Medicine is the host who manages to keep you at their party hours after you first think about leaving. ‘Don’t go before we’ve cut the birthday cake . . . You must meet Steve before you head off . . . I think Julie lives over your way – she’s off home in a minute, why don’t you go together . . .’ Then before you know it you’ve missed the last train back and you’re crashing on the sofa.
Having gone to medical school you might as well finish and become a house officer, then you might as well become an SHO, then you might as well become a registrar, then you might as well become a senior registrar and by then you’re practically a consultant. There almost certainly don’t need to be so many different grades; I strongly suspect it’s designed so that the next step is always just round the corner. It’s the £50 note you chase down the street, swept up by another gust of wind the millisecond before your hand makes contact. And it definitely works. One day I realized – as if blinking awake after a serious accident – that I was now in my thirties, still in a career I’d signed up for fourteen years earlier, based on the very flimsiest of reasons.
My ID card and salary now proudly said ‘senior registrar’ (although in fairness my salary also said ‘bank cashier’ or ‘reasonably experienced milkman’) and my next few postings would bridge the gap from junior doctor to consultant. And, in fact, life as a consultant looked pretty appealing. The pay goes up, the hours go down. Admin sessions, days off. No one forcing me to do urogynae clinics. My name in capital letters at the top of my parents’ will (probably followed by ‘he’s a consultant gynaecologist, you know’). And, best of all, stability: a job that I can stay in as long as I want, where I don’t have to pack my bags as soon as I’ve memorized the code on the changing-room door.
But first I had to get through my senior registrar posts – the storm before the calm. Yes, my registrar jobs had been manic and relentless, but this was a different kind of stress – now I was the highest-ranking person in the department out-of-hours. Knowing that when my bleep went off it was a problem that both the SHO and the registrar had failed to resolve. Knowing that if I couldn’t deal with it, a mother or a baby might die. Having a consultant at home ‘on call’ is just a formality: most emergencies will be over in a matter of minutes, before they can even change out of their dressing gown. I would now need to accept ultimate responsibility for the fails and fuck-ups of an SHO and registrar I may have never met before. While I’d often go unbleeped for an hour or two on a night shift, I preferred to prowl anxiously around labour ward, flitting from room to room asking ‘Is everything OK?’, suffering the occasional flashback to that registrar who told me as a student that obs and gynae was an easy speciality. Lying bastard.
So it wasn’t the biggest surprise in the world when I registered with a GP and the practice nurse recorded my blood pressure as 182/108 mmHg.* She wouldn’t accept my explanation that I was just off a night shift with two locums, still tightly wound from twelve hours on the wards, my mind jittering with a dozen medical equivalents of ‘Did I turn the gas off?’ Did the patient have that CT scan? Did I put in a second layer of stitches? Did I prescribe that methotrexate?
She booked me back in to see the GP the following week, and it was just as high. Again, I was straight back from work. I assured her I’d checked it myself in clinic and it was completely normal, but she wanted to be sure, just the same. In fairness to her, I was totally lying: I’d done no such thing. She arranged for me to have twenty-four-hour ambulatory monitoring.† Because days off work were in short supply, I wore it on an antenatal clinic day, making it practicable (I won’t have to go to theatre) plus theoretically low stress. I sat in clinic and explained to patients that I needed to start them on antihypertensive medication, despite the device strapped to my arm proudly displaying that my blood pressure was significantly higher than theirs.
Among all the predictably ‘hilarious’ remarks the patients made to me, one said something surprisingly astute. ‘It’s funny – you don’t think of doctors getting ill.’ It’s true, and I think it’s part of something bigger: patients don’t actually think of doctors as being human. It’s why they’re so quick to complain if we make a mistake or if we get cross. It’s why they’ll bite our heads off when we finally call them into our over-running clinic room at 7 p.m., not thinking that we also have homes we’d rather be at. But it’s the flip side of not wanting your doctor to be fallible, capable of getting your diagnosis wrong. They don’t want to think of medicine as a subject that anyone on the planet can learn, a career choice their mouth-breathing cousin could have made.
After an hour at home, my blood pressure returned to normal, so mercifully my arteries were still in decent nick. Plus it was interesting to be able to quantify in millimetres of mercury precisely how stressful it was to be a senior registrar.
