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 11

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 The
Hands-on Guide
for Junior Doctors

Donald_ffirs.indd i 2/2/2011 8:37:23 PM

Donald_ffirs.indd ii 2/2/2011 8:37:23 PM
 The
Hands-on Guide
for Junior Doctors
Fourth Edition

ANNA DONALD
BA (Sydney), BM, BCh (Oxon), MPP (Harvard)
Late of Bazian Ltd, London

MICHAEL STEIN
MB ChB, BSc (Hons) (UCT), DPhil (Oxon)
Chief Medical Officer, Map of Medicine, London
and Medical Advisor, Hearst Business Media,
Hearst Corporation, New York

CIARAN SCOTT HILL

BSc (Hons) MSc (Clin. Neuro.) MBBS MCSP MRCS MRCP
Speciality Trainee in Neurosurgery, London

A John Wiley & Sons, Ltd., Publication

Donald_ffirs.indd iii 2/2/2011 8:37:23 PM

 This edition first published 2011 © by A Donald, M Stein and C S Hill
Previous editions published 1996, 2002, 2006

Blackwell Publishing was acquired by John Wiley & Sons in February 2007. Blackwell’s publishing program has
been merged with Wiley’s global Scientific, Technical and Medical business to form Wiley-Blackwell.

Registered Office
John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK

Editorial Offices
9600 Garsington Road, Oxford, OX4 2DQ, UK
The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK
111 River Street, Hoboken, NJ 07030-5774, USA

For details of our global editorial offices, for customer services and for information about how to
apply for permission to reuse the copyright material in this book please see our website at
www.wiley.com/wiley-blackwell

The right of the author to be identified as the author of this work has been asserted in accordance with the UK
Copyright, Designs and Patents Act 1988.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted,
in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted
by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.

Designations used by companies to distinguish their products are often claimed as trademarks. All brand names
and product names used in this book are trade names, service marks, trademarks or registered trademarks of
their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This
publication is designed to provide accurate and authoritative information in regard to the subject matter covered.
It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional
advice or other expert assistance is required, the services of a competent professional should be sought.

The contents of this work are intended to further general scientific research, understanding, and discussion only
and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis,
or treatment by physicians for any particular patient. The publisher and the author make no representations or
warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all
warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing
research, equipment modifications, changes in governmental regulations, and the constant flow of information
relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information
provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any
changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult
with a specialist where appropriate. The fact that an organization or Website is referred to in this work as a citation
and/or a potential source of further information does not mean that the author or the publisher endorses the
information the organization or Website may provide or recommendations it may make. Further, readers should
be aware that Internet Websites listed in this work may have changed or disappeared between when this work
was written and when it is read. No warranty may be created or extended by any promotional statements for
this work. Neither the publisher nor the author shall be liable for any damages arising herefrom.

Library of Congress Cataloging-in-Publication Data

Donald, Anna.
The hands-on guide for junior doctors / Anna Donald, Michael Stein, Ciaran Scott Hill. – 4th ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4443-3466-1 (hardcover : alk. paper)
1. Residents (Medicine)–Handbooks, manuals, etc. 2. Medicine–Handbooks, manuals, etc.
I. Stein, Michael. II. Hill, Ciaran. III. Title.
[DNLM: 1. Medical Staff, Hospital–organization & administration–Great Britain–Handbooks.
2. Clinical Competence–Great Britain–Handbooks. 3. Internship and Residency–organization &
administration–Great Britain–Handbooks. 4. Medicine–Great Britain–Handbooks. WX 203]
RA972.D66 2006
610.92–dc22
2010039148
A catalogue record for this book is available from the British Library.

Set in 8/10pt Humanist by SPi Publisher Services, Pondicherry, India

1 2011

Donald_ffirs.indd iv 2/2/2011 8:37:23 PM

 Contents

Introduction xi Discharge summaries (TTO/TTA) 15

How to use this book xii Drug charts 16
Acknowledgements xiii Drug prescriptions 16
Dedication xiii Handovers 16
Abbreviations xiv Referral letters 16
Self-discharge 17
1 Starting up 1 Sick notes 17

Panic? 1
People to help you 1 4 Accident and
Three basic tips 2 emergency 18
Other useful start-up information 2 General 18
Dress 2 Admitting and allocating patients 18
Equipment 2 Keeping track of patients 19
First-day paperwork 3 Medicine 19
Geography 3 Overdose 20
Ward rounds 3 In general 20
Social rounds 4 Treating the patient 20
Night rounds 5 Surgery 23
Discharging patients 6 Medical and surgical assessment
Work environment 6 units (MAUs and SAUs) 24
Bibliography 6 Fast-track patients 24
2 Getting organized or
‘The Folder’ 8 5 Becoming a better
doctor 25
Personal folder and the lists 8
How to make a personal folder 8 Foundation programmes
Keeping track of patients (List 1) 10 (for UK readers) 25
List of things to do (List 2) 10 Assessments 26
Results sheet (List 3) 10 Moving on from the
Data protection and confidentiality 11 Foundation programme 27
Information technology 28
3 Paperwork and electronic The internet 29
medical records 12 Online medical databases 29
Keeping up with the literature 30
Patient notes 12 Evidence-based medicine 30
Accident forms 13 Clinical governance and
Blood forms and requesting bloods 14 paraclinical work 31
Consent 15 Clinical audit 31
Death and cremation certificates 15 Case reports 32

