By August 2005, I was a senior house officer. I was obviously still extremely junior, having only been a doctor for twelve months, but the word ‘senior’ had now been chucked into my job title. This was presumably to give patients a bit of confidence in the twenty-five-year-old about to take a scalpel to their abdomen. It was also the little morale boost I needed to stop myself jumping off the hospital roof when I first saw my new rota. It would be pushing it to call it a promotion, though – it happens automatically after a year as a house officer, much like when you get a star on your McDonald’s badge. Though I suspect Ronald pays better than NHS trusts do.*
I believe it’s technically possible to fail the house officer year and be required to repeat it, but I’ve never actually heard of that happening. By way of context, I count among my friends a house officer who slept with a patient in an on-call room, and another who got distracted and prescribed penicillin instead of paracetamol to a patient with a penicillin allergy. They both sailed through it, so Christ knows what you have to do to actually fail.
Senior house officer is the point at which you decide what to specialize in. If you choose general practice, you remain in hospital for a couple of years, doing things like A&E, general medicine and paediatrics, before moving to the community and being awarded your elbow patches and permanently raised eyebrow. If you choose hospital medicine, there are plenty of different roads you can stumble blindly down. If you fancy yourself as a surgeon, you can sign up to anything from colorectal surgery to cardiothoracics, neurosurgery to orthopaedics. (Orthopaedics is basically reserved for the med school’s rugby team – it’s barely more than sawing and nailing – and I suspect they don’t ‘sign up’ for it so much as dip their hand in ink and provide a palm print.)
There are the various branches of general medicine if you don’t like getting dirt under your nails, such as geriatrics,† cardiology, respiratory or dermatology (which can be a revolting but relatively easy life – you can count the number of times you’d be woken up for a dermatological emergency on the fingers of one scaly, flaky hand). Plus there’s a bunch of specialities that aren’t quite medicine or surgery, like anaesthetics, radiology or obstetrics and gynaecology.
I chose obs and gynae – or ‘brats and twats’ as it was charmingly known at my medical school. I’d done my BSc thesis in the field, so I had a little bit of a head start, so long as people only asked me questions about early neonatal outcome in the children of mothers with antiphospholipid syndrome, which somehow they never did. I liked that in obstetrics you end up with twice the number of patients you started with, which is an unusually good batting average compared to other specialties. (I’m looking at you, geriatrics.) I also remembered being told by one of the registrars during my student placement that he’d chosen obs and gynae because it was easy. ‘Labour ward is literally four things: caesareans, forceps, ventouse and sewing up the mess you’ve made.’‡
I also liked the fact that it was a blend of medicine and surgery – my house officer jobs had proved I shouldn’t really be majoring in either. It would give me a chance to work in infertility clinics and labour wards – what could be a better, more rewarding use of my training than delivering babies and helping couples who couldn’t otherwise have them? Of course, the job would be difficult emotionally when things went wrong – not every stork has a happy landing – but unfortunately the depth of the lows is the price you pay for the height of the highs.
There was also the fact that I’d ruled out every other speciality in quick succession. Too depressing. Too difficult. Too boring. Too revolting. Obs and gynae was the only one that excited me, a career I could genuinely look forward to.
In the event, it took me months to actually make up my mind, commit and apply. I think the reason I hesitated was that I hadn’t made any significant life decisions since I chose which medical school to go to at the age of eighteen – and even that was mostly because I was impressed with the curly fries in the students’ union. Age twenty-five was the first point I actually got to make an active decision in the Choose Your Own Adventure book of my life. I not only had to learn how to make a decision, but also ensure I made the right one.
You decide to pick up the forceps. Turn to the next page.
* My hourly rate as a first year SHO worked out as £6.60. It’s slightly more than McDonald’s till staff get, though significantly less than a shift supervisor.
† Geriatrics is now known as ‘care of the elderly’. Presumably they want it to sound less clinical – less like a place where someone might actually expire, and more like a luxury spa where you can get a mani-pedi while drinking something bright green from a smoothie-maker. Some hospitals have rebranded the speciality ‘care of the older patient’ or ‘care of the older person’ – I would suggest the more appropriate ‘care of the inevitable’.
‡ About a quarter of babies in the UK are delivered by caesarean section. Some are planned (elective) procedures for things like twins, breech babies or previous caesareans. The rest are unplanned (emergency) caesareans for failure to progress in labour, fetal distress and various other crises. If the baby gets stuck or distressed in the final furlong of a vaginal delivery then you perform an ‘instrumental delivery’ using either forceps – metal salad servers – or a ventouse, which is a suction cup attached to a vacuum cleaner. I wish I could say those descriptions were an exaggeration.