* You’d want your blood pressure to be under 120/80 mmHg, aka millimetres of mercury. If you stuck a glass tube full of mercury into your heart, it’s the number of millimetres the pressure would push the level up – though these days we use a slightly less invasive method to measure it. The top number is the pressure when your heart is going ‘lub’, the bottom number is when it’s going ‘dub’.
† Ambulatory monitoring involves wandering round with a blood-pressure cuff on your arm for a day, which inflates every fifteen mins or so and records the data for the doctor. It’s particularly useful in ‘white coat hypertension’ when patients get nervous on visiting the doctor, so their BP rockets up whenever it’s measured. About a week before finals at medical school, my friend Antonin asked during a tutorial, ‘Why’s it called white goat hypertension?’ He’s a consultant haematologist now if you want to watch out for him.
Monday, 9 August 2010
A patient named their baby after me today. It was a planned caesarean for breech presentation, and after I delivered the baby I said, ‘Adam’s a good name.’ The parents agreed, and job’s a good ’un.
I say ‘Adam’s a good name’ after every single baby I deliver, and this was the first time that anyone’s ever said yes. I’ve not even had a middle name before. But today this wrong was righted, and the squad of Adams I so richly deserve was launched in theatre two. (I’m not sure what I’ll do with this team once they’re assembled. Fight crime, maybe? Get them to cover my shifts?)
The SHO assisting me in the caesarean asked how many babies I’ve delivered. I estimated 1,200. He then looked up some population data and told me that on average 9 of every 1,200 babies born in the UK would be called Adam. I have genuinely put off eight sets of parents from naming their child after me.
Sunday, 15 August 2010
Summoned to a delivery room by one of the junior registrars – she’s struggling to lock a pair of forceps onto the baby’s head. We’ve had the occasional set of mismatched pairs sent to us recently – two left sides or slightly different models packed together after sterilization. On examination, the left blade is placed well on the side of baby’s head. The right blade, however, is wedged halfway up the patient’s rectum.
Mistake corrected and baby delivered safely. (By me – at this point I wouldn’t trust the registrar to deliver a limerick.)
‘Do we have to tell her?’ she asks conspiratorially, testing my ethical boundaries like I’m a builder and she’s hoping to avoid the VAT.
‘Of course not,’ I say. ‘You do.’
Monday, 23 August 2010
Week three of the job and I’m just about up to speed with the infertility* treatment eligibility criteria here. Today I saw a couple who’ve had an unsuccessful round of IVF – which was unsurprising. Chances of success in their particular case were around 20 per cent for a single cycle. Where I worked a month ago, a walkable distance away, they’d have qualified for three cycles, which would have upped their odds to nearer 50 per cent. They ask me what private treatment would cost and I tell them – around four thousand pounds for a cycle. The look on their faces tells me I may as well have said four trillion pounds.†
People say it’s a choice to have kids, which is of course true. But no one argues that patients with recurrent miscarriages shouldn’t be allowed treatment until they have a baby – and the NHS rightly doesn’t limit their care. And how about the patient who had two ectopic pregnancies, leaving her with no fallopian tubes and no chance of getting pregnant without IVF? All we’re doing is allowing people to make a choice they would have otherwise had were it not for a medical condition. Or not, because their surname begins with the letter G. I’m exaggerating of course – that would be ridiculous. They’d only be denied it for sensible reasons, such as living one road outside of an arbitrary catchment area.
I suggest they take a bit of a break to think about their options and come to terms with their feelings. I float the possibilities of fostering or adoption. ‘It’s not the same though, is it?’ the husband says, and no, it’s probably not.
In the short time I’ve been working here I’ve told a lesbian couple they are eligible for treatment but a gay male couple wanting surrogacy that they’re not. I’ve told a woman she’s too old for treatment according to our criteria, even though she wasn’t too old when she was referred here a few months ago. (And wouldn’t have been too old a few streets away.) I’ve been cast in the role of a malevolent god.
Here there’s a BMI limit for receiving treatment – something I’ve never encountered before. I had to tell a patient she was three kilos too heavy to be referred for IVF and to see me again when she’d lost the weight. She burst into tears, so I accidentally recorded her weight on the form as a few kilos too light.‡ Last week I wrote a letter citing exceptional circumstances, requesting treatment be allowed for a woman who had a child from a previous relationship who died in infancy, which cruelly makes her ineligible for treatment here.