Donald_ftoc.indd v 2/2/2011 8:38:25 PM

 Courses 32 Falls 68
Professionalism 33 Differential diagnoses 69
Communication 33 Fever 70
Consultants and senior Differential diagnosis 70
registrars 34 The immunocompromised
GPs 34 patient with fever 72
Nurses 35 Fits 73
Patients 37 Differential diagnoses 73
Patients’ families 37 Intravenous fluids 75
Confidentiality 38 Upper gastrointestinal bleeds 76
Exceptions to keeping Lower gastrointestinal bleeds 79
confidentiality 39 Glucose 79
Consent 39 Haematuria 80
References 39 Headaches 81
Differential diagnoses and key
6 Cardiac arrests symptoms 82
and crash calls 40 Hypertension 83
Peri-operative hypertension 84
Cardiac arrest calls 40 Hypotension 84
‘Do not resuscitate’ (DNR) orders 42 Differential diagnoses 85
Insomnia 86
7 Common calls 44 Differential diagnoses
and suggested management 86
How to use this section 44 Management with
Considerations for all ward calls 45 benzodiazepines 87
Abdominal pain 46 Itching 87
Differential diagnoses 46 Differential diagnoses (if no
Anaemia 47 visible skin lesions or rash) 87
Arrhythmia 49 Major trauma 88
Calcium 54 Minor trauma 89
Hypercalcaemia 54 The moribund patient 90
Hypocalcaemia 55 Nausea and vomiting 92
Chest pain 56 Differential diagnoses 92
Differential diagnoses 56 Oxygen therapy 93
Confusion 57 Methods of oxygen delivery 93
Differential diagnoses 58 Pulse oximetry 94
Constipation 59 Phlebitis 94
Differential diagnoses 60 Management 94
Diarrhoea 61 Potassium 95
Differential diagnoses 61 Hyperkalaemia 95
Electrocardiograms 62 Hypokalaemia 95
Important ECG abnormalities Rashes and skin lesions 97
to recognize 67 Disease categories 1–10 97
Eye complaints 67 Shortness of breath 98
The acute red eye 67 Differential diagnoses 99
Sudden loss of vision in Diagnosing the important
one or both eyes 68 common conditions
Floaters 68 causing acute SOB 100

vi | Contents

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 The sick patient 100 Writing prescriptions 121
Sodium 101 Controlled drugs 121
Hyponatraemia 101 Verbals 122
Differential diagnoses 101 Giving drugs 122
Transfusions 102 Drug infusions 123
Blood transfusions 102 Intravenous drugs 124
Platelet transfusions 103 Specific drug topics 126
Urine, low output (oliguria/anuria) 104 Antibiotics 126
Basic emergency routine 105 Anticoagulation 126
Obstetrics and gynaecology calls 106 Anti-emetics 128
Talking to the patient 106 Digoxin 128
Gynaecological examination 107 Night sedation 129
Obstetric examination 108 Therapeutic drug levels 129
Being a male 108 Steroids 130
Common gynaecological calls 108 Miscellaneous tips 130
Termination of pregnancy
(TOP) 109 10 Handle with care 131
Alcoholism 131
8 Death and dying 111
Alcohol withdrawal 131
Terminal care 111 Children 132
Communication 111 Depression 133
Breaking bad news 111 Elderly patients 133
Ongoing communication Haemophiliacs 134
with dying patients 112 Taking blood 134
Pain control 114 For theatre 134
Symptom control 114 HIV/AIDS 135
Prescribing for the dying 114 Taking blood 135
Support for the dying and for you 115 HIV testing 135
Death 115 Jehovah’s Witnesses/Christian
What to do when a patient dies 115 Scientists 136
Telling relatives about the Pregnant women 136
patient’s death 116 Sickle cell anaemia 137
Religious practices on death 116 The patient on steroids 137
Post mortems 116 Side effects of steroids 137
Death certificates 117 Managing ill patients
Writing the death certificate 117 on steroids 138
Referring to the coroner Treating common
(Scotland: procurator fiscal) 118 side effects 138
Cremation forms and fees 118 Withdrawing steroid therapy 138
To check for pacemakers 119
Further reading 119 11 Approach to the
medical patient 139
9 Drugs 120
History and examination 141
General 120 Clinical stalemate 141
Prescribing drugs 120 Preparing patients for medical
Drug charts 120 procedures 143

Contents | vii

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 Cardiac catheterization 143 Insertion of central lines 174
Elective DC cardioversion 144 Problems with temporary
Upper gastrointestinal and tunnelled central lines 177
endoscopy 145 Using central lines 177
Colonoscopy 146 Measuring the CVP 178
Flexible sigmoidoscopy 146 Chest drains 179
Liver biopsy 146 Managing a chest drain 179
Pacemaker insertion 147 How to remove a drain 180
Renal biopsy 148 DC cardioversion 181
Specialist referrals and Electrocardiogram 182
investigating the medical case 148 Reading ECGs 183
Cardiology 149 Exercise stress test 183
Gastroenterology 150 Relative contraindications
Haematology 152 (discuss with senior) 183
Neurology 152 The procedure 183
Renal medicine 153 Glucose tolerance test 183
Respiratory medicine 153 Injections 184
Rheumatology 154 Subcutaneous 184
Intramuscular 184
12 Pain 155 Intercostal block 186
Joint aspiration/injection 186
Pain control 155 Aspiration 186
General 155 Injecting joints 187
Specific analgesics 155 Local anaesthesia (for any
Inhaled drugs 155 procedure) 188
Oral drugs 155 Lumbar puncture 188
IM/IV opiates 158 Mantoux test 191
Other 160 Nasogastric tubes 192
Pain control by severity and Peritoneal tap (paracentesis) 192
underlying condition 160 Pleural aspiration 194
Pulsus paradoxus 196
13 Practical procedures 162 Respiratory function tests 196
Spirometry 196
General hints 162 Peak expiratory flow rate 197
Arterial blood gases 163 Sutures 198
Interpreting arterial
blood gases 165 14 Radiology 200
Respiratory disease and arterial
blood gases interpretation 167 Requesting investigations 200
Bladder catheterization 167 Minimizing radiation 201
Men 167 Common concerns about X-rays 202
Women 169 Pregnancy 202
Blood cultures 169 Plain films 202
Venepuncture 169 Chest X-rays before surgery 202
Cannulation (Venflon/Line Skull X-rays 203
insertion) 171 Abdominal films 203
Central lines 174 Contrast studies 204