Monday, 8 August 2005
First week working on labour ward. Called in by the midwife because patient DH was feeling unwell shortly after delivering a healthy baby. Nobody likes a clever dick, but it didn’t take Columbo, Jessica Fletcher and the entire occupancy of 221b Baker Street to work out the patient was probably ‘feeling unwell’ because of the litres of blood cascading unnoticed out of her vagina. I pressed the emergency buzzer, hoped someone a bit more useful would appear and unconvincingly reassured the patient that everything was going to be fine, while she continued to redecorate my legs with her blood volume.
The senior registrar ran in, performed a PV* and removed a piece of placenta that was causing the issue.† Once it was coaxed out, and the patient had a few units of blood replaced, she was absolutely fine.
I went to the changing rooms to get myself some fresh scrub trousers. It’s the third time in a week my boxers have been soaked in someone else’s blood and I’ve had no option but to chuck them away and continue the shift commando. At £15 a pop for CKs I think I’m running my job at a loss.
This time it had soaked through further than usual and I found myself washing blood off my cock. I’m not sure which is worse: the realization I could have caught HIV or the knowledge that none of my friends would ever believe this is how I got it.
* PV is a per vagina examination. PR is a per rectum examination, so do always clarify when somebody tells you they work in PR.
† If there’s anything left in the uterus after delivery – placenta, amniotic membranes, a Lego Darth Vader – the uterus can’t contract back down properly, and this causes bleeding until the offending item is removed.
Saturday, 27 August 2005
Accosted by a house officer to come and take a look at a post-surgical patient who hasn’t passed urine in the last nine hours.* I tell the house officer that I haven’t passed urine in the last eleven hours because of people like him wasting my time. His face crumples like a crisp packet in a fat kid’s fist and I instantly feel terrible for being mean to him – that was me a few months ago. I slink off to review the patient. The patient indeed has no urine output, but that’s because the tubing from her catheter is trapped under the wheel of her bed and her bladder is the size of a space hopper. I stop feeling terrible.
* Doctors are obsessed with urine output – though not in the kind of way that would make you rethink going on a second date with them – it’s how you tell if the patient has a low blood volume. This is particularly bad after surgery as it could mean they’re bleeding somewhere or that their kidneys are rogered, neither of which are great.
Monday, 19 September 2005
First ventouse delivery. I suddenly feel like an obstetrician – it’s a pretty notional job title until you can, you know, actually extract a baby. My registrar, Lily, talks me through it gently, but I do it all myself and it feels fucking great.
‘Congratulations, you did amazingly well there,’ says Lily.
‘Thank you!’ I reply, then realize she’s actually talking to the mum.
Wednesday, 21 September 2005
Signing a stack of letters to GPs after gynae clinic when Ernie, one of the registrars – arrogant but funny with it – strides in to borrow an examination lamp. He peers over my shoulder. ‘You’re going to get struck off if you write that. Change it to “pus-like” or put a hyphen in there somewhere.’
I look down at the offending phrase. ‘She has a pussy discharge.’*
* At my next hospital, the gynaecology ward was right next to the holding area they put patients in to await transport home, and the sign on the wall said,
GYNAECOLOGY WARD
DISCHARGE LOUNGE
Wednesday, 16 November 2005
I glance at the notes before reviewing an elderly gynae patient on the ward round.
Good news: physio have finally been to see her.
Bad news: the entry reads, ‘Patient too drowsy to assess.’
I pop in. The patient is dead.
Tuesday, 22 November 2005
I’ve assisted registrars and consultants in fifteen caesareans now. On three or four occasions they’ve offered to let me operate while they teach me the steps, but on every occasion I’ve wimped out – I’m now the only SHO of the new cohort not to have lost my virginity, as Ernie is so keen on putting it.
Ernie doesn’t give me any option today – he introduces me to the patient as the surgeon who’s going to deliver her baby. And so I do. Cherry well and truly popped, and with a live audience. I cut through human skin for the first time, open up a uterus for the first time and deliver a baby abdominally for the first time. I’d like to say it was an amazing experience, but I was concentrating far too hard on every step to actually take any of it in.
The caesarean takes a laborious fifty-five minutes* from start to end, and Ernie is remarkably patient with me. As I clean up the wound afterwards, he points out that my incision was on the wonk by about ten degrees. He says to the patient, ‘You’ll notice when you take the dressing off that we had to go in at a bit of an angle,’ which she somehow seems to accept without question – the miracle of motherhood sugaring that particular pill.
