Eventually there comes a point where you have to decide what kind of doctor to be. Not the technical stuff, like whether you’re into urology or neurology, but the more important matter of your bedside manner. Your stage persona evolves throughout your training but you generally settle on a way of dealing with patients a couple of years in, and carry it through into your consultant career. Are you smiley, charming and positive? Quiet, contemplative and scientific? I presume it’s the same decision policemen make when they decide if they’re good cop or bad cop (or racist cop).
I went for a ‘straight to the point’ vibe – no nonsense, no small talk, let’s deal with the matter in hand, a bit of sarcasm thrown into the mix. Two reasons, really. It was already my personality, so there wasn’t too much acting involved, plus it saves an awful lot of your day if you don’t do the five-minute preamble about the weather, their job and their journey every fucking time. It sets you up as a bit distant but I don’t think that’s such a bad thing; I didn’t really want patients trying to add me on Facebook or asking what colour they should paint their downstairs bog.
The conventional teaching is that patients want doctors to ask open questions (‘Tell me about your concerns . . .’), then give them a variety of treatment options, from conservative to medical to surgical, so the patient can make their own decisions. Terms like ‘choice’ sound good in theory – we all like to feel we are masters of our own destinies – but have you ever been in a canteen queue where there are more than a couple of mains? People dither, they change their minds, they look for affirmation from friends. Is the haddock nice? How about the shepherd’s pie? I don’t really know what I fancy. And all the while, your chips are getting cold. Sometimes, it’s best to cut to the chase and remove any room for doubt.
On labour ward especially, I found that patients gained confidence from their doctors advocating a single management plan – you need the patient to be calm and trust you implicitly with their life and the life of their baby. Likewise, in clinic I saved countless patients delays to effective treatment by not proffering a specials board of options that are almost certainly of no benefit, just so I can say there’s been patient choice. Instead I’ve offered my expert opinion; the patient’s choice is whether or not to take it. It’s what I’d personally want if I saw a doctor myself, or even if I took my car to the garage.
But there’s no hiding from the fact that a direct approach makes you a less ‘nice’ doctor. Being trusted is much more important than being liked, but it’s good to have the whole set, so I decided in my third post as a registrar – now working in a huge teaching hospital – to warm up my bedside manner. It wasn’t totally spontaneous, I’ll admit; someone had complained about me. It was about my clinical performance rather than my behaviour, but it so totally floored me that I realized I needed to do everything in my power to never attract a complaint again, and if that involved hairdresser-style chit-chat and an elbow-to-elbow smile then so be it.
A letter arrived at home out of the blue from the hospital I’d worked at two years previously, letting me know a patient I had operated on was suing me for medical negligence. As it happens, I wasn’t negligent – bladder injury occurs in 1:200 caesareans, and she was informed of this risk pre-operatively on the consent form she signed. I’d like to think the risk of me injuring your bladder is considerably less than 1:200, as I only did it once and had many more than 200 other opportunities to do so. I felt terrible at the time it happened, but knew it had been managed well – I spotted what I’d done immediately, the urologists came to repair it straight away, and although it must have been distressing for the patient, ultimately it resulted in nothing more than a slightly delayed discharge home. I also thought it was managed well with her afterwards: I was apologetic, honest and humble, which in this case didn’t require any acting at all. The last thing you want to do to a patient is actually give them one of the complications you warn them about. First, do no harm; it’s right at the top of the job description. But, shit happens, and on that occasion it happened to her.
Messrs Cunt, Cuntsome and Cuntiest – solicitors of the ambulance-pursuing ‘no win, no fee’ persuasion – took a different view. According to their expert opinion, which seemed to have been honed from skim-reading a book called Law: Just Throw the Fucking Lot at Them and See Who Gets Back Up Again, the trust was negligent, I carried out the operation well below the standard reasonably expected of me, I greatly extended the suffering of the claimant and I delayed her opportunity to bond with her newborn child.
Unfortunately, I wasn’t able to counter sue for the hours needlessly spent going through old medical records, taking meetings with lawyers and defence unions, or the damage inflicted on my relationship by eroding the precious little time we spent together, nor the cost of the Red Bulls that kept me awake on night shifts after sleepless days of report-writing. Or the suffering I felt – the anxiety and guilt mounted onto an already stressful working life, the unfairness of being accused of being terrible at my job, the fear that maybe I was terrible at my job. I always tried my absolute hardest for every patient I saw and it was like a dagger through my heart for anyone to suggest otherwise.