I leave clinic, passing a rack of leaflets that details all the different fertility treatment options that the NHS in this area makes it all but impossible to receive. We should be more honest and replace them all with one called, ‘Have you thought about getting a cat?’
* Infertility clinic got rebranded to ‘subfertility clinic’ during the course of my training to make it sound less negative, and then again to ‘fertility clinic’, which feels a bit ‘la la la this isn’t happening’ fingers-in-ears-y. Unless over in oncology they’re now running the ‘definitely not got breast cancer’ clinic?
† In most aspects of private medicine, you get a mild upgrade on the NHS, but no huge difference in actual care. You get seen a bit quicker, the receptionist’s got all her teeth and there’s a decent wine list for your inpatient stay – but ultimately you get the same treatment. When it comes to infertility medicine though, the private sector is leagues ahead – they will investigate and treat you until you have a baby (or an insolvency order). The NHS requires you to fit into quite a narrow demographic to qualify for any treatment, and it’s often not enough to achieve a positive result. I understand there’s a limited pot of money, but you don’t ever hear this said in other corners of medicine. ‘We don’t treat leukaemia – there’s a limited pot of money.’ ‘We only treat fractures on the right side of the body – there’s a limited pot of money.’
‡ Is this the ‘one weird weight-loss trick that doctors don’t want you to know about’ much vaunted by internet adverts?
Wednesday, 25 August 2010
An eighty-five-year-old, long-stay gynae oncology patient broke our hearts on yesterday’s ward round. She misses her late husband, her children have barely visited since she’s been in hospital and she can’t even have her usual whiskey nightcap in here. I decided to play Boy Scout, prescribed whiskey (50 ml nightly) on her drug chart and gave the house officer £20 to get a bottle from the supermarket to pass on to the nursing staff, so they can fulfil the prescription on their drug round.
This morning, the ward sister reports that the patient declined her drink because, and I quote: ‘Jack Daniel’s is fucking cat piss.’
Monday, 13 September 2010
A new midwife supervisor, Tracy, has started this week and seems absolutely lovely – calm, experienced and sensible. She is now the second midwife supervisor on the unit called Tracy, the current one being a flappy, angry nightmare. To avoid confusion, we have nicknamed them ‘Reassuring Trace’ and ‘Non-reassuring Trace’.
Friday, 24 September 2010
Moral maze. A Crackerjack bleep from theatre – it’s Friday, it’s five to five, it’s something enormously time-consuming. Today’s contestant is an emergency ectopic, and theatre would like me to pop up now. This is particularly annoying timing as it’s date night. In fact, it’s more than date night. It’s date night somewhere extremely expensive to apologize for half-a-dozen recently cancelled date nights and to paper over the widening fault lines in our relationship. It’s D-Date night. I should be fine if I leave by 6 p.m., I tell myself. At 5.45 it’s time to start operating. The evening registrar is stuck in A&E and can’t relieve me.
Best practice is to operate laparoscopically – about an hour’s work for me, it leaves the patient with a couple of tiny holes and she’ll be home tomorrow. Alternatively, I can make a quick incision in this twenty-five-year-old’s pristine abdomen and sentence her to a proper scar and a longer hospital stay – but get away on time and keep my relationship on track. Besides, maybe the patient likes hospital food? I hesitate for a moment more, then request the laparoscopy set.
Tuesday, 5 October 2010
On the phone to my friend Sophia, having a moan about the levels of exhaustion and demoralization in our hospitals. We’re both pretty fed up. She tells me she’s just got her private pilot’s licence and is planning to take a break from the NHS. ‘And work for an airline?’ I ask.
Actually, she’s going to charter an aircraft and fly it around twenty-four African countries, visiting remote areas where maternal morbidity is the highest and teaching the local midwives some life-saving techniques. She’ll also donate huge amounts of medical supplies and educational resources which she’s going to fundraise for before she sets off. Now I feel exhausted, demoralized and selfish.
Monday, 11 October 2010
A text out of the blue from Simon; no news has been good news for the last eighteen months so my heart rather sinks when I see his name pop up. He’s just asking for my address – he wants to send me a wedding invitation. I’m choked up that he’d think of me, and very much looking forward to intending to go, then pulling out at the last minute due to work.