Ernie shows me how to write up the operation notes and debriefs me over coffee, stretching his virginity metaphor to within an inch of its life like he’s some kind of sex pervert. Apparently, with practice my technique will improve, it’ll get less bloody and less nerve-wracking, and eventually it’ll all just start feeling like a boring routine. The anaesthetist chips in: ‘I wouldn’t try and make your performance last any longer though.’
* An uncomplicated caesarean should only take twenty to twenty-five minutes, with the wind in the right direction.
Thursday, 22 December 2005
Clinical incident. Bleeped at 2 a.m. and asked to review a gynaecology inpatient who was unconscious. I suggest to the nurse that most people are unconscious at 2 a.m., but she is still extremely keen that I attend urgently. The patient’s GCS* is 14/15, so ‘unconscious’ is rather pushing it, but she is disorientated and clearly hypoglycaemic. A nurse traipses off to find a blood glucose monitor for me from another ward. I’m fairly confident of my diagnosis so decide not to wait, and ask for the bottle of orange squash we keep handy in the clinical fridge for this situation. The patient drinks it but remains drowsy. It’s a bit late at night to be playing House, but I order some other tests and try to work out what else could be going on, as we wait for the machine to arrive. There’s never one to hand, even though they’re required all the time and cost about a tenner in Boots. I was thinking about just buying my own one, but it feels like a slippery slope that ends with keeping an X-ray machine in the back of the car.
The healthcare assistant points out that the empty bottle he was about to throw away is sugar-free orange squash – about as much use in this situation as a book token. I don’t know whether to laugh or cry, but am too tired to do either. A couple of nursing desk Ferrero Rochers later and the patient is feeling much better. The nurse in charge apologizes for an ‘ordering error’ and promises they’ll stock the right kind in future. Two quid says next time I see a hypoglycaemic patient they nip off to the fridge and return holding a butternut squash.
* GCS, or Glasgow Coma Scale, is a measure of conscious level. You get a mark from 1–4 for eye response, 1–5 for verbal response and 1–6 for motor response, giving you a maximum total score of 15 if completely normal and a lowest possible score of 3 if you’re dead. (Or a score of 2 if you’re dead and have no eyes.) For some reason, as if doctors’ lives aren’t hard enough already, patients – particularly in A&E – seem to enjoy pretending that they’re more unconscious than they actually are. In this situation, the textbooks teach applying a painful stimulus to assess if they’re faking it, such as pressing hard on a fingernail or rubbing your knuckles on their breastbone. My preferred method was always to raise one of their arms up and drop it onto their face. If they’re faking, they don’t let their arm plomp onto their face and it miraculously floats off to one side. The downside is if they’re genuinely unconscious and you have to explain yourself to their relatives.
Sunday, 25 December 2005
Good news/Bad news.
Good news: it’s Christmas morning.*
Bad news: I have to work on labour ward.
Worse news: my phone goes off. It’s my registrar. I didn’t set my alarm and now they’re wondering where the hell I am.
Even worse news: I’m asleep in my car. It takes me a while to establish where I am or why.
Good news: it seems I fell asleep after my shift last night and I’m already at work, in the hospital car park.
I leap out of the car, grab a quick shower and then I’m good to go, a mere ten minutes late. I have eight missed calls from H and a text saying ‘Merry Christmas’, full stop, no kiss.
This year we’re doing Christmas on my next day off: the sixth of January. ‘Just think how reduced the crackers will be by then!’ was the only positive I could offer.
* In the NHS, it’s irrelevant that you worked the Christmas before, firstly because that was almost certainly in a different hospital and, secondly, nobody gives the tiniest toss. There’s a pecking order of those least likely to work at Christmas: first up is the doctor who organizes the rota, followed by those with kids. Several rungs further down this hierarchy came me, my childlessness lumbering me with Christmas shifts practically every year. Despite no great paternal yearnings (a feeling exacerbated by working on labour ward), I seriously considered pretending to have children when I started a new job.
Wednesday, 18 January 2006
There are days when you get firm confirmation of your place in the hospital hierarchy, and today’s leveller was a cord prolapse.*
I clamber onto the mattress behind the patient and assume the veterinary position, and the bed gets wheeled through to theatre. Another caesarean is just finishing off, so we wait in the anaesthetic room for the time being. To keep the patient calm and make the situation seem less weird, we have a mundane chat about baby names, nappies and maternity leave.
Her partner had nipped to the cafe downstairs for a few minutes just before things got this . . . intimate, so he missed all the drama. On his return, the midwife quickly brings him up to speed and gets him changed into scrubs so he can come to theatre for the caesarean. She leads him into the anaesthetic room, where I’m kneeling, the vulva of the mother of his child halfway up my forearm. ‘Jesus Christ!’ he says, in a heavy Glasgow accent. The midwife remonstrates that she’d warned him I’d be holding the cord out of the way. ‘You did,’ he says, his eyes like dinner plates. ‘You didn’t say he’d be wearing her like Sooty though.’