The patient almost certainly had no idea how sad and exhausting the process would be for me – her lawyer no doubt smoothed down his moustache, put on his best concerned face and told her it was worth a roll of the dice in case it resulted in a nice payout* – and he was right, the hospital settled out of court, as they generally do. Maybe it’s just part of the gradual Americanization of the health service, that it necessarily becomes more litigious. Or maybe the patient was one of those joyless types who sues half the people she meets: the bus driver who doesn’t say good morning; the waiter who forgets her side of fries; me again for writing about all this. Whatever was going on behind the scenes, it left me at my lowest ebb as a registrar – asking myself why I bothered in the first place if now even the patients had it in for me. I seriously considered jacking it all in, something that had never occurred to me before. But I didn’t. I decided I would scrabble desperately around for a positive to take from it, which was to do my very best to protect myself from any future letters on legal headed notepaper.
‘Good morning!’ beamed Adam 2.0 in a typically over-running antenatal clinic.
‘You taking the piss, mate?’ said the patient’s husband. And so my revamp lasted two days.
* It would never be the doctor ending up personally out of pocket in a situation like this. The hospital will foot the bill, or a medical defence organization in the case of GPs. There can sometimes be a criminal case too if it’s considered gross negligence – and a complaint to the GMC can run in tandem with any legal complaint, jeopardizing your registration and ability to practise.
Friday, 6 February 2009
Patient HJ needs an emergency caesarean section for failure to progress in labour. This has not come as a surprise. When I met her on admission, she presented me with her nine-page birth plan, in full colour and laminated. The whale song that would be playing on her laptop (I don’t recall the exact age and breed of the whale, but I’m pretty sure it was documented to that level of detail), the aromatherapy oils that would be used, an introduction to the hypnotherapy techniques she would be employing, a request for the midwife to say ‘surges’ rather than ‘contractions’. The whole thing was doomed from the start – having a birth plan always strikes me as akin to having a ‘what I want the weather to be’ plan or a ‘winning the lottery’ plan. Two centuries of obstetricians have found no way of predicting the course of a labour, but a certain denomination of floaty-dressed mother seems to think she can manage it easily.
Needless to say, HJ’s birth plan has gone right up the fuck. Hypnotherapy has given way to gas and air has given way to an epidural. The midwife tells me the patient snapped at her husband to ‘turn that bullshit off’ when he was fiddling with the volume on the whale grunts. She’s been stuck at 5 cm dilatation for the best part of six hours despite Syntocinon.* We’ve ‘given it a couple more hours’ twice now, so I explain baby isn’t going to come out vaginally and I’m not prepared to wait until it inevitably becomes distressed and there’s a huge emergency. We’re going to need to perform a caesarean section. As expected, this doesn’t go down particularly well. ‘Come on!’ she says. ‘There must be a third way!’
I’m loath to court a PALS† complaint from a patient who wants their birth to be blogpost-perfect and has somehow been let down by nature. I’ve had a complaint in the past from a patient who I refused to allow to have candles burning while she laboured. ‘I don’t think it’s such an unreasonable request,’ she wrote. About having naked flames right next to oxygen tanks.
This patient’s got ‘strongly worded email’ written all over her, so I cover myself by asking the consultant to pop by and have a quick chat with her. Luckily, Mr Cadogan is on duty – he’s fatherly, charming and soothing, and he smells expensive, which has posh women flocking to the private ward he’d much rather be on. He soon has HJ consented for theatre. He even offers to do the section himself, to quiet mutterings of derision and amazement from the other staff. No one here can remember the last time he delivered a baby for free. Perhaps golf’s been rained off?
He suggests to the patient that he performs something called a ‘natural caesarean’ – it’s the first time I’ve heard of such a thing. The theatre lights are dimmed, classical music plays and baby is allowed to slowly emerge from the tummy while both parents watch. It’s a gimmick, and no doubt attracts a huge premium as part of his Platinum Package or whatever, but HJ laps it up. It’s the first time she’s looked remotely happy all day. With Mr Cadogan out of the room, HJ asks the midwife what she thinks about ‘natural caesareans’. ‘If that guy was operating on me,’ the midwife replies, ‘I’d want the lights turned up as high as they go.’
* Syntocinon (synthetic oxytocin) is an intravenous drug that increases contractions and speeds up a labour. You’re meant to progress by a centimetre of dilatation every hour or two, and if that’s not happening despite Syntocinon then it’s caesarean time.
† PALS (Patient Advice and Liaison Services) are the hospital’s complaints department. They take ‘the customer is always right’ to bizarre new heights and no matter how trivial the complaint would gladly have doctors turn up at patients’ houses carrying a bouquet of flowers and wearing a hair shirt.
Saturday, 7 February 2009
Missed the first half of Les Mis thanks to a tricky caesarean at twenty-nine weeks,* and didn’t have the fuckingest clue what was going on in the second half. (Especially as the goodie, Jean Valjean, and the baddie, Javert, essentially have the same name.)
Debriefing with Ron and the others in the pub afterwards, watching the first half didn’t seem to have helped anyone else understand it either.
