During my career as a doctor, for every ‘would you mind having a look at this lump/rash/penis?’ I heard off-duty, there was always one ‘I don’t know how you do it’. I generally heard it from people who wouldn’t qualify for jury service, let alone from medical school, but it’s still a valid point. It’s a difficult job in terms of hours, energy and emotion; and from the outside a pretty unenviable one.
By the time I was six years deep into medicine, the shine had definitely rubbed off the surface. On more than one occasion my finger had hovered over the ‘fuck it’ button – days where things had gone wrong, patients had complained, rotas had changed at the last minute – and my resolve wavered. Not quite enough to start circling the jobs page of the paper, but certainly enough to wonder if I might have any long-lost millionaire aunts on their way out.
But there were two things keeping me there. Firstly, I’d worked long and hard to get as far as I had. Secondly – and I realize it might sound a bit worthy – it’s a privilege to be allowed to play such an important role in people’s lives.
You may be an hour late home, but you’re an hour late home because you stopped a mother bleeding to death. You may have had forty women in an antenatal clinic designed for twenty, but that’s forty women relying on you for the health of their babies. Even in the parts of the job you hate – for me it was urogynaecology clinic, a bunch of nans with pelvic floors like quicksand and their uteri stalagtite-ing into their thermals – each decision you make can immeasurably improve someone’s quality of life. And then a patient sneezes, you have to get a mop and bucket, and you wish you’d plumped for a career in chartered accountancy.
You may curse the job and the hours, own voodoo effigies of the management and even carry a vial of ricin on you at all times in case you ever meet the health secretary, but on an individual basis you really care for all the patients.*
I must have been in this kind of upbeat mood in my fourth registrar posting when I accepted an invitation to represent medicine at my old school’s careers fair. It involved a morning sitting behind a table, while a bunch of gangly fifth-formers lumbered around and asked me questions about my job. Or as it turned out, mostly asked a bunch of other people questions about their more interesting and better-paid jobs. My table definitely looked the least appealing – everyone else had stacks of leaflets and bowls of pens, sweets and key rings. Deloitte were even handing out Krispy Kremes, which felt a bit like cheating. What should I have brought to entice people into a career in medicine? Toy stethoscopes? Amniotic fluid smoothies? Diaries with all your weekends, evenings and Christmases handily crossed out?
The students who did speak to me were clever, driven and erudite – I’m sure they would have all breezed into medical school if they chose to – and I found myself spending a lot of time discussing what’s bad as well as good about the job. Even though I felt protective of my profession, particularly with the other tables around, Christ knows we need people to go into it with both eyes open. So I told them the truth: the hours are terrible, the pay is terrible, the conditions are terrible; you’re underappreciated, unsupported, disrespected and frequently physically endangered. But there’s no better job in the world.
Infertility clinic: helping couples to fall pregnant after years of trying, who’ve all but given up hope – it’s difficult to explain how special that feels. It’s something I’d happily do in my own time and for free (which is handy as I frequently did – those clinics overran by hours). Labour ward: a true rollercoaster, by which I mean everyone generally ends up alive and well despite the fact it seems to be against the very laws of nature. You dart from room to room, delivering any baby who gets sick or gets stuck, making an indelible mark on the lives of these patients. A low-grade superhero – your utility belt containing a scalpel, some tongs and a wipe-clean hoover.
The careers on the other tables had their obvious draws – the principal one being a shit-ton of cash every month – but there’s no feeling like knowing you’ve saved a life. Not even that, half the time; just knowing you’ve made a difference is enough. You go home – however tired, late and blood-splattered – with a spring in your step that’s hard to describe, feeling like you have a useful part to play in the world. I said this little speech about thirty times, and by the end of the morning I felt like I’d been through rigorous couples therapy – talking all the problems out, realizing the spark was still there after all.
I felt uplifted as I left the school hall, actively looking forward to hitting labour ward on Monday. What an honour it is to do this job – even if it is significantly worse than the sum of its parts. I stole a Deloitte doughnut and headed home.†
And the next time someone asked me, ‘Seriously, how do you do it?’ I truly knew what the answer was. Although the reply I generally gave was, ‘I like operating on strangers’ vaginas,’ which at least ended the conversation quickly.
* Except the ones who try and sue you.
† Full disclosure: I did also take a leaflet about their graduate entry scheme.
Friday, 5 February 2010
Doing an elective section for a woman who’d had three previous sections – her abdomen is absolutely rock-solid with adhesions. I call my senior registrar in to help, and demote the SHO to a spectator role. Scar tissue means that bowel is matted to bladder is matted to uterus is matted to muscle is matted to God-knows-what. It’s like ten pairs of headphones have become tangled together, and then the whole thing has been encased in concrete.
The senior reg tells me it will take as long as it takes – we just need to be slow and methodical. Better that it takes three hours than the patient needs her bowel repaired and spends an extra week in hospital. We assume the pace of an arthritic archaeological dig. Every time it gets a bit easier and I speed up, the SR puts his hand on mine and I slow right down again.