* Cord prolapse means that a loop or two of umbilical cord comes out through the vagina during labour, and unless this is right at the point of delivery, it means a very urgent caesarean. Fair enough that the cord got a little caught up in the moment and couldn’t wait to make an appearance, like a firework exploding on the fourth of November, but if it gets cold it goes into spasm, meaning there’ll be no blood going to baby. So, it needs to be popped back into the vagina, and to keep pressure off the cord, the mother has to go up on all fours, resting on her knees and elbows, with the doctor standing behind until the moment she gets laid on her back for the caesarean. The doctor wears a very long glove that goes right up to the shoulder and is revoltingly called ‘The Gauntlet’.
Tuesday, 24 January 2006
God has had the good sense to stay the hell away from my job, aside from a few ‘Holy fuck’s and the odd ‘Jesus!’. Today I meet MM, a Jehovah’s Witness, to consent her for an open myomectomy.* It’s a bloody type of operation, and we should have four units of crossmatched blood in the theatre fridge on standby.
The snag is, of course, that Jehovah’s Witnesses refuse any blood transfusions because of their (fucking stupid) belief that blood contains the soul, and you shouldn’t put someone else’s soul into you. Nonetheless, it’s a free country – so we respect everyone’s (fucking stupid) values and wishes.
MM is bright, charming and erudite, and we have a very interesting discussion. She agrees to have cell salvage† performed during the operation and I give her the specific consent form for refusing blood transfusion, even if needed to save her life. A small possibility but a real one, even with cell salvage – numerous Jehovah’s Witnesses have died because they declined blood products. She signs, though admits part of the reason is that her family would never speak to her again if she received blood. (Even more of an incentive to have a transfusion if you ask me.)
Mr Flitwick, my consultant, tells me that in his sepia tinted, gung-ho version of ‘the good old days’ they’d just ignore the form and plough ahead with a blood transfusion regardless, if needed – the patient would never find out as they’d be under anaesthetic. Happily, today’s operation is gloriously uneventful and the cell salvage machine stays in the corner of the room. I review her back on the ward in the evening and on leafing through her notes I see that her birthday is in two days’ time and she’ll most likely still be in hospital. I commiserate, despite the fact that I, too, will very likely be in a hospital for every single one of my birthdays until I’m too weak to blow out the candles, but she tells me that Jehovah’s Witnesses don’t celebrate birthdays or even receive presents. This is even more fucked-up than the whole blood thing.
* A myomectomy is the removal of fibroids – benign swirls of growth in the muscle of the uterus that you remove using what is essentially a corkscrew.
† Cell salvage involves hoovering up any blood that’s lost during the operation, rather than swabbing it away, then running it through a machine that filters out any impurities (water used during the procedure, surgeon’s sweat, bits of paint that have flaked off the ceiling). Should there be any need for a transfusion, the patient’s own blood can be returned to them – and some Witnesses are happy this is in accordance with their teachings, as the blood stays within a closed circuit and isn’t thought to have truly left the body. I know.
Thursday, 26 January 2006
Moral maze. On the ward round, Ernie is talking to a very well-spoken woman in her thirties – basically a younger, posher version of the Queen. She’s now ready to go home, after an emergency admission a few days ago with ovarian torsion.* He books her in for review in outpatients in six weeks and tells her not to drive for three weeks. ‘Oh, for heaven’s sake!’ she says to Ernie. ‘The bloody thing’s in the car park here. Why don’t you just drive it until I see you in clinic?’ Ernie is about to say no, that’s insane, until she complicates matters by pulling a set of Bentley keys from her handbag. Anyway, Ernie currently drives a Bentley Continental GT.
* Ovarian torsion is where the ovary twists round on itself and cuts off its blood supply – if not operated on very quickly, it goes black and dies. And if not operated on at all, the entire patient becomes septic, then goes black and dies.
Friday, 27 January 2006
I’ve been visiting Baby L on SCBU* for three months now – it’s become part of my routine before I head home, and it’s nice to see a familiar face, even if it’s through the glass of an incubator wall.† His mum was admitted on my second Saturday in the job, twenty-six weeks into her first pregnancy, with a blistering headache that it quickly transpired was severe early onset pre-eclampsia.‡ She was stabilized and we delivered Baby L on the Sunday; I assisted the consultant in the section. Mum ended up spending a few days in intensive care – so we definitely couldn’t have waited any longer before delivering – and baby came out a tiny scrap of a thing, weighing in at just over a jar of jam.