* Caesarean sections are much more difficult for premature babies. The lower segment, which you normally cut through at full term, doesn’t properly form until around thirty-two weeks. This means you have to go through a much thicker part of the uterus, making it a harder and bloodier procedure.
Sunday, 8 February 2009
Simon called to say he’d cut his wrists last night after a fight with his new girlfriend and ended up in hospital for a bunch of stitches. He’s back home now and doing OK, with psychiatry follow-up arranged.
He asked if I was angry with him and I said of course I wasn’t. I was actually extremely angry – that he’d done it, that he hadn’t called me first so I could attempt to talk him down; surely he owed me that after the hours of time I’ve given him? I felt guilty that I hadn’t done enough – that I should have helped him better, or seen it coming and stopped it. And then I felt guilty about being so angry with him.
We chatted for an hour or so and I reminded him he can call me any time, day or night. But we’ve had this chat so often in the last three years, and it’s miserable to think that we’re no further forward than when he posted that first cry for help.
Actually, that’s probably the wrong way of looking at it. You don’t cure depression, the same way you don’t cure asthma; you manage it. I’m the inhaler he’s decided to go with and I should be pleased he’s gone this long without an attack.
Tuesday, 17 February 2009
The emergency buzzer goes and it’s a slightly tricky situation to restore calm in. As well as the usual dozen people buzzing around, there’s dust and rubble everywhere, and panic as a result. If this were an episode of Casualty, there’d be half an ambulance smashed into the room with us, but no. The midwife has pulled the emergency cord so hard she’s taken down most of the ceiling.
Thursday, 19 February 2009
It’s a great shame our child protection duties* don’t extend to vetoing some of the terrible names parents saddle their unfortunate babies with. This morning I delivered little baby Sayton – pronounced Satan, as in King of the Underworld. It’s hard to believe he’ll get through his school career unbullied, and yet we merrily wave him off on that journey. (Or maybe he’s actually the devil and I should have just shoved him back in.)
At lunch, fierce discussion with my colleague Katie as to whether my run-in with baby Sayton is better or worse than one she delivered called LeSanya, pronounced Lasagne, as in Lasagne. We regularly compare horror stories, like we’re playing Top Trumps: Obstetrics.
She tells me she once pulled out a baby girl called Clive, though I point out we’ve got a Princess Michael, so that’s not particularly impressive. Oliver says that where he was born, in Iceland, names must be picked from a specific list, from which it’s illegal to deviate. Doesn’t sound like the worst idea.
* All doctors have a duty, enshrined in their GMC code, to protect children and young people from abuse and neglect by acting on any concerns they have.
Wednesday, 4 March 2009
It shouldn’t be a notable event when I manage to leave labour ward on time, but today I do, and have a long-arranged dinner with Grandma in Teddington. She leans over after starters, licks her finger and wipes a dot of food off my cheek. As she licks her finger again, I realize slightly too late that it was a patient’s vaginal blood. I decide not to mention it.
Saturday, 7 March 2009
‘Doctor Adam! You delivered my baby!’ squeals the woman behind the cheese counter at Sainsbury’s. I have no recollection of her whatsoever, but her story seems to check out – that is, after all, my name and occupation. I ask about ‘the little one’, as obviously I have no memory of the baby’s gender. He’s doing well. She asks me ridiculously specific questions relating to the vagina-side small talk I had with her a year ago: how I got on with building the shed, if Costco stayed open until 8 p.m. on Thursdays like I’d hoped. I feel slightly guilty about the colossal mismatch in impressions we made on each other. But then again, I guess it was one of the most important moments of her life, and for me she may well have been delivery number six that day. It’s a peek into what it must be like to be a celebrity, a fan asking you if you remember a meet-and-greet after a concert ten years ago.
‘I’ll put it through as Cheddar,’ she whispers to me as she weighs my goat’s cheese – it’ll save me a couple of quid and will therefore be one of the biggest perks of the job I’ve ever had. I smile at her.
‘That’s not Cheddar, Rose,’ announces her supervisor as he stalks past, and my bonus evaporates.
Monday, 30 March 2009
I’ve just printed off a scan of their baby for some parents and am wiping the ultrasound jelly off mum, when dad asks if I can take another picture from a different angle, saying, ‘I’m just not sure I can put this one up on Facebook.’ My eyebrows are en route to my hairline at these life-chronicling, self-obsessed social media attention-seekers when I take a closer look at the photo. I see what he means: it very much appears that the fetus is wanking.
Friday, 3 April 2009
Having a drink with Ron – we’re talking about his job and how he’s decided it’s ‘time to move on’. I sometimes think about the idea of moving on myself, but it’s a slightly alien concept when I only have one possible employer in the country. He offers to set me up with his recruitment consultant and tells me he’s sure I’ve got plenty of transferable skills.