Eventually there’s nearly enough space to make the cut and deliver the baby – just one last loop of bowel to gently encourage away from the uterus. I’m in the process of peeling it off when the unmistakeable fetid stench of bowel contents fills the theatre. Shit. Literally. And we were so close.
The SR tells me to deliver the baby – he’ll pop out and bleep a bowel surgeon over to repair the damage.* My SHO interrupts sheepishly, ‘Sorry, guys – that was my bowel . . .’
* To test for a bowel perforation, it’s a remarkably similar method to locating a hole in the inner tube of a bike tyre. You fill the abdomen up with water and pump air through the patient’s anus until you can see where the bubbles are coming from.
Saturday, 6 February 2010
I meet Euan, a friend from university halls, and his wife, Milly, for lunch in town – they’re feeding me in return for picking my brains about fertility issues. The mains arrive and I switch from reminiscence mode to doctor mode. ‘So. How long have you been trying then?’
‘Seven months and two weeks,’ replies Milly robotically, like a cash machine dispensing a tenner. She’s weirdly precise.
In fact, weird and precise would prove to be her watchwords, as she then dips into a tote bag to produce a folder, which she passes to me, stony-faced. I am clearly being granted sight of a document of colossal importance. I flick through page after page of spreadsheets; it takes me a moment to absorb the sheer horror of her magnum opus. This is a database of every time they’ve had sex since coming off contraception, alongside the dates of Milly’s cycle and, distressingly, the length of the session and who was on top. Quite why this was documented in such detail I have no idea, unless it was a deliberate attempt to suppress my appetite and keep the lunch bill down.
I’m totally distracted for the rest of the meal, unable to shake thoughts of my ex-flatmate’s sexual positions and durations, and him clambering on and off, or out from under, with the regimented duty of a workhorse. I manage to collect myself long enough to give them some half-decent advice: giving up coffee and alcohol, the blood tests they should get from their GP, the point where they need referral to infertility clinic.
‘Is it worth keeping the diary going?’ asks Milly.
‘Oh, definitely,’ I say – partly so they don’t think they’ve needlessly shown me a sex almanac and partly to give some poor infertility registrar a good giggle in a few months’ time.
Tuesday, 9 February 2010
Today, as I was making a perineum look slightly more like a perineum after a forceps extraction, the midwife asks mum if she’s happy for her baby to have a Vitamin K injection. The patient treats us to some tabloid newspaper sensationalist scare-story quackery – except it appears this woman may have been holding her paper upside down.
She declines the Vitamin K because ‘vaccines give you arthritis’. The midwife patiently explains that Vitamin K isn’t a vaccine, it’s a vitamin, which is very important to help with baby’s blood clotting. And it doesn’t cause arthritis – maybe she’s thinking of autism, which also isn’t caused by vaccines. Which this injection isn’t.
‘Nah,’ the mum says. ‘I’m not taking any chances with my baby’s health.’
Sunday, 14 February 2010
First Valentine’s Day spent with H in four years. I suggest that, Valentine-wise, going out with a doctor is like having your birthday on the 29th of February.
A lovely Thai dinner at the Blue Elephant restaurant. At the end of the meal, the waiter brings over a pair of heart-shaped sweets in a beautifully carved wooden box. I eat mine whole. Turns out it was actually a candle.
Tuesday, 16 February 2010
Husband and wife are both in tears at the news that baby will need to come out of the sunroof for failure to progress in labour. The main sadness seems to be the husband’s slightly odd obsession with being the first person to touch the baby. There isn’t much time to muse upon why he might want to do this – perhaps he wants to break an enchanted spell or has superpowers he needs to transfer to his offspring – but he is really most insistent. Isn’t there a way he can still be the person who touches her first? If he lifts her out at the end of the caesarean maybe?
He would definitely faint, vomit or both at what it looks like inside an abdomen: a casserole of flesh and giblets cooked up by someone irrevocably insane. Besides, it takes most trainees a good few sections before they can get a baby out by the head – unless he can quickly practise by scooping cantaloupe melons out of a swamp one-handed? Plus no one seems to realize there’s a whole tricky ritual that takes time to learn, namely getting scrubbed and then into gown and gloves. Gloves! ‘How about if we pass baby straight to you?’ I suggest. ‘We’ll be wearing gloves so you’ll be the first person to actually touch her.’
Sold.
Thursday, 25 February 2010
The emergency buzzer goes off in labour ward. The whole team runs down the corridor and none of us can see a room with a flashing light outside.
You’d think they might come up with a more high-tech system given lives are at stake, but we’re stuck with the aeroplane passenger call set-up. One person presses a button, the entire place hears a piercing beep every couple of seconds, and then the cabin crew/obstetric team has to traipse up and down looking for a light, until they find whoever pressed it and can turn the noise off. If only I could swap medical emergencies for something as serene as refilling someone’s G&T or a terrorist saying he’s going to blow up the plane.
The alarm is still going and, with precious time draining away, we decide to go from room to room, checking in on every single labouring patient. Clearly one of the lights has broken.