Neonatologists make obstetricians look like orthopaedic surgeons – they’re so academic, so meticulous – defying God and nature to make these babies pull through. As recently as 1970, this baby would have had chances of survival under 10 per cent, but today the odds are over 90 per cent. After twelve weeks of neonatal magic he’s gone from a transparent-skinned shrew attached to a dozen tubes and wires to a proper screaming, vomiting, sleeping little baby, and he’s getting discharged home this afternoon.
I should be delighted he’s going home – and I am, of course, that’s our entire raison d’être – but I’m going to miss seeing my little pal every couple of days.
I buy the least ghastly card they have in the League of Friends shop and leave it with the paediatric nurses to pass on to his mum. I say how pleased I am their story had a happy ending, give her my phone number and ask her to maybe text me a picture of him every so often. Yes, it’s probably against GMC regulations and hospital protocol and contravenes all sorts of small print, guidelines and best practice, but I’m prepared to go down for this one.§
* SCBU (pronounced Scaboo) is the Special Care Baby Unit, NICU is Neonatal Intensive Care, PICU is Paediatric Intensive Care, PIKACHU is a type of Pokémon.
† Something very unsatisfying about house-officer jobs was the way you never found out the end of the story – every patient’s box set was missing the final DVD. A patient would come in with pneumonia, you’d get him well enough to go home, and then he’s gone – he could live another fifteen years, die on the bus home or anything in between and you’d almost certainly never know. Extreme nosiness aside, it always felt like it might have been useful to find out if our management plans were any use. I liked that obstetrics played out much quicker – you would get to watch right through to the credits; and by reflecting back on your decisions in the context of these outcomes, you could learn and improve as a doctor. And so, if a baby went to SCBU, I made a point of popping by to see how they were doing.
‡ Pre-eclampsia is a disorder of pregnancy which can affect most organs of the mum’s body, causing liver and kidney damage, swelling of the brain, fluid in the lungs and platelet problems, as well as problems with baby’s growth and well-being. It ultimately progresses to eclampsia – life-threatening fits. Most cases of pre-eclampsia are mild, but every pregnant patient has their blood pressure and urine protein measured at each visit, in order to pick up the condition at an early stage. The only cure for pre-eclampsia is delivering the placenta (and necessarily the baby first). For the vast majority of pre-eclamptic patients, they’ll end up just being monitored throughout pregnancy, taking some tablets to reduce their blood pressure or having labour induced a week or two early. Some patients, however, develop the condition severely and much earlier in pregnancy, leading to the painful decision to deliver the baby prematurely, to prevent terrible consequences for both mother and child.
§ And she did text me.
Thursday, 2 February 2006
Signing letters to GPs in the gynae office.
Dear Doctor,
I saw XA in clinic with her husband Sam, Esther Sugar and their two children . . .
A moment while I try to remember the appointment. Who of these three were the children’s parents? I feel I should know who Esther is – why the full name? Is she famous? Wife of Sir Alan? As it turns out, Esther wasn’t there at all.
Two months ago, the trust laid off almost all the hospital secretaries, replacing them with a new computer system. The first key difference is that rather than giving your Dictaphone tapes to the secretaries, you now dictate straight onto your clinic computer, which chooses to either upload your audio and send it abroad to the secretarial equivalent of a sweatshop or to instantly delete it without trace. The second key difference is that the quality of the transcription would suggest the backend of the system involves two tin cans, a length of string and a lemur who’s been trained to type. We’re not to worry about that though: the main thing is all the money the trust is saving by sacking so many long-serving, hardworking members of staff who adored the hospital. The one advantage of this system is that you can listen back to your original audio when reviewing documents. I press play.
‘Dear Doctor,
I saw XA in clinic with her husband Sam (S for sugar) and their two children.’
I’m confident this takes me to the top of the leader board in departmental dictation fuck-ups, unseating ‘The patient has known analogies’ (no known allergies).
Wednesday, 22 March 2006
Three a.m. attendance at labour ward triage. Patient RO is twenty-five years old and thirty weeks into her first pregnancy. She complains of a large number of painless spots on her tongue. Diagnosis: taste buds.