I hear this a lot from non-medics, but I don’t really buy it. The feeling is that doctors are expert problem-solvers, who pull together a constellation of symptoms to deduce a unique diagnosis. The reality is we’re more Dr Nick than Dr House. We learn to recognize a limited set of specific problems from patterns we’ve seen before – like a two-year-old who can point and say ‘cat’ and ‘duck’, but would struggle to identify a breeze block or a chaise longue. I strongly suspect I wouldn’t last long as a management consultant, applying my problem-solving skills to a failing branch of La Senza.
‘You should absolutely be on six figures by now,’ says Ron, texting me the contact details of his recruiter. I tell him I’ll get in touch with her, but I’m not sure I want to. I’m not convinced she’ll want me either when I outline my core competency: pulling babies and Kinder Eggs out of vaginas.
Monday, 6 April 2009
Eyes down for an elective caesarean section – this time for placenta praevia.* In the event, a very straightforward one, but everyone is quiet and focused in case it gets messy. Everyone, that is, except the dad, who is determined to engage me in pitiful banter.
‘Whoa, I’m glad she’s got skin covering that the rest of the time’, ‘This must put you off women, doc’, something about the baby’s penis and the umbilical cord – all the classics. I presume it’s just because he’s nervous, but it’s extremely irritating and distracting, and none of his lines would even make it onto the speech bubble of a saucy seaside postcard. I ‘mm-hm’ at his zingers, and all but say, ‘I’m really trying to concentrate here. Let me deliver this baby. I didn’t rock up at the conception and distract you from your pumping with my pound-shop repartee.’
He continues. ‘Better not come out black, eh? Ever had a baby come out a different colour to the parents?’
‘Does blue count?’ I offer. Banter over.
* Placenta praevia is a placenta that is attached at the lower part of the uterus. The implications of this are that the baby needs to be delivered by caesarean because the placenta’s in the way for delivering vaginally. It also means that if mum goes into labour, it’s a bit of an emergency as the placenta is liable to shear off, with profound consequences for both baby and mother (700 ml of blood goes through the placenta every minute – her entire blood volume in five minutes).
Friday, 17 April 2009
Patient JS is twenty-two years old and has presented to A&E with acute abdominal pain. The A&E officer tells me she’s had a negative pregnancy test and has been reviewed by the surgeons, who suspect it’s probably a gynae issue. I review her. She looks reasonably well – pulse a bit high, tummy a bit tender, but walking and talking easily. Admitting her to the ward would be overkill, and sending her home would probably be underkill. If this was a daytime shift during the week I’d probably just squeeze her onto someone’s ultrasound list to check there’s nothing sinister going on. But it’s a Saturday night and the NHS runs a skeleton service. Actually, that’s unfair on skeletons – it’s more like when they dig up remains of Neolithic Man and reconstruct what he might have looked like from a piece of clavicle and a thumb joint.
One would generally err on the side of caution and admit her until she can be scanned in the morning, wasting a night of the patient’s life rather than sacrificing my career if I’ve called it wrong. It also wastes the cost of a hospital bed, which is around the £400 mark. I suspect the cost of an ultrasonography shift would be considerably lower than this, and you’d save at least one such admission a night, but who am I to tell the hospital how to spend their money? Particularly when they’ve just decided to get rid of the beds from our on-call rooms. (Perhaps they’ll save money on the bed linen they remember to change every week or two? Perhaps they were worried morale was running a little too high? That doctors would be too alert, too on it, if they got some sleep?)
We’re OK in obs and gynae – the Early Pregnancy Assessment Unit sister took pity on us, no doubt clocking the size of the bags under our eyes, and had a spare key cut so we can kip on a hospital bed in her unit. It’s an act of charity so kind and so rare that it made my colleague Fleur cry, and then scour the honours website trying to work out if Sister would be eligible for an OBE. It’s hard to describe the joy of hearing you’ll have a bed to lie in, after a few night shifts spent trying to snatch some sleep in an office chair. It’s a bed with stirrups, but beggars can’t be choosers; I’d have accepted a bed with a grand piano dangling from the ceiling above it by a single pube if there was any chance of some shuteye.
I suddenly realize it’s also a bed with an ultrasound machine sat next to it. I check JS is still good to walk, and take her off upstairs – if all looks well on a quick scan she can head home, and I won’t even bill the NHS the £400 I’ve saved them through my ingenuity.
In retrospect, it was a mistake to not tell the A&E sister I was borrowing the patient. I imagined being informed of some bit of protocol that meant I wouldn’t be allowed to, and nobody’s got time for that kind of argument. It was also a mistake not to book a porter to take her up with me in a wheelchair. But the biggest mistake of all was definitely made by the A&E officer who told me the patient had had a negative pregnancy test – unless ‘negative pregnancy test’ is the rather confusing term he uses for ‘I have not performed a pregnancy test’.