No one seems to be having an emergency. Where else is there? Changing rooms, labour ward theatres, toilets, anaesthetic rooms, tea room – we split up like Scooby Doo and the gang to cover every inch of the ward. Nothing. A literal false alarm. Aside from the fact it’s deafeningly loud, every single member of staff is conditioned to react to this sound by leaping into action. It’s too unsettling for background noise, much like if the radio started playing an air-raid siren.
We call engineering. Some bloke comes up and fucks around uselessly with a box on the wall for ten minutes. They’ll get someone over to fix it tomorrow, apparently – until then we have the choice of a constantly blaring alarm or no alarm system at all. We summon Prof. Carrow, the on-call consultant, and he’s furious. Mostly because he’s spent the last decade successfully avoiding walking onto labour ward during his shifts, and also – as he points out to the engineer – this counts as an extremely serious clinical incident. Lives are being endangered and the company needs to come out immediately to resolve it. The engineer mutters he’ll do his best, but no promises – and besides, what happened on labour wards a hundred years ago, before emergency buzzers?
Prof. Carrow fixes him with a zero-degree-Kelvin glare. ‘One in twenty women died in childbirth.’
Wednesday, 3 March 2010
Putting in the last of the skin staples after an uncomplicated elective caesarean when the scrub nurse announces there’s a discrepancy in the swab count – one’s unaccounted for.* Don’t panic, we tell ourselves, panicking. We check on the floor and inside the drapes – no swab. We rifle through the placenta and blood clots in the clinical waste bin like the world’s most horrific bran tub – no swab. I call in Mr Fortescue, today’s on-call consultant, to make the decision as to whether we re-open the patient or send her for an X-ray.†
Mr Fortescue decides we should re-open, and we wait for the anaesthetist’s epidural top-up to take effect. He tells me a story from a few years ago: an elderly woman presented to him in clinic complaining of lower abdominal pain. After performing various other investigations, he sent her for an X-ray. The principal finding was the presence of a spoon in her abdominal cavity. After asking various pertinent questions – ‘Have you ever eaten a spoon?’, ‘Do you stick spoons up your vagina or rectum?’ – it seemed unlikely the origin of the object would be discovered. But it was causing her pain and needed to be removed at open surgery, under general anaesthetic.
Sure enough, at surgery, nestled among her intestines and other gizzards, was a dessert spoon. On removal, its only notable features were a number of scratches on the rear surface and the words ‘Property of St Theodore’s Hospital’ stamped onto the handle. Mr Fortescue saw her on the ward post-operatively and they were each equally baffled as to how the spoon had somehow managed to backpack its way from St Theodore’s into her abdominal cavity. Her last contact with them, save for their spoon stirring her innards like a risotto, was a caesarean section back in the 1960s. Some correspondence with St Theodore’s followed, where they firmly denied the routine surgical implantation of spoons, but were able to dig out the patient’s notes. They were unrevealing, spoon-wise – it seems very few doctors who empty canteens of cutlery into patients’ stomachs are going to document it – but did provide the name of the surgeon. The gentleman was long since dead, but Mr Fortescue was eventually able to speak to someone who trained under him, to ask if his old boss was in the habit of breaking mid-caesarean for a spot of baked Alaska. Amazingly, this revealed the explanation. The surgeon in question routinely used a sterilized dessert spoon when sewing up the rectus sheath,‡ to protect underlying structures. On this occasion the spoon had clearly fallen in, and he’d just decided ‘sod it’ and ploughed on.
Our anaesthetist calls over that we’re good to proceed, and as I start to remove the skin staples a midwife runs into theatre telling us to stop because the swab has been found: the baby was holding it. Much relief all round, except from the scrub nurse, who has been subjected to half an hour of unnecessary stress and binsearching. ‘The thieving little cunt,’ she says – not seeing that directly behind the midwife is the swab in question, held by the baby in question, held by its father.
* For every operation, an inventoried set of instruments are used – and they are counted meticulously in and out. Swabs are packed together in stacks of five, and at the end of the procedure, the scrub nurse makes sure that she’s discarding a total number of swabs that are a multiple of five so we know that none have been left inside the patient. (Unless five have somehow been left inside the patient.)
† Swabs are designed with a radio-opaque thread running through them as a marker, which show up on X-rays as a line. A bit unimaginative – I’d have gone for a radio-opaque ‘WHOOPS!’
‡ The rectus sheath is a fibrous layer underneath your abs – when you sew it back up you need to be careful not to accidentally nick any of the underlying organs.
Thursday, 18 March 2010
A&E bleep urgently – a woman is delivering a baby at twenty-five weeks in a cubicle. Myself, SHO, anaesthetist and midwife peg it down to A&E, with the neonatal team following shortly behind, wheeling all their gubbins. She’s huffing and puffing and in a terrible state – the anaesthetist gives her some pain relief. The midwife can’t pick up a fetal heart with the Sonicaid – not good.
I examine the patient. She’s not actively delivering. In fact her cervix is long, hard and closed – she’s not in labour at all. This is odd. I ask where she’s booked for this pregnancy and she says it’s here. Someone looks her up on the computer and there’s nothing, not that this is unusual. The computer denies knowledge of almost every patient – we’d be better off with tarot cards.