Tuesday, 12 October 2010
The final patient of a comically busy antenatal clinic requests an elective caesarean section because of a previous traumatic vaginal delivery. This is a fairly common request – principally because there’s no such thing as a non-traumatic vaginal delivery. The SHO who saw her last did the sensible thing and requested the notes from the hospital where she had her last baby, and I skim through them to see if anything particularly traumatizing had happened.
She had a long labour, resulting in a forceps extraction, and needed repair in theatre afterwards for a cervical tear. That night, she had a gargantuan postpartum haemorrhage, which caused her to arrest. She was successfully resuscitated – clearly, given she’s sitting in clinic – and was taken back to theatre to resew her tear. This second attempt – almost unbelievably – went even worse and resulted in damage to her small bowel, and ultimately to a small bowel resection and stoma formation. Then a series of clinic letters from psychiatry, documenting her gradual recovery from PTSD caused by these events, and the collapse of her marriage. And now she’s back to do it again. The woman must be so hard you can skate on her; let her have what she wants.
I book her in for an elective section. It’s nice to have the bar set so low that almost anything we do will be a considerable upgrade on last time.
Thursday, 14 October 2010
I was slightly weirded out the first time a patient started texting during an internal examination, but now it seems reasonably common. Today, during a smear test, a patient FaceTimed her friend.
Sunday, 17 October 2010
I attend an emergency buzzer late at night – it’s a shoulder dystocia.*
It’s clearly a big baby, quadruple-chinned through how tightly its neck is being squeezed back against mum’s perineum – and it’s an experienced midwife, who I know will have already tried everything in the book. There’s no pretending to the patient this isn’t serious, but she’s a dream so far – remaining calm and going along with everything asked of her.
I drain the bladder with a catheter, put her legs in McRoberts’ position, apply suprapubic pressure. This is like no shoulder dystocia I’ve dealt with before. There’s no give at all; the baby isn’t budging. I ask the midwife supervisor to see if there are somehow any obstetric consultants in the building. I attempt Wood’s Screw manoeuvre: nothing. I attempt to deliver the posterior arm: impossible. I roll the patient onto all fours and try all the manoeuvres again in this position. I ask the midwife to get my consultant on the phone. It’s approaching five minutes of shoulder dystocia and something needs to happen urgently if the baby’s going to live.
As I see it, I have three options as last-ditch attempts. The first is Zavanelli’s manoeuvre – push the baby’s head back inside and perform a crash caesarean section. I’ve never seen it done but I’m confident I can manage it. I’m also fairly confident that by the time we get her delivered in theatre the baby will have died.
Second option is to intentionally fracture baby’s clavicle to allow baby to deliver. I have never seen this done either, and have no real idea how to go about it – it’s a famously difficult procedure, even in much better hands than mine.
Third option is to perform a symphysiotomy, cutting the mother’s pubic bone to make the outlet bigger. Again, I’ve never seen it performed, but I’m sure I can do it easily, and that it will be the quickest way to get the baby out. I inform the consultant over the phone that this is what I’m going to do – she checks what I’ve tried so far and confirms my understanding of how to perform it. She’s driving in from home, but we both know that by the time she arrives everything will be over, one way or the other.
I feel as sick as I’ve ever felt in a clinical situation: I’m about to break a patient’s pelvis and it might already be too late for her baby. Before I take the scalpel to her I have one last attempt to deliver the baby’s posterior arm. All the various manoeuvres and shifts in position have somehow made something budge, and the arm delivers, followed by a very limp baby, who the midwife passes to the paediatricians. As we wait for the cry that may or may not come, I remember an old phrase in the textbooks that describes a successful shoulder dystocia delivery as ‘greater strength of muscle or some infernal juggle’ and totally get what the author was on about. The baby cries. Hallelujah. The midwife bursts into tears. We will have to wait and see if there’s an Erb’s,† but the paediatrician whispers in my ear that both arms seem to be behaving normally.
I see that I’ve given the mother a third-degree tear, which isn’t ideal, but is pretty minor collateral damage in the grand scheme of things. I ask the midwife to prepare her for theatre – that’ll give me twenty minutes to write up my delivery notes and grab a cup of coffee. My SHO comes in – can I quickly do a ventouse extraction in another room?