By the time we’ve gone upstairs, through a depressing lab-rat maze of corridors and into my makeshift bedroom with en-suite ultrasound machine, JS is looking a little peaky and a lot out of breath. Ultrasound of her abdomen shows a ruptured ectopic pregnancy, her belly swimming with blood. Instead of being where she should be, in close proximity to life-saving equipment, she’s kicking back with me in a closed-off part of the hospital, like we’re two teenagers who’ve slunk off for a snog.
Half an hour of panicked phone calls later, we’re in theatre, JS is a few bags of blood better off, a fallopian tube worse off, and will be absolutely fine. I have no idea what the moral of this story is.
Sunday, 26 April 2009
Called to review a patient in A&E. According to her notes she is aged thirty-five and employed in a massage parlour, in a capacity one suspects doesn’t involve a whole lot of massaging – at least not with her hands. She presents with a lost object in her vagina. A busy shift, so no time for too many questions, and it’s legs up, lights on, speculum in, see it, grab it, remove it. Without doubt, this is the worst smell I’ve ever experienced. Truly indescribable – other than to say that I retch, and the nurse chaperone has to immediately leave the cubicle. I imagine every bunch of flowers in the hospital suddenly wilted. I hardly want to ask, but I need to know the culprit.
The short answer is it was the head of a Fireman Sam bath sponge. But of course! The long answer is she realized a number of months ago her income was being seriously compromised because there were certain dates of the month when her clients didn’t want to be ‘massaged’ – so she created an impromptu menstrual barrier device by decapitating Samuel. Christ knows how she explained the change in his appearance to her children – did any of them notice? Were they worried they’d be for the guillotine next if they asked as to its whereabouts? While effective at soaking up menstrual blood from above, and quite noticeably effective at absorbing other fluids from below, Sam’s bonce-barrier didn’t have a string to facilitate its removal. Plus it had been schnitzeled flat by her clients’ pummellings over the past three months.
Actually, it’s unfair to say the smell was indescribable – it’s describable as three months of menstrual blood mixed with vaginal secretions and the fetid semen of assorted men, the number of whom must have run into three figures. While prescribing her some antibiotics, I let her know that no further novelty sponges needed to be executed in her honour – she can also stop her periods by the more traditional method of taking the oral contraceptive pill back to back. I leave it to A&E to decide how to label the item within the microbiology sample pot.
Monday, 4 May 2009
Another day, another emergency buzzer or twelve. I go to perform a ventouse extraction for a non-reassuring trace, but as I’m about to Dyson the little bastard out of there the trace improves so I take my gloves off and hand back over to the midwife for a normal delivery. I loiter at the back of the room to keep an eye on the trace in case it misbehaves again, but all is well and soon baby’s head is crowning.
Dad is down the business end, witnessing the miracle of childbirth for the first time – awwing, cooing and excitedly telling his wife how brilliantly she’s doing. The midwife tells mum to stop pushing and start panting, so she can guide baby’s head out slowly and hopefully avoid too much of a tear. As the head advances, dad screams, ‘Oh my God – where’s its face?!’ Mum understandably also screams, her baby’s head shoots out uncontrolled and her perineum explodes. I explain to them that babies are generally born facing downwards,* and their baby’s face looks perfect (if slightly more blood-splattered than it might have been). I put some gloves on and open a suture set.
* Only 5 per cent of babies are born looking upwards – the medical term for which is ‘occipito-posterior’. The cutesy-wutesy term is ‘star-gazing’, the old-fashioned term is ‘face to pubis’, and the term I misheard as a junior SHO and then mortifyingly used for a year, until I was corrected by a colleague, is ‘face to pubes’.
Tuesday, 5 May 2009
Patient in antenatal clinic requests a caesarean section without a clinical indication. I explain our unit doesn’t perform caesareans on request: there needs to be a medical reason, because it’s an operation, with attendant risks of bleeding, infection, anaesthetic and so on. Her argument was she didn’t want to go through a long labour and then end up with an emergency caesarean. I was obviously bang to rights – a planned section is much safer than an emergency one, and generally safer than an instrumental delivery too – but couldn’t say so.
She wasn’t done trying. ‘Aabaat fimetoo poshtapush?’ she said in her finest estuary drawl, which I eventually decoded as ‘How about if I’m too posh to push?’ I felt mean saying no, especially as a third of female obstetricians elect for caesareans – it’s clearly not fair.
I was on the other side of the fence yesterday. H and I were looking to upsize mildly and were going round a flat we liked with an estate agent. The barely twenty-year-old weasel was doing the hard sell; it’s a great location, we were told – he bought his own place on the road behind. This made it all the more depressing; an embryo in shiny nylon could spare the cash to buy a flat somewhere we can barely afford. Was I in the wrong job? Or is an estate agency like a charity shop, where the staff get first dibs on everything that comes in?