One of the A&E staff scrambles to find me an ultrasound machine and I ask the patient when she had her most recent scan. Last week. This hospital, right? Yep. On the fifth floor? Yep. Ah, I see. I send the anaesthetist, midwife and paediatricians away. Any scans for patients here happen on the ground floor of this three-storey hospital.
The ultrasound machine appears, and luckily, given I’ve just sent away the rest of the team, there’s no baby – just some distended loops of bowel making her look pregnant-ish. If you squint.
‘But where’s the baby? Where’s it gone?’ she screams to a packed and no doubt fascinated A&E department. I tell her my colleagues will be along shortly to explain, then ask A&E to contact psychiatry to kindly take over her management. I scoot over to the coffee shop for a sit-down and a quiet reflection on what I’ve just experienced. I’m cross other patients have been potentially endangered by her wolf-cry dragging so many clinicians away from labour ward. I’m baffled as to what she thought was going to happen – she knew she was about to get rumbled, right? And I’m sad for her – what kind of traumas and demons have taken her to a place where she does this? Hopefully my friends in psychiatry are currently giving her the help she needs.
Shame on me for thinking I’d be able to get through a whole coffee undisturbed. I’m suddenly fast-bleeped to labour ward and run there as quickly as I can.
‘Room four!’ shouts the senior midwife as I wheeze onto the ward. It’s the woman from A&E, huffing and puffing away again. She’s clearly not giving up so easily and has absconded from A&E before her psychiatric review to try her luck elsewhere.
She sees me and looks extremely pissed off, parade well and truly rained upon.
Saturday, 27 March 2010
A nice evening out with a few old med school friends to persuade ourselves that our lives are fine, despite significant evidence to the contrary. It’s nice to catch up, even if it needed to be rearranged seven times.
After dinner, we end up at the med school bar for old times’ sake, and then for some reason, perhaps muscle memory from the last time we were there, start playing drinking games. The only game we can all remember the rules to is ‘I have never’. It descends into therapy: all six of us have cried because of work, five of us have cried while at work, all of us have been in situations where we’ve felt unsafe, three of us have had relationships end because of work and all of us have missed major family events. On the plus side, three of us have had sex with nurses, and one of us while at work, so it’s not all bad.
Monday, 19 April 2010
Miss Burbage, one of the consultants, has taken two weeks’ compassionate leave because one of her dogs has died. Much piss-taking in the labour ward coffee room. I come to her defence, to everyone’s surprise, not least my own.
Miss Burbage despises me – she decided I was hateful the moment she met me and hasn’t budged from this standpoint. When I asked if I could get away from clinic early one evening for an anniversary dinner (earlier than it was going to end, not earlier than I was contracted to be there), she told me I should stay, on the grounds that I’d ‘find it easier to get a new partner than a new job’. She told me if I expected to work in diabetic antenatal clinic, where I’d have to speak to patients about their diet, I’d need to have some self-respect and lose some weight (my BMI is 24). She has slapped my hand in theatre for holding a retractor incorrectly, and told me off for blasphemy after I said ‘damn’. She has shouted in front of a patient that I’m an idiot and need to go back to med school.
And yet I’m sat defending her in front of my colleagues. Why make fun of someone for being upset? Surely this is cause to respect her – she knows everyone will find out her tough exterior was just that, an exterior. Shouldn’t we feel sorry for someone who has so little else in their lives that they can be so totally floored by the death of their pet? Grief is grief – there’s no right way and no normal. Mumblings of ‘maybe’ all round, and I wander off, having thoroughly suffocated that conversation with the pillow of my compassion. Two weeks for a dead dog though – the woman’s fucking nuts.
Wednesday, 21 April 2010
One of the medical students saw me after a tutorial and asked me if I wouldn’t mind taking a look at his penis. I did mind, but didn’t really have much choice – it presumably takes quite a lot of nerve to ask one of your teachers to look at your dick. (Except in porn, where it seems to happen fairly regularly.) I took him into a side room and put on some gloves for the illusion of professionalism. He told me his penis was bruised and he’d had trouble urinating since last night.
It seemed there were certain elements of the story he’d omitted; his cock looked like an aubergine that had been attacked by a tiger – swollen, purple, and with deep oozing gashes down its entire length. On further questioning, I learned he was boasting to his girlfriend last night about the strength of his erections and announced to her that its throbbing robustness could stop the rotary blades of a desk fan. His hypothesis was monumentally incorrect and the desk fan proved the clear winner.
I suggested he attend A&E – a couple of the wounds needed closing and I suspected he might need catheterization until the swelling died down. And maybe go to a different hospital’s A&E actually unless he fancied being known to his colleagues for the rest of his time here as Cock au Fan.*
* Or Tony Fancock. Or Dick Fan Dyke. Or Knob-in-Fan Persie.
Thursday, 22 April 2010
Perform my first cervical cerclage,* under the supervision of Prof. Carrow. In pretty much any other procedure, the consultant supervising you can slam his foot on the metaphorical dual controls at any point and stop you doing too much damage. But cerclage is all on you – they can talk you through it, but the tiniest slip with your stitch, anything but the steadiest hand, and you can rupture the membranes and end the pregnancy, doing exactly what the procedure is trying to prevent. And there’s no way to practise the technique at home, like the way we learned to close wounds as house officers by cutting into an orange and sewing it back up.
