things up to make herself look important. ‘What other options are there?’

‘A nerve block. We can do that as a day case, and it’s much lower risk than microvascular decompression.’ She pulled a face. ‘But it’s still not going to be a pleasant experience. It’s done under sedation, so she won’t remember much about it afterwards, but the op itself is a bit scary.’

‘How scary?’

‘Basically I’d put a needle through her cheek under local anaesthetic so it’s just inside the skull by the nerve, and then wake her up just enough so she can tell us when the needle touches the nerve in the place where it corresponds to the pain site.’

Tom could imagine explaining that to Mrs Cooper—and he knew she’d hate the idea. ‘And it’s going to hurt.’

‘Briefly, yes. Otherwise I’d work on the wrong part of the nerve and she’d end up still having the pain as well as having to deal with numbness in her face. Once I know
which part of the nerve I’m working on, my patient would be back under sedation so she wouldn’t be aware of what I’m doing. That’s when I’d deaden the nerve—either by injecting glycerol, or using radiofrequency.’

‘You’re right, it’s a scary procedure,’ he admitted. ‘That’d be tough for anyone to deal with, let alone someone who’s terrified of hospitals.’

‘And it might need to be repeated,’ Amy told him. ‘The pain relief lasts from a couple of months through to a couple of years. It leaves the face feeling numb, and some people find that hard to deal with.’

‘And that’s it? Deadening the nerve under sedation, or open surgery?’

‘There’s a third possibility,’ she said. ‘Gamma knife.’

‘Which is?’

‘A radiation beam, based on cobalt,’ she explained. ‘It destroys the nerve, and that sorts the problem.’

‘It’s really not something I’ve come across,’Tom admitted.

She spread her hands. ‘You’re a GP. You can’t be expected to have in-depth knowledge of every single condition and its treatment. That’s why you refer patients to specialists.’ Her tone was matter-of-fact but she was smiling, and the tightness in his chest eased.

‘Would you mind talking me through it?’ he asked.

‘Sure. Again, some of it sounds scarier than it really is. First of all, I’d need to attach a metal frame to the patient’s skull with pins. The frame’s really important because it stops her head moving during the scan and the treatment, and it also means we can be precise about where we’re going to direct the radiation beam. It’s a bit like the difference between someone taking a photograph at a slow shutter speed and getting a blurred picture, or someone using a tripod so the camera doesn’t move and the picture’s really sharp.’

Tom liked the way her mind worked; she’d explained it in a way that a layman could understand really well. The sort of specialist he’d be delighted to refer a patient to. ‘Does the frame hurt?’

‘Yes and no. It feels a bit strange, but it’s not heavy, and we’d put a local anaesthetic under the skin at the places where it’s pinned—it’s no more painful than, say, an injection at the dentist.’

‘What happens next?’

‘We do an MRI scan, so we can plan the treatment. Then the patient has a break while we look at the scans and work out where the radiation’s needed to treat the nerve and how many shots we need to fill that area. We make some final checks then take them into the treatment area. It doesn’t hurt and it isn’t noisy like an MRI scan is; and if the patient wants to listen to music, we can arrange that.

‘What happens after the treatment?’

‘We remove the frame and take the patient to the ward for a rest. They might have a bit of a headache and feel tired afterwards, but that’s usually from tension rather than the result of the radiation. Some people get a little bit of swelling at the pin sites where the frame’s attached, but that goes down in a couple of days.’

‘And it’s safe for anyone?’ Tom asked.

‘It’s painless, you don’t have the risks of an anaesthetic or the risk of haemorrhage or infection that you do from surgery, and the patient can go back to normal activities the next day. So the short answer is yes—but it’s still a fairly new procedure, so we don’t have any long-term results.’

‘If it’s new, do I assume that not many centres offer it yet?’

‘Not yet,’ she admitted.

‘Did you use it?’ he asked, suddenly curious.

She nodded. ‘Last summer, I did a stint with the radiotherapy
team, because it’s kind of cross-discipline. They use it mainly for treating tumours, but it’s also used for movement disorders and for intractable pain, like TGN.’

‘So you treated adults rather than children.’

She took a deep breath. ‘Sorry, Tom, I’d rather not go there.’

He’d pushed her too far. Time to backtrack swiftly. ‘Sorry, my fault. I didn’t mean to press you. And thank you for talking to me—I can put my patient’s mind at ease now.’

‘That’s good.’

‘And I have to admit, I enjoyed talking medicine with you. I’ve missed being able to do that.’ It was more of an admission than he should’ve made, he knew, because Amy looked tense again. ‘Sorry. I guess I’d better leave you in peace.’

She shook her head. ‘I’m not pushing you away. It’s just…’ She sighed. ‘Look, I’m not going to dump my problems on you.’

‘That’s what friends are for,’ Tom said softly. ‘I know we don’t know each other very well yet, but I think we could be friends.’

She gave him a loaded glance. ‘Just friends.’

Yes, he was attracted to her. Very. But he wasn’t going to act on it. It wouldn’t be fair to anyone. And if he agreed with her now…then that would save them having to have a seriously awkward conversation about that kiss. Maybe then they could pretend it hadn’t happened. Retreat into safety. And he could take cold showers to dampen any inappropriate thoughts about how much he’d like to kiss her again. How much he’d like to touch her, feel her touching him. ‘Just friends,’ he confirmed, lifting his glass. ‘Here’s to you and me. And friendship.’

‘You, me and friendship,’ she echoed, lifting her own glass.