* Shoulder dystocia is one of the scariest experiences as an obstetrician – the baby’s head delivers, but the shoulders get stuck. All the time this is going on, baby’s brain isn’t getting any oxygen, so it’s a ticking time bomb of a matter of minutes before irreversible brain damage occurs. We all train regularly in how to manage this particular emergency. Embedded into our brainstems are all manner of mnemonics to help us through it, and all sorts of physical manoeuvres: exerting suprapubic pressure, McRoberts (hyper-flexing the legs), Wood’s Screw (rotating the baby by its shoulders), delivering the posterior arm.
† Erb’s palsy is nerve damage to the arm resulting from straining the neck in this kind of scenario.
Wednesday, 20 October 2010
Maybe it’s because his first language is Greek. Maybe he’s forgotten our previous discussion where I’d offered to help him with ultrasound technique. Maybe I should have phrased it as ‘determine fetal gender’. But judging by the SHO’s look of confusion and disgust and his hasty retreat down the corridor, what I shouldn’t have said was a cheery, ‘Would you like to watch me sex a baby?’
Thursday, 21 October 2010
I pick up notes for the next patient I’m seeing in gynae clinic. I recognize the name – flicking through the notes, I see a clinic letter I wrote to her GP back in March. I spot a horrifying typo in my sign-off, thanks to a missing ‘hesitate to’.
If you have any questions whatsoever, please do not contact me.
It worked, though. Not a peep.
Wednesday, 27 October 2010
I’m in occupational health for a follow-up HIV test after a needle-stick injury from a positive patient three months ago. She had an undetectable viral load but it’s still not ideal by any stretch, and I’ve had it constantly in the back of my mind since, like a bill from HMRC.
Making nervous small talk with the occupational health registrar as he takes my blood, I ask what happens to an obstetrician who’s HIV positive. ‘You wouldn’t be able to do clinical procedures, so no labour ward, theatre, on-calls – just clinics, I guess.’ I don’t say it, but that would really take the sting out of the diagnosis.*
* Since 2013, it’s been OK for an HIV-positive doctor with an undetectable viral load to operate, after a decade of lobbying that the risk to patients was negligible. My blood test was negative, in case you wondered whether the book was about to take a dark turn.
Sunday, 31 October 2010
At a friend’s Halloween party I spot someone I know from somewhere. School, I think.
I amble over to say hi. Blank face. Not school. University? Nope.
Where did you grow up? Have we worked together? Humiliatingly for me, but probably for his own sanity, he has to stop me and say that I’ve probably just seen him on TV before – he’s a presenter called Danny. Humiliatingly for him, I say the name maybe rings a bell, but I’m pretty sure that’s not it. His wife wanders over and I work it out – I delivered their baby by caesarean a year or so back.
Much hugging, hand-shaking and what-a-coincidence-ing. Danny jokes he’s glad it was a caesarean, because he doesn’t know how he’d feel about talking to a man who’s seen his wife’s vagina. I want to say that actually I’d have seen it when catheterizing her for the procedure, plus, if he really wants something to get his brain imploding, I’d have also seen its reverse side during the operation. I don’t say this, just in case he wasn’t joking and things get even more awkward.
Monday, 8 November 2010
The cherry on top of a record-breakingly hellish night shift (with a locum registrar who was of barely more than ornamental value) was a crash caesarean at 7.45 a.m., fifteen minutes from the supposed finish line. Caesarean, then another caesarean, then ventouse, then forceps, then caesarean, then I lost count, but a bunch more babies, and now a final caesarean. I’m absolutely exhausted, and would gladly have dragged my feet and handed it over to the morning shift were the trace not pre-terminal.*
I’ve not sat down for twelve hours, let alone rested my eyes, my dinner’s sitting uneaten in my locker and I’ve just called a midwife ‘Mum’ by accident. We run to theatre and I deliver the baby very quickly – it’s limp, but the paediatricians do their black magic and soon it’s making the right sort of noises. Cord gases confirm we made the right decision and I close up the patient on a vague high.
The paediatrician grabs me for a word after I leave theatre and tells me I’ve cut the baby’s cheek with my scalpel while making the uterine incision – it’s not bad, but just to let me know. I go straight to see the baby and parents. It’s not a deep cut, nor is it long – it didn’t need any skin closure and it surely won’t scar – but it was totally my fault. I apologize to the parents, who couldn’t seem to give less of a toss. They’re in love with their gorgeous (and only mildly mutilated) little girl, and they tell me they understand she had to be delivered in a bit of a rush – these things happen. I want to say that these things aren’t meant to happen, that they haven’t happened to me before and they almost certainly wouldn’t have happened to me at the start of the shift.