viii | Contents

Donald_ftoc.indd viii 2/2/2011 8:38:25 PM

 Intravenous urography 204 Follow-up 225
Barium swallow 205 Home visits 225
Barium meal 205
Small bowel enema 205 17 Self-care 227
Barium enema 205
Ultrasound 206 Accommodation 227
Computed tomography 206 Alternative careers 227
General 206 Bleep 228
CT head – some emergency British Medical Association (BMA) 228
indications 206 Car and insurance 229
Arteriography 206 Clothes (laundry/stains) 229
Magnetic resonance imaging 207 Contacting medical colleagues 229
Radioisotope scanning 208 Contract and conditions
of service 230
15 Surgery 209 What you need to
know about your contract 230
Clerking: pre-admission clinic 209 Doctors’ mess 235
Perioperative prescribing 213 Making money for the mess 235
Consent 214 Drug representatives 235
Common or important European Working Time Directive 236
expected side effects Insurance (room contents) 236
after specific surgical Jobs 236
procedures 216 Trust and other non-training
Anaesthetics 216 posts 237
Drawing up theatre lists 217 Curriculum vitae 237
Marking patients for surgery 217 The interview 239
Post-operative care 217 Consultant career prospects 239
Complicated patients 218 Locums 239
Jaundice 218 Meals 240
Diabetes 218 Medical defence 241
Steroid-dependent patients 219 Money 241
Thyroid surgery 220 Income protection if
Pituitary surgery 220 long-term sick or disabled 241
Day surgery 220 Student debt 241
Oro-facio-maxillary surgery 221 Mortgages 242
Surgical protocol clerking sheet 221 Payslip deductions 242
Pensions 242
16 General practice 222 Tax 243
Telephone and online banking 244
What you can and cannot do 222 Needlestick injuries 245
You can: 222 If the patient is known to be
You cannot: 222 HIV-positive 245
Referral letters and note keeping 222 If the patient is known to be
General points 222 hepatitis-positive 246
Public health and health promotion 223 Not coping 246
The hidden agenda and Part-time work (flexible training) 246
health beliefs 224 Representation of junior doctors 247

Contents | ix

Donald_ftoc.indd ix 2/2/2011 8:38:26 PM

 Sleep and on-call rooms 247 Glasgow Coma Scale (GCS) 251
When things go wrong 248 Mental Health Act 251
Bullying and psychological Mini-mental test score 252
stress 248 Notifiable diseases 252
Whistle-blowing 248 Results 253
Haematology 253
Appendices: Useful tests, Biochemistry 253
numbers and other Useful biochemical formulae 254
information 250 Fitness to drive 255

Addresses 250 Index 258

Barthel score 250 Further resources 265

x | Contents

Donald_ftoc.indd x 2/2/2011 8:38:26 PM

 Introduction

Your junior doctor years are guaranteed information not readily available in
to be one of the big experiences of your standard texts that will help you to feel
life. Free at last from rote learning and competent and confident despite sleep-
endless exams, your first job is intensely less nights and low blood sugars. It
practical. The trouble is that the theo- assumes minimal practical know-how.
retical training in medical school does Subjects are listed in alphabetical order
not usually prepare you for the physical within each chapter. A detailed index is
and emotional rigours of hundreds of also provided for rapid reference.
tasks being thrust upon you around the Whatever you do, keep your head
clock. Similarly, medical textbooks rarely up and keep smiling. Hospitals are funny
deal with the practical know-how which places. Lots of people love their first job;
makes all the difference between clumsy we hope you are one of them. Take care
and elegant doctoring. and good luck!
This book is based on the collective A.K.D.
experience of junior doctors who C.S.H.
remember only too well the highs M.L.S.
and lows of their first year. It contains J.T.H.T.

Introduction | xi

Donald_flast.indd xi 2/2/2011 5:55:41 PM

 How to use this book

This book is designed as a user-friendly We want to emphasize that this book

manual. We recommend skimming is not the Oxford Textbook of Medicine, so
through it when you first buy it, and then please don’t expect to find the 337 causes
referring to relevant sections for particu- of tropical swollen legs here!
lar problems that you come across. To keep the book compact and max-
This book provides standard algo- imally relevant to what you need, we
rithms for diagnosis and management have not attempted to replicate the
of clinical problems that worked for us British National Formulary. While we do
and our colleagues, in different settings suggest drugs where relevant, we real-
throughout Britain. Please don’t follow our ized from our own experience that the
instructions slavishly. We realize that every safest and most efficient way to prescribe
firm has its own way of doing things and drugs is to use the BNF in conjunction
that there may be more appropriate algo- with your hospital’s drug formulary.
rithms for specialist wards or unusual situa- Finally, if you discover a better way of
tions. Like a recipe book, feel free to scrawl doing something, please let us know. If
in the margins to make it more usable for we can use your suggestion, you will be
you. We have included some blank pages acknowledged in the next edition of the
at the back for extra notes. book.

xii | How to use this book

Donald_flast.indd xii 2/2/2011 5:55:41 PM

 Acknowledgements

This book is dedicated to Uncle Ivan Fifty per cent of the authors’ royalties
Harris and to Bruce, Janet and Tom for this book are donated to the
Donald, for the support and love that University of Cape Town Medical
made writing this book possible. School.