Monday, 3 April 2006
It’s 2 a.m. and there’s not much doing on labour ward so I slope off to the on-call room to catch up on some personal admin (Adamin?) and stare at Facebook for a bit. I comment on how cute a friend’s latest ugly baby looks, which I can do very convincingly as I spend a large proportion of my working day doing the same thing to total strangers. For me, the true miracle of childbirth is that smart, rational people with jobs and the ability to vote look at these half-melted fleshy blobs, their heads misshapen from being squeezed through a pelvis, covered in five types of horrendous gunk, looking like they’ve spent a good two hours rolling around on top of a deep-pan pizza, and honestly believe they look beautiful. It’s Darwinism in action, an irrational love for your progeny. The same hardwired desire to keep the species going that sees them come back to labour ward for round two, eighteen months after the irreparable destruction of their perineum.
The other miracle of childbirth is that I can put metal forceps on a baby’s head and lean backwards – applying 20 kg of traction force on it, generally getting a sweat on – and the baby comes out absolutely fine, rather than, as you might expect, decapitated. Once it’s born, every new mother obsesses over keeping the head straight with a cradled hand. If photographs could talk, ‘Careful of his neck!’ is the shriek you’d hear over any picture of a childless relative posing with a newborn. But I’m pretty sure you could carry it by its head and it’d be totally OK.*
I’m just going through exes’ profiles to check they’re colossally miserable and overweight without me when I see a post pop up from Simon, a school friend’s younger brother. He’s twenty-two and even though I’ve only spoken to him twice, a decade ago, this is Facebook, where everyone’s your friend. It’s simple and devastatingly effective. Four words: ‘Goodbye everyone. I’m done.’
I realize I’m probably the only person to be reading this at 2.30 a.m. on a Monday, so I send him a private message to ask if he’s OK. I say I’m awake, remind him I’m a doctor and give him my mobile number. I’m scrolling through my phone to see if I have his brother’s number, when Simon rings. He’s an absolute mess: drunk, crying. He’s just split up with his girlfriend.
I’m actually no better trained to counsel him than I would be to talk him through replacing a gearbox or laying a parquet floor, but he assumes I am, and that’s good enough for both of us. Two (miraculously bleep-free) hours later and we’ve had a good chat. He’s going to get a cab to his mum’s then make an emergency appointment with his GP in the morning. I feel the same weird endorphin rush as after dealing with any medical emergency – exhaustion plus exhilaration and the vague feeling of having done a ‘good thing’ (like how you’d feel after running a 10k for charity). It’s likely I’ve made a bigger difference to Simon than any of my patients tonight.
I answer a bleep and head to labour ward to review a woman at thirty weeks who decided she needed her eczema seen at 5 a.m. ‘I thought it would be quieter now than in the morning,’ she says.
* This is not medical advice.
Monday, 10 April 2006
Referral from an A&E SHO – patient has some kind of warty vulval growth. I ask him if he can describe it a bit more. ‘Like cauliflower florets, mate. Actually, what with the discharge, it’s more like broccoli.’
H did not enjoy this story over dinner.
Friday, 21 April 2006
Ron is having a minor knee op next week and wants me to reassure him that he’s not going to die during the anaesthetic, reassurance that I’m underqualified yet perfectly happy to give him.
He also asks if sometimes the anaesthetic ‘doesn’t work’, so I tell him a story from earlier this year at work:
‘So, there are two main drugs that anaesthetists give. Firstly, a muscle relaxant – so that the surgeon can have a proper fiddle around. With the body completely paralysed, you can’t breathe unassisted, which is why you get hooked up to a ventilator during the procedure. The second drug’s a cloudy fluid called propofol, which makes you unconscious, so you’re asleep throughout the procedure.*
‘Now imagine that your anaesthetist accidentally grabs the wrong cloudy fluid off his trolley and injects you with an antibiotic instead of propofol. You’re lying on an anaesthetic table, totally paralysed by a muscle relaxant, but without the propofol you’re entirely awake – able to hear everything that’s being said, able to feel the surgeon cleaning you up with antiseptic and with no way of alerting anyone that something’s gone horribly wrong. You silently scream as his scalpel cuts through your skin – a worse, more searing pain than you’ve ever experienced in your life . . .’ Ron’s expression looks like it’s been drawn on by Edvard Munch. ‘But I’m sure you’ll be just fine!’
* Or indefinitely if you’re Michael Jackson.
Tuesday, 6 June 2006
Called to see a patient in A&E. She had a Medical Termination of Pregnancy a couple of days ago and is in absolute agony. I don’t quite know what the matter is, but something is definitely up – I admit her to the ward for pain relief and senior review. Ernie examines her.
‘She’s having cramping pains. Scan before her MTOP showed an intrauterine pregnancy. Normal. Send her home.’
I try to justify my admission – surely this is way too much pain? She’s on morphine!
‘Only because you prescribed her morphine . . .’
No one is in pain like this with an MTOP, though.
‘How do you know her pain threshold?’ comes the no-nonsense reply. ‘Maybe she’s like this when she stubs her toe as well.’
