The Rot

My brother​ is not dead. So far, he has lost only the top part of the index finger of his right hand, though he may lose more. He works with chainsaws. Or rather, he used to work with chainsaws. He did not lose the fingertip in a chainsaw accident, though. That would be an improbable scenario, since he is right-handed: this was the trigger finger. In October last year, my brother burned the tips of two fingers on his right hand, picking up something hot through gloves which melted more quickly and easily than he had anticipated. Holding the burned fingers awkwardly, he then caught the index finger in a pop riveter. For those not in the know, a pop riveter is operated by squeezing the handle together, just as you squeeze the handle of a pair of scissors. You have to apply pressure until it suddenly ‘gives’, snapping together and firing the rivet, somewhat like the action of a stapler. A finger caught in the handle when it snaps is subject to a crushing motion, similar to being slammed in a car door. Quite painful. Too painful, my brother decided at the time, to drive with – and there is no other way to get to a hospital from where he lives. Besides, he had had countless minor injuries before, and all had eventually healed of their own accord.

But when in January the finger was still somewhat swollen and painful, he went to Ipswich Hospital’s A&E department. The finger was X-rayed, showed no obvious fracture, and my brother was sent home. More weeks passed, and the finger hadn’t healed. He decided to see his GP. As anyone who has tried that in the last few years knows, this is not an easy business. You either win the early-morning telephone game, in which the phone lines open at 8 a.m. and appointments are booked up by five past, or you call the magic number (111) and hope to get in that way (a more likely outcome is to be promised a return phone call from a doctor). Or you do what the old ladies in the village say they do: you turn up at the surgery and refuse to leave until someone sees you. Otherwise you wait, often for weeks, for an appointment. My brother chose the early-morning game, and eventually got lucky. ‘Have you got private medical insurance?’ the GP asked, ‘Because you could do with an MRI.’ He sent my brother away with some antibiotics.

This process was repeated over many more weeks. My brother or his partner would phone early in the morning, and occasionally secure an appointment with a doctor, who would ask my brother what he did for a living. ‘Oh, I’ve got a chainsaw in my garage,’ the doctor would say, ‘but it’s not working properly.’ My brother would explain to the doctor – a different one each time – what to do about the malfunctioning chainsaw: ‘Have you tried sharpening it?’ Then the doctor would prescribe more antibiotics – eight separate courses, a nurse calculated later, as we sat in another emergency department in another city. This didn’t make much sense, even at the time. After the first two courses, my brother asked for a blood test. Having no medical expertise, he believed that this might not only confirm the presence of an infection – in the absence of which antibiotics would be unnecessary and irresponsible – but also indicate what pathogen, if any, was present, so that it might be possible to identify and prescribe the kind of antibiotics that might actually work on the finger (as the generic ones appeared not to). The test came back normal. More antibiotics were prescribed.

In May, my brother was referred to the hand clinic at Ipswich Hospital. He was told that the finger was not infected, given a little sheath with a splint to wear over it, and prescribed some exercises. After two days of ‘exercising’ the finger, it responded by discharging greenish, foul-smelling pus (just like the smell of the meaty treats he gives to the dog, my brother said). We had invested more hope than we should have in the hand clinic in the weeks while we waited for an appointment there – I suppose because ‘hand clinic’ had a specialist sound to it. But you don’t have to be a medical expert to figure out that non-infected fingers do not exude pus. What we didn’t know is that exercising and manipulating an infected finger is a bad idea. As a rule, I try to resist the urge to research medical matters on the internet: everything is cancer, pregnancy, or both. And doctors tend not to appreciate it. But if we had placed our trust in Dr Google, we might have known earlier about closed-space infections. The soft tissue at the end of each finger is divided into small compartments called ‘closed spaces’. Applying pressure to an infected closed space causes the infection and pus to spread from one compartment to another. The kind of closed-space infection my brother seems to have had is called – much t0 his delight – a ‘felon’ (emphasis added):

FELON: A painful, throbbing infection of the pulp of the fingertip … This closed space is separated into many small compartments, each of which fills with infection and pus. Felon can occur after gardening or other activities that involve sharp objects near the fingertip. Some felons will resolve with soaks and oral antibiotics, but many also need to be drained. If not treated early, destruction of the soft tissues and even bone can occur.