Dedication

The wonderful Anna Donald died during evidence-based health policy. Anna’s
the preparation of this fourth edition of professional passion was the delivery of
Hands-on Guide for Junior Doctors. For high-quality health care for everyone.
those who never had the privilege of Indeed, in 1998, as a pioneer in evi-
meeting Anna, here is a little bit about an dence-based health care, Anna founded
extraordinary friend and colleague (also Bazian, one of the first companies in the
see her obituary in the BMJ – 4 February world to provide specialist evidence-
2009 – by Richard Smith and Sir Muir based consulting and analysis to support
Gray): the delivery of health care.
Anna had a brilliant and inquisitive In 2007, Anna learned that her
mind, receiving degrees from not one breast cancer, first diagnosed in 2003,
but three top-flight universities: had metastasized. Anna remained
■ University of Sydney: Bachelor of incredibly positive and said this: ‘When
Arts, majoring in history and preclinical you discover you have metastatic cancer
medicine you think you’ve picked a black ball in
■ University of Oxford: Bachelor of the lottery. But I’ve discovered it’s a
Medicine and Surgery degree (Rhodes luminescent ball. I’m becoming the per-
Scholar) son I want to be. I’m not putting it off
■ Harvard University: Master’s degree until I retire’.
in Public Policy Anna died two years later on 1
Anna worked as a doctor and lec- February 2009 having become the
turer in epidemiology and public policy person she wanted to be. And she was
at University College London, and was always a person that everyone who met
founding editor of the British Medical her, loved.
Journal’s Clinical Evidence, the journal For more about Anna Donald, see
of evidence-based health care and her entry in Wikipedia.

Acknowledgements | xiii

Donald_flast.indd xiii 2/2/2011 5:55:42 PM

 Abbreviations
We include a long list of abbreviations to AVCs additional voluntary
aid reading medical notes and for refer- contributions
ence throughout this book. AXR abdominal X-ray (plain)
Ba barium
μg micrograms BBB bundle branch block
−ve negative bd bis die (twice per day)
+ve positive bHCG beta-human chorionic
A&E accident and emergency gonadotrophin
ABC airway, breathing, circulation BMA British Medical Association
ABG arterial blood gases BMJ British Medical Journal
ac ante cibum (before food) BNF British National Formulary
ACE angiotensin-converting BP blood pressure
enzyme bpm beats/minute
ACTH adrenocorticotrophic Ca carcinoma
hormone Ca calcium
ADH antidiuretic hormone CABG coronary artery bypass graft
AF atrial fibrillation CBD common bile duct
AFB acid-fast bacillus CCF congestive cardiac failure
AIDS acquired immunodeficiency CCU coronary care unit
syndrome CEA carcino-embryonic antigen
ALP CFC complement fixation test
(alkphos) alkaline phosphatase CI contraindications
ALS Advanced Life Support CK creatinine kinase
ALT alanine aminotransferase CK-MB creatine kinase cardiac
ANA antinuclear antigen isoenzyme
ANCA antineutrophil cytoplasmic CLL chronic lymphocytic
antigen leukaemia
ANF antinuclear factor CML chronic myeloid leukaemia
APTT activated partial CMV cytomegalovirus
thromboplastin time CNS central nervous system
ARC AIDS-related complex COAD chronic obstructive airways
ARDS adult respiratory distress disease
syndrome COPD Chronic Obstructive
ARF acute renal failure Pulmonary Disease
ASAP as soon as possible CPR cardiopulmonary
ASD atrial septal defect resuscitation
ASOT antistreptolysin O titre CRF chronic renal failure
AST aspartate transaminase CRP C-reactive protein
ATN acute tubular necrosis CSF cerebrospinal fluid
AV atrioventricular CT computed tomography

xiv | Abbreviations

Donald_flast.indd xiv 2/2/2011 5:55:42 PM

 CTG cardiotocography FVC forced vital capacity
CV curriculum vitae Fx family
CVA cerebrovascular accident F Y1 Foundation Year 1
CVP central venous pressure F Y2 Foundation Year 2
CVS cardiovascular system g gram(s)
CXR chest X-ray G&S group and save
D&V diarrhoea and vomiting G6PD glucose-6-phosphate
DDAVP desmopressin dehydrogenase
DIC disseminated intravascular GBM glomerular basement
coagulation membrane
DIP distal interphalangeal GCS Glasgow Coma Scale
DKA diabetic ketoacidosis GFR glomerular filtration rate
dl decilitre(s) GGT gamma-glutamyl transferase
DM diabetes mellitus GH growth hormone
DNR do not resuscitate GI (GIT) gastrointestinal
DOA date of admission GKI glucose, potassium and
DOB date of birth insulin
DOD date of death GMC General Medical Council
DoH Department of Health GN glomerulonephritis
DVLC Driver and Vehicle Licensing GP general practitioner
Centre GT glutamyl transferase
DVT deep venous thrombosis GTN glyceryl trinitrate
DXT radiotherapy GTT glucose tolerance test
EBV Epstein–Barr virus GU genito-urinary
ECG electrocardiogram HB heart block
ECHO echocardiography Hb haemoglobin
EDTA ethylene diamine HBsAg hepatitis B surface antigen
tetra-acetic acid Hct haematocrit
EEG electroencephalogram HDL high density lipoprotein
ELISA enzyme-linked immuno- HDU high dependency unit
sorbent assay Hep hepatitis
EM electron microscope HiB Haemophilus influenzae B
ENT ear, nose and throat vaccine
EPC early pregnancy clinic HIV human immunodeficiency
ERCP endoscopic retrograde virus
cholangiopancreatography HLA human leukocyte antigen
ESR erythrocyte sedimentation HO House Officer
rate HOCM hypertrophic obstructive
FBC full blood count cardiomyopathy
FDP fibrin degradation product HPC history of presenting
FEVl forced expiratory volume in complaint
first second HS heart sounds
FFP fresh frozen plasma HT hypertension
FOB faecal occult blood IBD inflammatory bowel disease
FSH follicle stimulating hormone IBS irritable bowel syndrome