Patient SW lost her first pregnancy at twenty weeks and is now thirteen weeks into her second. Prof. tells me to take it nice and slow, as steadily as I can. I’m aware that any shaking of my hand is magnified tenfold at the other end of the long needle-holding forceps, up by her cervix. Deep breaths, blink the sweat out of my eyes, one stitch, two, three, four, done. Got away with it.
I think it’s the first time I’ve changed into a fresh pair of scrubs because my own sweat was the bodily fluid soaking me. It occurs to me scrubs are probably that shade of blue so patients can’t see your sweat marks – a calm and professional demeanour is all well and good until the rapid darkening of your underarms betrays you.
Later, I realize there actually would be a way to practise the exact kind of small motor skills I need ahead of next time. I text my mum to ask if she by any chance still has that game of ‘Operation’ tucked away in a drawer.
She replies to say she’s found it. She also has a Magic 8-Ball, she tells me, in case I need it for my diagnoses.
* Cervical cerclage is the treatment for cervical incompetence – a slightly horrible, cervix-shaming term for when the neck of the womb opens far too early in the pregnancy, causing late miscarriages or very pre-term births. The cerclage stitch is inserted during the first trimester of pregnancy and hopefully holds the cervix shut until just before full term.
Saturday, 24 April 2010
Moral maze. Patient AB is in labour and has a non-reassuring trace. She’s on her third midwife of the shift, having hurled racist abuse at the first two (black) midwives who had been looking after her. One more episode like that, she’s been warned, and she’ll be kicked off the labour ward. My SHO has reviewed the CTG and advises me that AB needs a caesarean section. Because I’m not entirely sure of the legality of following through with the threat to boot her out, the Indian SHO and I choose to ignore the fact that the patient has made racist comments to her too.
On reviewing the patient, I agree with the SHO – c-section it is. I transfer her to theatre and decide to stay tight-lipped about the fact I’m Jewish. The operation is straightforward, and a little boy is delivered safely (presumably to be immediately dressed up in ‘Baby’s First KKK Hood’ and given a rattle in the shape of a burning cross).
But. If the patient had a dolphin tattoo on her right groin, would it be so bad if my skin incision was slightly wider than usual and I had no choice but to decapitate the dolphin? I could say, if pushed by an official inquiry (or some EDL henchman) that I’d been worried the baby was larger than average and it had made sense to have a good-sized operative field. And on closing the skin, would it be so bad if the wound didn’t approximate very well for some strange, almost certainly unprovable reason, leaving the dolphin’s head positioned a good inch to the left of its body?*
* Well, we’ve spoken to a lawyer and the answer, it turns out, is, ‘Yes. That would totally be assault.’ So we’ll say that I didn’t do it.
Saturday, 1 May 2010
I’m discussing a case with my colleague Padma in the coffee room after antenatal clinic, and a midwife leaps into the conversation with, ‘We actually don’t like to use that word any more.’ Wondering what outmoded terminology we’ve accidentally used (Consumption? Scrofula?), she lets us know that we said ‘patient’. We should actually say ‘client’ – calling them patients is not only paternalistic and demeaning, but pregnancy is a normal and natural process rather than a pathological one. I just smile and remember the wise words taught to me by Mr Flitwick, one of my very first consultants, with regards to arguing with midwives – ‘Do not negotiate with terrorists.’
Padma clearly has no such qualms. ‘I had no idea patient was such a demeaning term,’ she says. ‘I’m so sorry, I’ll never use it again. Client. Client’s much better. Like what prostitutes have.’
Sunday, 9 May 2010
Having a poo on labour ward when the emergency buzzer goes off, and within minutes I’ve delivered a baby at crash caesarean section. The second the buzzer sounded I crimped it off, but my wiping was cursory at best, which is why my arse is now unbearably itchy while I’m scrubbed into theatre. It’s acceptable to ask someone who’s not scrubbed – a midwife or ODP – to push your mask or glasses up if they’re falling off, or even to itch your nose. Would it be pushing it too far to ask them for a quick anal scratch?
Monday, 24 May 2010
I never volunteer my opinions on home births, but if, as today, a patient specifically asks me what I think of them, what I’d have if it were me, then I’ll be honest. It’s a five-minute speech, as follows: I tell them I don’t doubt for a second that a home delivery that goes to plan must be a hundred times more calm, relaxing and pleasant than a hospital birth. (Though I’m not sure I could ever personally relax knowing that at any moment a blood and amniotic fluid emulsion might slosh onto the sofa. How would you go about getting that out?)
I then tell them I respect patient choice and that it’s crucial they feel absolute ownership of their care. I tell them I get worried by the increasing promotion of ‘natural’ birth, and that demedicalization of pregnancy isn’t necessarily a good thing – we should be proud of medical advances that objectively save lives, not scared of them.
I say I’ve seen a number of near misses, including one where we were seconds away from losing a child who’d been transferred to the labour ward when a home birth had gone pear-shaped. I also describe hospital deliveries I’ve seen in low-risk* mothers where rare and unpredictable events meant they or their baby would certainly have died outside of a hospital environment.