I venture that something weird is going on here, and he dismisses me.
‘If you hear hooves clip-clopping outside your bedroom window, it could be a zebra. But when you take a look, it will almost always turn out to be a horse.’ He tells me I can prescribe her some antibiotics just in case there’s an infection brewing – but she still needs to go home.
The bleep from the ward saying that the patient had deteriorated would ideally have come at that exact moment. Instead, it came a few hours later, but the result was the same: assisting Ernie in theatre to remove an ectopic pregnancy* and a metric fuck-tonne of blood from her pelvis. The scan she’d had before her termination was dangerously wrong.
The patient is now fine and back on the ward. Ernie hasn’t apologized to me, as that would require him to change his entire personality. I’m currently on Amazon, ordering him a key ring in the shape of a zebra.
* An ectopic pregnancy is when an embryo attaches in the wrong place – most frequently in a fallopian tube. Left untreated, they will eventually rupture, and this is the most common cause of death in women in the first three months of pregnancy. Every woman with pain and a positive pregnancy test must be considered as having an ectopic unless otherwise proven by a scan. In this case, the scanner had mistakenly interpreted an ectopic pregnancy as an intrauterine one.
Monday, 12 June 2006
Counselling a patient that weight loss would help control her PCOS,* I refer her to the dietician and ask her about exercise. Just because something is obvious to me, it might not always be obvious to the patient – it feels like knocking on the door of a blazing building to tell the owner their house is on fire, but occasionally it does make a difference. Steeling myself for the predictable answer about a lack of time, I offer: ‘It might help you to join a gym?’
‘I’m a member of one already,’ comes the reply. ‘But I haven’t been in about £3,000.’
* Polycystic Ovarian Syndrome (PCOS) is the most common endocrine condition in women, affecting between 1 in 5 and 1 in 20 females, depending on how they define it, which will have changed another three or four times between me writing this and anyone reading it. PCOS can cause problems with fertility, skin and body hair, and menstrual disturbance.
Monday, 19 June 2006
Called to urgently review an antenatal patient on the ward. Patient ES has begun induction of labour for postmaturity.* The concerned midwife leads me to a toilet on the ward; the patient has just opened her bowels and the pan looks like Lush have released a horrific new red and brown bath bomb. It doesn’t augur well for either the cleaners’ tea break or the patient herself.
I examine her to check the bleeding isn’t vaginal, which it isn’t, and am pleased to see the baby looks fine on the CTG.† The rectal examination was totally normal, the patient says she’s never had anything like this before and has no other symptoms. I send off bloods, crossmatch her, put up some fluids and refer her urgently to gastro. I also google whether Prostin can cause massive gastrointestinal bleeding. There’s no history of it happening before, so this would be the first case – I idly wonder whether they’ll name the syndrome after me. I was rather hoping Kay Syndrome might be a more glamorous discovery than someone shitting themselves inside out during induction of labour, but perhaps it’s a price worth paying for immortalization in the textbooks.
The gastro consultant appears before I’ve finished writing up my notes, and after a quick chat and another lubricated finger, she’s wheeled off for a colonoscopy. Happily, all looks normal and there’s no evidence of recent bleeding. A bit of further questioning and the consultant comes up with the diagnosis: he bleeps to let me know.
The nightmare in the toilet bowl I’d witnessed was in fact the rather damning evidence of the two large jars of pickled beetroot that ES had inexplicably taken it upon herself to eat the night before. Next time I want to refer him someone’s bowel movement, the consultant ‘respectfully’ asks that I taste it first.
* Much like your drunk mate insisting you go on to one more club even though she’s already got vomit in her hair, pregnancies sometimes keep going longer than is wise. After forty-two weeks the placenta can start to give up the ghost, so we induce labour before mums get to that point, the first step being a vaginal pessary such as Prostin.
† The cardiotocograph, known as the CTG or ‘trace’, is a belt strapped to mums during labour that measures and continuously records a tracing of contractions and baby’s heart rate. They are generally described as a ‘reassuring trace’ or a ‘non-reassuring trace’.
Tuesday, 20 June 2006
Our computer system has been upgraded and, as happens eleven times out of ten when the hospital tries to make life easier, they’ve made everything much more complicated. It certainly looks much whizzier (and less like an MS-DOS program from school), but they’ve not actually fixed any of the massive clunking problems with the software, they’ve just slapped an interface on top of it. It’s the equivalent of treating skin cancer by putting make-up over the lesion. Actually, it’s worse than that. This glossy interface uses so much of the exhausted system’s resources that it’s now slowed to a nearly unusable crawl. It’s like treating skin cancer with some make-up that the patient has an extreme allergic reaction to.