He told us the sellers of this place had previously rejected a below-asking-price offer, but he couldn’t tell me how far below asking price – it’s against estate agents’ weasel-law, a code of honour among the dishonourable. I asked him if his colleagues tipped him the wink about how far below asking price any other offers were when he was buying his own flat. He went a delightful shade of sun-dried tomato. ‘Ask me my favourite number of pounds!’ he said. Turns out his favourite number was 11,500.
‘Ask me why some women have caesareans,’ I said to the patient. I waited for her intellectual satellite delay to catch up, and she asked. I answered that some women are worried about the significantly worse long-term effects of normal deliveries on bladder and bowel continence, as it would markedly affect their lifestyle. Turns out she was too, and is now booked in for an elective caesarean at thirty-nine weeks.
Thursday, 25 June 2009
Down in A&E around 11 p.m. to review a patient, and thumbing through Twitter while I work up the strength to see her. There’s a big news story breaking, but so far only gossip-merchants TMZ have reported it. ‘Oh Christ,’ I gasp. ‘Michael Jackson’s dead!’ One of the nurses sighs and stands up. ‘Which cubicle?’
Saturday, 18 July 2009
If they’re updating the Hippocratic oath any time soon, they should add in a line about never mentioning you’re a doctor at parties. Particularly for obs and gynae staff, where it opens up an entire hell-mouth of discussion with every woman on the planet – questions about contraception or fertility or pregnancy. I’ve become extremely good at being vague about what I do when I meet new people, or magically changing the subject.
At a house party tonight, conversation turns to the niqab, and someone chips in that underneath their niqabs a lot of women wear very high-end fashion, often thousands of pounds of clothing hidden from view. ‘It’s true,’ I say. ‘And underneath that I’ve seen so many orthodox Muslim women with Agent Provocateur lingerie, and half a dozen with really elaborate pubic topiary. Initials shaved in, spirals, the lot!’ Absolute silence. Then I realize that I’ve overdone it on the mystery. ‘I’m a doctor by the way.’
Tuesday, 28 July 2009
Booking a couple in for an elective caesarean and they ask me if there’s any chance they could choose a particular date. They’re a British Chinese couple, and I know that according to the Chinese zodiac, certain days of the year are lucky or unlucky, and it’s of course preferable to deliver on an ‘auspicious date’, as it’s known.
Obviously we’ll try our best to accommodate this, if safe and practicable. They ask me to check for the first or second of September. ‘Auspicious dates?’ I ask, smiling and mentally clearing a space on my lapel for an ‘excellence in cultural sensitivity’ badge.
‘No,’ the husband replies. ‘September babies go into a different school year and perform better in exams.’
Monday, 10 August 2009
Yes, madam, you will shit during labour. Yes, it’s completely normal. It’s a pressure thing. No, there’s nothing I can do to stop it. Although if you’d asked me yesterday I’d have suggested that the massive curry you ate to ‘induce labour’* probably wasn’t going to help matters.
* Curry can’t induce labour. Nor can pineapple. Nor can sex. There is no scientific evidence whatsoever for these three perennial old wives’ tales. I presume they were dreamt up by the inventor of the pineapple madras when he was horny.
Monday, 17 August 2009
Teaching the medical students a bit of pelvic anatomy when someone from med school administration appears with news of Justin, the missing member of the group. He won’t be joining us for the rest of the term, and it sounds very much like he won’t be joining the medical profession at all. Last night, he got into a fist fight with his boyfriend at a nightclub and the police were called. The police spotted that Justin had a quantity of white powder on him; they suspected it wasn’t Canderel and arrested him on the spot. Justin’s defence was that he should be immediately released on the basis that he’s a medical student and his country needs him. This backfired ever so slightly and the police contacted the medical school, accounting for his absence this morning.
The administrator leaves and no one’s particularly interested in learning pelvic anatomy any more (if they ever were). We have a discussion about fitness to practise among medical students and getting struck off before you even get struck on. Every single student asks at least one gossamer thinly veiled ‘What if a student did this?’ hypothetical question, before each of their faces drains of colour on hearing my answer. I regale them with the story of some contemporaries of mine who got sent down. A bunch of third years were on a rugby tour in France; a tour that consisted of the odd game of rugby and countless hours of drinking games. The most inventive of these games involved visiting local hostelries and making ‘Very Bloody Marys’. They would order large measures of vodka from the bar, return to their tables, produce needles and syringes, venesect each other, squirt blood into each other’s vodkas and then neck them. The gendarmerie point-blank ignored the rule of ‘what goes on tour stays on tour’ and responded quite urgently to the bar staff’s concerns about all the discarded needles on their premises, arresting the students and informing the university. My tutorial group seemed happy that this was a striking-off offence, although one raised the mitigating factor that it’s pretty impressive for a group of third years to be able to take blood.