I promote midwife-based units, where women can have magical, wonderful births in more controlled environments. Crystals, beanbags, someone singing Radiohead songs backwards in Swedish – whatever floats your boat, just as long as you’re a few hundred yards from a labour ward and their team of shit–fan separation specialists.
I acknowledge that when it comes to home births I only see the disasters and never the successes, which some people describe as a fatal flaw in my argument. Presumably they also have issues with firemen who advise the use of seatbelts, because they only see the drivers they angle-grind out of pile-ups, not the majority of safe car journeys. I will put my hand on my heart and tell the patient I implore anyone close to me to think twice about having a home delivery.
Unfortunately, today’s clinic is running massively late, and I’ve got a dinner date, so I don’t have time for all this. Instead, I give the abbreviated version: ‘Home delivery is for pizzas.’
* On booking into antenatal clinic, patients are categorized as either high or low risk, and low-risk mothers are eligible for home births. People tend to forget that ‘low risk’ doesn’t mean ‘no risk’.
Wednesday, 2 June 2010
Teaching medical students this morning – they’re keen to brush up on their X-ray reporting skills. I grab a couple of films from the trolley and shove one up on the light box. It’s a normal chest X-ray of a patient, taken pre-operatively. The first student steps up to present.
‘This is a PA chest radiograph taken yesterday of a sixty-four-year-old female patient with name NW and date of birth 03/01/46. There is adequate inspiration and the film is well penetrated and not rotated.’ He’s good.
‘The trachea is central, the mediastinum not displaced and the cardiac contours are normal. The obvious abnormality is a curvilinear mass in the superior lobe of the right lung, occupying . . .’
Hang on. Abnormality? Where the hell did that come from? Holy fuck. I reviewed this earlier and missed a tumour – I’ve sent the patient off to surgery and her certain death. I push past the student to get a better look at the cancer. Then I reposition the X-ray slightly and the mass moves. It was a ‘Give Blood’ sticker on the light box.
*My friend Percy was working as an orthopaedic SHO when there was a trauma call to A&E – a motorcyclist had flown off his bike and broken all sorts of bones. The chest X-ray (routinely performed to check lungs haven’t been punctured), Percy was proud to announce, showed Varicella Pneumonia – a rare and dangerous complication of chicken pox with a characteristic X-ray appearance. The patient was clearly septic with this pneumonia, which caused him to lose control and fly off his bike. Or, as it eventually turned out, his lungs were fine – but loads of gravel had gone up the back of his jacket and shown up on the X-ray.
Saturday, 5 June 2010
My life is starting to feel like an episode of Quantum Leap. I’ll suddenly wake up and not know where I am or what I have to do. Today, I startle awake to a loud knocking sound – I’m sitting in my car asleep at a set of lights and an old boy is rapping on the window with the handle of his umbrella, asking if I’m OK.
It’s the second unexpected power nap of the night shift, after a scrub nurse tapped me on the shoulder while I was sat fast asleep on a theatre stool to tell me the patient was just being wheeled in for her marsupialization.* We’re repeatedly reminded not to use empty patient side rooms to catch any sleep overnight – the management maintains we’re paid to work full shifts. I want to ask the management if they’ve heard of that big ball of fire in the sky that makes it slightly harder to sleep during the day than at night? Or how easy they think it is to suddenly switch from working during the day and sleeping at night, to the exact opposite within twenty-four hours? But most of all I want to ask: if they or their wife needed an emergency caesarean section at 7 a.m., would they rather the registrar doing it had caught forty minutes’ sleep when things were quiet, or had been forced to stay awake every second of the shift?
It’s a surreal feeling being this tired – almost like being in a computer game. You’re there but you’re not there. I suspect my reaction times are currently the same as when I’m about three pints deep. And yet if I turned up at work pissed they’d probably be unimpressed – it’s clearly important my senses are only dulled through exhaustion.
I left work at 9.30 a.m. – it took me an hour to write up the notes for my last caesarean because I was really struggling to find the words, like I was trying to bodge the sentences together in Spanish for my GCSE. Do the courts take this into consideration when you nod off and mow down an entire family on the way home?
* Marsupialization is the treatment for a Bartholin’s abscess – when the glands that provide vaginal lubrication become infected. You create a pouch to help the abscess drain – hence marsupialization, like a genital kangaroo.
Friday, 11 June 2010
I tell a woman in antenatal clinic that she has to give up smoking. She shoots me a look that makes me wonder if I’ve accidentally just said, ‘I want to fuck your cat,’ or, ‘They’re closing Lidl.’ She refuses to entertain the idea of a smoking cessation class. I explain how bad smoking is for her baby, but she doesn’t particularly seem to care – she tells me all her friends smoked through pregnancy and their kids are fine.
I’m tired and just want to go home. I look at the clock: it’s half six, clinic was meant to end an hour ago and she’s far from the last patient on my list. I snap.