The blood tests now all live in a drop-down menu, and to order one involves scrolling down an alphabetical list of every test any doctor has ever ordered in the history of humanity. To get down to ‘Vitamin B12’ takes 3 minutes 17 seconds. And if you press the letter ‘V’ rather than wading down there manually, then the system crashes so badly you have to turn the computer off at the wall and all but use a soldering iron to get it working again. Ninety-nine per cent of the time we order the same dozen tests and yet, rather than prioritizing those at the top of the list (even the easyJet website knows to put the UK above Albania and Azerbaijan), they’re scattered throughout a billion tests I’ve never heard of or requested. Who knew there were three different lab tests for serum selenium? As a result, there’s a very narrow window of anaemic patients I will now order Vitamin B12 levels for. If you’re only mildly anaemic I’m not wasting the day with my finger pressing on the down arrow for three minutes. And if you’re severely anaemic, I won’t order it because you’ll probably be dead by the time I’ve done so.
Friday, 21 July 2006
Bleeped to the gynae ward at 5 a.m. to write a discharge summary for a patient due to go home in the morning. It should have been done during the day by her own SHO and there’s no reason for me to be doing it. But if I don’t do it tonight then it will delay the patient’s discharge. I sit down and get on with it – it’s fairly mindless work so gives me a bit of time to plot some appropriate revenge act on the SHO in question. On my way out, I notice the light is on in patient CR’s side room, so I pop my head in to check if everything’s OK.
I admitted her from A&E last week with tense ascites* and the suspicion of an ovarian mass. I’ve been on nights since and not caught up with what’s happened. She tells me. Suspicion of an ovarian mass has become a diagnosis of ovarian cancer has become confirmation of widespread metastases has become talk of a few months left. When I saw her in A&E, despite obvious suspicions, I didn’t say the word ‘cancer’ – I was taught that if you say the word even in passing, that’s all a patient remembers. Doesn’t matter what else you do, utter the C-word just once and you’ve basically walked into the cubicle and said nothing but ‘cancer cancer cancer cancer cancer’ for half an hour. And not that you’d ever want a patient to have cancer of course, I really really didn’t want her to. Friendly, funny, chatty – despite the litres of fluid in her abdomen splinting her breathing – we were like two long-lost pals finding themselves next to each other at a bus stop and catching up on all our years apart. Her son has a place at med school, her daughter is at the same school my sister went to, she recognized my socks were Duchamp. I stuck in a Bonanno catheter to take off the fluid and admitted her to the ward for the day team to investigate.
And now she’s telling me what they found. She bursts into tears, and out come all the ‘will never’s, the crushing realization that ‘forever’ is just a word on the front of Valentine’s cards. Her son will qualify from medical school – she won’t be there. Her daughter will get married – she won’t be able to help with the table plan or throw confetti. She’ll never meet her grandchildren. Her husband will never get over it. ‘He doesn’t even know how to work the thermostat!’ She laughs, so I laugh. I really don’t know what to say. I want to lie and tell her everything’s going to be fine, but we both know that it won’t. I hug her. I’ve never hugged a patient before – in fact, I think I’ve only hugged a grand total of five people, and one of my parents isn’t on that list – but I don’t know what else to do.
We talk about boring practical things, rational concerns, irrational concerns, and I can see from her eyes it’s helping her. It suddenly strikes me that I’m almost certainly the first person she’s opened up to about all this, the only one she’s been totally honest with. It’s a strange privilege, an honour I didn’t ask for.
The other thing I realize is that none of her many, many concerns are about herself; it’s all about the kids, her husband, her sister, her friends. Maybe that’s the definition of a good person.
We had a patient in obstetrics a couple of months ago who was diagnosed with metastatic breast cancer during pregnancy, and was advised to deliver at thirty-two weeks so she could start treatment, but waited until thirty-seven weeks to give her baby the absolute best possible chance. She died after a fortnight spent with her baby – who knows whether starting treatment a month sooner would have made any difference. Probably not.
And now I’m sitting with a woman who’s asking me if she shouldn’t have her ashes scattered on the Scilly Isles. It’s her favourite spot, but she doesn’t want it to be a sad place for her family once she’s gone. The undiluted selflessness of someone fully aware what her absence will do to those she leaves behind. My bleep goes off – it’s the morning SHO asking for handover. I’ve spent two hours in this room, the longest I’ve ever spent with a patient who wasn’t under anaesthetic. On the way home I phone my mum to tell her I love her.
* Ascites is fluid in the abdomen, and almost always very bad news.