As my brother diligently massaged the infection into new parts of his finger, dispensed more chainsaw maintenance advice to GPs and swallowed the antibiotics they prescribed, the bone in his finger-tip was slowly softening to the consistency of toffee or old chewing gum. The X-ray in January had, apparently, looked normal. By the time a GP noticed that this finger business had been going on too long and referred him to the Surgical Assessment Unit at Ipswich A&E, it was the end of May. My brother called me and I drove him to the hospital. We waited in the triage room, where an elderly man lay on the floor vomiting. Staff occasionally came by to tell him to get back on his chair, that there were no beds free for him. My brother was seen by a smiling, besuited doctor whom he mentally nicknamed ‘Foxtons’, after the estate agents. ‘It’s probably going to have to come off,’ he told my brother, cheerfully. ‘If you’re going to lose a finger, it’s the best one to lose! Did you know that half your grip strength is in the little finger? That’s why the Japanese used to cut off the little fingers of their enemies.’ Foxtons ordered an X-ray to clinch the deal, then accosted my brother as he was looking for a toilet – foiling my plan to accompany him when his name was called. The X-ray confirmed his suspicions that the bone was beyond retrieval. ‘I’ll book you in for 5 June,’ he told my brother. ‘Someone will call you.’

Instead, the next morning, my brother and I and two of my closest friends descended on the A&E department of Addenbrooke’s Hospital in Cambridge. They were there for more than just moral support. There is something about my brother that rubs authority figures up the wrong way, and it’s a family trait; this helps to explain why, out of my dad, brother, nephew and me, none of us made it past the age of 13 at school. We can’t help it. Admittedly, we’re not always trying. But my brother had been on his best behaviour with the doctors. In retrospect, he worries that he was too meek, not assertive enough. But he was also aware of the need to avoid antagonising them, not to seem to be questioning their judgment or commitment to his care. He had also noticed the signs warning that patients who were confrontational or aggressive would be denied care. My brother is not aggressive, but he talks loudly and fast, and can come across as a little manic. He was afraid that assertiveness on his part could be construed as aggression – and he also knew that it would be the doctor, not him, who got to decide who was aggressive and who wasn’t. So, for a day, my brother had an extra sister: a professionally charming, hyper-organised former fundraiser with extensive experience of dealing with the medical profession on her own and others’ behalf. The ‘brother-in-law’ and I fetched coffee.

It was probably overkill. After Ipswich, Addenbrooke’s was like another world. A nurse took a detailed history, examined the finger carefully and took photographs. Another X-ray was taken, and this time, it was shown and explained to us. We saw the place where the infection had taken a bite out of my brother’s distal phalanx (the top bone of the finger); we saw the fuzzy, greyish bone of his index finger alongside the sharper image of his healthy middle-finger bone. A multidisciplinary team was assembled, and a bone biopsy was ordered to determine the pathogen responsible for the infection. The course of treatment would likely be intravenous antibiotics and ‘debridement’, a procedure in which the finger is opened and the bone cleaned and disinfected. Amputation was still a possibility, but now it was a last rather than a first resort. We celebrated with pizza.