‘Poor Justin’ still seemed to be the prevailing feeling amongst them. My suggested ‘Poor Justin’s beaten-up boyfriend’ fell on fairly deaf ears.
‘I just can’t believe it,’ one girl sighed loudly. ‘Justin’s gay?’
Wednesday, 19 August 2009
Moral maze. Working my way through the day’s elective caesareans. This one is for breech presentation – I cut through the uterus and the baby quite clearly isn’t breech. Fuck. I should have scanned the baby before I started – you’re always meant to, just in case the baby has turned since the last ultrasound. Which it never has. Except today.
My choices are as follows:
a) Deliver the magical revolving baby and confess to the patient I’ve done a completely unnecessary caesarean section, scarred her abdomen and confined her to hospital for a few days, when she could have had a normal delivery.
b) Deliver the baby and pretend it was breech – this would involve lying in the notes, and persuading my assistant and scrub nurse to perjure themselves by colluding.
c) Stick my hand inside the uterus, rotate the baby, grab a leg and deliver it breech.
I choose a) and fess up to the remarkably understanding patient, who I suspect actually wanted a caesarean in any case. Then it’s time to fill in the clinical incident form and tell Mr Cadogan. He’s very nice about it and says at least I’ll never forget to scan a patient before a section again.
He also makes me feel much better by telling me about an unnecessary section he once performed as a junior trainee. Baby wasn’t coming out with forceps, so he performed an emergency caesarean. Unfortunately, when he got inside the abdomen, the baby had somehow delivered vaginally in the meantime.
‘How did you explain that to the patient?!’ I ask.
There’s a pause. ‘Well, we weren’t always quite so honest with the punters back then.’
Thursday, 20 August 2009
I consent patient YS for Termination of Pregnancy – an unplanned, unwanted pregnancy in a twenty-year-old student following condom failure. We discuss alternative methods of contraception and correct condom usage.* I identify an error in her technique. I’m as big a fan of recycling as the next man, but if you turn a used condom inside out and put it back on for round two, it’s probably not going to be that effective.†
* I performed a large number of TOPs in this job, as a lot of the other junior doctors had objections for ethical or religious reasons (or pretended to, because they’re work-shy bastards). No one’s first choice of a way to spend a morning, but a necessary evil, and as a result I developed excellent surgical technique for ERPC – the near-identical surgical procedure required following certain miscarriages. By now I could probably hoover the stairs through my letter box if needed. This patient didn’t want to raise a child, and we live in a civilized society – it’s not fair on her or the child to force her to go through with it, as some of our near neighbours should note. According to the letter of the law (the 1967 Abortion Act to be precise), two doctors need to agree that continuing with a pregnancy would be damaging to the patient’s mental health, but in reality that covers any unwanted pregnancy. In this case the patient had attempted to take reasonable precautions against falling pregnant. Used correctly, condoms can be 98 per cent effective, but frequent mistakes include late application, early removal and incorrect lubrication, so it’s always good to check they’re being used properly.
† A couple of years later, I encountered an example of condom failure where the guy thought that because a condom was coated with spermicide, and he didn’t really like the feeling of them, he could roll it on to coat his cock with spermicide, then take it off before sex.
Tuesday, 20 October 2009
We’re one registrar down in antenatal clinic, so I’m sailing this shitshow alone. I saw thirty patients in morning clinic, which finished at 3 p.m., two hours after my afternoon clinic was meant to have started.
All the patients I see are pissed off, and rightly so – they’ve been sitting in a waiting room for four hours, crotchety as a pen of wet hens. Safe to say my sincere apologies and not-my-faults don’t count for much while they grunt their way through their appointments. I strongly suspect if I was a pilot and my co-pilot didn’t turn up, the airline might find a better solution than ‘plough ahead and see what happens’.
Seven p.m. and two patients from the finish line I have to make an urgent psychiatric referral for someone who’s had a relapse of severe anorexia nervosa at thirty weeks. And she’s eaten more than I have today.
Wednesday, 28 October 2009
I need to admit a woman for pelvic inflammatory disease, to receive intravenous antibiotics. Unfortunately, she doesn’t want to receive any because she thinks I’m in the pocket of the pharmaceutical industry, so we’ve reached a bit of a stalemate. We talk through her concerns. It turns out this is a very recent worry, having read something about it on Facebook yesterday.
Yet another mark against technology as far as I’m concerned. The trust have finally acknowledged we’re in the twenty-first century and digitized our radiology system, doing away with all light boxes and physical printed X-rays. Instead we can now access them from any computer in the hospital. Unfortunately, the system has been broken since they installed it, thereby putting our practice back to the nineteenth century, before the introduction of X-rays.