I offer them a leaflet with the details of the PALS office – they don’t want it. A close shave for my GMC registration and an actual shave for the poor baby. A couple of centimetres higher and I’d have taken her eye out, a couple of millimetres deeper and I could have caused scarring and blood loss. Babies have even died from lacerations at caesarean. I document our discussion in the notes, fill in the clinical incident form, do everything demanded of me by the system that allowed this to happen in the first place. Before long I’ll get sat down by someone to be gently or not-so-gently chastised, and at no point will it occur to them that there might be a more fundamental problem here.†
* Pre-terminal means the baby is about to die if nothing is done.
† Almost a decade previously, I worked at the same hospital as a medical secretary during university holidays. We were obliged to take a twenty-minute break after every two hours of staring at a computer screen because of ‘health and safety’.
Thursday, 11 November 2010
I suspected the husband of the couple in infertility clinic had a urinary tract infection so I gave him a specimen pot and sent him off to the toilet for a sample. He took the jar from me and peered at it for a few seconds before tottering off. I suppose it was my fault for not being specific enough, but he returned (admirably quickly) with the pot containing a few millilitres of semen. The miscommunication could have been worse, of course – he could’ve shat in it, bled into it or stuck a skewer into the ventricles of his brain to draw out a pot of cerebrospinal fluid. I do rather wonder whether the reason they’re struggling to conceive is that he’s urinating into his wife during sex.
Sunday, 14 November 2010
It’s Sunday lunchtime and patient RZ needs a caesarean section for failure to progress in labour. The patient is happy to have a section, but her husband doesn’t want me to perform it because I’m male. They are orthodox Muslim and have apparently been told they can have all female doctors. I say I don’t know who told them that but, although there are often women doctors available, we work on a rota and currently the entire team in obs and gynae is male, including the consultant on call at home.
‘So you’re honestly telling me that there are no female doctors in the hospital?’
‘No, sir, I’m telling you there are no female doctors in the hospital capable of performing a caesarean. I’m sure I could easily find your wife a female dermatologist.’
The patient is clearly much happier with the idea of me doing the section than her husband is, but she’s not really being allowed to speak up. We go through the motions, getting even further away from the result we need the more we dance around it. ‘When’s a woman doctor next here?’ When the shifts change in seven hours, which would be a very bad idea for your baby. ‘Can’t the midwife do it?’ No, and nor can the cleaner.
I call the consultant for some moral support. He suggests I drag up, and I suspect he’s only half joking. Back in the room, I ask, ‘Does the Koran not allow for male doctors to operate in the case of an emergency?’ Which, I remind them, this is. It’s a total bluff, but it seems the sort of thing a religious text might say. They ask me to give them five minutes, make some phone calls, then the husband comes to find me to say that they’re happy for me to deliver the baby. He says it in a way that implies I should be grateful. In fact, I am grateful, but only because my main concern was the safe appearance of his child, not his (or anyone else’s) God’s feelings on the matter. Plus I don’t have a Plan B and can’t begin to contemplate the unending quantity of paperwork that would otherwise haunt me forever.
The (male, naturally) anaesthetist pops in to get them sorted for theatre, and I wonder whether this will be a growing trend. Perhaps we should take a leaf from toilet cleaners and litter the floor with yellow ‘Male Obstetrician on Duty’ signs.
Before long we’re in theatre, and I’ve safely delivered their baby girl. Healthy mum, healthy baby – it’s all we ever aim for, and they should be glad everything worked out fine for them, when it doesn’t for so many families who come through these doors.
In the event, the husband is extremely thankful – he apologizes for wasting my time and adding to my stress, and tells me he’s grateful for all I’ve done. As with most husbands who kick off, he was probably just stressed by the situation, and I presume the added jeopardy of potential eternal damnation didn’t help either.
He’s going down to the shops, would I like anything? I half want to see his reaction if I ask for a BLT, a bottle of Smirnoff and some poppers.
Thursday, 18 November 2010
Was meant to be back home at 7 p.m. sharp but it’s 9.30 and I’ve only just come off labour ward. Feels appropriate that work commitments mean I have to reschedule collecting all my belongings from the flat. On the plus side, my depressing new bachelor pad is only ten minutes from the hospital.