Abbreviations | xv

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 ICP intracranial pressure mane in the morning
ID identification MC&S microscopy, culture and
IDDM insulin-dependent diabetes sensitivity
mellitus MCV mean cell volume
Ig immunoglobulin MDU Medical Defence Union
IHD ischaemic heart disease Mg magnesium
IM intramuscular mg milligrams
INR international normalized MI myocardial infarction
ratio (prothrombin ratio) ml millilitres
IPPV intermittent positive mmHg millimetres of mercury
pressure ventilation MND motor neurone disease
ISDN isosorbide di-nitrate MPS Medical Protection Society
ITP idiopathic thrombocyto- MRI magnetic resonance imaging
penic purpura MRSA methicillin resistant
ITU intensive therapy unit Staphylococcus aureus
iu (IU) international unit MS multiple sclerosis
IUCD intrauterine contraceptive MSK musculoskeletal
device MST morphine sulphate tablets
IV intravenous MSU midstream urine
IVC inferior vena cava N&V nausea and vomiting
IVI intravenous infusion Na sodium
IVU intravenous urography NB nota bene (note well)
JAMA Journal of the American NBM nil by mouth
Medical Association NEJM New England Journal of
JVP jugular venous pressure Medicine
K+ potassium NGT nasogastric tube
KCCT kaolin-cephalin clotting time NIDDM non-insulin dependent
KCl potassium chloride diabetes mellitus
kg kilograms nocte in the evening
kPa kilopascals NR normal range
L left NSAIDs non-steroidal anti-inflamma-
l litres tory drugs
LBBB left bundle branch block O&G obstetrics and gynaecology
LDH lactate dehydrogenase obs observations
LDL low density lipoprotein OCP oral contraceptive pill
LFT liver function test OD overdose
LH luteinizing hormone od once a day
LIF left iliac fossa PaCO2 partial pressure of CO2 in
LMN lower motor neurone arterial blood
LMP last menstrual period PAN polyarteritis nodosa
LOC loss of consciousness Pap Papanicolaou
LP lumbar puncture PaO2 partial pressure of O2 in
LUQ left upper quadrant arterial blood
LV left ventricle PAYE pay as you earn
LVF left ventricular failure PBC primary biliary cirrhosis
LVH left ventricular hypertrophy pc post cibum (after food)

xvi | Abbreviations

Donald_flast.indd xvi 2/2/2011 5:55:42 PM

 PCA patient controlled analgesia RUQ right upper quadrant
PCP Pneumocystis carinii RV right ventricle
pneumonia RVF right ventricular failure
PCR polymerase chain reaction RVH right ventricular
PCV packed cell volume hypertrophy
PDA personal digital assistant Rx treat with
PE pulmonary embolism SAH subarachnoid haemorrhage
PEFR peak expiratory flow rate SBE subacute bacterial
PID pelvic inflammatory disease endocarditis
PIP proximal interphalangeal SC
PM post mortem (sub cut) subcutaneous
PMH past medical history SD standard deviation
PMT premenstrual tension SE side effects
PN percussion note SHO Senior House Officer
PND paroxysmal nocturnal SIADH syndrome of inappropriate
dyspnoea ADH secretion
PO per orum (by mouth) SL sublingual
PPD purified protein derivative SLE systemic lupus
PPF purified plasma fraction erythematosus
PR per rectum SOA swelling of ankles
PRN pro re nata (as required) SOB shortness of breath
pro tem as required, on an ongoing SpR specialist registrar
basis SR slow release
PRV polycythaemia rubra vera SRN state registered nurse
PSA prostate specific antigen SSRV structured small round virus
PTC percutaneous transhepatic stat statim (immediately)
cholangiography STD/STI sexually transmitted
PTH parathyroid hormone disease/infection
PTT prothrombin time SVC superior vena cava
PU peptic ulcer(ation) SVT supraventricular
PV per vaginum tachycardia
qds quarte in die somemdum SXR skull X-ray
(to be taken four times a day) T temperature
qid quarte in die T1/2 biological half life
(four times a day) T3 triiodothyronine
R right T4 thyroxine
RA rheumatoid arthritis (tetraiodothyronine)
RBBB right bundle branch block TB tuberculosis
RBC red blood cell tds ter die somemdum
RCC red cell count (to be taken three times
RF rheumatic fever a day)
Rh rhesus TENS transcutaneous electrical
RIF right iliac fossa nerve stimulation
RS respiratory system TG triglyceride
RTA renal tubular acidosis/road TIA transient ischaemic attack
traffic accident TIBC total iron binding capacity

Abbreviations | xvii

Donald_flast.indd xvii 2/2/2011 5:55:42 PM

 tid ter in die (three times a day) UMN upper motor neurone
TLC tender loving care URT upper respiratory tract
TOP termination of pregnancy US ultrasound
tPA tissue plasminogen activator UTI urinary tract infection
TPN total parenteral nutrition VDRL venereal diseases research
TPR temperature, pulse and laboratory
respiratory rate VF ventricular fibrillation
TRH thyrotrophin releasing VLDL very low density
hormone lipoprotein
TSH thyroid stimulating hormone VMA (also
TTA to take away HMMA) vanillyl-mandelic acid
TTO to take out VQ scan ventilation perfusion scan
TU tuberculin units VSD ventriculo-septal defect
TURP transurethral retrograde VT ventricular tachycardia
prostatectomy WBC white blood cell
TURT transurethral retrograde WCC white cell count
tumourectomy WPW Wolff–Parkinson–White
u (U) units syndrome
U&E urea and electrolytes ZN Ziehl–Nielsen stain
UC ulcerative colitis Zn zinc