Patients frequently attend clinic with reams of paper they’ve googled, printed off and highlighted, and it’s pretty tedious spending an extra ten minutes per patient explaining why a blogger in Copenhagen who uses a pink hearts WordPress theme might not be a reliable source. Then again, if it wasn’t for Google I wouldn’t be able to send patients off for a urine sample while I look things up in a panic.
Today technology is serving up conspiracy theories. The patient asks me to prove I’m not being bribed by drug companies. I point out that the antibiotics I want to put her on cost a matter of pennies, and that drug companies would probably be furious with me for not choosing something more expensive. She doesn’t waver. I point out that the antibiotics I’ve prescribed are generic* rather than pushing one company’s product. Still unmoved. I point out that I drive a five-year-old Peugeot 206, so I’m probably as far out of anyone’s pocket as is possible. ‘Fine,’ she says and agrees to the antibiotics.
* Almost any drug you get at the chemist comes in both branded and cheaper generic forms. Panadol is a brand name for the generic drug paracetamol, Amoxil is a brand name for amoxicillin.
Wednesday, 4 November 2009
Patient TH is an accountant in her mid-thirties, who has been diagnosed with an ectopic pregnancy. She is a candidate for medical management using methotrexate,* and is keen to do so and avoid surgery. I consent her for receiving the drug, and talk through the follow-up procedure. I explain the possible side effects and the various ‘dos and don’ts’ while on treatment, emphasizing that she must use effective contraception for the next three months and abstain from sex altogether for the first month after treatment. She pauses to consider this, before asking, ‘How about anal?’†
* Certain patients with ectopic pregnancies can be managed with a drug called methotrexate, if they’re medically well and the ectopic is small. It’s a pretty nuclear drug which attacks rapidly dividing cells, meaning it’s effective at dissolving the ectopic pregnancy and can also be used in chemotherapy.
† If you’re interested, the answer is ‘yes, even anal’. There’s still a risk of the ectopic pregnancy rupturing, so we try to avoid any prangs in that neck of the woods.
Wednesday, 18 November 2009
Visiting Ron’s dad in hospital. He looks terrible, jaundiced skin stretched tight over jutting bone. A roadmap of blood vessels is visible across his face where his body has burnt away every single fat cell, throwing all its energy at fighting a cancer it has no chance against. ‘I wish people didn’t have to see me like this,’ he says. ‘We’ll be spending a fortune on the undertakers making me look nice afterwards – can’t you just wait a few more months?’
He’s in hospital for an oesophageal stent insertion so he can continue to eat and drink, to make his final chapter as comfortable as possible. The retired engineer in him is fascinated by the mechanism of the stent, a self-expanding metallic mesh, strong enough to push back the tumour and open up his gullet. ‘Wouldn’t have been possible twenty years ago,’ he says, and we talk about being lucky to live in this current blink of civilization’s eye. ‘Do you think they’ll be able to cure cancer twenty years from now?’ he asks. I can’t work out whether saying yes or no would be more comforting. I deflect with, ‘I only know about vaginas, pal,’ and he laughs.
Next question. ‘Why do we always say that people lost their battle with cancer, and never that cancer won its battle against them?’ He keeps making jokes – to be fair, he’s done it the entire time I’ve known him. I find it uncomfortable for the first few minutes of my visit, but I’m soon genuinely enjoying a morning I’d been dreading. It’s a kind and clever move – it doesn’t just make it easier for his friends and family when they visit, it also means we’ll remember him as he always was, diminished physically maybe, but not in personality.
Thursday, 10 December 2009
A poignant ventouse delivery – it’s a mum I saw in infertility clinic at the start of this job. I feel like holding the baby aloft like Simba and blasting out my best ‘Circle of Life’.
While I’m patching her up, I ask how her fertility treatment went – turns out she got pregnant without any treatment the week after our appointment. Still, I’m taking it.
Thursday, 17 December 2009
Tragically, domestic abuse in pregnancy is still responsible for the deaths of mothers and babies every year in this country. Every obstetrician has a duty to look out for it. This is often difficult as controlling husbands are likely to attend clinics with their wives, denying them an opportunity to speak up. Our hospital has a system to help women disclose abuse – in the ladies’ toilet there is a sign that says ‘If you want to discuss any concerns about violence at home, put a red sticker on the front of your notes’, and there are sheets of red-dot stickers in every cubicle.
Today, for the first time in my career, a woman has dotted a few red stickers on the front of her notes. It’s a tricky situation as she’s attended clinic with her husband and two-year-old child. I try and fail to get the husband to leave the room. I call in the senior midwife and consultant and between us we get her alone.
As gently as we interrogate, it’s not doing any good; she’s clamming up – scared, confused. After ten minutes we establish that the red dots were the early artistic efforts of her two-year-old, who stuck them on the notes when they went to the toilet together.