‘If you don’t stop smoking when you’re pregnant with a child then nothing on earth will stop you smoking, and you’ll die of a smoking-related illness.’ As I’m saying this I can hear it being repeated back to me slowly by a lawyer – I immediately apologize. But strangely, it seems to have worked – she looks at me like it’s the first time she’s ever truly listened to anyone, like she’s about to stand on the chair and exclaim, ‘O Captain! My Captain!’ She doesn’t, as luck would have it, because the chair doesn’t look like it could take it, but she does ask me about those smoking cessation classes. Good to know that death threats are effective on my patients.
On her way out she jokes, ‘Maybe I’ll start heroin instead!’ I laugh, and don’t mention that yes, that would genuinely be safer for her unborn child.
Monday, 14 June 2010
Prof. Carrow is the consultant on call for labour ward today, which is about as much use as having a cardboard cutout of Cher on call for labour ward. In fact, Cardboard Cher might at least raise morale a bit.
You don’t see Prof. Carrow during the day, you don’t phone him at night – he’s far too important for all that nonsense. When he appears on the ward this evening I can only assume that he’s got lost or one of his first-degree relatives is currently giving birth.
It all falls into place as a documentary film crew show up behind him, cameras rolling.* ‘Talk me through the labour ward board,’ Carrow says to me, which I do. He nods along for the cameras. ‘Sounds like you’ve got it all under control, Adam. But if you’ve got any problems at all during the night, just call me.’ The crew have what they want and stop recording. Prof. doesn’t miss a beat before saying, ‘Obviously, don’t.’
* In London you’re never more than six feet from a rat – and in a big hospital you’re never more than six feet from a documentary film crew.
Tuesday, 15 June 2010
I’ve spent a lot of time with patient VF, as I’ve been performing FBSes* on her baby every hour. She and her husband have been having a blazing argument for the last four. It started with something about his parents, we’ve heard all about some friend’s wedding where she was flirting with Chris again and now we’re on to money. If I was at their dinner party I’d have secreted my uneaten pudding into a napkin, made my excuses and headed home ages ago, but I don’t really have any choice but to eavesdrop. It’s a thorough demonstration of the threadbare state of their relationship – I feel like a marriage counsellor who’s been rendered completely mute.
In truth, they’re behaving equally despicably, but given she’s currently in labour – a famously non-fun process – I have to award him 100 per cent of the bastard points.
At one stage he goes out to take a phone call and the midwife quite rightly checks with VF that he’s not been hitting her. She assures the midwife this isn’t the case. He returns, the arguments continue, then escalate. He’s puce-faced and yelling at her – we all ask him to either calm down or step out of the room. He screams at her, ‘I never wanted this fucking baby anyway,’ and storms out, never to reappear in the hospital. Jesus.
* Fetal Blood Sampling (FBS) is the most accurate way of checking baby’s well-being – you lie mum on her side, stick a short length of guttering in her vagina and make a cut on the top of baby’s head using a knife on a long stick. There’s no pretending it’s any more advanced than this. You then collect a drop of blood in a small capillary tube, and the midwife runs off to drop it, lose it, find that the machine is broken or occasionally report back with the pH of the baby’s blood. For some reason they choose not to mention this fairly common procedure in antenatal classes.
Friday, 18 June 2010
Patient RB presented to A&E with an ambulance crew and two police officers. And also, of note, a foot of metal pole protruding from her. She was being chased on foot by the police for some reason or other, and her escape plan involved climbing over some railings into a park. The escape plan unfortunately failed just as she was getting over the railings, when she slipped and one of the metal spikes slid up her vagina and penetrated through the front of her abdomen.
She’d had the presence of mind to get off her face on cocaine earlier in the evening, which anaesthetized her sufficiently until the Fire Brigade arrived on the scene and were able to cut off the railing just below vagina level (while presumably saying ‘holy shit’ quite a lot). She arrived here haemodynamically stable and remarkably well, all things considered, so we arranged an urgent CT to delineate precisely which cuts of meat were skewered on this particular kebab. Miraculously, she’d avoided damage to her bladder and major blood vessels, so it was just a case of taking her to theatre and sewing up the entry and exit wounds.
We reviewed her after surgery – sober, sore, embarrassed and with a police chaperone, as she was still under arrest. We told her that all looked well and gave her a post-operative management plan. She asked if she could keep the spike as a souvenir, and I said I couldn’t see any reason why not. The policeman came up with a convincing one – it’s really not a good idea to give an arrested criminal a weapon capable of piercing an abdomen.
Tuesday, 22 June 2010
What to do when you’re managing an emergency and there’s another emergency? I’m on labour ward when the buzzer goes off – mum’s pushing and there’s a horrendous-looking trace, baby needs to be urgently lifted out with forceps. I do the necessary and baby comes out quickly, but it’s floppy. The paediatrician does her magic and the baby yelps to life. Placenta out and the patient is bleeding moderately, from a combination of the generous episiotomy* and a slightly boggy uterus. I start to do part two of the necessary when I hear another emergency buzzer. I’d better stay – this could quite easily escalate into a major PPH,† and in any case she’s already losing blood every moment I’m not sewing her up or calling out the name of the next drug for the midwife to inject. On the other hand, this other unknown emergency could be much worse – and my current patient is very unlikely to suffer permanent harm if I leave her in the hands of an experienced midwife.