xviii | Abbreviations

Donald_flast.indd xviii 2/2/2011 5:55:42 PM

Another random document with
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If a bomb had exploded in their midst it could scarcely have created
a greater mental sensation than those seven quietly uttered words.
There was a low-voiced chorus of exclamation from his astounded
listeners, which he heard unmoved, never raising his eyes from the
cigar-box: then Cummings-Browne’s stern voice,
“Go on. Tell us everything.”
Thomson looked up then, met Cummings-Browne’s eyes full and
steadily, and thenceforth addressed himself to him direct.
“I will, sir—from the beginning. On that morning when the papers
were missing from Sir Robert’s safe I was awake very early—I often
am. At that time I slept in the basement: it is only since that date
and Sir Robert’s illness that I have occupied a room on this floor. I
thought I heard a sound in the library just above. Later I had reason
to believe it was the sliding of the panel that concealed the safe——”
“What time was this?”
“Just after five, sir. I had heard the clock strike. I went out and along
to the foot of the stairs in the dark and then saw there was a light in
the hall. Thinking there might be burglars, I felt in a stand that is
there in the lower hall, took a thick stick, and went softly up the
stairs. Just as I got to the top I saw my lady, in a green dressing-
robe, pass up the stairs, and a moment later the light went out—
there is a control switch on the first floor. I went back to bed,
thinking my lady had been down for a book.
“It was not till the middle of the morning, nearly noon, that Sir
Robert sent for me to the library and told me some papers were
missing. Mr. Carling was there and they were both very upset—very
upset indeed.”
“Did you tell Sir Robert what you had seen?”
“No, sir. I realize now that I ought to have done so, but at the
moment I didn’t like to. Sir Robert told me not to say anything to
anyone, and I did not. I went down and thought it over. I felt sure in
my mind that my lady had the papers, whatever they were. I knew
she was out—she had gone out about ten o’clock—so was her maid,
Mam’selle Périer, who had been given the day out. I wondered if my
lady had gone to Rivercourt Mansions.”
“How do you know she was in the habit of going there?”
“I had known it a long time, sir. I discovered the address almost by
chance, from a letter.”
“Blotting paper?” asked Cummings-Browne dryly.
“Well, yes, sir. My lady was careless once or twice that way, though
it was only the address I could make out. I believe she was always
very careful to post those private letters herself.”
“And you had tracked her to the place?”
“Yes, sir, a good many times—usually at night. I nearly always knew
when she was going; it would be on Mam’selle Périer’s evening out,
or when my lady sent her to a theatre, as she often did.”
“Well, go on.”
“I found out quite a lot one way and another about Mr. Melikoff and
the Russians who used to go there, and the old Italian gentleman. It
wasn’t my business, of course, and I don’t quite know why I did it,
for I had no real grudge against my lady, except that I knew how my
master doted on her, so to speak, and I felt she was not doing the
right thing by him.
“And now I made up my mind all in a moment to go there and see if
I could find out anything. I didn’t ask Sir Robert. I thought I would
risk him missing me, as I’d often done before, and it wasn’t
necessary for me to tell Mr. Jenkins or anyone else. I took the train,
and just got to the corner of the square when, sure enough, I saw
my lady herself cross the road to go into that post office. I knew it
quite well, having been in and out several times when I’d happened
to be in the neighbourhood.
“I followed her sharp, and peeped in. My lady was standing at the
counter, and there was no one else in the shop but the person
behind it, who had her back turned getting a telephone call. I went
straight through—neither of them saw or heard me—passed the
telephone-booth and turned to the right by the foot of some stairs
and the side door. There was another door farther on half open,
leading into a scullery.”
Cummings-Browne nodded. He knew—so did Snell—how accurate
the description was to the last detail.
“I don’t quite know what I meant to do. I think it was to snatch her
bag as she went into the booth and make a run for it. But—I had
this in my pocket.”
He opened the cigar-box, took out an article that looked like the haft
of a small dagger, of some dull metal elaborately chased, and held it
up to view. There was a click, and out of the haft sprang a slender,
vicious-looking little blade, some four inches long. Snell involuntarily
put out his hand as if to seize Thomson’s arm, but the latter, having
exhibited the weapon, pressed the spring again, causing the blade to
disappear, and laid the thing on the table.
“I bought it off a sailor years ago in Constantinople, when I was
there with my master, and he used to go about so reckless by
himself in places that weren’t safe for an English gentleman that
often I followed him, with this as a sort of protection, but I never
had to use it—never did use it but the once!
“I don’t know what came over me all in a moment. When my lady
had gone into the telephone-booth I found I’d got the dagger in my
hand. I opened the door, struck at her, and snatched the bag that
was resting on the little sloping shelf under the instrument. She only
made a little gurgling sound and dropped forward. I shut the door
on her and went through to the scullery and pushed to the door. The
whole thing couldn’t have taken half a minute, and I was just in
time, for I heard someone come along to the stairs and call ‘Jessie!’
There was a wet rag on the scullery table—the place didn’t seem to
be used much for anything but rubbish: there was a heap of waste
paper and boxes in the corner. While I waited I wiped my glove on
the rag and took it off; here they both are. I’ve never cleaned them.”
He took a neatly folded pair of tan gloves out of the cigar-box and
laid them on the table.