Monday, 22 November 2010
A patient awaiting review in A&E for some minor abdominal pain has sunk lower and lower down my list of priorities throughout the afternoon as labour ward has become busier and busier. I’m in the middle of stabilizing a patient with severe pre-eclampsia when I’m bleeped by a furious A&E registrar.
‘If you don’t come to A&E right now this patient is going to breach the four-hour target.’*
‘OK. But if I do come right now my current patient is going to die.’ Mic drop.
There’s a good five seconds of radio silence where he clearly wonders if there’s anything he can fire back that will persuade me to come down and save him a load of aggro. I spend this time marvelling at a system that’s so obsessed with arbitrary targets that his reply should take this long to generate.
‘Fine. Just come when you can,’ he replies. ‘But I’m really not happy about this.’ When she’s out of the woods I must remember to have my pre-eclamptic patient write him an apology.
* Because hospitals aren’t under quite enough pressure, the government has decided that all patients in A&E need to be admitted or discharged within four hours, whether they’ve had a stroke or stubbed their toe. If more than 5 per cent of these patients breach the target (unfortunately not the type of breech that interests me), the hospital gets fined and the management unleash a heap of hell on the A&E staff.
Friday, 26 November 2010
The last of my pre-operative patients to consent before theatre is QS, an elderly lady having a hysteroscopy following some recent PV bleeding. She’s accompanied by a red-trousered roaring chin of a son. He’s under the impression that the more he treats medical staff like crap, the more convinced they will be of his importance, and thus the better treatment they will receive. Amazingly, this is a commonly held belief and, annoyingly, he’s absolutely right. People like this are exactly the type to complain to PALS if she gets so much as a chip in her toenail polish.
I bite my tongue harder with every question he asks. ‘How many of these have you done?’ ‘Is this not a case that your consultant should be doing?’ If this was a restaurant and I was a waiter, I would currently be stirring my spit and semen into his beef bourguignon; but she’s a sweet old lady, and she’s not going to suffer just because her son’s an arsehole. We’re all done. ‘Treat her as if she’s your own mother,’ he instructs me. I assure him he really doesn’t want that at all.
Thursday, 2 December 2010
Spending my Sunday afternoon on labour ward with an excellent SHO. She asks me to review the CTG of a patient and I agree with her assessment that the patient needs a caesarean section for fetal distress. They are a lovely couple, recently married; it’s their first baby, and they understand the situation.
The SHO asks if she can perform the caesarean while I assist. In theatre, the SHO goes through the layers: skin, fat, muscles, peritoneum 1, peritoneum 2, uterus. After the uterine incision, rather than amniotic fluid, blood comes out – lots of blood. There has been an abruption.* I stay calm and ask the SHO to deliver the baby – she says she can’t, there’s something in the way. I take over the operation – the placenta is in the way. The patient has an undiagnosed placenta praevia. This should have been noticed on scans, she should never have been allowed to go into labour. I deliver the placenta and then deliver the baby. The baby is clearly dead. Paediatricians attempt resuscitation but without success.
The patient is bleeding heavily from the uterus – one litre, two litres. My sutures have no effect, drugs have no effect. I call for the consultant to come in urgently. The patient is now under general anaesthetic and receiving emergency blood transfusions; her husband has been escorted out of theatre. Blood loss is now five litres. I try a brace suture† – no luck. I’m squeezing the uterus as hard as I can with both hands – it’s the only thing that stops the bleeding.
The consultant arrives, attempts another brace suture – it doesn’t work. I see the panic in her eyes. The anaesthetist tells us he can’t get fluid into the patient fast enough to replace what she’s losing and we’re risking organ damage. The consultant calls another colleague – he’s not on duty, but he’s the most experienced surgeon she can think of. We take it in turns squeezing the uterus until he arrives twenty minutes later. He performs a hysterectomy; the bleeding is finally under control. Twelve litres. The patient goes to intensive care and I am warned to expect the worst. My consultant talks to the husband. I start to write up my operation notes but instead just cry for an hour.
* Abruption is a complication of pregnancy where all or part of the placenta separates from the uterus. Because all of baby’s oxygen and nutrients are delivered via the placenta, this can be extremely serious indeed.
† Brace sutures are very large stitches that go around the uterus like a pair of braces to compress it and stop the bleeding.