It’s daytime, but who’s to say all my colleagues aren’t busy with patients, each assuming someone else will attend the emergency buzzer, which continues to sound. Or what if it’s the kind of emergency that needs all hands on deck? I consider sending the midwife to report back, but that minute might be critical for the other patient. I hand the midwife a large swab and tell her to press hard on the perineal wound until I get back, and give her instructions about the next couple of drugs to get into the patient if necessary. I sprint out. The light is flashing outside room three and I bound in, hoping I’ve made the right decision. Naturally, I haven’t.
A midwife is running a CPR drill. There’s a mannequin on the bed and a bunch of doctors and nurses calling out what they’d do were this a real emergency. Which it isn’t. Unlike the one I’ve just left. ‘Right, the registrar is here,’ says the midwife to the SHO. ‘What would you like him to do?’ What I in fact do is walk up to the mannequin, push it off the bed and call the midwife a cretin, accusing her of deliberately sabotaging patient safety. Then I bolt back to the first room, where all is thankfully stable, and get my non-imaginary patient as good as new. (OK, not quite.)
I clearly hadn’t expressed my feelings adequately earlier, as the midwife supervisor takes me aside afterwards and asks me to apologize to the midwife in question for disrupting her simulation and upsetting her. My apology takes the shape of a clinical incident form, citing this simulation as a dangerous near miss. I’m sure I used to be nice before this job.
* An episiotomy is a cut made with scissors (I’d love to say they were special surgical scissors but they’re just normal scissors) into the perineum to prevent a tear that would be harder to repair or might go into the anus. Essentially, it’s a controlled explosion.
† PPH means postpartum haemorrhage to half of all doctors and primary pulmonary hypertension to the other half, due to a naming ambiguity.
Wednesday, 23 June 2010
An email reminds us of the crucial importance of skills drills training for all clinical staff. However, before any drill is called, it is now policy to check all rooms to ensure no staff are otherwise engaged in emergencies.
Monday, 5 July 2010
A rare bit of continuity of care today. I saw this patient a month or so back in Miss Burbage’s general gynae clinic, and it sounded very much like she had premature ovarian failure. Early menopause is rather beyond my scope, which I confessed to the patient, and excused myself while I left the room to speak to Miss Burbage for a management plan. She thought it was beyond her scope too, and it would be best to pop her into Mr Bryce’s specialist endocrinology clinic in the next available slot. The patient wasn’t too upset about the waste of her morning, knowing that she was getting to see the expert next time.
Today, however, I’m the registrar in Mr Bryce’s endocrinology clinic, and he’s off on holiday. Last time I saw the patient, I said I didn’t have the faintest idea about her condition, and now she’s sitting opposite me, having given up another afternoon to be here, expecting answers, needing help. Do I say I was just being modest last time? That I’ve been on a course since then? Do I put on an accent? Fake moustache?
I book her into clinic in a fortnight, when I know I’ll be on nights, to avoid the possibility of a hat-trick.
Tuesday, 27 July 2010
Ron tried to dump me as a friend today – a proper, sombre, grown-up discussion. He doesn’t know why he bothers trying to keep in touch with me when it’s clear our lives have drifted apart massively since school.
I should at least vary up the excuses I give him. Do I really expect him to believe I couldn’t come to his engagement party or his stag do because of work? That I couldn’t make the wedding ceremony because of work, and almost missed the reception as well? That I missed his dad’s funeral and his daughter’s christening because of work? He knows my job’s full-on, but how hard can it be to swap shifts if it’s something you really want to do?
I put my hand on my heart and swear to Ron that I love him, he’s one of my best friends and I wouldn’t lie to him. I know I’ve been useless, but I’ve seen a lot more of him than almost anyone else I know – the job is just unimaginably busy. Non-medics can never appreciate quite how tough it is to be a doctor and the impact it has on real life. I totally lied about the christening, though – fuck that shit.
Monday, 2 August 2010
It’s the final shift of the job – a night shift, naturally. My new post starts an hour before this one ends, about ten miles away – but I’ll cross that bridge when I come to it, two hours late and bleary-eyed.
Technically this job ended at midnight, a fact that occurs to me on the stairwell at 12.10 a.m. when my swipe card refuses to let me back onto the ward and I realize it’s been automatically deactivated. I’m Cinderella in scrubs.
If you ask the hospital to adequately staff a department, provide an effective computer system or even supply enough chairs for clinic, you’ll get a shrug and a display of colossal incompetence. And yet when it comes to being able to get in and out of doors, they somehow take on the organizational skills of a cyborg librarian. If swipe cards suddenly start developing cancer, a cure will be found immediately.
I endure a mere quarter of an hour of banging on doors and praying the crash bleep doesn’t go off before someone spots me and lets me back onto the ward.*
* The savvy obstetrician doesn’t carry his mobile phone in his scrubs. All it takes is one iPhone to drown in a tsunami of blood for you to learn your lesson; and I can assure you that no amount of soaking it in rice will revive it.