“I opened the bag, found the big envelope addressed to Sir Robert
just as Mr. Carling had said, and knew the papers must be inside,
but didn’t try to look at them. I also found this key and this little
box, and put them in my pocket.”
He took out a Yale latchkey and a small ornate powder box of gold
set with jewels, and placed these beside the other articles.
“I saw through the window a taxicab standing before the side door.
There was no one at all in sight, so I listened for a minute—by the
sound there were several people in the shop—then went out at the
side door, put the bag through the cab window, walked away,
slipping the envelope into the post box at the corner. Then I walked
to the station, got a train at once—I had taken a return ticket—and
was back here soon after two. I had only been away just over an
hour, and so far as I know I had never been missed.
“I found my dinner on a tray in my room—I have always had my
meals in my own room—and I sat down and ate it.”
“Ate his dinner! Good heavens!” muttered Lord Warrington. The
others were silent, Austin Starr, an expert stenographer, was taking
down the confession verbatim; the Home Secretary and Cummings-
Browne making occasional notes; Snell maintained his ceaseless
vigilance.
“I had just finished when Sir Robert’s bell rang for me. I went up to
the library and found him and Mr. Snell there. Sir Robert again
questioned me about the papers, and while he was speaking the
news came by telephone that my lady had been murdered, and my
master fell down in a fit.
“That’s about all it’s necessary to tell, I think, though if I might be
permitted to say a few words more—about this key, and something
else——”
“Go on; say all you have to say,” Cummings-Browne responded.
“Thank you, sir. I knew this key wasn’t one of ours—of this house—
and I thought it just possible it might be the key to Mr. Melikoff’s
flat. I knew, too, that my lady had written him a lot of letters first
and last, and that if they should ever be found they might raise a
scandal that would add to Sir Robert’s trouble, and I made up my
mind to try and get hold of these. It was some time before I got the
opportunity—it was a risky thing to do, of course. But the day that
Mr. Carling was committed for trial I managed it. I knew the whole
household was in the police court—I saw them there when I was in
the witness-box in the morning—and in the late afternoon I went to
the flat, and sure enough the key fitted. I had a look round just to
take my bearings, found Mr. Melikoff’s room—there was a photo of
my lady on his writing-table—and found the letters in a drawer of it.
I was just about to go when they all came back; I’d run it a bit too
close! I slipped into a room opposite Mr. Melikoff’s—a bare room,
that looked like a schoolroom with very little in it except a piano and
music-stands—and bolted the door. I thought, and so it turned out,
that it wouldn’t be used at night. Hours and hours I waited there in
the dark and cold before it seemed safe to try and get out.
“At last I ventured, and when I got into the hall, where the light was
on, I saw the drawing-room door was ajar; there was a curtain
inside, so I couldn’t see in.”
“But the door had been closed!” ejaculated Austin Starr.
“I beg your pardon, Mr. Starr, I assure you it was open then, just an
inch or two, and I heard voices inside—your voice, sir, and a lady’s,
and you were talking about Lady Rawson. Dangerous as it was I
couldn’t help listening for a minute; then I turned off the hall light
and slipped off, closing the front door quietly with the key, and got
away all right. Here are the letters.
“One word more, my lord and gentlemen. It was a terrible shock to
me when Mr. Carling was accused, and I never believed they’d find
him guilty, and right up to to-day I hoped he would be reprieved, so
that it mightn’t be necessary for me to own up just yet. If my master
had died I would have owned up at once; but I did hope I should be
able to tend him as long as he needed me—and he needs me more
now than he ever did before.”
For the first time his voice faltered, and he leaned with both hands
on the table, as if for support. Snell half rose, but sat down again as
Thomson recovered himself and resumed:
“It would be very kind if you could keep the truth from Sir Robert,
for a bit anyhow—if you could tell him I’d been taken ill. And Mr.
Carling will be safe—he’ll soon be released now, won’t he, sir?” He
looked at the Home Secretary, and from him to Lord Warrington.
“And you’ll excuse the liberty I took in sending for you all. I wouldn’t
leave nothing to chance, so to speak. And now, Mr. Snell, I’m quite
ready for you, and I’ll go quiet, of course, though I suppose you’ll
want to put on the handcuffs, if you’ve got them with you?”
They all rose, and Thomson, respectful to the last, stepped back and
stood, with Snell close beside him, as if the buzz of low-toned,
agitated conversation among the others did not concern him in the
least.
Austin Starr unceremoniously clutched Lorimer’s arm.
“Say, Mr. Home Secretary, this does it! Roger Carling’s saved? You’ll
put the order for his release through right now?”
“It will have to be ‘the King’s pardon,’ of course, and it will be put
through at the earliest possible moment. Thank God that—that
extraordinary old villain confessed to-night!”
“When will Roger be home?”
“That I cannot say at the moment—possibly to-morrow.”
“I may ’phone right now to his poor young wife?”
“Assuredly; and I will telephone to her myself later.”
Austin glanced round the room. A telephone was there, but
concealed under a tall Sèvres china doll gorgeously arrayed in Louis-
Seize court costume, and he couldn’t see it. Downstairs he dashed,
and seized the instrument in the hall.
“Victoria ten-four-double-three, quick please! That you, Grace?
Austin speaking. Oh, my dear girl, it’s all right! Roger’s saved—
cleared! He’ll be home as soon as ever the Home Secretary can fix
it. Old Thomson’s confessed everything right now. It was he who
murdered Lady Rawson!”
 CHAPTER XXVII
INTO THE LIGHT