As it turned out, it was too late to escape the chop altogether. When the surgeon opened my brother’s finger and removed the fingernail, he had to pull out the dead part of the bone with what looked like long-nose pliers – under local anaesthetic, my brother was able to watch him do it. There was something of a dilemma about how much to leave. In the end, after a second and third opinion, the surgeon decided to leave the ‘borderline’ bone – the bit that was not completely dead but clearly damaged – to see if it could be saved. Doing so would leave my brother with a possibly useable top finger joint, which, given his line of work, seemed important. The risk was – is – that the bone would not recover even with the strong antibiotics they intended to prescribe, and that more would still have to be removed, with the additional risk of further infection with each opening of the wound. But as the surgeon said, ‘once I’ve taken it off, I can’t put it back on again.’ So, over the next few weeks or months, we will be back and forth to Addenbrooke’s. The best-case scenario is that my brother will not lose any more of his finger. If we are unlucky, he will lose at least the top joint. The worst-case scenario is much worse than that. Osteomyelitis – infection of the bone – is notoriously difficult to treat. If it spreads, it could result in the loss of the hand, or arm. If the infection enters the bloodstream – closed-space infections are unusually ‘contained’ – there is a risk of sepsis. The prognosis is less good for people over fifty. My brother is 47.

The term ‘postcode lottery’ is often used to talk about regional discrepancies in healthcare provision. Those discrepancies are real enough, but the term is unhelpful. There is nothing random about the difference in the kind of care you can get in Ipswich as opposed to Cambridge. It has everything to do with the tight complex of class, wealth and education. Like most people in the Ipswich area, my brother, his partner and their son are a low-income family – even lower now. But they also have some significant class advantages. Most significantly, thanks to an inheritance some years ago, they don’t have rent to pay. And through me – largely because of where I went to university – my brother has a network of people in a position to offer information and advice that he would not otherwise be able to access. As he put it, grappling with the health tourist’s brand of survivor guilt: ‘It’s just because I have an educated sister.’ It’s also because I have my own car and can afford the petrol with which to drive him back and forth to Cambridge. Even so, one man’s fingertip has so far caused the lives of three women to be disrupted or put on hold. My brother has a ten-year-old son who has a diagnosis of Asperger’s and, in keeping with family tradition, is already out of the school system. My brother’s partner, a gardener, depends on my brother to look after their son while she is at work. When my brother and I are out doing our health tourism, our mother sometimes steps in. But she works part-time as a carer, and is needed, sometimes three times a day, to give meals to the elderly woman she looks after. My brother asked me: ‘Is this the patriarchy?’

Meanwhile, he has to keep his right hand ‘elevated’ at all times, to reduce the swelling. He can’t work, drive or do much at all. As a result, the muscles in his right arm have begun to waste. The skin there is already palpably looser than the skin of his left arm. Even if things go well, it’s likely that he won’t be able to work with power tools again due to the vibrations. He doesn’t know what he will do instead. He fears being put on universal credit. At least he doesn’t have to fear eviction. As he said to me on one of our days in the hospital: ‘If I was homeless, I’d die of this, wouldn’t I?’ Most likely, he would. As it is, with luck, he won’t. Neither of us believes that things would have been allowed to get to this stage had he been a surgeon, or a classical pianist – someone whose fingers matter – or even a member of the local yacht club. Nonetheless, he keeps trying to work out where he went wrong, at what point between being told there was nothing to worry about and being told that it was too late. I keep telling him he did nothing wrong. He could have gone to the doctor earlier, but there is little reason to think that the outcome would have been very different. It was Alan Milburn, Andrew Lansley and Jeremy Hunt who cut off my brother’s finger. The rot in the NHS started a long time ago and, like the finger, it may already be too late to save it.

Even Addenbrooke’s, by all accounts, is not what it was. The process of opening the NHS to private sector investment began under Tony Blair and has been exploited by successive Conservative governments. If all goes to plan – and any hope that it won’t is fading fast – the collapse will come soon, and mainly American firms will finally get their hands on a chunk of capital that has been tantalisingly out of their reach for so long. As a number of Conservative politicians pointed out on the occasion of Trump’s state visit to the UK – during which he violated the usual rules of etiquette by openly looking forward to buying up a supposedly public health service as part of post-Brexit trade deals – American firms are already in the NHS. It’s just a question of finishing the job.