At Argeles in the Pyrenées—where already the sheltered valleys

were glorious with spring blossoms, where the snow mountains
shone dazzling under the strong sunshine against the deep blue of
the sky, and the air was exhilarating as champagne—Roger and
Grace Carling finished and prolonged the honeymoon that had been
so tragically interrupted.
They left England as soon as possible after Roger’s release, which
created even more sensation than his trial and condemnation had
done, and here in this idyllic retreat, where they were quite
unknown, these two lovers, who had gone together through the very
valley of the shadow of death, in which all seemed lost, save love,
rejoiced in the sunshine, and in each other, restored as if by a
miracle to life and hope and youth.
Miss Culpepper, at her own desire, remained in charge of the little
flat until they should return. The staunch little woman’s joy at
Roger’s vindication—“vitiation” was her word for it—was very little
affected by the knowledge that Thomson was the criminal; in fact,
she accepted it quite philosophically.
“It’s terrible to think James should have done such a deed, but I
don’t think I am really surprised after all. I saw a great change in
him when he came here on Christmas day, as I think I told you, my
dear. It was something—oh, I don’t know how to describe it in
English—something mécompte—that means sinister, you know—that
I didn’t like at all. I shall never again wear that brooch he gave me!”
The day before they left England Roger had a message from Sir
Robert, begging him to go to see him. He did so and found the old
man still in bed, very frail and broken.
“Can you ever forgive me, Roger?” he asked piteously, clinging to
Roger’s hands and searching his worn face with anxious, haggard
eyes.
“There’s nothing to forgive, sir. Things looked so very black against
me, it was only natural that you should have thought as you did;
and I know how that belief must have added to your grief and
distress.”
“I shall never forgive myself. I ought to have known you better, my
boy. And to think that it should have been Thomson, of all people in
the world—after all these years I have trusted him! Well, well, it’s a
strange and terrible world; but I shall soon be done with it. I shall
never see you again, Roger; but while I do last—I hope it won’t be
many weeks—you’ll never be out of my mind. You’ll come back, with
your dear young wife—ask her to forgive me too—and take up your
career. It will be a brilliant one. I think I’ve been able to ensure that
you will have your chance, and I know how great your abilities are!
Have you seen Warrington yet?”
“Yes, I’ve just come from him. He was kindness itself, and has
offered me an excellent post; I am to take up my duties after Easter.
He told me what you said about me, Sir Robert. It was very good of
you!”
“Good! It was the bare truth, and the very least I could do to make
some amends. I shall make more amends, as you’ll know in time,
Roger. Good-bye, my dear boy, good-bye. In time perhaps—Time is
always the great healer—you will be able to forget as well as to
forgive!”
Roger never saw him again. Next week news of his death reached
them at Argeles, and later tidings that he had bequeathed to them
both ten thousand pounds, and to Roger the greater part of his
superb library.
Towards the end of Easter week, Austin and Winnie unexpectedly
turned up at Argeles, also on their honeymoon, having been quietly
married on the previous Tuesday. “Nobody there but George, and a
dear fat old pew-opener,” Winnie announced gleefully. “And we
decided we must come and have a peep at you two. Can’t we all go
back together next week as far as Paris? Then we’re off to the
States, via Havre.”
“That’s so, but only for a few months. We shall come back to London
in the fall,” said Austin. “Say, Roger, have you seen any New York
papers?”
“Not I, and very few others. We’ve almost forgotten, here, that the
Press exists!”
“I guess so. But you may be interested to hear that Cacciola’s first
concert—Melikoff’s début—was an immense success. Melikoff got
right there—a regular furore; the critics are just about raving over
him and Miss Maddelena—or Mrs. Melikoff as I suppose she is by
this time, for they’re to be married this week. Won’t she mother him
—some; keep a tight hand over him, too, I guess.”
Later, when Austin and he were alone together, Roger asked for
news of Thomson.
“I meant to tell you, though not while Grace was here. You know he
was certified as insane and unable to plead, and so was consigned
to Broadmoor?”
Roger nodded.
“Well, I got permission to go and see him last week. He’s mad, right
enough, but only on the one point, that he seems to have forgotten
everything about the murder, and thinks he is still in Sir Robert’s
service; but on every other point he appears as sane as you or me.
He’s a model prisoner, gives no trouble, and devotes himself to a
fellow-criminal—patient I suppose one might say—whom he believes
to be Sir Robert, an old man who really does resemble him, white
beard and all. He waits on him hand and foot, and they tell me he’s
always miserable when he’s out of his sight! He knew me well
enough and seemed glad to see me.
“‘I take it very kind of you to come, Mr. Starr,’ he said. ‘We’re fairly
comfortable here, though it’s not what Sir Robert has been used to,
of course; but he’s much better—very much better. May I ask if
you’ve seen Mr. Carling lately?’
“I said I hadn’t—that you and Mrs. Carling were abroad, but I should
probably be seeing you soon, and he answered:
“‘If you do, sir, perhaps you’ll give them my best respects and good
wishes. A very nice gentleman is Mr. Carling. My master misses him
greatly and will be glad to see him back.’
“Then he said something that I couldn’t make sense of; perhaps you
can? Would I ask Mrs. Carling to tell little Maria that he did write to
her more than once, and she never answered, so that it really wasn’t
his fault. Do you know what he meant?”
“Yes. Grace told me. Maria’s our little Miss Culpepper. They were in
service together, and more or less in love with each other years ago,
but somehow drifted apart and only met the day old Thomson came
round and insisted on lending five hundred pounds of his savings for
my defence. Oh, of course that’s news to you; I forgot he enjoined
Grace to secrecy.”
“He did that! Well, he’s the most extraordinary case I’ve ever struck!
I wonder whether he really is mad, or only consummately clever?
Anyhow, I’m convinced that when he killed Lady Rawson he did it
with no more animus—and no more compunction—than I’d kill a
’squito!”
Roger made a warning gesture.
“Hush, here are the girls. Don’t speak of him before Grace!”
* * * * * * *
Later from the balcony he and Grace watched these two loyal friends
go down the road to their hotel, and stood there long after the
sound of their footsteps had died away. Roger’s arm was round his
wife, her dear head rested on his shoulder.
It was a beautiful evening, with a full moon flooding the valley and
the towering snow mountains beyond with almost unearthly
radiance, and no sound but the murmur of the river and the light
breeze stirring the young leaves and white “candles” of the
chestnuts.
London and the great busy world—all the tragedies and the shadows
of the past—seemed very far away!

THE END
 *** END OF THE PROJECT GUTENBERG EBOOK THE 'PHONE
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